COLLEGE OF MEDICINE AND

HEALTH SCIENCES
Department of Anesthesiology
Introduction to Anesthesia II
M I N T E S I N O T B I R H A N U (BSc., MSc. In Anesthesia)

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OUTLINE
§ Historical Background of Anesthesia
§ Definition of Anesthesia
§ Pharmacologic and Non-Pharmacologic anesthetic techniques used throughout history
§ Contribution of different persons to modern anesthetic practice
§ History of Local Anesthetic, Inhalational Anesthetic, IV anesthetic ,Opioids and Muscle relaxants
§ General Anesthesia
§ Components of General Anesthesia
§ Stages of General Anesthesia
§ Premedication
§ Regional Anesthesia
§ Types of Regional Anesthesia
§ Drugs used for Regional Anesthesia
§ Indications and contraindications of Regional Anesthesia
§ Complications of Regional Anesthesia
§ Peripheral Nerve Blocks
§ Summary
§ References

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OBJECTIVE
• The Aim of this presentation is to enable Students
§ Summarize the history of Anesthesia
§ Define General Anesthesia
§ Point out the Stages and components of General Anesthesia
§ Describe Regional Anesthesia
§ Characterize Spinal, Epidural and Caudal Anesthesia
§ State the Indications and Contraindications of Regional
Anesthesia
§ Identify Complications of Regional Anesthesia
§ Explain different types of peripheral Nerve blocks

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 The Historical Background
of Anesthesia

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What is Anesthesia?
• Definition: - the word anesthesia came from two Greek words;
• An means lack of
• Aesthesia means sensation
• Hence, an anesthesia is literally defined as lack of sensation with
or without consciousness.

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an es thesi a! (an es-the ze-a)
1. Loss of sensation resulting from pharmacologic depression of
nerve function or from neurologic dysfunction.
2. Broad term for anesthesiology as a clinical specialty.

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• Anesthesia is a comparatively recent discovery with traceable
origins in the mid-19th century.
• An epitaph on a monument to William Thomas Green Morton,
one of the founders of anesthesia, summarizes the contribution of
anesthesia:
“BEFORE WHOM in all time Surgery was Agony.”

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• Fanny Burney’s experience of surgery(Mastectomy) in the early 19th
surgery
• She received wine cordial as a sole anesthetic
• As seven male assistants held her down, the surgery commenced:
• “When the dreadful steel was plunged into the breast-cutting through
veins-arteries-flesh–nerves, I needed no injunction not to restrain my
cries. I began a scream that lasted unintermittently during the whole
time of the incision–and I almost marvel that it rings not in my Ears still!
So excruciating was the agony. Oh Heaven!–I then felt the knife racking
against the breast bone–scraping it! This performed while I yet
remained in utterly speechless torture.”

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• Although most human civilizations evolved some method for
diminishing patient discomfort
• How we have changed perspectives, from one in which surgical
pain was terrible and expected to one in which patients
reasonably assume they will be safe, pain free, and unaware
during extensive operations, is a fascinating story and the subject
of this chapter.

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Anesthesiologists are like no other
physicians:
• We are experts at controlling the airway and at emergency resuscitation
• we are real-time cardiopulmonologists achieving hemodynamic and respiratory
stability for the anesthetized patient
• we are pharmacologists and physiologists, calculating appropriate doses and
desired responses
• we are gurus of postoperative care and patient safety
• we are internists performing peri anesthetic medical evaluations and therapy
• we are the pain experts across all medical disciplines and apply specialized
techniques in pain clinics and labor wards
• we manage the severely sick and injured in critical care units
• we are neurologists, selectively blocking sympathetic, sensory, or motor functions
with our regional techniques;
• we are trained researchers exploring scientific mystery and clinical phenomena.

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Areas of Practice
• Operating Room
• Intensive care unit
• Labor and delivery suite
• Pain clinic
• Radiology suite
• Gastroenterology suite
• Ambulatory care centers

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Common drugs used in Anesthesia
Care
• Inhaled anesthetics
• Local anesthetics
• Induction agents
• Muscle relaxants
• Opioids

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The Objectives of Anesthesia
• Loss of awareness / Amnesia!
- If Desired
• Analgesia!
- Reduce movement in response to stimuli!
-Minimize autonomic responses to surgical stimuli
• Muscle relaxation- if required
• Autonomic Regulation!

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Why learn about the history of
anesthesia
• Anesthesiology is an amalgam of
• specialized techniques,
• equipment,
• drugs, and
• knowledge that like the growth rings of a tree have built up over time.
• Knowledge of the history of anesthesia enhances our appreciation
of current practice and foretells where our specialty might be
headed.

