Shalya tantra -- Anaesthesia

Anaesthesia

• Presented By – • Prof.Dr.R.R.Deshpande (M.D

in Ayurvdic Medicine & M.D. in Ayurvedic Physiology)

• www.ayurvedicfriend.com• Mobile – 922 68 10 630• professordeshpande@gmail.

com

9/10/2016 Prof.Dr.R.R.Deshpande 1

http://www.ayurvedicfriend.com/

mailto:[email protected]

mailto:[email protected]

Purpose of this PPT

• This PPT is based on Shalya Tantra Syllabus of CCIM -2012

• Points covered are

• Paper 1 Part A Point 4 --- Local anaesthesia• Paper 1 Part A Point 4 --- Regional and

General anaesthesia-

9/10/2016 2Prof.Dr.R.R.Deshpande

Topics covered in this PPT

• Types of Local Anesthesia• Drugs used in Local Anaesthesia• General Anesthesia & drugs for GA• Muscle Relaxants• Stages of GA• Spinal Anesthesia• Comparision of LA & GA


Paper 1 Part A Point 4

• Local Anesthesia –

• Reversible depression of nerve impulse conduction

• So temporary loss of sensation & relief of pain


Equipments for Anesthesia

• 1) Laryngoscope 2) Endo Tracheal Tube (ETT)• 3) Ambubag 4) Boyle’s apparatus• 5) Pulse oximeter 6) Cardiac monitor• 7) B. P. Instrument 8) Stethoscope• 9) Spinal Needle 10) Tray of Emergency drug • 11) Suction catheter 12) O2 cylinder


Anaesthetic machine


Pre Anesthesia

• Physical fitness must • Control of DM & BP• Oral hygiene ( there should not be Pyorrhoea

like septic focus , loose or artificial denture ) • Nutritional & hydration should be normal • Base line Lab reports should be normal like Hb,

Bl sugar ,KFT,LFT, & ECG• Systemic Examination findings – Normal


Grades of Patient by ASA

• ASA = Americal Society of Anesthesiologist• Grade 1=No abnormality• Grade 2= Mild systemic disorders• Grade 3 = Severe systemic disease• Grade 4 = Life threatening severe systemic

disease• Grade 5 = Highest risk • Grade 6 = Dead 9/10/2016 8Prof.Dr.R.R.Deshpande

Anesthesia - Premedication

• Tab Calmpose – 1 hs ,previous night of operation ( As a Tranquiliser)

• Inj Calmpose – at the time of surgery

• Inj Atropine – 0.6 mg IM ( reduces secretions)


Types Local Anesthesia

• 1) Infiltration Anesthesia

• 2) Field Block

• 3) Nerve Block

• 4) Surface Anesthesia


1) Infiltration Anaesthesia

• Local anesthetic drug is injected into the area which is to be incised in a circular manner

• Used in - Excision of lipoma, polyp, dermal cyst, etc.



• Anesthetic is infiltrated into the tissues to be operated upon

• • Suitable for small skin lesions ,for suturing

small lacerations • Xylocaine with adrenaline is used .But if

longer duration of action is required Bupivacaine is used



• In case of lacerated wound ,the injection may be given from inside the margin of wound

• In palms ,soles ,nose ,infiltration is difficult ( because skin is tightly bound down)

• For infiltrating dome of an abscess ,a small quantity is given by insulin syringe ,very superficially


2) Field Block

• Zone of analgesia is created around the operative field by injecting local Anesthetic

• Used in Minor surgery ( when unconsciousness with GA can be fatal )


3)Nerve Block

• Local anesthetic drug is injected near the nerve ,which is supplying operated area

• Used as Brachial block, Finger (ring) block, Intercostal nerve block etc.


