1. Principles of Anesthesia
ST210 Concorde Career College

2. Objectives
Assess the action, uses, and modes of administration of drugs and anesthetic agents used in the care of the surgical patient
Recognize general terminology and abbreviations associated with anesthesia
Recognize the side effects and contraindications for the use of various anesthetic drugs

3. Objectives
Interpret factors that influence anesthesia selection for individual patients
List the equipment used during anesthesia administration
Analyze how sterile technique is used in relation to anesthesia procedures
Compare and contrast the roles of the surgical technologist and circulator during the administration of anesthesia

4. Definitions
Anesthesia - From the Greek meaning lack of sensation; particularly during surgical intervention.

5. Definitions Review HYPNOSIS ANESTHESIA AMNESIA MUSCLE RELAXATION
POSITIONING
HOMEOSTASIS

6. Anesthesia History Timeline
1500s: Coca leaves used as local anesthetic during trephination of the skull
1725: Ether was discovered by Spanish chemist Raymundus Lillius
1800s: Social use of ether - “ether frolics”
1842: Crawford W. Long may have been the first to use ether for surgical pain control, but did not publish his findings until 1848

7. Anesthesia History Timeline
1846: William T.G. Morton performed surgery at Mass General Hospital in front of an audience
First Surgical Use of Anesthetics – Click Here
Ether Dome: Mass General Hospital
1905: Long Island Society Anesthetists (LISA) formed
1936: LISA changed name to ASA (American Society of Anesthesiologists)

8. Anesthesia History Timeline

9. Anesthesia History Timeline

10. Anesthesia History Timeline

11. Anesthesia Administration
Two primary methods of anesthesia administration:
Inhalation Agents
Typically for General Anesthesia
Injectable Agents
Typically for Nerve Conduction Blockade, or
Regional Anesthesia

12. Alteration in the patient’s level of consciousness
General Anesthesia
Alteration in the patient’s level of consciousness
(patient is “asleep”)
Accomplished by:
Agent inhalation
Agent injection
Agent instillation

13. Nerve Conduction Blockade
Prevent initiation of conduction of nerve impulses along a nerve pathway (patient is “awake”)

14. Factors that affect selection of the type of anesthesia:
Anesthesia Selection
Factors that affect selection of the type of anesthesia:
Planned procedure and estimated duration
Patient position
Age, size, and weight of the patient
Patient status (emotional, mental, and physical)
General health of the patient (comorbid conditions)

15. Factors that affect selection of the type of anesthesia: (continued)
Anesthesia Selection
Factors that affect selection of the type of anesthesia: (continued)
Medication status
Allergy status
History of substance abuse
Emergency conditions
Preference (surgeon, anesthesia provider, patient)

16. ASA Risk Classification System
Class 1 – No organic, physiological, biochemical, or psychiatric disturbance
Class 2 – Mild to moderate systemic disease or disturbance (e.g., controlled hypertension or diabetes, asthma, anemia, smoking, mild obesity, age – less than 1 or greater than 70)

17. ASA Risk Classification System
Class 3 – Severe systemic disease or disturbance (e.g., stable angina, previous MI, poorly controlled hypertension or diabetes, symptomatic respiratory disease, massive obesity)
Class 4 – Severe (life threatening) systemic disease or disturbance (e.g., unstable angina, CHF, debilitating respiratory disease, hepatorenal failure)

18. ASA Risk Classification System
Class 5 – Moribund Class 6 – Brain dead E – Emergency modifier

19. Roles of the Surgical Team Members
(refer to the tables on pp )
Preoperative case management duties
Intraoperative case management duties
Postoperative case management duties

20. Anesthesia Evaluation & Preparation
Preanesthetic evaluation and preparation processes
Preoperative routine
Preoperative education
Patient possessions
Preoperative procedures

21. Preoperative Routine Enema Nail polish and makeup
Hygiene (shower and shave)
Attire
Sedation
Call to the OR
Family visit
Identification, chart, consent, transportation, transfer...

