NOTE TO STUDENTS

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GENERAL ANESTHESIA

This is defined by a loss of sensation with a loss of consciousness and reflexes. It consists of four
components, amnesia, analgesia, inhibition of noxious reflexes and skeletal muscle relaxation. It
is therefore, usually the choice category for clients who

1. Are to undergo a procedure that requires significant skeletal muscle relaxation lasting for
long periods
2. Require awkward positions because of the location of the incision site
3. Are extremely anxious
4. Refuse local or regional anesthesia

General anesthesia may be administered by four different methods, namely

1. Intravenous
2. Inhalational
3. Rectal
4. Intramuscular

The Intravenous Agents

Mostly, all adult general anesthetics begin with an intravenous induction. The agents have a
smooth and rapid action, but do not maintain the unconscious state for more than a few minutes,
if given alone. The IV agents are subdivided into

A. Barbiturates: Most frequently administered. They are short acting with rapid induction.
Commonest examples include thiopental sodium (Pentothal) and sodium methohexital
(Brevital). High doses can lead to cardiovascular depression, hypotension, tachycardia
and respiratory depression. Accidental leakage of the barbiturates into surrounding
tissues can cause severe pain and damage due to the alkalinity of the drugs. Also,
injection into an artery will elicit arterial spasms.
Rectal administration may occasionally be done in children to induce a sleepy state
before use of other anesthetic.
B. Non-barbiturate hypnotics: Examples include Etomidate (Amidate) and Propofol
(Diprivan). Etomidate produces little or no cardiorespiratory depression and is hence
 mostly preferred to barbiturates especially with unstable clients. A side effect common
here is the annoying pain felt on injection. Etomidate can also cause myoclonia and
postop nausea and vomiting. Propofol is used as an induction agent to maintain general
anesthetic levels. It also is rapidly eliminated from the system and is useful for short
period outpatient procedures. It also causes less nausea and vomiting than many other
agents.

The Inhalational Agents

These agents may be volatile liquids or gases. They enter the body through the alveoli in the
respiratory tract. Their depth is easily altered by changes in respiratory exchange.
Inhalational agents may also be used to induce general anesthetic in a technique called
INHALATION INDUCTION, and also to maintain the anesthetic state. They may however
elicit an irritating effect on the respiratory passages including coughing, laryngospasm,
increased secretions and respiratory depression at deep planes of anesthesia some agents may
also stimulate the vomiting center of the brain, raising potentials for postop aspiration of
secretions.

Administration of the inhalational agents may be via a mask, a tracheal tube or an

 Endobronchial intubation, i.e tube inserted too far and only one lung is ventilated
 Esophageal intubation.

The safest means of delivery is through a cuffed endotracheal tube. It permits mechanical
ventilation, control of respiration with an open airway, easy access to the tracheobronchial tree
for suctioning and reduced chance for regurgitation of stomach content and aspirated secretions.

Complications are linked to the insertion or removal of the endotracheal tube, including damage
to teeth, laryngospasm, post op sore throat, laryngeal edema, and hoarseness due to injury or
irritation of the vocal cords or surrounding tissues.

Volatile Liquids: in the 19th century, Diethyl ether was introduced accepted and used as a
general anesthetic. The signs of anesthesia (altered consciousness, excitement, surgical
relaxation and cardiorespiratory failure in overdose case) were noted with its use. Today, the
signs are rapidly gone through with the introduction of newer agents. Diethyl ether,
cyclopropane, ethylene and divinyl ether are obsolete due to their high inflammability, while
Methoxyflurance, which is nonexplosive is obsolete for its nephrotoxicity.

More commonly used agents include Halothane (Fluothane), a strong anesthetic and
bronchodilator in appropriate doses, with a low incidence of postop nausea and vomiting. It may
however result in hypotension through cardiac depression and peripheral vasodilation during its
administration.

Its use in the adult population has been reduced drastically since it has been suspected of
hepatotoxicity. For the pediatric population, it is still in use, as there has been no evidence
whatsoever of hepatic problems with its use. It is also less pungent in odor for them.

Next Enflurane (Ethrane) is a rapidly acting non explosive halogenated ether, that allows for
management of cardiovascular status and produces minimal respiratory secretions. It is a good
muscle relaxant and provides postop recovery, with minimal nausea and vomiting. It has
however been indicted in seizure activity with high concentration and renal damage.

Isoflurane (Forane), an isomer of enflurane, more rapid in action and less metabolized by the
body. It is not found toxic to any organ, and is preferred to use with unstable clients. High doses
may however cause tachycardia at times.

