INTRODUCTION TO ANESTHESIA -PART 1 SURGERY

JOSELITO T. MORETE, MD, MHA, DPBA, FPSA

December 2 2020 5.1A
Outline B. COMPONENTS – PREOPERATIVE EVALUATION
I. Definition of Anesthesia  Anesthesia History – most important part of pre-op
II. Basics of Anesthesia assessment
A. Goals- Preanesthetic Assessment o Past and current medical history
B. Components- Preoperative Evaluation
o Surgical history
C. Objectives-Preoperative Medication
D. Four (4) Practical Skills
o Family history
E. Perioperative Skills o Social history
III. Types of Anesthesia ▪ Use of tobacco
A. Local Anesthesia ▪ Use of alcohol and illegal drugs.
B. Regional Anesthesia o History of drug allergies
C. IV/Monitored Sedation (MAC) o Current and recent drug therapy
D. General Anesthesia o Unusual reactions and problems to drugs
IV. Infiltration Anesthesia
o Problems and complications of previous anesthetics
V. Nerve Field Block
VI. Peripheral Nerve Block • Focused Physical Examination
VII. Nerve Blocks of Trunk and Cutaneous • Laboratory work up
VIII. Intravenous Regional Anesthesia (IVRA) • Drug history
IX. Regional Anesthesia/ Neuraxial Block  Must be obtained in ALL patients especially the geriatric
A. Advantages of Regional Anesthesia (RA) vs General group since they consume more systemic medication than any
Anesthesia (GA)
other group. Numerous drug interactions and complications
X. Spinal/Subarachnoid Block
arise in this population and special attention should be given to
XI. Epidural Block
XII. Caudal Block them.
XIII. Appendix • Perioperative risk assessment
PERIOPERATIVE RISK ASSESSMENT
LEGEND • Association of Society of Anesthesiologists Physical Status
 Book  Recording  Previous Trans Must know (ASA PS) Classification and Classified System [See Table 1
WE APOLOGIZE, THIS TRANS IS MAHABA, IT HAS 2 PARTS
and 2]
TRANS 5.1A and 5.1B AND IT IS HEAVILY AUDIO BASED.
 The ability to predict the postoperative complications is
PLEASE READ THE AUDIO, DOC ADDED A LOT OF
INFORMATION SA AUDIO FOR US TO UNDERSTAND THE valuable to the decision making of surgeons, anesthesiologists,
TOPIC. and patients. Perioperative risk is a function of the preoperative
TIP: STUDY THE TABLES AND THE IMAGES WELL medical condition of the patient, the invasiveness of the surgical
procedure and the type of anesthetic administered. The ASA
References: (Association of Society of Anesthesiologists Physical
1. PowerPoint Lecture Status) is the most common classification, this is a simple
description of the physical state of the patient, so It is extremely
I. DEFINITION OF ANESTHESIA useful and should be applied to all patients who present for
• An altered physiological state characterized by a reversible surgery. An increase in the physical status is associated with an
state of consciousness produced by anesthetic agents, with increase in mortality. So emergency surgery increases the risk
loss of sensation of pain over the whole body or in part of it, dramatically especially in patients Class ASA 4 and 5.
with amnesia and some degree of muscle relaxation. Table 1. ASA Physical Status (PS) Classification
II. BASICS OF ANESTHESIA I A normal healthy patient
A. GOALS - PREANESTHETIC ASSESSMENT  In Class 1, patient is fit and healthy usually non-smoking
 Before we perform the surgery and anesthesia, we perform with no or minimal alcohol use. For example, fit, non-obese
the preanesthetic assessment to ensure that the patient is as fit patients and nonsmoking patients with good exercise
as possible for surgery or anesthesia. tolerance. The absolute mortality rate is about 0 to 0.3% and a
• Documentation of condition 30-day death probability is less than 2%.
• Patient’s overall health status II A patient with mild systemic disease
• Hidden conditions  In Class 2, these are patients with mild systemic disease
• Risk assessment such as hypertension, current smoker, social alcohol drinker,
• Optimization of medical condition pregnancy, obesity, well-controlled diabetes, and those with
• Perioperative care plan mild lung disease. The absolute mortality rate is about 0.3 to
• Patient education 1.4%.and a 30-day death probability is around 2 to 2.5%.
• Prevent adverse events. III A patient with severe systemic disease
• Reduce cancellation and delays.  In Class 3, these are patients with severe systemic disease
which is not incapacitating or not life threatening. For
• Increase patient satisfaction.
example, poorly controlled diabetes or hypertension, COPD

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 SURGERY INTRODUCTION TO ANESTHESIA LECTURE 5.1A

those with morbid obesity with a BMI of more than 40, active without COPD, mild obesity, and
hepatitis, alcohol dependence or abuse, those with implanted pregnancy.
pacemaker and moderate reduction of ejection fraction, those • Some functional limitations
with end stage renal disease undergoing regularly scheduled • Has a controlled disease of
dialysis, premature infant, bronchospastic lung disease with more than one body system or
intermittent exacerbation and stable angina. The absolute one major system.
mortality rate for this group is about 1.8 to 4.5% and the 30-day • NO immediate danger of death
death probability is about 5-10 %. • Controlled CHF, stable angina,
IV A patient with severe systemic disease that is a old heart attack, poorly
constant threat to life. controlled HTN, morbid obesity
 In Class 4, are those with incapacitating illness that is a ASA PS A patient with
BMI of at least 40, end-stage
constant threat to life so under these we have patients with 3 severe disease
renal disease with regularly
functional limitation, such as unstable angina, poorly controlled schedule dialysis,
COPD, symptomatic congestive heart failure, recent bronchospastic disease with
myocardial infarction, or stroke, also those with dyspnea and intermittent exacerbation, active
patients with end stage renal disease not undergoing regularly alcohol dependence or abuse,
scheduled dialysis. The absolute mortality rate is 7.8 to 25.9% implanted pacemakers,
and the 30-day death probability is more than 10%. moderate reduction of ejection
V A moribund patient who is not expected to survive fraction, premature infant
without the operation • Has at least one severe
 In Class 5, patients are not expected to live for more than disease that is poorly controlled
24 hours, such as those with ruptured thoracic aneurysm, or at end stage.
massive trauma, intracranial bleed with mass effect, ischemic A patient with
• Possible risk of death
bowel, significant cardiac pathology, multiple organ system severe systemic
ASA PS • Unstable angina, symptomatic
dysfunction and hypovolemic patients. The absolute mortality disease that is a
4 poorly controlled COPD,
rate is 9.4 to 57.8%. constant threat
symptomatic CHF, hepatorenal
VI A declared brain dead patient whose organs are being to life
failure without regular dialysis,
removed for donor purposes.
recent myocardial infarction or
 In Class 5, are those with declared brain-dead patients for
stroke, dyspnea
organ donor. So, a brain-dead patient whose organs are being
• Not expected to survive
removed with the intention of transplanting them into another
>24hours without surgery.
patient.
• Imminent risk of death
We append an “E” if the patient comes in as an emergency.
• Multi-organ failure, sepsis
 Capital Letter E denotes an Emergency Surgical Procedure.
A moribund syndrome with hemodynamic
An emergency is defined as existing when delay in treatment
patient who is instability, hypothermia, poorly
of the patient would lead to a significant increase in threat to ASA PS
not expected to controlled coagulopathy,
life. 5
survive without ruptured thoracic or abdominal
PLEASE STUDY THIS TABLE. 😊
the operation aneurysm, massive trauma,
DOC SAID “THIS IS ANOTHER TABLE SHOWING THE ASA intracranial bleed with mass
PHYSICAL STATUS CLASSIFICATION. I WANT YOU TO effect, ischemic bowel with
FOCUS ON THE COMMENTS AND EXAMPLES” PLEASE insignificant cardiac pathology,
STUDY THIS TABLE!! hypovolemic patient.
Table 2. ASA Physical Status (PS) Classified System A declared
brain-dead —
Perioperative Comments, Examples
Category ASA PS patient whose
Health Status
6 organs are being
• NO organic, physiologic, or
removed for
psychiatric disturbance
donor purposes
ASA PS Normal healthy • Excludes the very young and
C. OBJECTIVES – PREOPERATIVE MEDICATION
1 patient very old.
• Reduce anxiety and fear.
• Healthy with good exercise
• Promote relaxation.
tolerance
• Reduce pharyngeal secretions.
• No functional limitations
o Especially for smoker patients
• Has a well-controlled disease
A patient with • Prevent laryngospasm.
ASA PS of one body system.
mild systemic o Pediatric patients because they are prone to this.
2 • Controlled hypertension or
disease • Reduce the volume and increase the pH of gastric secretions.
diabetes without systemic
o Reason why patients scheduled for elective surgery are
effects, cigarette smoking
advised to do fasting.
• Decrease the amount of anesthetic needed.