22. Anesthesia Equipment Equipment and techniques used to monitor the patient
Blood pressure
O2 Sat
Temperature
I&O
Heart
BIS
Respiration
SARA
Doppler
Peripheral Nerve Stimulator
ABG

23. Anesthesia Equipment Equipment and techniques used to monitor the patient
Blood Pressure
Sphygmomanometer
(with stethoscope)

24. Anesthesia Equipment Equipment and techniques used to monitor the patient
O2 Sat
Pulse Oximeter

25. Esophageal Stethoscope with temperature probe
Anesthesia Equipment Equipment and techniques used to monitor the patient
Temperature
Thermometer
Esophageal Stethoscope with temperature probe

26. Anesthesia Equipment Equipment and techniques used to monitor the patient
I&O
Intake and Output

27. Apical Stethoscope Earpiece
Anesthesia Equipment Equipment and techniques used to monitor the patient
Heart
Apical Stethoscope Earpiece

28. Anesthesia Equipment Equipment and techniques used to monitor the patient
Heart
Electrocardiogram
Electrodes

29. Anesthesia Equipment Equipment and techniques used to monitor the patient
Heart
Electrocardiogram
Leads

30. Anesthesia Equipment Equipment and techniques used to monitor the patient
Heart
Electrocardiogram
(ECG)

31. Anesthesia Equipment Equipment and techniques used to monitor the patient
BIS Monitor
(Bispectral Index)

32. (System for Anesthetic and Respiratory Analysis)
Anesthesia Equipment Equipment and techniques used to monitor the patient
Respiration
SARA
(System for Anesthetic and Respiratory Analysis)

33. Anesthesia Equipment SARA is capable of several functions including:
Capnography
Spirometry
Oxygen analysis

34. Anesthesia Equipment Equipment and techniques used to monitor the patient
Doppler

35. Peripheral Nerve Stimulator
Anesthesia Equipment Equipment and techniques used to monitor the patient
Peripheral Nerve Stimulator

36. Anesthesia Equipment Equipment and techniques used to monitor the patient
ABG
(Arterial Blood Gas)

37. Methods of Anesthetic Administration
General
Balanced
Neuroleptanalgesia
Nerve Conduction Blockade
Regional
Local
Topical

38. Common Anesthetic Agents
Inhalation Agents
Oxygen
Nitrous oxide
Waste gases

39. Common Anesthetic Agents
Oxygen
Inhalation agent
Not anesthetic agent
Necessary for life

40. Common Anesthetic Agents
Nitrous Oxide
Produces analgesia and amnesia
Produces little muscle relaxation
Decreases myocardial contractility and respiratory function

41. Common Anesthetic Agents
Waste gas scavenger system

42. Common Anesthetic Agents
Volatile Agents
Liquids with potent evaporative vapors
CNS depression produces general anesthesia
Myocardial and respiratory depression
Decrease muscle tone

43. Volatile Agents Halothane (Fluothane) Enflurane (Ethrane)
Isoflurane (Forane)
Desflurane (Suprane)
Sevoflurane (Ultane)

44. Halothane Rapid acting Sweet odor
Nonirritating to the respiratory tree
Used for induction and maintenance

45. Enflurane Halogenated Sweet odor Rapid induction Rapid recovery
Hypotension (when not surgically stimulated)
Potentiates nondepolarizing NMB

46. Isoflurane Rapid induction and recovery Musty smelling
Profound respiratory depression and hypotension
Markedly potentiates NMB
Increases ICP

47. Desflurane Halogenated Requires heated vaporizer Pungent aroma
Not biotransformed in the liver

48. Sevoflurane Odorless No irritation to respiratory tree
Causes bradycardia,
hypotension, dysrhythmias, decreases cardiac output

49. Intravenous Agents
Permit rapid pleasant transition from consciousness to unconsciousness
Produce marked sedation and amnesia
Produce hypotension and respiratory depression
Some induction agents may also be used for maintenance

50. Intravenous Agents for Induction
Propofol (Diprivan)
Etomidate (Amidate)
Thiopental sodium (Pentothal Sodium)
Methohexital sodium (Brevital)

51. Propofol Sedative hypnotic
Soy oil in water emulsion (inhibits microbial growth)
Induction or conscious sedation
Alkaline – irritating to the vein
Causes increased ICP and hypotension

52. Propofol
Formulations of intravenous anesthetic propofol emulsions are provided which contain sufficiently low concentrations of soybean oil to produce a stable emulsion and simultaneously provide reduced nutrients, which inhibit microbial growth thereby providing protection against accidental microbial contamination during long-term IV infusions. In addition to the inhibition of microbial growth due to a reduction of nutrients, the formulation exhibits unanticipated additional microbial inhibition due to an increased availability of propofol. The low concentration of soybean oil also provides a formulation that reduces the chances of fat overload when administered over an extended period of time to chronically ill patients.