Gaseous Agents: Nitrous oxide provides more of analgesia than unconsciousness. It is the most
widely administered gas. It speeds up the passage of volatile anesthetics into the client. It is
administered as a single agent in minor procedures only. The primary harmful effect stems when
it is used without sufficient amounts of oxygen, which can lead to hypoxia and respiratory
depression. Its effects are readily reversible by discontinuation. It has been shown to increase the
incidence of nausea and vomiting, as well as cardiac depression. Clinical studies have shown
significant cardiac depression with the use of Nitrous oxide. This may easily cause problems in a
client with cardiac disease and dysfunction.

Also, since this agent easily diffuses into existing air spaces in the body, it can cause problems if
the increase in pressure cannot be equalized or balanced out.

Compressed air may be used with oxygen where Nitrous oxide is contraindicated such as in
severe cardiac disease, history of nausea and/or vomiting, an existing bowel obstruction and
surgery of the middle or inner ear.

Another gas that is occasionally used is Helium. It is however very expensive.

ADJUNCTS TO GENERAL ANESTHESIA

Note again that general anesthesia is rarely limited to one agent. Adjuncts to general anesthesia
are in place to aid with pain relief, amnesia and muscle relaxation. They include opiates, muscle
relaxants and hypnotics.

1) Opiates also called Narcotics reduce the concentration of inhalation agents and allow for
analgesia to continue post op. Commonly used today are Fentanyl, Sufentanil and Alfentanil.
 They are potent, but short acting. The primary disadvantage is respiratory depression by
slowing the respiratory rate.
2) Neuromuscular Blocking Agents are given to produce paralysis. They are subdivided into

Depolarizing agents such as Succinylcholine, which depolarize the end plate and prevent
further depolarization.

Nondepolarizing agents such as Vecuronium bromide and Metocurine, which interfere with
nerve impulse transmission at the myoneural junction, by competing with acetylcholine.

The primary disadvantage of muscle relaxants is that the duration of its effect may be longer than
the surgery, or reversal agents may not completely clean up residues.

3) Hypnotics cause amnesia and sedation. They are given in small incremental doses until the
desired effect is reached. This allows for observation to note any adverse side effects. The
commonly used hypnotics are Diazepam and Midazolam.
4) Antiemetics: medication that reduce or eliminate the incidence of nausea and vomiting. The
most commonly used agent is Droperidol (Inapsine). At normal dosage, it reduces nausea,
and leads to heavy sedation and tranquilization when given at higher doses. Droperidol gives
greater potent to the depressant effect of other drugs.
5) Dissociative Anesthetics: interrupt associative brain pathways whilst blocking sensory
pathways. The client may seemingly be awake, but is actually asleep. The involved agent is
Ketamine Hydrochloride (Ketalar), administred intravenously or intramuscularly. It is
suitable for for clients with poor surgical risks, as it does not relax upper airway muscles and
tissues, minimizing the risk of airway obstruction. However, there must always be
resuscitative equipment close by, with its administration. The main disadvantage is the
postoperative effect of a hallucinogenic state. This can be controlled by administering lower
doses and using adjuncts.

Specific Complications

1. Anaphylaxis: this can occur with any anesthetic agent and in all types of anesthesia. The
severity of the reaction may vary, but features may include rashes, bronchospasm,
hypotension, angioedema and vomiting. It requires careful study during pre-op
assessment and with previous anesthesia (general). The medical/nurses chart may help. If
a patient is suspected of an allergic reaction, the individual should be referred for further
investigation, to try to determine the exact cause. Anaphylaxis must be properly
recognized and managed. Such patients should be encouraged to, have on a medical
emergency identification bracelet at all times.
 2. Aspiration Pneumonitis: A reduced level of consciousness can result to an unprotected
airway. If the patient vomits, there is a possibility to aspirate the vomitus into their lungs.
This can trigger inflammation with infection. The risk of aspiration pneumonitis and
aspiration pneumonia is reduced by fasting for several hours prior to the procedure and
cricoid cartilage pressure during induction of anesthesia.

However, the evidence for use of cricoid pressure isn’t clearly documented and further
investigation is required. Other methods of reducing aspiration pneumonitis associated
with anesthesia include the use of Metoclopramide to enhance Gastric emptying or
Proton Pump inhibitors, to increase the pH OF gastric contents.
Aspiration pneumonitis may also occur in spinal anesthesia if the level of spinal block is
too high, resulting in paralysis or impairment of the vocal cords and respiratory system.