Regional Anesthesia

• Particular area is anesthetized by a field or nerve block

• For removal of a sebaceous cyst on the back ,field block can be used ( Local aneasthetic is infiltrated on the skin of back in the area ,encircling the cyst )


Regional Anesthesia

• In Nerve block ,the anaestheic drug is deposited near the nerve

• Flooding technique – As there are anatomical variations in localization of nerves ,large volume of Anaesthetic drug is given in wider area

• Injection should never be given in nerves ( recognized by the occurance of paraesthesia during infiltration )


Examples of Nerve blocks

• 1) Supraorbital Nerve block – To anesthetize skin of forehead

• 2) Digital Nerve block – without adrenaline.By blocking dorsal digital nerve ,whole finger can be anaesthetized

• 3) Median Nerve block – This nerve lies behind palmaris longus tendon at the wrist .This will anaesthetize thumb,index,middle & half of ring finger & corresponding of area of palm –dorsal & palmer aspect


Local Anesthesia



• 4) Ulnar nerve block -- This will block little finger & medial half of ring finger .A combined median & ulnar block will anaesthetise the whole hand

• 5) Posterior Tibial nerve block – Xylocaine is injected ,just anterior to Achilles tendon at the level of medial malleolus .Used in cases of injuries on plantar aspect of foot



• 6) Calcaneal Nerve block – 5 ml Xylocaine is injected as a band into the skin below the level of medial malleolus .Skin of heel is anaesthetized .

• Useful for removal of corn ,For suturing laceration in Plantar skin .Useful for giving steroid injection to a patient of Plantar fasciitis



• 7) Ankle block – This will anesthetize whole foot .Rarely used

• 8) Penile block – Never use Xylocaine with adrenaline .Use plain Xylocaine .Complete ring block is not required ,because nerve enters only along dorsal aspect .Useful for circumcision & for correcting paraphimosis


4) Surface Anaesthesia

• Local anesthetic agents is used in the form of spray, ointment, cream & jelly, lotion to anesthetized surface skin

• Used in Catheterization, Cystoscopy, Insertion of Ryle’s tube, etc.


4) Surface Anaesthesia

• Anesthesia is obtained by application of local anaestheic drug to the surface of skin or mucous membrane

• EMLA skin cream ( Lignocaine + prilocaine) • With this cream anaethesia is produced after 1

hour ,after thick application• Mucous membrane can easily anaesthetised

by eye or ear drops ,throat lozenges,rectal jelly


5) Spinal & Epidural Anesthesia

• Both are Types of Local Anesthesia


Advantages of LA

• 1) Simple & easy to administer• 2) Body metabolism is not disturbed .So

special attention is not required • 3) Less bleeding• 4) Cheap • Note – In spite of these advantages some

patients prefer GA ,due to fear of remain conscious during operation


Examples of Medicines for LA

Sr.No Specialty of Drug Drug

1 Low potency + short acting Procaine

2 Moderate Potency + moderate duration

Lignocaine ( Xylocaine)

3 High Potency + Long duration

Bupivacaine,Marcaine


Local Anesthetic drugs

• Commonly used drugs – Lignocaine –either plain or with adrenaline ,Bupivaine , Procaine, Amethocaine

• Procaine ( Novocaine ) & Amethocaine ( Tetracaine) – Less potent & give frequently Hypersensitive reactions


Lignocaine ( Xylocaine)

• Most commonly used• Stable & can be stored at room temperature• Onset of action is rapid & duration of action ranges

from 30 to 60 min ( depending on local vascularity & site)

• Addition of Adrenaline ( 1 in 2 Lakhs) – prolongs action up to 2 hours

• Available as 2 % solution with or with out adrenaline


Adrenaline

• Usually combined with Lignocaine .Adavantages are –

• Adrenaline is local vasoconstrictor .So less amount of Lignocaine is absorbed by which it remains in tissue longer & we get prolonged local anaesthetic effect

• Combination is useful in highly vascular areas like face & scalp .It gives dry operative field within 10 min


Adrenaline

• Although there are advantages ,there is risk as well – • Due to effect of local vaso constriction ,if it is used

around end arteries ( around digit or penis) ,it will cause gangrene

• So Lignocaine with adrenaline should be avoided at digits,tip of nose,pinna of ear,shaft of penis

• Plain & lignocaine with adrenaline are available in different colour bottles


Reaction to Lignocaine

• Anaphylactic is possible but rare• Reactions occur due to use of large doses or large

amount enters into systemic circulation • Aspirate ,before injecting locally .Needle should be

kept constantly moving forward & backward ( so even if needle enters into blood vessel ,small amount enters in circulation)

• Lignocaine poisoning – Hypotension, Bradycardia, Heart block


Bupivacaine ( Marcaine)