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 SURGERY INTRODUCTION TO ANESTHESIA LECTURE 5.1A

• Produce anterograde amnesia. III. TYPES OF ANESTHESIA

• Reduce PONV (Post-operative Nausea and Vomiting)  There are 4 types of Anesthesia.
• Reduce vagal reflexes. A) Local Anesthesia (LA)
Especially in pediatric patients because their o Topical, Infiltration, Nerve block, Bier block
parasympathetic reflexes are more dominant than their  Wherein a Local Anesthetic drug is injected at the site of
sympathetic reflexes. Hence, introduction of any noxious the surgery to cause numbness so you will be awake but
stimulant can easily produce bradycardia, which can lead to feel no pain. For example, is the numbing an area of skin
cardiac arrest. before having a cut stitch.
• Limit sympathoadrenal response B) Regional Anesthesia (RA)
 Especially during tracheal intubation and during surgery o Spinal blocks, Epidurals
 Inner Block numbs the part of the body where the
D. FOUR (4) PRACTICAL SKILLS surgeons operate, and this avoids the need for general
Anesthesia training in hospital is evidence based and anesthesia. So, you may be awake or sedated. For
includes theoretical knowledge, clinical and practical example, the use of epidural anesthesia in labor pains,
experience. At its most basic level 4 practical skills are spinal anesthesia for caesarian section and eye blocks for
required for anesthesia providers which includes. cataracts.
• Intravenous cannulation C) IV/ Monitored Sedation (MAC)
• Bag-mask ventilation o Minimal, Moderate, Deep
• Tracheal intubation  Sedation wherein the anesthesiologist administers drug
• Initiation of Neuraxial/Peripheral nerve block anesthesia to make you relax and drowsy. This is sometimes called
twilight sleep or intravenous sedation and may be used for
E. PERIOPERATIVE CARE some eye surgery, some plastic surgery, and
PREOPERATIVE PHASE gastroenterological procedures. Recall of events is possible
 These are the things that anesthesiologist do with sedation. Most patients prefer to have little or no recall
of the event. There are three main levels of sedation.
• Preoperative Evaluation
o History, Physical Examination, and Airway exam • Minimal- It helps you to relax, but you will likely be
awake, you will understand questions, your doctor is
• Vascular Access
asking and be able to answer as well as follow
o Peripheral line, Central line, and Arterial line
directions. So, this is needed when your doctor needs
• Risk stratification and mitigation
you to be involved in the procedure.
• Formulate anesthetic plan.
• Moderate- You will feel drowsy and maybe even fall
INTRAOPERATIVE RISK ASSESSMENT
asleep during the procedure. So, you may or may not
• Anesthetic Monitors and Equipment remember some of the procedure.
• Anesthesia Induction and Intubation • Deep- In deep sedation you will not actually be
 Induction is the start of your Anesthesia. unconscious, but you will sleep through the procedure
• Airway Management and Ventilation and probably will have little or no memory of it.
 Especially if the patient is prone to Obstructive Sleep D) General Anesthesia
Apnea o Intravenous
• Positioning ▪ TIVA / Monitored Sedation (MAC)
o Based on the type of surgery o Inhalational
• Anesthetic Technique In general anesthesia, you are put into a state of
• Fluid Management unconsciousness for the duration of the operation. This is
• Thermoregulation usually done by injecting drugs through a cannula placed in
o If a patient is under general anesthesia, his temperature the vein and maintain with intravenous drugs or a mixture
decreases by 1OC after one hour. of gases which you will breathe while you remain unaware
o Temperature shall be maintained above 35 OC of what is happening around you the anesthesiologist
intraoperatively. monitors your condition and constantly adjust the level of
POSTOPERATIVE RISK ASSESSMENT anesthesia. You will often be asked to breathe oxygen
• Recovery through a mask just before your anesthesia starts.
o Before operation, check first if there are any neurological “Are you an inhaler because you took my breathe away 😊”
deficit especially if it is a spinal surgery because the A. LOCAL ANESTHESIA
physician shall be accountable for any negligence. IDEAS PROPERTIES OF LA
o A physician could pay 7-8million pesos if proven that there  Local Anesthetics are drugs that block the conduction of
is indeed a negligence. electrical impulses in excitable tissues. This tissues includes the
• Postop visit nerve cells and myocytes in both cardiac and skeletal muscles.
 Anesthesiologist do Post OP visit until the 48 hours of Anesthesia and analgesia occur as a result of the blockage of
operation. We check if there are any neurological sequala electrical impulses. This is achieved by reversibly binding to and
especially in regional anesthesia. inactivating the sodium channels. Sodium influx through this
• Pain management channel is necessary for the depolarization of nerve cell

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 SURGERY INTRODUCTION TO ANESTHESIA LECTURE 5.1A

membranes and subsequent propagation of impulses along the o K+ channels

course of the nerve. So, when a nerve loses depolarization and
capacity to propagate an impulse. The individual loses sensation
in the area supplied by the nerve.
 These are the Ideal Properties of Local Anesthetics
• Non-irritating to the tissues
• Produce REVERSIBLE blockade
o After operation, the patient must be able to move again.
• Highly selective for sensory neuron (nerve membranes)
• Rapid onset ► Local anesthetics block the sensory transmission from
the limited area of the body to the CNS.
• Sufficient duration of action
► Thus, it prevents depolarization by reversibly blocking
• Chemically stable
the fast voltage gated sodium channels of the excitable
• No systemic toxicity
membrane.
• Wide margin of safety
► Results to inhibition of the sodium influx and
• Compatible with co-administered drugs
preventing depolarization threshold from being
• Absence of adverse effects reached.
• Inexpensive ► Local anesthetics has no effects on resting or threshold
STRUCTURE-ACTIVITY RELATIONSHIP OF LA potential, although the refractory period and repolarization
• Weak bases (because of the amino group) may be prolonged.
► Local Anesthetics are weak bases that are formulated in
an acidic milieu. Hence, containing a large proportion of
the drug in the ionized state.
► However, it is the unionized fraction that can cross the lipid
bilayer neuronal membrane and block the voltage gated
sodium channel from the inside of the axoplasm.
► So, this blockade renders the sodium channel inactive and
hence no generation of action potential is prevented so the
effect is terminated by absorption through the systemic
circulation.