3. Peripheral nerve damage: This can occur with all the types of anesthesia and results from
nerve compression. The most common cause is exaggerated positioning for prolonged
periods of time. The anesthetists and the surgeons should be aware of this complication
and the patient should be moved as regularly as possible. The most common nerves
affected are the Ulnar nerve and Common Peroneal nerve. More rarely is the Brachial
plexus affectation.
Injuries to nerves can be avoided by prevention of extreme postures for lengthy periods
during surgery. If nerve damage occurs, the patient should be followed up, and further
investigations such as Electromyography should be done.

4. Embolism: This is rare, but potentially fatal.

REGIONAL ANESTHESIA

It can be described as central, with administration of the agent in, or around the spinal cord,
blocking the nerves of the spine. The main benefit of this method is that it does not require
ventilation, as long as the blockage is not too high.

Types

1) Nerve Block: an injection of a specific nerve at a given point to numb the area of the body
temporarily. E.g. an intercostal, median or axillary nerve block.
a) Central Nerve Blocks are those that anesthetize the spinal cord nerves (motor and
sensory) near their origin.
b) Spinal block affects the nerves in the subarachnoid space.
c) Epidural block affects nerve roots passing through the epidural space. It may use a
lumbar or sacral approach.
2) Intravenous Regional Block: (Bier’s block) is the injection of the agent intravenously into the
extremity after the tourniquet has been applied. The tourniquet should remain inflated for a
minimum of 30minutes.
3) Field Block: infiltration in which the anesthetic is injected around the area of the surgical
procedure by a series of injections.
4) Peripheral Block: involves injection of an agent (e.g Epinephrine) near to the nervous plexus.
A brachial plexus block would numb the shoulder, arm and hand.

Specific Complications

 Post dural Puncture Headache; treatable with analgesics, bed rest and adequate hydration.
Occasionally, an epidural blood patch is used.
 Total spinal block.
 Hypotension, occurring in as much as 70-80% of women receiving pharmacological
anaphylaxis for elective caesarian delivery.

LOCAL ANESTHESIA

This allows an operative procedure to be performed on a part of the body without loss of
consciousness. It blocks the conduction of nerve impulses by altering nerve cell permeability to
sodium, and resulting in a decrease of membrane depolarization which prevents the development
of a propagated action potential.

Frequently administered local anesthetics are cocaine, procaine hydrochloride, tetracaine

Advantages

It is advantageous for use in a patient who is deemed suitable; not allergic, undergoing a
procedure that does not require an unconscious state and is not excessively anxious.

1) It lacks the risk of induction and recovery hazards as seen in general anesthesia
2) It requires minimum equipment and hence, is less expensive.
3) Client can eat or drink before the surgery.

Disadvantages

1) Client being aware during the procedure may cause restlessness and disturbance.
2) Lack of feasibility to localize some anatomical sites.
3) Rapid absorption of the agent into the bloodstream in unsuspected circumstances, resulting in
lightheadness, dizziness, ringing in ears, loss of consciousness and seizure activity.
Methods of Administration

1) Topical Application: application of the agent directly to the skin, mucous membrane or open
surface.
2) Local infiltration: injection of the agent into the tissues from where the surgical incision will
be made.
3) Regional Application: injection of the agent at some location along the conduction nerve
pathway to and from the region selected to be anesthetized.

Important General Complications

The practice of anesthesia, though with some problems, is fundamental to medical practice.
However, it is difficult to determine the exact incidence of death directly attributable to general
anesthesia, as cause of death is often multifactorial and study methodology varies, making
comparisons difficult. Complications may include:

1. Pain
2. Nausea and vomiting
3. Damage to teeth
4. Sore throat and laryngeal damage
5. Cardiovascular prolapse
6. Aspiration pneumonitis
7. Hypothermia
8. Hypoxic brain damage
9. Awareness during anesthesia
10. Respiratory depression
11. Embolism (air, thrombus, venous or arterial)
12. Nerve injury
13. Backache
14. Headache
15. Anaphylaxis to anesthetic agent
16. Idiosyncratic reactions related to specific agents (e.g malignant hyperparesia)
17. Iatrogenic reactions (e.g pneumothorax related to central line insertion)
18. Bleeding and formation of hematoma
19. Infection
20. Ischemic necrosis
21. Urinary retention
22. Limb damage
23. Death
I WISH YOU ALL THE BEST
- PT. Osayi Nkiru