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Effect of Pain on Different Systems
• CVS •GU
• Tachycardia, hypertension, • Urinary retention
• CNS • Skin
• Anxiety, agitation, arousal •Peripheral Vasoconstriction
• GI •Respiratory System
• Nausea, delayed gastric emptying • Tachypnea
• decreased tidal volume

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The early history of anesthesia-
‘prehistory’
• Pain control during surgery was not seen as important
• patients distress during surgery were not considered
• pain was seen rather a sign of survival
• some clergy men thought that pain during labor is a will of God
• pain is unpleasant sensory or emotional experience associated to actual or
potential tissue damage.

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Anicent Times
• ca. 4000 BCE (Sumerian artifacts depict opium poppy)
• ca. 2250 BCE (Babylonians relieve toothache with henbae.)
• ca. 1600 BCE (Acupuncture is being practiced in China, according
to Shang Dynasty pictographs on bones and turtle shells.)
• ca. 1187 BCE (In Homer’s Odyssey, the Greek goddess Circe uses
deliriant herbs (Mandragora and/or Datura) in a brew to
seemingly transform Odysseus’ men into swine.)

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• ca. 400 BCE (Assyrians use carotid compression to produce brief
unconsciousness before circumcision or cataract surgery. Egyptians
employ the same technique for eye surgery.)
• ca. 350 BCE (Plato refers to ANAIΣΘHΣIA in his work Timaeus)

• 64 Dioscorides, a Greek surgeon in the Roman army of Emperor Nero,

recommends mandrake boiled in wine to “cause the insensibility of
those who are to be cut or cauterized.”

•.
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• Pre-1846 - the foundations of anesthesia

• 1846 - 1900 - establishment of anesthesia

• 20th Century - consolidation and growth

• 21st Century - the future

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 The Foundations of Anesthesia
Pre-1846

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The foundation of anesthesia
• Pharmacologic • Non-Pharmacologic
methods methods
• Alcohol • Cold
• Laudanum
• Opium (poppy) • Concussion

• Hyoscine (Mandrake) • Carotid compression

• Cannabis (Hemp) • Nerve compression

• Cocaine (New World • Hypnosis

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Soporifics( sleep-bearing sponge (“spongia
somnifera”)) and Early Analgesics

• Dioscorides, a Greek physician from the first century AD commented on the

analgesic property of mandragora( obtained from mandrake plant)
• He observed that the bark and leaves of mandrake plant could be boiled in
wine, strained, and used to produce anesthesia ..in the case of persons…
about to be cut or cauterized.
• it was used until 17th century

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9th -13th century ( Soporific Sponge)
• Soporific Sponge was predominantly used
• Mandrake leaves, along with black nightshade, poppies, and other herbs,
were boiled together and cooked onto a sponge.
• The sponge was then reconstituted in hot water and placed under the
patient’s nose before surgery.
• the sponge generally contained morphine and scopolamine—drugs used in
modern anesthesia—in varying amounts.

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 Arabic Anesthetists preparing to use the
Soporific Sponge

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Alcohol and Ice (Refrigeration
Anesthesia)
• Around 11th Centaury the anesthetic effect of cold water was
discovered
• In the 17th century, Marco Aurelio Severino described the
technique of “refrigeration anesthesia”
• in which snow was placed in parallel lines across the incisional
plane such that the surgical site became insensate within minutes.
• The technique never became widely used, likely because of the
challenge of maintaining stores of snow year-round

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Hypnosis (Mesmerism)
• In the early 17th centaury Anton Mesmer practiced hypnosis to relive surgical
pain in patients
• However his work was discredited by the French academy of science
• followers of Anton mesmer… French Physicians Charles Dupotet and Jules
Cloquet continued with mesmeric experiments and pleaded to the
Academie de Medicine to reconsider its utility.
• In a well-attended demonstration in 1828, Cloquet removed the breast of a
64-year-old patient while she reportedly remained in a calm, mesmeric sleep
• This demonstration made a lasting impression on British physician John
Elliotson,
• Elliotson started mesmeric movement in England in the 1830s and 1840s
• Support for mesmerism faded when in 1846 renowned surgeon Robert Liston
performed the first operation using ether anesthesia in England

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The Establishment of Anesthesia (1846-
1900)
• General Anesthesia • Local Anesthesia
• Ether • anesthesia without sleep
• spread to Europe

• Nitrous oxide • New techniques

• early landmarks
• Chloroform
• James Young Simpson
• John Snow

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Ether (Diethylether)
• Known for centuries prior to its first public use.
• it may have been synthesized by
• 1st eighth-century by Arabian philosopher Jabir ibn Hayyam, or
possibly by Raymond Lully,
• a 13th century European alchemist
• In the 16th century, Valerius Cordus and Paracelsus prepared by
distilling H2s04(oil of vitriol) with fortified wine to make ether (sweet oil
of vitriol)

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• Paracelsus applied on chickens and observed that ether caused to
fall asleep and awaken unharmed.
• He must have been aware of its analgesic qualities because he
reported that it could be recommended for use in painful
illnesses.
• For three centuries thereafter, this simple compound remained a
therapeutic agent with only occasional use.

