ANESTHESIA 9 Resusitation drugs equipment

Equipments Required for Resuscitation

•   Anesthesia machine with breathing circuit/Artificial Mecha­nical breathing unit (AMBU BAG).

•   Oxygen source attached to the machine (cylinder or pipeline)

•   Equipment required for tracheal intubation.

•   Suction apparatus.

•   Emergency drugs:

     a.  Vasopressors—Adrenaline, Noradrenaline, Dopamine Dobutamine, Nitroglycerin, Metaraminol Methoxa­mine, Mephentermine, Phenylephrine.

     b.  Antihypertensive—Nifedipine, Isoptin.

     c.  Sodium bicarbonate, Calcium chloride, potassium chloride.

     d.  Hydrocortisone.

     e.  Aminophylline.

     f.   Antihistamines - Pheniramine.

     g.  Antiemetic-Stemetil, Sequil.

     h.  Antiarrhythmic-Xylocard, Isoptin, Procainamide, Propranolol.

     i.   Atropine sulphate.

     j.   Anticonvulsants-diazepam, dilantin sodium, Thiopen­tone Intravenous fluids-crystalloids and colloids and infusion sets.

•   Disposable syringes (2, 5, 10, 20, 50 ml) and needles (16, 18, 20, 22 G).

•   IV cannulae (16, 18, 20 G).

•   Cleaning tray-Gallipot, sponge holding forceps, sterile gauze swabs.

•   Antiseptics—Savlon, iodine, spirit.

•   Intravenous cannula—18 G/16 G.

•   Intravenous infusion set and intravenous fluids

     a.  5% dextrose

     b.  Normal saline

     c.  Ringer’s lactate

     d.  Haemacal.

•   Patient monitors—ECG, Spo2, NIBP.

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ANESTHESIA 8 Regional anesthesia

REGIONAL ANESTHESIA

Definition

Regional (local) anesthesia is the reversible blockade of conduction by regionally injected agents, for the purpose of sensory ablation. The examples are spinal and epidural caudal and major nerve blocks.

Local Anesthetic Agents

Local anesthetic agents act by inducing a blockade of nerve transmission in peripheral nerve impulses. This occurs as a result of obstruction to sodium channels in the axon membrane.

     Local anesthetic agents belong to one of two chemical classes according to their structure.

Ester Class

The only ester still in frequent use is cocaine, which is an ester of benzoic acid. It is used generally only for topical anesthesia of mucous membranes in the nose and sinuses.

Amide Class

The first amide to be synthesized was lignocaine others are listed in Table 4.3.

Anesthetics

Drugs

Local anesthetics

•   Lignocaine 5%, heavy (hyperbaric)*

•   Bupivacaine (Marcaine) 0. 5% heavy, (hyperbaric)*

•   Cinchocaine (Nupercaine, Dibucaine, Sovacaine)0.5%, heavy (hyperbaric)

•   Amethocaine (Tetracaine, Pantocaine, Pontocaine, Decicain, Decicain Butethane, Anethaine) 1% solution prepared in saline, water or dextrose

•   Mepivacaine (Scandicaine, Carbocaine, Meaverin)-4% heavy (hyperbaric).

Other drugs* available in India

•   Vasopressors

•   Metaraminol (Aramine)

•   Ephedrine

•   Methoxamine (Vasoxine)

•   Phenylephrine

•   Noradrenaline/adrenaline

•   Mephentermine.

Sterile cutting file

Sterile drapes—Four separate towels or a simple sheet with center eye hole.

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Anesthesia 7 Tracheal Intubation Objectives Procedure steps

 

Tracheal Intubation

Follows induction of anesthesia.

Objectives

•     To ensure a clear airway for anesthetized patients.

•     To protect airway from regurgitation and aspiration.

•     To aid and assist in control of ventilation when muscle relaxants are used.

•     To facilitate suction of respiratory tract.

•     To prevent collapse of lungs in thoracic operations.

Position for Laryngoscopy and Intubation

•     Supine.

•     Flexion of the head at the neck and extension of the head at the atlanto-occipital level, the so called ‘sniffing’ position.

•     The head is elevated placing a low pillow or ring Oral cavity axis (OA), Pharyngeal axis (PA) and laryngeal axis (LA) are different. In this all three axis brings into alignment position and vocal cords will be viewed best with laryngoscopy.

Procedure

1.   Awake intubation in neonates sometimes.

2.   Emergency awake intubation in adults when airway is compromised.

3.   Adequate anesthesia and muscle relaxation is the usual technique.

4.   After IV or inhalational induction of anesthesia, short acting depolarising muscle relaxant, Suxamethonium (Scoline)
(1 to 1.5 mg/kg) or non-depolarising relaxant IV given.

5.   Assisted ventilation is maintained via mask with 100% O2 or with 50% N2O in Oxygen till the muscle relaxation occurs and then tracheal intubation is performed.