• More prolonged action

• 4 times more potent than Xylocaine

• So popular for spinal anaesthesia & painless labour

• No benefit in minor surgeries of GP level


For LA

• Enquire about history of allergy to anaesthetic drug

• Do not exceed Toxic dose• Be carful in patients with heart & liver disease• Select proper site for nerve block• Avoid accidental IV injection• Keep watch on bradycardia & twitching on

face ( These are early signs of Toxicity)


Lignocaine

• Used for –• Nerve block & Infiltration 0.5 to 2 % • Ointment 2 % • Eye drops 4%• Spinal Anesthesia 5%

• Dose – 5 mg / kg


Lignocaine – Caution

• Lignocaine with adrenaline should never used ,where end arteries are present

• Tip of fingers • Lips & Ear• Penis• Otherwise – Vasoconstriction effect – Necrosis• Lignocaine with adrenaline is contraindicated in

MI & HT• Dose of Lignocaine with adrenaline – • 5 to 7 mg /kg --- Max 300 mg


Bupivacaine

• Basically this is long acting Anesthesia ,but can be used for LA

• Max dose = 150 mg

• Duration = 4 to 6 hours


LA – Disadvantages

• Allergic reaction – From minor to serious like Anaphylactic shock

• Nerve or vessel injury

• Lignocaine can not act in the acidic condition of pus


GA

• Reversible loss of sensations & consciousness

• Clinical features – Loss of sensations ,muscle relaxation, diminished reflexes, unconsciousness

• Types – 1) Inhalation of Nitrous oxide ,Ether 2) Intravenous – Thiopentone sodium ,ketamine


GA

• Techniques – Open drop method or Nitrous oxide through Boyle’s apparatus

• Complications – Hypotension, Respiratory depression, Nausea & vomiting, Hepato or renal Toxicity


Drugs for GA – Nitrous oxide

• Laughing gas ,Non irritating ,better smelling ,safest, administered with oxygen ,Post OP complications less

• Disadvantages are BP may increase , Teratogenic effect


Drugs for GA – Ether

• Colourless volatile liquid

• Muscle relaxation is good so used in all abdominal surgeries ,safe

• Disadvantages are as vapours are highly irritative to URT,causes Nausea & vomiting ,increases secretions of all glands


Drugs for GA – Thiopentone sodium

• Ultra short acting for minor surgeries • Non irritant to lungs .Less nausea & vomiting

,Muscle relaxation is rapid • Disadvantages are shock may occur due to fall

in BP ,respiratory depression,recovery period is long

• Dose – 5mg/kg ,IV


Drugs for GA – Ketamine

• Called as ‘Dissociative Anesthesia’• Good for repeated use• Respiration not depressed• Used while dressings of burn ,Incision &

Drainage• Contraindicated in IHD (HR,BP –Elevated)• 2mg/kg IV & 10mg/kg IM


Muscle relaxants

• During abdominal surgeries or in fracture reduction process ,in addition to Anesthetic drugs muscle relaxants are also used

• Scoline – 50 to 70 mg –action for 5 min • Flaxedil – 80 to 120 mg – action for 30 min• Curare – 15 to 18 mg IV –action for 45 min• Pavulon – 6 mg – action for 60 min • Neostigmine – Antidote for Curare


Stages of Anesthesia

• 1) Stage of Analgesia

• 2) Stage of Excitement

• 3) Stage of surgical Anesthesia

• 4) Stage of respiratory paralysis



• I) Stage of Analgesia ---• Stage is from giving of Anesthetic drugs up to

loss of consciousness• In this stage pain is diminished • Respiration & reflexes are normal • Used for minor operations like labour & for

Incision & Drainage



• II) Stage of Excitement

• This stage is from loss of consciousness to regular respiration

• Patient gets excited , involuntary movements occur , pupils are dilated, blood pressure and heart rate increases



• III) Stage Of Surgical Anesthesia

• In this stage there will be shift of respiration from regular to irregular

• BP goes down ,Muscle tone decreases


3 – Stage of Surgical Anesthesia

• This stage is divided into 4 planes

• 1) Roving eye balls • 2) Loss of Corneal & laryngeal reflexes• 3) Pupils starts dilating & light reflex loss• 4) Intercostal paralysis, shallow abdominal

respiration



• IV) Stage Of Respiratory Paralysis

• Irregular respiration• BP drops down • Pupils fully dilate • Finally patient may die if situation is not

treated properly


Complications of Anesthesia

• Airway obstruction, Bronchospasm, Respiratory failure

• Hypertension or hypotension, Arrhythmias, Cardiac arrest

• Drowsiness, Nausea & vomiting, Renal failure, Hepatic failure


Epidural Anesthesia

• Type of local anesthesia • Direct block of spinal nerve roots in epidural

space leading to centrifugal spread ,which affects the nerve in block

• It can be done with the patient in the lateral decubitus position.