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 The first public demonstration of modern anaesthesia 16 October 1846
Boston, MA, USA

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William E. Clarke
• in January 1842.
• William administered ether, from a towel, to a young woman
named Hobbie for teeth extraction.
• Then extracted without pain and unconsciousness was due to
hysteria

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Crawford Williamson Long
• on March 30, 1842.
• Gave soaked ether in towel for his patient Venable who refuse excision of
his tumor due to fear of pain.
• having the procedure successfully completed.
• Patient was unaware of the removal of the tumors.
• And 1st fee of anesthesia, Long settled on a charge of $2.00.

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William Thomas Green Morton
• October 16, 1846.
• After learning that ether analgesia, he began experiments with inhaled ether.
• He began experimenting with inhaling ether by anesthetizing his dog, later
his patients.
• First public demonstration.
• Patient-Abbott
• Surgeon-wretch
• Surgery- to excise a vascular lesion from left side of neck
• Anesthesia-inhalation of ether by inhaler
• Result –successful, news traveled through out the world

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Robert Liston
• 1847: Liston became an increasingly important supporter of ether in the
following months at a time when many surgeons tried, then abandoned its
use returning to practice without anaesthesia
• Reasons for possible abandonment
• attempts to “patent” anaesthesia and so limit its use
• inadequate anesthesia
• excessive secretions
• vomiting patients
• risk of explosion and fire (candlelight!)
• perceived “risks” of rendering patient unconscious for surgery

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Nitrous oxide
• First prepared in 1773 by Joseph Priestley.
• Made by heating ammonium nitrate in the presence of iron filings.
• In 18th century, H.Davy experimented with N20 and discovered its anti pain
effect and named as ‘laughing gas.’
• In 1845,US dentist H.well discovered anesthetic effect of N20 and applied to
his dental work
• Well tried to publish but fail.
• Not used as frequently as ether ,as it is complex to prepare and to store.
• N20 was therefore temporarily forgotten

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Chloroform
James Young Simpson
• successful obstetrician in Scotland.
• use ether for the relief of labor pain and dissatisfied with it.
• In his home with his friends inhaled chloroform after dinner at a party on
November 4, 1847.
• They fell unconscious and, when they awoke, were delighted with their
success.
• In the 19th century, controversial pain relief in labor, which the pain of the
parturient was viewed as both a component of punishment and a means of
atonement for Original Sin.
• relieving labor pain opposed God's will

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• Then he tried to address the answer for the religious question
from the bible and the labor pain was a result of scientific and
anatomic causes(muscular uterine contraction)
• People started to accept after the delivery of Queen Victoria’s
baby anesthetized by John snow using chloroform.

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Local Anesthetics
• Discovered in the 19TH Centaury
• COCAINE:-Is the first local anesthetics.
• -Extracted from coca leaves
• -Use for centuries in Peru.
• -Koller around 1885 successfully demonstrated the
analgesic properties of cocaine applied to the eye in a
patient with glaucoma.
• Form first report of cocaine use there were reports of central nervous
system and cardiovascular toxicity.
• As the popularity of cocaine grew, so did the frequency of toxic reactions
and cocaine addictions.
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1898
• The first amino amide local anesthetic Nivaquine was synthesized.
• It proved to be an irritant to tissues and its use was immediately
stopped.
• Then in 1900 and 1905 benzocaine and procaine amino ester
local anesthetics synthesized respectively.

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Into the 20TH Century

• AUGUST BEIR:
• The father of spinal anesthesia
• Attempted using cocaine on a dog.
• Later, on his assistance and each other.
• Used on patients after they knew that they were successful
• Discover bier block
• Epidural anesthesia was attempted by different surgeons from different
countries
• Nerve block and plexuses blocks gradually introduced.

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Inhalational Anesthetics In the 20TH
Century
• Ether and chloroform were imperfect:
• Ether was unpleasant to inhale.
• Chloroform had series toxic effects on liver and heart.
• Ethylene was problematic, explosive, and unpleasant
• In 1920 Cyclopropane was discovered by Lucas.
• But it was problematic as it was explosive.