53. Etomidate Non-barbiturate hypnotic
Produces minimal cardiovascular system effects
Causes nausea, vomiting, and adrenal suppression

54. Thiopental Sodium Potent barbiturate Short acting
Alkaline – irritating to the vein
Less expensive than propofol

55. Methohexital Sodium
Similar in action to propofol and thiopental sodium
Ultrashort onset and duration of action
Ideal agent for short term loss of consciousness during nerve conduction blockade

56. Dissociative Agents
Interrupt the associative pathways of the brain (patient appears awake, but is unaware of surroundings
Produce amnesia and profound analgesia

57. Ketamine Hydrochloride (Ketalar)
Dissociative Agents
Ketamine Hydrochloride (Ketalar)
Most commonly used
IM or IV administration
Rapid induction of dissociative state
Potentiated by other agents (narcotics/barbiturates)
Increases muscle tone
Increases ICP and IOP

58. Opiate/Opioids Narcotic (Class II) analgesics
(decrease pain impulse transmission from CNS and spinal cord receptors)
Also produce sedation
Produce euphoria and decrease anxiety
High doses lead to unconsciousness and respiratory depression

59. Opiate/Opioids Morphine sulfate Meperidine (Demerol)
Fentanyl citrate (Sublimaze)
Sufentanil citrate (Sufenta)
Alfentanil hydrochloride (Alfenta)
Remifentanil hydrochloride (Ultiva)

60. Narcotic Antagonists Antagonize or reverse narcotic effects
Increased level of consciousness seen in 1-2 minutes
Naloxone hydrochloride (Narcan)

61. Benzodiazepines Sedative tranquilizers Reduce anxiety/apprehension
Adjunct to general anesthesia (reduce amount and concentration of other agents)
Do not produce analgesia

62. Benzodiazepines Diazepam (Valium) Midazolam (Versed)
Droperidol (Inapsine)

63. Benzodiazepine Antagonist
Flumazenil (Mazicon)
Reverses the sedative effects, but may not reverse the amnesia effects
May cause convulsions
Rebound sedation and respiratory depression may occur

64. Neuromuscular Junction

65. Neuromuscular Junction Review

66. Neuromuscular Junction

67. Neuromuscular Blockers (NMBs)
Skeletal muscle relaxants (cause weakness – paralysis)
Interfere with passage of impulses from motor nerves to skeletal muscles
May use only one dose or re-administer throughout procedure

68. Neuromuscular Blockers (NMBs)
Used to relax the jaw for ease of endotracheal intubation
Muscles of respiration are affected (mechanical ventilation required)
Surgical site relaxation to allow for tissue retraction

69. Neuromuscular Blockers (NMBs)
Depolarizing Agents
Mimic release of acetylcholine across the neuromuscular junction
Causes muscle contraction (fasciculation) followed by a period of muscle fatigue
Patient may experience postprocedure muscle ache

70. Neuromuscular Blockers (NMBs)
Depolarizing Agents
Metabolized by plasma cholinesterase in the synapse reversing the effect of the agent
NO pharmacologic antagonist

71. Neuromuscular Blockers (NMBs)
Depolarizing Agents
Succinylcholine (Anectine)
Most commonly used
Short acting
Known triggering agent for MH
Decamethonium (Syncurine)

72. Neuromuscular Blockers (NMBs)
Nondepolarizing Agents
Compete for post synaptic receptors
Prevents stimulation of muscle contraction
Duration (short, intermediate, long)
Spontaneous recovery may occur
Pharmacologic antagonist available
Edrophonium chloride (Tensilon)
Neostigmine (Prostigmin)

73. Neuromuscular Blockers (NMBs)
Nondepolarizing Agents
Short Acting
Mivacurium chloride (Mivacron)
Vecuronium bromide (Norcuron)
Rocuronium bromide (Zemuron)

74. Neuromuscular Blockers (NMBs)
Nondepolarizing Agents
Intermediate Acting
Atracurium Besylate (Tracrium)
Cisatracurium besylate (Nimbex)

75. Neuromuscular Blockers (NMBs)
Nondepolarizing Agents
Long Acting
Tubocurarine chloride (Curare)
Pancuronium bromide (Pavulon)
Metocurine iodide (Metubine)

76. Antimuscarinic (Anticholinergic)
Used to limit salivation and bradycardia
Two commonly used agents
Atropine sulfate
Glycopyrrolate (Robinul)

77. Nonsteroidal Anti-Inflammatory Agents
NSAIDs
Nonsteroidal Anti-Inflammatory Agents
Aid in pain management
Main agent
Ketoralac (Toradol) – May be given IM intraoperatively to aid in emergence and recovery pain management

78. Gastric Acid Management
Used to alter the pH of gastric secretions and reduce gastric acid volume
Reduce the risk of stress ulcer
Agents
Oral agent citric acid (Bicitra)
IV agent cimetidine (Tagamet)
IV agent ranitidine (Zantac)
Metoclopramide (Reglan) – promotes pyloric emptying

