ANESTHESIA RECOVERY ROOM

9. RECOVERY ROOM

-  On  the  completion of a surgical  procedure  the  patient  is

   allowed  to recover from the effect of the anaesthetic  agents

   and  the relaxants by giving appropriate medication  till  the

   point   that  the  patient  is  respiring  spontaneously   and

   adequately.

-  He is disconnected from the anaesthetic machine and the  endo-

   trachael  tube  can  now be removed after  ensuring  that  the

   patient has a clear air-way by sucking out all secretions.

-  He  is  then  wheeled in the recovery room  where  he  can  be

   observed   frequently till complete recovery from the  effects

   of the pre-medication and the anaesthetic agents.

The points to be observed are:

   *  Continuous free airway

   *  Adequate perfusion is observed by skin colour, temperature,

      pulse, blood pressure records

   *  Prevention of aspiration

   *  Medication for pain

 

Patients  that are severely ill because of extensive surgery  are

kept  in an intensive care unit. Monitoring to  gain  information

on;

   -  Cardiac function (ECG)

   -  Blood biochemistry, pH, PCO2

   -  Pulse, Blood pressure and central venous pressure records

   -  Adequate ventilation

 

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ANESTHESIA RELAXANTS

8. RELAXANTS

Muscle relaxants given intravenously can cause profound muscular

relaxation without increasing the depth of anaesthesia.

* It is to be noted that these patients will have inability

to maintain ventilation because of relaxation of

respiratory muscles.

* This can be compensated for by artificial ventilation to

maintain normal arterial oxygenation and normal carbon-

dioxide excretion.

* There are two varieties of muscle relaxants.

- Curare which interferes with transmission of impulse

at the myo-nural junction by competing with

acetylcholine at the motor-end plate(Non-depolarizing).

They are longer acting.

- Succinylcholine: These interfere with myo-neural

transmission by producing depolarization of the end-

plate.These agents are shorter acting.

 

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ANESTHESIA STAGES

7. STAGES OF ANAESTHESIA

Using volatile agents specially, ether.

 

7.1 FIRST STAGE

This  is  the  stage of analgesia starts from  the  beginning  of

induction to the point where there is loss of consciousness.

   *  It is also referred to a stage of disorientation

 

7.2 SECOND STAGE

Stage  of  excitement  starts at the loss  of  consciousness  and

prevails till the onset of automatic breathing.

   *  The patient demonstrates struggling breath holding,

      vomiting, coughing, swallowing.

   *  These various reflex activities can be minimised by

      adequate pre-medication and psychological preparation of

      the patient.

   *  On recovery from anaesthesia,patient may demonstrate

      delirium in this stage.

 

7.3 THIRD STAGE (Surgical Anaesthesia)

The  onset  of  this stage is indicated  by  the  observation  of

automatic  respiration and goes on till the stage of  respiratory

paralysis and it is divided into four planes.

 

   Plane 1:  Starts with the onset of automatic respiration to

             the cessation of eye ball movements.

   Plane 2:  Starts from the cessation of eye ball movements to

             commencement of intercostal paralysis.

   Plane 3:  Starts with the commencement of intercostal

             paralysis to its completion.

   Plane 4:  Starts with complete inter costal pralysis and ends

             with diaphragmatic paralysis.

 

7.4 FOURTH STAGE (Overdosages)

Fourth stage starts with the beginning of diaphragmatic paralysis

apnea goes on to death.All reflex activity is lost,and the pupils

are widely dilated.

 

OBJECTIVE 

It would be seen that by constant observation of respiration  and

ocular movements.

   *  pupils, eyes-reflexes laryngael and phyarngael reflexes.

   *  respiratory responses to skin stimulation and lastly

      muscular tone.

   *  Patient can be kept in the surgical stage of anaesthesia

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PRE ANAESTHETIC PREPERATION

6. THE PRE-OPERATIVE PREPARATIONS

The stomach, rectum and bladder should be empty before taking the

patient to the theatre. Therefore,it is customary to have a

patient on empty stomach and a low enema given the night before.