SEQUENCE OF LA
Figure 1: Components of LA
 The sequence of Anesthesia relates to the nerve fiber
 Local Anesthetics Molecules consists of 3 three components, biology.
each of which contribute distinct properties of the molecule. • SMALL DIAMETER FIBERS ARE MORE SENSITIVE to LAs
I. Aromatic ring than larger diameter fibers.
► Determines the lipid solubility, hence, the POTENCY  The distance of impulse propagation in small fibers is
II. Intermediate chain shorter.
► Either an ester or amides linkage • MYELINATED FIBERS ARE MORE SENSITIVE than
► Determines the pattern of biotransformation or their unmyelinated fibers.
potential stability in the solution Since myelinated nerves need only to be block at several
III. Amine group nodes of Ranvier to inhibit the impulse propagation thus
► Either in tertiary form/insoluble form OR requiring smaller concentration of anesthetics.
quaternary/water soluble form • Nerves with HIGHER FIRING FREQUENCY ARE MORE
► Dependent on the pH SENSITIVE
► Determines the time of onset • The affinity of LAs for Na+ channels DEPENDS ON THE
• Amphiphilic (Water-loving and fat-loving) property STATE OF CHANNEL
MECHANISM OF ACTION OF LA o Open state → Inactivated state → Resting state.
• Reduce the entry of Na+ (Fast voltage gated channels)  Meaning the Open State has a greater affinity, followed by
• Initiation and propagation of nerve impulse the inactivated state then the resting state
• At higher doses, it also blocks: • PAIN FIBERS HAVE HIGHER FIRING RATE and relatively
o Voltage-gated Ca++ channels LONGER ACTION POTENTIAL than motor fibers and thus
are MORE SENSITIVE
Table 3. Sequence of LA Block
Diffusion of base through nerve sheath
↓
Binding of cationic form to membrane receptor site
↓
Blockade to sodium channel

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 SURGERY INTRODUCTION TO ANESTHESIA LECTURE 5.1A

↓ • Metabolized in PLASMA by Pseudocholinesterase’s

Decrease in sodium conductance. o Except for Cocaine that is metabolized by the liver
↓ o Sensitization and cross reactivity occur resulting in
Depression of rate of electrical depolarization Delayed type 4 reactions between the esters.
↓ • Unstable solutions
Failure to achieve threshold potential level. • Allergic reaction: due to PABA metabolite
↓  PABA may cause allergic reactions that ranges from
Lack of development of propagated action potential urticaria and anaphylaxis.
↓ • Used ONLY in patients with cirrhosis.
Conduction blockade Toxicity occurs in patients with plasma
pseudocholinesterase enzyme deficiency.
DETERMINANTS- PHYSIOLOGIC ACTIVITIES ESTERS HAVE ONLY ONE “i”
Table 4. Determinants of Physiologic Abilities of LA Cocaine Tetracaine
Lower pKa = More unionized fraction present 2-Chloroprocaine Benzocaine
pKa* for any given pH = FASTER ONSET OF Procaine Proparacaine
ACTION  Cocaine- potent vasoconstrictor, it is used topically,
Lower the pH = More acidic = LESS POTENT intranasally for concurrent anesthesia and hemostasis.
In acidic conditions, the ionized fraction • Chloroprocaine- rapidly metabolized and favored by
predominates, so there is less of the obstetricians due to low fetal exposure.
unionized fractions and there is less of the
• Procaine with a tradename of Novocane has a rapid
Local Anesthetics available to cross the lipid
onset and short duration, it is not effective topically.
bilayer and block the voltage gated sodium
pH • Tetracaine under a tradename of Pontocaine is
channel. So, this explains why local
effective topically as well as for spinal anesthesia.
anesthetics does not have much efficacy in
AMINOAMIDES/AMIDES COMPOUNDS
reducing pain in infected tissues.
 They have an amide link between the intermediate chain and
For example, Abscesses are acidic. Thus, in
the aromatic end. Widely distributed by the circulation.
infected tissues with abscess, anesthetic
agents are less effective. • Hydrolyzed in LIVER by Cytochrome P450
More lipid soluble the agent = MORE • Patients with hepatic impairment have the increase risk for
Lipid solubility POTENT, FASTER ACTION, and LONGER overdosage and reactions.
DURATION OF ACTION • NO cross reactivity
Intermediate • Very STABLE in solution
Longer chain = MORE POTENT • Allergic reaction(rare): due to Methylparaben
chain
Protein Higher the protein binding= LONGER  Patient allergic to epinephrine containing amides can be
binding DURATION OF ACTION given Mepivacaine without epinephrine.
 *pKa = pH on which the number of ionized and unionized AMINES HAVE “i" BEFORE “aine”
fraction of the drug is in equilibrium Lidocaine Bupivacaine Prilocaine
Mepivacaine Ropivacaine Levobupivacaine
Etidocaine
CLASSIFICATION OF LOCAL ANESTHETICS
Topical or Surface Anesthetics are classified into two groups
 Lidocaine- rapid onset, moderate duration, highly
Soluble and Insoluble.
stable and non-irritating.
SURFACE ANESTHETICS
 Mepivacaine- longer duration and more rapid onset
• SOLUBLE than lidocaine.
o Cocaine, Lidocaine, Tetracaine, Benoxinate  Bupivacaine with a tradename of Mercaine has a slow
• INSOLUBLE onset, long duration, high potency, and toxicity. It is
o Benzocaine, Butylaminobenzoate, Oxethazaine usually mix with Lidocaine for rapid onset and long
INJECTABLE ANESTHETICS duration block. It preferentially blocks the sensory
• LOW POTENCY, SHORT DURATION versus the motor fibers.
o Procaine, Chloroprocaine  Ropivacaine is similar to Bupivacaine but less potent
• INTERMEDIATE POTENCY AND DURATION and less cardiotoxic.
o Lidocaine, Prilocaine  Etidocaine is used for regional blocks it has a
• HIGH POTENCY, LONG DURATION preference for motor over sensory fibers.
o Tetracaine, Bupivacaine, Ropivacaine, Dibucaine  Prilocaine is 40% less toxic acutely, but its metabolite,
CHEMISTRY OF LAs otoluidine can cause methemoglobinemia.
AMINOESTERS/ESTER COMPOUNDS
 Aminoesters have an ester link between the intermediate DOC SAID” STUDY THIS TWO TABLE (TABLE 5 AND 6 ) THE
chain and the aromatic end. SEQUENCE OF ANESTHESIA AND NERVE FIBER
CHARACTERISTIC FOR YOUR LONG EXAM”

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 SURGERY INTRODUCTION TO ANESTHESIA LECTURE 5.1A

Table 5. Sequence of Anesthesia Based on Nerve Fiber Lidocaine 1–5% 7.9 R 2 4 5 7