79. Antiemetic Used to prevent or alleviate nausea Agents
Droperidol (Inapsine)
Metoclopramide (Reglan)

80. Administration Devices
Anesthesia Machine
Vaporizer
Anesthesia Circuit
Airway Delivery/Maintenance Devices
Hypo/Hyperthermia Devices

81. Administration Devices
Anesthesia Machine

82. Administration Devices
Anesthesia Cart

83. Administration Devices
Vaporizer

84. Administration Devices
Vaporizer

85. Administration Devices
Anesthesia Circuit

86. Administration Devices

87. Administration Devices
Soda lime
(calcium hydroxide)
Chemically removes carbon dioxide from the breathing circuit with the aid of activators such as sodium, potassium, and barium hydroxide

88. Administration Devices
Airway Delivery/Maintenance Devices
Face Mask

89. Administration Devices
Airway Delivery/Maintenance Devices
Oxygen Mask

90. Administration Devices
Airway Delivery/Maintenance Devices
Nasal Cannula

91. Administration Devices
Airway Delivery/Maintenance Devices
Endotracheal Tube

92. Administration Devices
Airway Delivery/Maintenance Devices
Laryngoscope

93. Administration Devices
Positioning of Laryngoscope

94. Administration Devices
Cuffed ET Tube in Position

95. Administration Devices
Airway Delivery/Maintenance Devices
McGill Forceps

96. Administration Devices
Airway Delivery/Maintenance Devices
Oral Airway

97. Administration Devices
Airway Delivery/Maintenance Devices
Nasal Airway (Trumpet)

98. Administration Devices
Airway Delivery/Maintenance Devices
Nasal Airway (Trumpet)

99. Administration Devices
Airway Delivery/Maintenance Devices
Tracheotomy Tube

100. Administration Devices
Airway Delivery/Maintenance Devices
Tracheotomy Tube

101. Administration Devices
Airway Delivery/Maintenance Devices
Laryngeal Mask Airway
(LMA)

102. Administration Devices
Airway Delivery/Maintenance Devices
Laryngeal Mask Airway
(LMA)

103. Administration Devices
Ambu Bag

104. Administration Devices
Laryngeal Tracheal Anesthesia (LTA) Kit

105. Hyper/Hypothermia Devices
Bair Hugger
Heating/Cooling Unit
Heat Lamp

106. Hypo/Hyperthermia Devices
Bair Hugger

107. Hyper/Hypothermia Devices
Heating/Cooling Unit
(Blanket)

108. Hyper/Hypothermia Devices
Heat Lamp

109. Positioning for Anesthesia
Supine
Lateral
Sitting

110. General Anesthesia Alteration in the patient’s level of consciousness
Accomplished by agent inhalation, injection, or instillation

111. Goals of General Anesthesia
Lack of sensation
Lack of movement
Muscle relaxation
Autonomic control (homeostasis)

112. General Anesthesia (Four Stages – Depth) Stage I – Amnesia
Stage II – Excitement
Stage III – Surgical Intervention (4 planes)
Stage IV – Overdose

113. General Anesthesia (Four Phases) Induction Maintenance Emergence
Recovery

114. General Anesthesia
Advantages
Disadvantages

115. Cricoid Pressure (Sellick’s Maneuver)
Purpose – To minimize the risk of aspiration
Apply external pressure to the cricoid cartilage using the thumb and first finger to form a “V”
Pressure occludes the esophagus between the cricoid ring and the body of the 6th vertebral body
Must apply prior to induction and maintain until patient is intubated
Do NOT release pressure without permission from the anesthesia provider

116. Cricoid Pressure (Sellick’s Maneuver)
Indications
Emergency surgery shortly after eating
NPO status cannot be verified
GI bleeding
Basic life support, if needed

117. Nerve Conduction Blockade
Anesthetic agent is used to prevent initiation and/or transmission of impulses along an individual nerve pathway or at a nerve plexus to provide anesthesia to tissues adjacent or distal to the site.