6.   Handle of the laryngoscope held in the left hand.

7.   The laryngoscope blade is inserted between the teeth at the right side of the mouth and the tongue is displaced on the left side.

8.  The blade is advanced until the epiglottis comes into view and then lift it upwards.

9.   The vocal cords will be identified. If they are not seen, an assistant is asked to push downward on the larynx.

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Anesthesia 6 Induction Steps drugs equipment

Intravenous Induction

Objectives

•     To induce loss of awareness rapidly at the start of anesthesia.

•     Induction is achieved with intravenous agents (thiopentone 3-5 mg/kg, methohexitone 1-1.5 mg/kg, etomidate 0.3 mg/kg, propofol 1.5-2.5 mg/kg or ketamine 2 mg/kg).

Position

Supine.

Premedications

Any combination of anxiolite and antisialgogue.

Procedure

•     Intravenous cannula inserted into a peripheral vein, preferably on the dorsum of the hand and infusion fluid attached

•     Drugs prepared in syringes and labelled (IV induction agent, muscle relaxant, atropine)

•     Patient connected to the monitor for ECG, non-invasive blood pressure (NIBP), and oxygen saturation

•     100% oxygen by mask before the drugs are injected

•     Small test dose of intravenous induction agent given and effects observed for any anaphylactic reaction

•     Slow injection of the drug into the vein till the eye lash reflex is obtained

•     Rapid sequence induction technique used in emergency situation where the stomach is full or chances of regurgitation are a potential problem

•     Anesthesia maintained with inhalational agent

•     Tracheal intubation done using muscle relaxant.

Instruments

•     Intubation tray

•     Anesthesia machine (Check list I, )

•     Breathing circuits, face mask, inhalation set (Check list I, )

•     IV cannula, infusion, fluid, spirit and Iodine swab, adhesive plaster

•     Drug tray and labels

•     Normal saline bottle for dilution of drugs

•     Induction agents - Thropentone, Propofol, ketamine

•     Arm boards

•     Patient monitors for ECG, Spo2, NIBP, ETCO2 

•     Anesthesia machine monitors (Oxygen analyser, gas monitor)

•     Emergency drug tray (Check list II, see).

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Anesthesia 5 General

GENERAL ANESTHESIA

General anesthesia is a reversible, drug-induced state of non-responsiveness to outside stimuli.

      With the use of agents such as the muscle relaxants, modern general anesthesia aims at a balance between ‘relaxation’, ‘analgesia’ and lack of awareness.

      General anesthesia is achieved by using intravenous or inhalational agents (gases or vapours)

•     Patient receives a premedication one hour before the anesthetic procedure

•     The next step to anesthesia is induction which can be achieved by administration of intravenous drugs or inhalation agents

•     On induction, muscle relaxation is necessary to facilitate tracheal intubation. Relaxation during maintenance of anesthesia is also required.

Intravenous Inducting Agents

Intravenous anesthetic agents are used commonly in anesthesia as induction agent. Induction is more rapid and smoother than that associated with inhalational agents. Sometime for maintenance also, these agents can be used.

 

             The intravenous agents (IVA) can be classified as:

      A.  Rapidly acting agents:

             1.   Thiopentone (Barbiturate).

             2.   Etomidate (Imidazole compound).

             3.   Propofol (Phenol group).

             4.   Propanidid (Eugenol derivative).

      B.  Slower acting:

             1.   Ketamine (Phenocyclidine derivative).

             2.   Diazepam and other benezodiazepine derivative.

             3.   Morphine, fentanyl, alfentanyl, sufentanil (Narcotics).

             4.   Haloperidol, droperidol with opioids.

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ANESTHESIA 4 Premedication

GENERAL PRINCIPLES

Premedication and Anesthesia

Premedication is the prescribing of drugs to be administered preoperatively. These are usually agents prescribed by the anesthetist, at the preoperative visit.

•     To reduce anxiety

•     To relieve pain

•     To dry saliva.

Morphine Sulphate

•     Morphine is a narcotic analgesic

•     It depresses awareness, anxiety, pain.

It is used :

•     As a premedicant.

Diazepam

•     This is a minor tranquilizer

•     It relieves tension and anxiety

•     It is used mainly as a premedicant.

Antisialgogue

•     These produce drying of the salivary and respiratory secre-tion

•     The drugs include atropine sulphate, glycopyrrolate and hyoscine

•     One of them is used as a premedicant drug along with analgesics.

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ANETHESIA Equipment 3 anesthesia room

ANESTHESIA ROOM

The anesthesia room is used for preoperative preparation of the patient and;

•     Induction of anesthesia.

•     Giving regional techniques.

•     Short term observation of patients after anesthesia.

It is situated next and on the way to the OT

The anesthesia room should have:

•     A tiltable and portable table

•     An Anesthesia machine

•     Intubation equipments

•     A drug trolley

•     A blood pressure instrument

•     Oxygen saturation monitoring equipments

•     Suction apparatus.

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