Physiology Etidocaine 0.5–1.5% 7.7 R 4 8 2.5 4
1st Vasodilation (B fibers) Mepivacaine 1.5% 7.6 M 3 6 5 7
2nd Pain and temperature sensation (C and A fibers) Ropivacaine 0.5% 8.1 M 3 6 2 3
3rd Light touch and pressure sensation (A fibers) Prilocaine 4% 7.9 M 1.5 6 5 7.5
4th Motor (A) and proprioception (A fibers) Bupivacaine .25-.75% 8.1 S 4 8 2.5 3
Ester
Table 6. Nerve Fiber Classification and Characteristics Procaine 0.5–1% 8.9 R 0.75 1.5 8 10
Conduction Chloroprocaine 2–3% 8.7 R 0.5 1.5 10 15
Fiber Diameter
velocity Myelin Function Tetracaine 0.1–0.5% 8.5 S 3 10 1.5 2.5
type (m)
(m/s) R=Rapid; M=Medium; S=Slow
A 13 – 20 80 – 120 Heavy Somatic motor
A Heavy Light touch, COMMONLY USED LOCAL ANESTHETICS
6 – 12 33 – 75
pressure Table 9. Commonly Used LAs
A Moderate Proprioception, • Fast onset and longer duration
5–8 4 – 24
muscle tone
• Dense motor block and low
A Moderate Pain (fast
toxicity
1–5 3 – 30 localizing), Mepivacaine
• For shoulders surgery
temperature (Carbocain)
• Used for infiltration anesthesia,
B Light Preganglionic
1–3 3 – 15 IV anesthesia, and peripheral
autonomic
and regional block
C None Pain (non-localizing
0.3 – 1.3 0.5 – 2 • Used for infiltration anesthesia,
ache), temperature
peripheral and regional block,
Levobupivacaine and epidural and spinal
ADVANTAGES OF AMIDES vs ESTER LAs
(Chirocaine) anesthesia
• More intense and longer-lasting anesthesia • NOT used for blocks on toddler
• Alpha-1-acid glycoprotein (<3 years of age)
• Not hydrolyzed by plasma esterases
• 40% less toxic because of
• Rare hypersensitivity reaction
metabolite o-toluidine, which can
cause methemoglobinaemia
DOC SAID”I WANT YOU TO STUDY THIS TWO
Prilocaine (Citanest) • Used for infiltration anesthesia,
TABLE(TABLE 7 AND TABLE 8) THE COMPARISON OF
peripheral and regional block,
ESTERS AND AMIDES AND THE PHARMACOKINETICS
and oral anesthetics by the
AND MAXIMUM DOSAGE OF COMMON LOCAL
dentist
ANESTHETICS FOCUS ON THE pKa, ONSET AND THE
MAXIMUM DOSE WITHOUT EPINEPHRINE AND WITH • Slow onset andlonger duration
EPINEPHRINE” • High potency and toxicity
Table 7. Comparison of Esters and Amides • Preferential block on the sensory
Properties Esters Amides fibers
Bupivacaine(Marcaine,
Metabolism Rapid, by plasma Slow, hepatic • 3-4x more potent than lidocaine
Sensorcaine)
cholinesterase • Used for infiltration anesthesia,
System toxicity Less likely More likely epiduralandspinal anesthesia
Allergic Possible via PABA Very rare • NOT use for artertial block
reaction derivative formation because of its cardiotoxicity
Stability in Breaks down in Very stable chemically • Less potent and less
solution ampules (heat, cardiotoxic
sunlight) • Used for infiltration anesthesia,
Ropivacaine (Naropin)
Onset of action Generally slow Moderate to fast regional blocks, epidural and
pKa Higher than pH=7.4 Close to pH=7.4 spinal anesthesia
(8.5 – 8.9) (7.6 – 8.1) • Can be used for children
• First local anesthetic
Table 8. Pharmacokinetics and Maximum Dosages (Prototype of Amides) that was
of Common Local Anesthetics introduced in 1948
Lidocaine (Xylocaine,
Max dose • One of the most widely used,
Duration (h) Lignocaine
(mg/kg) rapid onset, modulate duration,
Drug pKa Onset
w/o w/ w/o w/ and highly stable
epi epi epi epi • Not irritating and low toxicity
Amide

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 SURGERY INTRODUCTION TO ANESTHESIA LECTURE 5.1A

• Used for infiltration anesthesia, o Manifests first in the more sensitive CNS and then the
IV block or IV regional cardiovascular system.
anesthesia, peripheral and
regional blocks, and topical CENTRAL NERVOUS SYSTEM EFFECTS OF LA
anesthesia for the skin and • EARLY
extremities o Lightheadedness, perioral/tongue numbness, metallic
• Classified as Class 1B anti- taste
arrythmic • IN HIGHER DOSE
• Used for the treatment of o Tinnitus, visual dysfunction, agitation, anxiety
ventricular • IN A MUCH HIGHER DOSE
arrhythmia/tachycardia o CNS depression, unconsciousness, respiratory arrest,
• A/E: Malignant hyperthermia seizure activity
due to accumulation of Calcium ▪ Treatment for LA-induced seizure: Hyperventilation
• Used for regional block as a AND Benzodiazepines or small doses of Thiopental
Etidocaine (Duranest) preference for motor fiber ▪ If the seizure persists, the trachea must be intubated
sensory fibers with a cuffed endotracheal tube to guard against
pulmonary aspiration of stomach contents.
• A sympathomemtic due to
norepinephrine reuptake
CARDIOVASCULAR EFFECTS OF LA
• A vasoconstrictor
• Cardiac arrhythmias, depressed contractility, and cardiac
• Commonly used in the ENT
arrest
surgeries
• Occurs when the blood concentration rises high enough.
• Fast onset of action (about 20-
• LA bind on sodium channels present in myocardial cells that
30 minutes) due to its ability to
Cocaine reduces the myocardial automaticity and shortens the
sensitized adrenergic receptors
refractory period
• Relatively contraindicated to
o With increasingly elevated plasma levels of local
the patient with hypersensitivity
anesthetics, progression to hypotension, increased P-R
and ischemic heart disease
intervals, bradycardia, and cardiac arrest may occur.
• Contraindicated with concurrent
• Greater CARDIOTOXICITY
use with adrenaline because of it
o BUPIVACAINE
is a potent vasoconstrictor
▪ More cardiotoxic than other local anesthetics
• Rapidly metabolized ▪ Has a direct effect on ventricular muscle
Chloroprocaine • Favored by obstetricians because ▪ More lipid soluble than lidocaine, thus it binds tightly to
of its low fetal exposure sodium channels
• Rapid onset and short duration ▪ Experience profound hypotension, ventricular
• NOT effective topically tachycardia and fibrillation, and complete
Procaine
• LA of choice for Malignant atrioventricular heart block that is extremely refractory
Hyperthermia to treatment
• Used as topical and mucosal ▪ Bretylium – DOC for Bupivacaine-induced ventricular
anesthesia by the dentist tachycardia
Benzocaine o ROPIVACAINE
• Associated with
methemoglobinemia
NEUROTOXICITY
• An ester
A. LIDOCAINE 5%
• Has relatively fast onset of
• Cauda Equina Syndrome
action and longer duration
o Permanent neurologic injury
• Effective topically
o Due to spinal microcatheters
• Treat local illness and used to
Tetracaine (Pontocaine, ▪ The pooling of the concentrated local anesthetic in the
desensitize venipuncture site
Amethocaine) catheter fibers cause the neurotoxic effects.
or IV insertion sites, especially
o Discontinued and is replaced by 2% and 4%
for pediatric population
• Transient Neurologic Symptoms (TNS)
• Least metabolized among the
o Transient hypesthesias, paresthesias, and motor
esters
weakness.
• Possess higher risk of toxicity
 TNS is significantly more common with Lidocaine
o Usually symptoms resolves for 3 days
SIDE EFFECTS AND TOXICITY OF LAs o But occasionally it persists for as long as six months
• TOXICITY
o Results from absorption into the bloodstream or from B. 2-CHLOROPROCAINE
inadvertent direct intravascular injection. • Due to low pH & metabisulfite preservative