118. Nerve Conduction Blockade
Two types of agents used to accomplish nerve conduction blockade
Amino amide group
Metabolized in the liver
Excreted by the kidneys
Amino ester group
Biotransformed by pseudocholinesterase in the plasma

119. Nerve Conduction Blockade
Amino amide group
Lidocaine hydrochloride (Xylocaine, Lignocaine)
Mepivacaine hydrochloride (Carbocaine)
Bupivacaine hydrochloride (Marcaine, Sensorcaine)
Etidocaine hydrochloride (Duranest)

120. Lidocaine Hydrochloride
Rapid onset
Moderate duration
Topical, local, regional
Available with or without epinephrine
Has properties that affect the heart

121. Mepivacaine Hydrochloride
Action similar to lidocaine
Longer action than lidocaine
Does not produce significant cardiac effects

122. Bupivacaine Hydrochloride
Four times as potent as lidocaine
Longer onset of action than lidocaine
Longer duration of effect than lidocaine
Available with or without epinephrine

123. Etidocaine Hydrochloride
Prolonged onset
Long duration
Highly toxic
Contraindicated in children

124. Nerve Conduction Blockade
Amino ester group
Cocaine hydrochloride
Procaine hydrochloride (Novocain)
Tetracaine hydrochloride (Cetacaine, Pontocaine)

125. Cocaine Hydrochloride
CNS stimulant
Controlled substance
Topical application only
Produces anesthesia and vasoconstriction causing shrinkage of mucous membranes

126. Procaine Hydrochloride
Similar properties to cocaine
Less toxic than cocaine
SC, IM, or intrathecal

127. Tetracaine Hydrochloride
Slow onset
Prolonged duration
Primarily used as a topical agent

128. Nerve Conduction Blockade
Adjunctive Agents
Influence onset and duration of action
Two common agents
Hyaluronidase (Wydase)
Epinephrine (Adrenalin)

129. (Monitored Anesthesia Care)
MAC
(Monitored Anesthesia Care)
Provides monitoring, sedation, analgesia, and amnesia
Used in conjunction with nerve conduction blockade

130. Nerve Conduction Blockade
Types of Nerve Conduction Blockade
Topical
Local
Regional

131. Topical Anesthesia
Placement of a nerve conduction blocking agent onto a tissue layer (skin or mucous membrane)
Anesthesia is limited to the area in contact with the anesthetic agent
In addition to pharmaceutical agents, cryoanesthesia is another example of topical anesthesia

132. Local Anesthesia
Placement of a nerve conduction blocking agent onto a tissue layer
Only the nerve or nerves that supply that limited (localized) area are affected

133. Regional Anesthesia
Nerve conduction blocking agent is injected along a major nerve pathway blocking conduction of impulses from all tissue (the entire region) distal to the injection site
Examples of regional anesthesia include:
Bier Block
Nerve Plexus Block
Spinal
Epidural
Caudal

134. Bier Block Provides anesthesia to the distal portion of an extremity
Used on procedures expected to last one hour or less
Procedure is as follows:
IV catheter is inserted
Double cuffed tourniquet is applied
Exsanguination is achieved with the use of an Esmarch bandage
Proximal cuff of tourniquet is inflated
Nerve conduction blocking agent is injected intravenously distal to the tourniquet
Distal cuff of tourniquet may be inflated and then the proximal cuff may be deflated

135. Nerve Plexus Block
Anesthetic solution is injected at a major nerve plexus – usually located at the base of a structure. For example the brachial plexus is at the base of the arm.

136. Spinal (Intrathecal) Block
Anesthetic solution is injected into the subarachnoid space (into the CSF)
Provides loss of sensation below the diaphragm (patient should be able to breathe independently)

137. Epidural Block
Anesthetic solution is injected in the epidural (outside the dura) space and is absorbed into the CSF through the dura
Provides loss of sensation below the diaphragm (patient should be able to breathe independently)

138. Caudal Block
Type of epidural that is administered with the patient in the lithotomy position.
Agent is injected into the epidural space of the sacral canal
Used primarily in obstetrics

139. Nerve Conduction Blockade
Advantages
Patient is awake
May be used to avoid undesirable cardiac and respiratory side effects
Recovery time from anesthesia is decreased
Disadvantages
Patient is awake
Patient maintains sensory awareness
Patient retains ability to move
Positioning may be difficult to maintain

140. Postanesthesia Care (Recovery)
May occur in the PACU or the ICU
Duration approximately 1 hour or longer, if necessary – Patient is transferred or discharged when ready
Patient is monitored
Ventilatory support is provided, as needed
Medications (e.g., analgesic, antibiotic) and fluids (e.g., blood) are provided as needed
Dressings are maintained
Emotional support provided, as needed

141. Adjunctive Anesthesia Treatments
Induced Hypothermia
Induced Hypotension
Neuroleptanalgesia
Neuroleptanesthesia

142. Alternative (Nontraditional) Anesthesia Treatments
Hypnoanesthesia
Acupuncture