6.1 PRE-ANAESTHETIC MEDICATION

A patient is usually apprehensive and,therefore,spends a

sleepless night.

It is desirable to sedate the patient with a hypnotic or

tranquilliser (barbiturates of valium).

6.2 AN HOUR PRIOR TO SURGERY

The patient receives;

* an injection of Pethidine 50 mg.

* Phenargen 25 mg., and injection Atroprine 1/100th of grain

intramuscularly.

This produces basal narcosis which is the ideal state for the

patient prior to the induction of anaesthesia.

The choice of the type of anaesthesia will depend upon the

surgical procedure to be undertaken, and the result of the pre-

anaesthetic check in which the health status has been defined

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 .

ANESTHESIA REGIONAL

5.4 REGIONAL ANAESTHESIA

Technique used for the interruption of sensory pathways  involves

the  use  of local anaesthetic agents at different sites  in  the

nervous system and can be used -

   1.  On mucosal surfaces

   2.  For subcutaneous infiltration

   3.  For nerve blocks

   4.  For regional blocks (spinal and   extradural anaesthesia)

       

   5.  For intravenous regional anaesthesia

Substances used are:

a) Cocaine is used essentially for topical anaesthesia and thus

   for operations in the nasal cavity in a concentration ranging

   from 4-20%.

b) Procaine (Novocaine) the substance was introduced in 1905 and

   is not effective topically but is much less toxic than

   cocaine.

   It can be used for subcutaneous infiltration in a 0.5%

   solution; 2% solution is required for nerve blocks.

c) Lignocaine (Xylocaine) 0.5% solution is used for local

   infiltration. 1-2% for nerve block. The relative advantages

   and disadvantages of procaine and lignocaine are there.

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ANESTHESIA GENERAL

5.3 GENERAL ANAESTHESIA

The inhalation agent for inducting is in most instances delivered

through an endotracheal tube .

Short term barbiturates (pentothol) is injected intravenously.

This is referred to as induction and facilitates the introduction

of the endotracheal tube with the help of direct lyrangoscope

.

The tube is then connected with an anaesthesia machine  .

5.3.1 TECHNIQUE

The dose of anaesthetic to be given to any patient by inhalation

cannot be calculated based on milligrams of anaesthetic per

kilogram body weight.

* In addition, there is a problem of maintaining sufficient

ventilation.

* Both these objectives are obtained by frequent clinical

examination of the patient so as to ensure sufficient level

of anaesthesia and adequate ventilation.

* The mixture of the anaesthetic agent and oxygen is adjusted

to provide sufficient anaesthesia without causing excess

depression of the central nervous system by observing the

effect on reflexes.

* The ideal state to be maintained is a plane of anaesthesia

in the 3rd state.

The ideal plane will depend upon the surgical procedure to

be performed.

* In all events, 4th stage, a stage of overdosage is to be

avoided.

These reflexes are listed and the stages indicated in the

       are based on the effects described by Guedel

(1937).

 

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ANESTHESIA CHECK 2b

INTERCURRENT DISEASE (CONT)

3.4 LIVER FUNCTIONS

Those with acute viral hepatitis have a 9% risk of mortality.

Those with acute fulminant hepatic failure have an 85% mortality.

3.5 PULMONARY

Infections and chronic obstructive airway disease increase the

risk of post-operative complications.

Thus, risk is increased in patients with asthma and with a

history of heavy smoking.

This information is required to set into motion an action plan

which is directed:

i) Correct the effects of the disease process for which he

is undergoing surgery.

ii) Correct the effect of any inter-current disease so as

to reduce risk.

iii) Identify the need for intra-operative monitoring

devices.

iv) Make correct choice of anaesthetic technique to be

employed.

v) Plan post-operative care.

vi) Prepare the patient emotionally for the anaesthetic

experience.

 

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