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 SURGERY INTRODUCTION TO ANESTHESIA LECTURE 5.1A

o Once used as spinal anesthesia during 1950’s but o LA needle penetration

discontinued because of neurotoxicity. o Venipuncture/Vein cannulation
o Laceration repair (for pedia)
METHEMOGLOBINEMIA o Ulcers
• Can be caused by PRILOCAINE and BENZOCAINE o For superficial and soft tissue manipulation
o Large doses of these can convert hemoglobin to • DIFFERENT FORMS
methemoglobin. o EMLAcream (2.5% Lidocaine + 2.5% Prilocaine)
• Treatment: Methylene blue ▪ EMLA: Eutectic Mixture of Local Anesthetic
▪ Eutectic means when two solid substances are mixed, it
HYPERSENSITIVITY/ALLERGY becomes oily mixtures.
 Allergic reactions are most often associated with esters ▪ Prevents anesthetic penetration of your keratinized
because of sensitivity to their metabolites (PABA), should this layer of the skin as deep as 5mm producing local
occur we should consider switching to amide anesthetics. response.
• Can be caused by LIDOCAINE ▪ Usually used during cautery of warts
▪ Used in children and some adults.
• Treatment of LAST (Local Anesthetic Systemic Toxicity):
▪ Not recommended for use in mucous membranes
Infusion of 20% lipid emulsion (Intralipid)
because lidocaine and prilocaine is absorbed faster in
o It reverses the symptoms of local anesthetic toxicity
mucous membranes than through the skin.
o Mechanism of Action: The fraction of LA is sequestered in
o Xylocaine ointment, 4% cream
a lipid emulsion and effectively remove from the plasma
o Flavored xylocaine gel
DOC SAID”I WANT YOU TO STUDY THIS TABLE THE
o Lidocaine spray and solutions
MAXIMUM DOSE WITH AND WITHOUT EPINEPHRINE AND
▪ Usually used before intubation
THE DURATION OF ACTION”
▪ Sprayed on the trachea.
Table 10. Maximum Dose Per Day of LA
o Ethyl chloride spray
Maximum Maximum
▪ Usually used for athletes
LOCAL Dose (mg/kg) Dose (mg/kg) Duration of
▪ Gives cold/freezing sensation upon application.
ANESTHETICS WITHOUT WITH Action
Epinephrine Epinephrine
ESTER
Procaine 7 10 60 – 90
2-Chloroprocaine 15 20 30 – 60
Tetracaine 1 1.5 180 – 600
AMIDE
Lidocaine 4 7 90 – 200
Mepivacaine 5 7 120 – 240
Bupivacaine 2 3 180 – 600 Figure 2: Proparacaine
Levobupivacaine 2 3 180 – 600  Proparacaine is a rapid acting topical
Ropivacaine 2 3 180 – 600 anesthetic.
 Used to induce anesthesia for eye
Articaine − 7 60 – 230
examination and procedures such as the
measurement of the intraocular pressure
CLINICAL USED OF LOCAL ANESTHETICS or tonometry.
• Topical/Surface anesthesia  Removal of foreign bodies and sutures
from the cornea.
• Infiltration anesthesia
 Also, in conjunctival scrapings in
• Peripheral nerve block diagnosis and gonioscopic examination.
• Intravenous Regional block (Bier’s block)  It is also indicated for use as a topical
• Regional block (Spinal, epidural, caudal) anesthetic prior to eye surgery such as
cataract extraction.
1) TOPICAL/SURFACE ANESTHESIA
• Surface anesthesia of mucosa and skin
o Nose, mouth, tracheobronchial tree, cornea, esophagus,
genitourinary tracts
• Chief nerve affected: Sensory nerve endings
• Available forms: Ointment, spray, lotion, lozenges, EMLA
• Usually applied before IV insertion
• Examples: Lidocaine, Tetracaine (Ametop®), Cocaine,
Benzocaine
• CLINICAL APPLICATIONS

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SURGERY INTRODUCTION TO ANESTHESIA LECTURE 5.1A

IV. INFILTRATION ANESTHESIA

• Subcutaneous injection of LA
• Chief nerve affected: Terminal nerve endings.
• Affects the injected area only.
• Rapid in onset
• Surgical procedure involving small area of tissue.
• Injected around the region to be operated prior to skin
Figure 3: EMLA repair, lumbar puncture, or insertion of vascular catheters.
• Examples: Lidocaine, Procaine, Prilocaine, Mepivacaine,
 EMLA is indicated as a topical anesthetic Bupivacaine
for used in normal, intact skin for local • CLINICAL APPLICATIONS
analgesia during IV insertion in children
o Dental procedures
and occasionally in adults.
o Skin surgery (e.g. skin biopsy, superficial tumor, scar
 It is also used for genital mucous
membranes for superficial minor surgery. revision, small skin grafts)
 For treatment for infiltration anesthesia o Repair or suturing of open/ lacerated wound
o Wound irrigation
o Foreign body removal
o Insertion of vascular catheters
o Lumbar puncture

Figure 6: Infiltration Anesthesia

Figure 4: Cetacaine
 This picture shows an example of
infiltration anesthesia wherein your local
 Cetacaine topical anesthetic spray is a anesthetic is injected in the left eyelid.
long-acting prescription topical
anesthetic that permits direct application
to the required site.
 It is indicated for suppressing the Gag
reflex, controlling pain, and easing
discomfort during dental, ent and
medical procedures.

Figure 7: Infiltration Anesthesia of the foot

 Infiltration of the local Anesthetic for

excision of a recurrent and infected corn
or calluses.
Figure 5: ProJel-20 Pina Colada

 Projel-20 is a 20% Benzocaine topical

anesthetic gel used in the practice of
Dentistry. It offers no bitter aftertaste and
comes with different flavors (cherries,
bubblegum, pina colada and mint).
 It is used for temporary relieve of pain due
to minor irritation or injury to the mouth or Figure 8: Infiltration Anesthesia for tooth
gums (chancer sores, dentures, extractions
orthodontic appliances).
 It is also used for temporally relief of pain  Maxillary and Mandibular Nerve
associated with local anesthetic injections Infiltration for tooth extractions
to oral mucosa.

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 SURGERY INTRODUCTION TO ANESTHESIA LECTURE 5.1A

V. NERVE FIELD BLOCK o Pre-existing neurologic deficit

• Referred also as local infiltration. • COMPLICATIONS
o Injection of LA subcutaneously in the surrounding area o Systemic toxicity of LA (LAST)
of the nerve o Hematoma
• Chief nerve affected: Larger terminal nerve fiber (nerve o Engorgement of the extremity
plexus or trunk) o Ecchymosis and subcutaneous hemorrhage
• Circumscribed/Encircled area is anesthetized o Nerve injury
o Example use is in patients with Sebaceous cyst. Encircle o Damage to other structures
the area that needs to be anesthetized. o Pain at the injection site
• LESS anesthetic is needed o Local hematoma
• USES • NERVE BLOCKS OF THE HEAD, NECK, AND TRUNK
o Used for minor surgery, dentistry and analgesia o Scalp block
Nerve blocks of the head,
o Heavily contaminated wounds o Cervical plexus block
neck and trunk
o Incision and drainage of skin abscess o Intercostal nerve block
o Suturing, minor superficial surgery, line placement o Thoracic paravertebral block
 This is used for heavily contaminated wounds or when o Intrafascial plane blocks (Pecs I, Pecs II,
anesthetizing for incision and drainage of skin abscess, prepare o Serratus plane blocks) Nerve
the patient and the wound in the same way as direct infiltration. o Transverse abdominis plane (TAP) block blocks
The aim is to anesthetize the region distal to the site of injection. o Subcostal TAP block of trunk
• ADVANTAGES o Rectus Sheath block
o Minimal equipment o Ilioinguinal and iliohypogastric nerve block
o Technically easy o Pudendal and paracervical blocks
o Rapid onset • NERVE BLOCKS OF THR TRUNK
• DISADVANTAGES o Subcostal TAP block
o Potential for toxicity if large field o Rectus Sheath Block
o Ilioinguinal and iliohypogastric nerve block
o Pudendal and Paracervical blocks

Figure 9: Field Block

 In this picture, field block is done by infiltrating Figure 10: Peripheral Nerve Block
the area surrounding the mass incision or
lacerated wound. ► Nowadays, peripheral nerve block is much safer
because UTZ and nerve stimulator is now being used
VI. PERIPHERAL NERVE BLOCK as a guide
• Peripheral block – means it is applied away from the ► Nerve stimulator gives out microcurrent in
vertebral column. milliampere (mA), which will be detected by the UTZ
• INDICATIONS probe
o High risk of respiratory depression ► There are two wires present:
o To avoid systemic medications ► One is for the electric microcurrent
o Intolerant or not responsive to oral medications ► The other one is for the local anesthetic
► Once the UTZ identified or located a nerve, a needle
• CONTRAINDICATIONS
will be inserted to stimulate the nerve, which will then
o LA allergy
produce a muscle twitch
o Inability to cooperate.
► If there is a muscle twitch, it confirms that it is a nerve
o Patient refusal
► A local anesthetic is then introduced to the other wire
o Infection at the injection site
o Coagulopathy or on antithrombotic drugs

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SURGERY INTRODUCTION TO ANESTHESIA LECTURE 5.1A

Figure 11: Head and Neck

 Here is the different Head and Neck Block

Figure 13: Scalp Block

 Scalp Block for Suturing of Lacerated wound.