Epidural Anesthesia

• Epidural needle does not have sharp tip, so chance of puncture in dura matter is very rare.

• In epidural anesthesia 16 to 18 number touhy needle is used

• Needle is passed through the midline or para median• Needle passes structure as similar to spinal

anesthesia except penetration into sub-arachnoid space


Spinal Anesthesia

• Also called as saddle block or saddle anesthesia

• Local anesthetic drugs is injected around spinal cord to block transmission of neural impulses

• When drugs are injected in sub arachnoid space it is called as Spinal Anesthesia.


Spinal Anesthesia

• After injecting anesthetic drug in subarachnoid space patient is given sitting position on table for 10 min. Then it is known as Saddle Block or Saddle Anesthesia.

• In sitting position CSF has more than 375 mm of Hg pressure & in supine position CSF has 180 mm of Hg pressure.

• So that drug does not go upward but spreads mostly in lower limb .Hence more effect of drug can be seen in lower abdomen


Spinal Anesthesia

• Types – • 1) Low spinal Anesthesia• 2) Mid spinal Anesthesia • 3) High Spinal Anesthesia• Advantages• Adequate relaxation with retention of

consciousness + No irritation of lungs• Operative haemorrhage is less due to fall of Blood

pressure


Spinal Anesthesia


Spinal Anesthesia – Used in --

• Prostectomy, LSCS, Hysterectomy• Hemorrhoidectomy & Fistulectomy• Lower limb fractures• Urological, gynaecological, lower limb, &

below umbilical operations• If patient is unfit for GA due to respiratory

diseases ,liver & kidney diseases , diabetes


Spinal Anesthesia can not be used

• Severe Anaemia• Shock

• Hypoxia

• Nerological diseases • Patient of migraine or chronic headache


Drugs for Spinal Anesthesia

• 1) Lignocaine• Dose - 15 to 100 mg Duration – 1 to one &

half hour

• 2) Bupivacaine• Dose - 25 to 50 mg Duration – up to 3 hours


Drugs for Spinal Anesthesia

• 3) Tetracaine• Dose - 5 to 25 mg , Duration – up to 2 & half

hour

• 4) Cinchocaine (Nupercaine) / Dibucaine• Dose - 2.5 to 10 mg , Duration – Up to 3 hours


Spinal Anesthesia Procedure

• In sitting position or in left lateral position.• In lying position ,back is kept parallel to edge

of table.• In sitting position Leg should be flexed with

back bent forward & advised to rest his arm on his shoulder.

• The back is cleaned with savlon, iodine & spirit, under strict aseptic precautions.



• L3, L4 intervertebral space or L4 & L5 space is commonly used.

• Lumbar puncture needle 25 to 27 G is inserted in midline between intervertebral space perpendicular to skin.



Sitting position Lying down position


Spinal needle passes through

• 1) Skin • 2) Subcutaneous tissue• 3) Supra spinal ligament • 4) Inter spinal ligament• 5) Ligamentum Flaveum • 6) Epidural space• 7) Dura matter • 8) Sub arachnoid space


Spinal needle

• How to confirm of correct insertion of spinal needle in subarachnoid space ?

• Free resistant to hand & continuous CSF free flow


Complications of Spinal Anesthesia

• 1) Hypotension due to vasodilation • 2) Septic meningitis

• 3) Backache

• 4) Retention of urine • 5) Headache


Difference in LA & GA

• 1) Site of action in LA is peripheral nerve but in in GA it is CNS

• 2)LA gives anesthesia to restricted area & GA gives to whole body

• 3) Patient remains conscious in LA but not in GA

• 4) LA is for minor procedures but GA is for major operations


Prof.Dr.R.R.Deshpande

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Shalya tantra -- Anaesthesia