Figure 12: Facial Nerve Block Figure 14: Occipital Nerve Block

 Facial Nerve Block is used in Cosmetics Surgery and the  Occipital Nerve Block
repair of complex lacerations that might otherwise be
distorted by direct wound infiltration.

*Break Muna.. Youre Halfway there na.. *

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 SURGERY INTRODUCTION TO ANESTHESIA LECTURE 5.1A

VII. NERVE BLOCKS OF TRUNK AND CUTANEOUS

Transverse abdominis plane (TAP) block
• Indications:
o Postoperative analgesia for laparotomy,
appendectomy, laparoscopic surgery,
abdominoplasty, cesarean delivery
o An alternative to epidural anesthesia for
operations on the abdominal wall

Ilioinguinal and Iliohypogastric nerve block

• Indications:
o Anesthesia and postoperative analgesia for
inguinal hernia repair and other inguinal surgery;
analgesia following suprapubic incision.

Rectus Sheath
• Indications:
o Postoperative analgesia for umbilical hernia repair
and other umbilical surgery

Lateral Femoral Cutaneous Nerve

• Indications:
o Postoperative analgesia for hip surgery, meralgia
paresthetica, and muscle biopsy of the proximal
lateral thigh.

Table 11. Nerve Block: UPPER LIMB

PNB INDICATIONS ADVANTAGES DISADVANTAGES
• Shoulder surgery
• Also results in anesthesia in supraclavicular • Hemidiaphragmatic paralysis
INTERSCALENE • Any surgery on the
nerves • Unless certain of inferior trunk blockade (by
BRACHIAL PLEXUS arm and humerus
• Superficial, easy to perform, and comfortable using US or low-interscalene approach), not
BLOCK • Manipulation of frozen
for patient recommended for elbow, forearm, hand surgery
shoulder
• Anesthesia of all portions of the arm distal to
the shoulder
SUPRACLAVICULAR • Arm surgery of the • Fast onset
• Potential for pneumothorax (may be less with
BRACHIAL PLEXUS arm distal to the • Simple to perform under US guidance
US guidance)
BLOCK shoulder • Superficial/comfortable to the patient
• Requires relatively small amount of LA (20–
25mL)
INFRACLAVICULAR • Provides anesthesia to the entire arm distal to • Deeper block
• Arm surgery of the
BRACHIAL PLEXUS axilla • Greater discomfort during block placement
arm distal to the axilla
BLOCK • Good choice for catheter placement • Requires more expertise
• Hematoma resulting in post-block local
AXILLARY BRACHIAL • Arm surgery on the • No risk for pneumothorax, neural axial block, or discomfort and/or discoloration relatively
PLEXUS BLOCK elbow or below phrenic nerve blockade common (with trans-arterial technique)
• Site of injection can be tender post-operatively
• Procedures on lateral forearm/wrist require
• Avoids motor block of biceps and triceps,
DISTAL BLOCKS OF separate blockade of either lateral cutaneous
allowing patient greater post-operative function
THE MEDIAN, ULNAR, nerve of forearm or its parent nerve,
while maintaining analgesia of hand
AND RADIAL NERVES • Handsurgery musculocutaneous nerve
• Reduction in dose and volume of LA, compared
(AT ELBOW, • Tourniquet on arm/forearm may not be
with other proximal brachial plexus block
FOREARM) tolerated for long periods
approaches
• Requires separate sedation/analgesia
PNB=Peripheral Nerve Block; LA=Local Anesthesia; US=Ultrasound

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 SURGERY INTRODUCTION TO ANESTHESIA LECTURE 5.1A

Table 12. Nerve Block: LOWER LIMB

PNB INDICATIONS ADVANTAGES DISADVANTAGES
• Surgical anesthesia
• Risk of bilateral & epidural spread
for knee arthroscopy
• Higher risk of toxicity due to absorption of LA
• Superficial procedures • Block of obturator nerve (supplies both hip and
injected in the muscles
of the anterior high knee joints)
• Deep block (care with anticoagulated patient)
LUMBAR PLEXUS • Patella tendon repair • Covers lateral femoral cutaneous nerve, site of
• Other reported complications include peritoneal
BLOCK • Quadriceps tendon incision for hip replacement
puncture, renal subcapsular hematoma
repair • Can be combined easily with spinal anesthesia
• Risk of hypotension due to high/epidural/spinal
• Postoperative with patients in lateral position
anesthesia
analgesia for hip or
• Cardiac arrests reported
knee arthroplasty
• Knee arthroscopy
• Superficial procedures
of the anterior high
• Incomplete analgesia for hip or knee surgery
• Quadriceps tendon
FEMORAL NERVE • Superficial, simple to perform (sciatic, obturator, LFCN)
repair
BLOCK • Can be used in anticoagulated patient • Lumbar plexus provides better coverage for
• Patella fracture ORIF
knee and hip
• Post-operative
analgesia for hip or
knee arthroplasty
• Relatively deep blocks
POSTERIOR • Anesthesia for • Can be uncomfortable for patients, requiring
• Reliable landmarks makes location easy to find
(TRANSGLUTEAL OR procedures on the significant premedication
• Provides motor block of hamstrings, if desired
SUBGLUTEAL) knee (combined with • Requires semiprone/prone position
• Little risk of vascular puncture
SCIATIC BLOCK femoral) • Requires advanced skill to visualize by US
• Posterior cutaneous nerve of thigh not blocked
• Anesthesia for
• Risk of femoral vessel puncture
procedures on the • No need for lateral/prone position for block
ANTERIOR SCIATIC • Deep block; uncomfortable for patients
lower limb below the placement
BLOCK • May require multiple attempts to localize the
knee (i.e. foot and • Convenient to combine with femoral block
nerve
ankle)
• Surgical anesthesia
for procedures on the
• Can be done in supine, oblique, and prone
foot and ankle
position
• Lesser saphenous • Does not provide anesthesia for tourniquet
POPLITEAL SCIATIC • Posterior approach simple to perform
nerve stripping (calf tourniquet must be used, except for short
NERVE BLOCK • Not uncomfortable for patients; intertendinous
• Supplementary procedures)
approach does not require needle insertion
analgesia for
through muscle
procedures about the
knee
PNB=Peripheral Nerve Block; LA=Local Anesthesia; US=Ultrasound

AGAIN: TIP FOR THIS TRANS

STUDY THE TABLES AND IMAGES LIFTED FROM PPT

DOC SAID IT MULTIPLE TIMES SA AUDIO.

**ALL IMAGES AND TABLES IN THIS TRANS ARE LIFTED

FROM PPT

LABAN!

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 SURGERY INTRODUCTION TO ANESTHESIA LECTURE 5.1A

• Complications
VIII. INTRAVENOUS REGIONAL ANESTHESIA (IVRA) o Lidocaine allergy (rare)
 Also known as Bier Block and was described by a German o Lidocaine toxicity
surgeon Dr. August Bier in 1908. It is a technique involving o Thrombophlebitis
administration of local anesthetic into a region where venous o Tissue extravasation of anesthetic agent
return is mechanically impeded. So local anesthetic diffuses out • Advantages
to nonvascular tissue such as the axon and nerve ending. So o Easy to administer
the efficacy depends on the interruption of blood flow and the o Low incidence of block failure
probable mechanism of action is the drug action on the nerve o Safe technique when used appropriately
endings and nerve trunks. o Rapid onset and recovery
o Patient is awake during the procedure
o Controllable extent of anesthesia
• Disadvantages
o Only for short procedures
o Tourniquet pain after 20 – 30 minutes
o Sudden cardiovascular collapse or seizures if the
local anesthetic is released into the circulation to
early

• Intravenous Regional Anesthesia Steps

Figure 15: IV Regional Anesthesia
• IV administration of LA into a tourniquet occluded limb.
• Rapid anesthesia onset
• Skeletal muscle relaxation
• Examples: Lidocaine (most commonly used),
Ropivacaine, Prilocaine, Mepivacaine
 Here we use Lidocaine 3mg per kg without preservative
and without epinephrine or Ropivacaine 1.2- 1.8 mg per kg Figure 16: Bier Block Procedure Part 1 lifted from PPT
which has more residual analgesia. We also use about 12
– 15 ml of 2% lidocaine or 30 - 40 ml of 0.5% lidocaine for  In performing a Bier Block we place a double
upper extremity regional anesthesia. Since the duration of pneumatic tourniquet on the operative site on
anesthesia depends on the length of time the torniquet is the layer of soft cloth with the proximal cuff near
inflated, there is no need to use long acting or more toxic the axilla. Then insert and secure a small gauge,
agents. such as gauge 20 or 22 on the venous cannula
• Mechanism of action: Drug action on nerve endings and in the hand then flush with saline.
nerve trunks
• DOA: Tourniquet inflation time
 Duration of Anesthetic Action is dependent on how long
the tourniquet is kept inflated following tourniquet deflation
so there is a rapid recovery as blood dilutes the local
anesthetic concentration.
• Uses: Short procedures (30 –45 mins.)
 It is use for upper limb and orthopedic procedure that will
be completed within 40-60 minutes. It is not appropriate for
surgeries lasting longer than 1 hour because of the
discomfort cause by the torniquet typically beginning within
30-45 minutes. Figure 17: Bier Block Procedure Part 2 lifted from PPT
• Upper limb surgery, short procedure on foot
• Indications:  Next is elevate the limb for 1 minute.
 Bier Block is used in the following procedures of the arm that
require operating anesthesia and muscle relaxation such as;
o Reduction of closed fractures and dislocations
o Laceration repair
o Foreign body removal
o Burn debridement
o Abscess I&D
o Carpal tunnel surgery or tendon repair
• Absolute Contraindications
o Allergy to anesthetic agent
o Uncontrolled hypertension
• Relative Contraindications
o Severe Raynaud’s disease/ Buerger’s disease Figure 18: Bier Block Procedure Part 3 lifted from PPT
o Crushed or hypoxic extremity
o Procedure taking >90 minutes  After elevating the limb apply a 10-12 cm rubber
o Unreliable or inadequate tourniquet elastic bandage in a distal to proximal direction
o Young children starting at the fingertips ending at the tourniquet.

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SURGERY INTRODUCTION TO SURGICAL ANESTHESIA PART 1 LECTURE 5.1A

Figure 19: Bier Block Procedure Part 4 lifted from PPT Figure 22: Spinal Vertebral Column and Spinal Cord lifted
from PPT enlarged image at the appendix
 Next is inflate the proximal cuff 50-100mmHg
above the systolic arterial pressure.

Figure 20: Bier Block Procedure Part 5 lifted from PPT

 Finally, the limb is lowered and the local

anesthetic is slowly injected through the
previously inserted intravenous catheter.
Figure 23: Spinal Cord lifted from PPT enlarged image at the
IX. REGIONAL ANESTHESIA / NEURAXIAL BLOCK appendix
• Neuraxial block – means it is aligned with the vertebral
column.  The spinal needle is usually inserted at the level of
• Examples: Spinal blocks, epidurals Lumbar area particularly L3, L4, and L5.
 Regional Anesthesia numbs the part of the body where
the surgeon operates which avoids the needs for general
anesthesia. Patient maybe awake or sedated. 2 examples
are Epidural Anesthesia for labor and Spinal Anesthesia
for cesarean section.

A.ADVANTAGES OF REGIONAL ANESTHESIA (RA) vs

GENERAL ANESTHESIA (GA)
• Safe and reliable technique
• Patient is alert early postop
• Lower incidence of PONV
• Alternative for day care surgeries
• Minimal risk of postop respiratory depression
• Limited stress response to surgery
• Better pain control –less narcotic requirement Figure 34: The meninges lifted from PPT enlarged image at
• Cost effective the appendix.

 The meninges are the membranes located between

the bone and soft tissues in the nervous system. The
dura mater is the outermost layer wherein you will
Figure 21: Spinal (Subarachnoid) Block lifted from PPT see the blood vessels. The arachnoid mater has no
blood vessels, and this is the in-between layer, and
The spinal needle is correctly positioned in the it resembles a spider web. The pia mater is the inner
subarachnoid space confirmed by free-flowing membrane it contains the nerves and blood vessels
cerebrospinal fluid. to nourish the cells.

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 SURGERY INTRODUCTION TO SURGICAL ANESTHESIA PART 1 LECTURE 5.1A

• Small volume of LA administered (around 2-4mL)

Indications
• Surgeries involving lower half of the body
o Upper abdomen
o Lower abdomen
o Perineum
o Anorectal and lower spine(e.g. Hemorrhoids)
o Lower extremity
• Obstetrics
o Labor analgesia
o Caesarian section
• Painful diagnostic and therapeutic procedures below
Figure 25: The Meninges lifted from PPT the diaphragm
• Postoperative and chronic pain management
 The brain and spinal cord are surrounded by three
membranes or meningeal coverings.
 Dura mater Contraindications
• The outer covering. • ABSOLUTE
• Envelops the cord loosely. o Patient refusal
• Separated from the arachnoid mater by the
o Infection
subdural space and from the bony wall of the
vertebral canal by the epidural space. o Anticoagulation or Coagulopathy
 Arachnoid mater o Severe hypovolemia
• Soft impermeable translucent membrane that o Increased intracranial pressure (ICP)
loosely envelops the brain, o Severe aortic or mitral stenosis-
• Lies between the pia and the dura.  It can cause abrupt decrease in blood pressure
• Between it and pia lies the subarachnoid space of the patient
which contains the cerebrospinal fluid.  To manage this, preloading and IV crystalloids
 Pia mater
20mL are given
• Innermost, thin delicate and highly vascular
membrane that contains the cord and the nerve • RELATIVE
roots. o Sepsis
• It is attached to the arachnoid and to the dura o Uncooperative patient
by the denticulate ligament. o Preexisting neurological deficit
o Severe spinal deformity (e.g. Scoliosis)
X. SPINAL / SUBARACHNOID BLOCK • CONTROVERSIAL
o Prior surgery at the site of injection
• INTRATHECAL injection of LA into the subarachnoid  The site may be fibrotic
space.
o Complicated surgery
 Subarachnoid space – where the CSF can be
found, hence, injecting of the agent here will o Prolonged operation
provide a more rapid onset. o Major blood loss
• SPINAL NERVES
 In upper abdominal procedure, it is injected at the Complications
level of T4 (nipple area)
• Hypotension
 Higher than this level is avoided because this is
where the cardioaccelatory fibers (T1-T4) are • Bradycardia
located, and therefore, can cause bradychardia. • Total Spinal Anesthesia
 If injected higher than the spinal, it can cause loss • Neurological Complications: Cauda Equina Syndrome
of voice. • Post Dural Puncture Headache
 If this happens during a procedure, the
anesthesiologists sedates the patient. • Infection
• LUMBAR PUNCTURE – done at the lumbar level only • Backache
o Below L1 (adults)– at the L3 and L4 level
o Below L3 (children)– at the L4 and L5 level
 In children, there spinal cord ends at L3, hence,
above this level is avoided
 Deposited on the sac to provide space for the RA
 Blind procedure is sometimes done to avoid hitting
the cauda equina
Advantages
• Dense motor blockade
• No sacral sparing
• Fast onset

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SURGERY INTRODUCTION TO SURGICAL ANESTHESIA PART 1 LECTURE 5.1A

Spinal Anesthesia Needles

Figure 26: Spinal Needle lifted from PPT

 This is the spinal needle, it has a transparent half

Figure 28: Meninges lifted from PPT
to see the flow of cerebrospinal fluid
 Length: 3 ½ inches long. • Where you place LA into the EPIDURAL SPACE
 Color Coded: The lowermost needle is what we o Epidural Space
called the introducer needle mainly use for fine ▪ OUTSIDE the dura
gauge needle like gauge 27 and gauge 29. ▪ Filled with adipose tissue
▪ Houses an extensive Internal
Vertebral Venous Plexus, lymphatic
vessels, small arteries and
Recurrent Meningeal nerves
• SLOWER in onset (10 –20 minutes)
• HIGHER volume of LA (20 –40 mL)
o A test dose is usually needed prior to injection
to avoid complications such as cardiac arrest.
• Puncture sites: CERVICAL, THORACIC, LUMBAR,
CAUDAL (lower most part of epidural)
• INDWELLING EPIDURAL CATHETER
o Prolong or extend the block
o Postoperative analgesia 3-5 days after the
surgery
• LA Volume– efficacy depends on how much anesthetic
is given to the patient
 Used AFTER SURGERY
 For CHRONIC pain syndromes

Figure 27: Spinal Anesthesia Needles lifted from PPT

 These are the most commonly use spinal needles.

 All of them have stylet to avoid or prevent plugging
or tracking epithelial cells into the subarachnoid
space
 Quincke is a cutting needle with end injection. It has
increased incidence of post-dural puncture
headache.
 Whitacre & Sprotte are both pencil point needle
with rounded points. These 2 are use to prevent
post dural puncture headache seen in Quincke
Needle.

XI. EPIDURAL BLOCK

Figure 28: Epidural Block lifted from PPT

 This is Epidural Block or Anesthesia inserted into epidural

space.
 Usually, it is combined with general anesthesia in older
infants and children.

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 SURGERY INTRODUCTION TO SURGICAL ANESTHESIA PART 1 LECTURE 5.1A

Indications  STUDY THIS TABLE!

NOTE: Same indications with spinal block, except with the
additional indication of postop pain management using epidural
catheter. Table 14: Differences between Spinal Anesthesia
and Extradural Anesthesia
• Surgeries involving lower half of the body Spinal Anesthesia Extradural
o Upper abdomen Anesthesia
o Lower abdomen Below L1/L2, where At any level of the
o Perineum Level
the spinal cord ends vertebral column
o Anorectal and lower spine (e.g. Hemorrhoids)
o Lower extremity Subarachnoid Epidural
• Obstetrics space, i.e. puncture spacebetween
o Labor analgesia of the dura mater ligamentum flavum
Injection
o Caesarian section and dura mater, i.e.
• Painful diagnostic and therapeutic procedures below the without puncture of
diaphragm the dura mater
• Postoperative and chronic pain management
Subarachnoid Peridural space:
• Postop pain management using epidural catheter
Identification space: When CSF Using the Loss of
Contraindications of space appears Resistance
• ABSOLUTE technique
o Patient refusal 2.5–3.5mL 15–20mL
o Infection Doses Bupivacaine 0.5% Bupivacaine 0.5%
o Anticoagulation or Coagulopathy heavy
o Severe hypovolemia Onset of Rapid (2–5min) Slow (15–20min)
o Increased intracranial pressure (ICP) action
o Severe aortic or mitral stenosis- Density of More dense Less dense
 It can cause abrupt decrease in blood pressure block
of the patient. Hypotension Rapid Slow
 To manage this, preloading and IV crystalloids A probable NOT a probable
Headache
20mL are given. complication complication
• RELATIVE  STUDY THIS TABLE!
o Sepsis Table 15: Comparison of Spinal Anesthesia
o Uncooperative patient and Extradural Anesthesia
o Preexisting neurological deficit Spinal Anesthesia Extradural
o Severe spinal deformity (e.g. Scoliosis) Anesthesia
Larger-gauge
Smaller-gauge
Complications needle is more
needle is easier to
NOTE: Same complications with spinal block, EXCEPT epidural difficult to place
place
block does NOT have Post Dural Punctuate Headache. Needle
• Hypotension placement Movement of a fluid
CSF flowing through
drop or loss of
• Bradycardia the needle is a more
resistance are more
• Total Spinal Anesthesia reliable endpoint
subtle endpoints
• Neurological Complications: Cauda Equina Syndrome
Potential for
• Infection
local
• Backache Negligible Considerable
anesthetic
Table 13: Characteristics of Different Central Neuraxial toxicity
Blocks Potential for Higher incidence, Lower incidence,
SUBARACHNOID / SPINAL EPIDURAL headache often less severe often more severe
Injection through dura into Catheterization of potential Incidence of
CSF space outside dura neurologic Very low Very low
Low volume (up to 3mL) High volume (>10mL) complications
Variable concentration local Intensity of
Profound Less profound
High concentration local anesthetic, analgesia 0.1% anesthesia
anesthetic 0.5% bupivacaine bupivacaine, anesthesia up to Incidence of
2% lignocaine Very low More frequent
patchy block
Rapid onset dense Gradual titration of block Spread of
sensorimotor block density, may be motor sparing Highly predictable Less predictable
anesthesia
Profound vasodilation causing Gradual titration causing less Onset of
hemodynamic instability hemodynamic disturbance Rapid Slow
anesthesia

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SURGERY INTRODUCTION TO SURGICAL ANESTHESIA PART 1 LECTURE 5.1A

Duration of Variable based on Limitless using

action agents selected catheter technique
Hemodynamic
More pronounced Less pronounced
alterations
 STUDY THIS TABLE!

XII. CAUDAL (KIDDIE CAUDAL) BLOCK

Figure 30: Caudal Block lifted from PPT

 Caudal anesthesia requires identification of the

sacral hiatus.
 The sacral coccygeal ligament is the extension of
the ligament Flavum overlying the sacral hiatus
that lies between the sacral cornua.
 To facilitate locating the cornua, the posterior
superior iliac spine should be located and by using
the line between them as one side of the
equilateral triangle the location of sacral hiatus is
estimated.
 After identifying the sacral hiatus, the index and
middle fingers of palpating hand are place on the
sacral cornua.

Figure 29: Caudal Block lifted from PPT Figure 31: Caudal Block lifted from PPT

• Popular technique in PEDIATRIC patients  Caudal needle is inserted at a 45 degrees angle to

 Locate the sacral hiatus first using your index, the sacrum.
middle and ring finger, making an inverted U  While advancing the needle, a decreased to
shape. resistance to needle insertion should be
 Usually naka-General Anesthesia yung baby appreciated as the needle enter the caudal canal.
before they do the caudal block The needle is advance until the bone is contacted
• Caudal catheters can be given during long
and then slightly withdrawn then the needle is
procedures
• SINGLE-SHOT TECHNIQUE
redirected so that the angle of insertion relative to
o Urological, lower extremity and lower skin surface is decreased.
abdominal procedures  In male patient this angle is almost parallel to the
• INDWELLING CATHETER coronal plane.
o Abdomen and thoracic procedures  In female patient slightly steeper angle for about
o Added benefit of continuous post-operative 15 degrees is necessary.
analgesia  After redirecting the angle of insertion the needle
is slightly advance 1-2 cm into the caudal canal.

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 SURGERY INTRODUCTION TO SURGICAL ANESTHESIA PART 1 LECTURE 5.1A

Indications
• Anesthesia and analgesia below the umbilicus
• Obstetric analgesia
• Chronic pain problems

Contraindications
• Infection near the site of the needle insertion.
• Coagulopathy or anticoagulation therapy
• Congenital abnormalities of the lower spine or
meninges

Complications
• Intravascular or intraosseous injection.
• Dural puncture
• Perforation of the rectum
• Sepsis
• Urinary retention
• Hematoma
----------------------------END OF PART 1-----------------------------

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SURGERY INTRODUCTION TO SURGICAL ANESTHESIA PART 1 LECTURE 5.1A

XIII. APPENDIX

Appendix 2: Spinal Cord lifted from PPT.

Appendix 1: Spinal Vertebral Column and Spinal Cord lifted from PPT.

Appendix 3: The Meninges lifted from PPT.

[Derain, Palay, Sale] EDITOR: [Navarro, H] Page 21 of 21