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• By the end of WWII fluorinated hydrocarbon were introduced as
anesthetic agents.
• 1953 halothane
• 1960 methoxy fluorine
• 1963&65 Enflurane and isoflurane
• 1992 desflurane
• 1994 sevoflurane

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Intravenous Anesthetics
▪ The development of IV anesthetics has been an important component of
anesthetic management for more than 70 years.
• The first successful attempt at intravenous anesthesia was performed by
Pierre-Cyprien Oré in 1872 on human being.
• Paraldehyde was used as IV agent during and after WWI
• As the same time morphine and scopolamine were popular combination iv
obstetric analgesia.
• The first barbiturate, barbituric acid, discovered in 1864, but the drug had
no sedative properties then the first sedative barbiturate (hexobarbital)was
synthesized in 1903 by Emil Fischer (1852-1919)

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▪ Sodium thiopental followed hexobarbital in 1934.
▪ Etomidate, an intravenous anesthetic introduced in 1973 that was
used to induce anesthesia.
▪ Experimental study on clinical useful drug benzodiazepines
introduce in chlordiazepoxide (1960) ,Diazepam (1963) and
midazolam (1978)
• Ketamine was synthesized in 1962 and Propofol in 1977
introduced clinically.

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Opioids
• Opioids historically referred to as narcotics.
• The analgesic and sedating properties of opium have been known and
Opium is derived from the seeds of the poppy.
• The first alkaloid isolated, morphine, was extracted by Prussian chemist from
poppy seeds.
• Codeine, another alkaloid of opium, was isolated in 1832.
• Meperidine(Pethidine) was the first synthetic opioid and was developed in
1939.
• phenylpiperidine derivatives, fentanyl, sufentanil and alfentanil, are staples in
the anesthesia pharmacopoeia synthesized around 1960

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Muscle Relaxants
• Curare was used as a poison in India
• Curare used in surgery in 1912
• Regular use of curare from 1939
• Gallamine synthesized in 1948
• Non depolarized muscle relaxants in 1960’s

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• 1949: Sux synthesized by Nobel winner Bovet
• 1956: Distinction between depolarizing and non depolarizing
muscle relaxants
• 1964: Pancuronium
• 1970: Vecuronium
• 1994: Rocuronium

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Introduction to General
Anesthesia

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Definition of General Anesthesia
• General anesthesia is a drug-induced reversible condition
composed of four behavioral and physiologic states:
1. analgesia
2. unconsciousness
3. amnesia
4. immobility
• and stability of the physiologic systems, including the autonomic,
cardiovascular, respiratory, and thermoregulatory system
(attenuation of these systems to noxious stimuli).

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COMPONENTS OF GENERAL
ANESTHESIA
• General anesthesia may have all/or some of the following Properties
• Analgesia

• Unconciousness(sedation)

• Amnesia

• Muscle relaxation(immobility)

• Attenuation of autonomic response to noxious stimuli

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STEPS OF GENERAL ANAESTHESIA
• General anesthesia have the following three steps
• Induction of Anesthesia
• Maintenance of Anesthesia
• Emergence/Recovery

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During induction and maintenance anesthesia the main routes of
drug administration are IV IM and Inhalation.
• During induction IV route is chosen for faster recovery though
inhalational route can be used as necessary.
• During maintenance inhalational is commonly used.
• During emergence all anesthetics drugs are withdrawn by
metabolism and reversal agent is administered to remove residual
Neuromuscular blockade.

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Preanesthetic medication
• It is the use of drugs prior to anesthesia to make it more safe and
pleasant.
• To relieve anxiety – benzodiazepines, Ketamine.
• To prevent allergic reactions – antihistamines.
• To prevent nausea and vomiting – antiemetics.
• To provide analgesia – opioids, Ketamine, Paracetamol.
• To prevent bradycardia and secretion – atropine.

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Stages of Anesthesia
• In the past, when physical examination offered the only clue as to
a patient's depth of anesthesia, an anesthetic overdose by an
inexperienced anesthetist quickly occurred.
• In 1937, Dr Arthur Guedel created one of the first safety systems
in anesthesiology, with a chart that explained the stages of
anesthesia
• Guedel's classification was initially established to deliver diethyl
ether, the single available volatile anesthetic at the time.

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• Ether offered analgesia, amnesia, and relaxation of muscles.
• However, ether was phased out in the United States by the 1980s and
replaced with the current fluorinated hydrocarbon anesthetics.
• Today, the "balanced anesthesia" technique is commonly used which
can disguise the characteristic clinical markers of each defined
anesthesia stage.
• Therefore, some anesthesiologists view Guedel's work as antiquated.
• Yet others still employ his classification to describe developments in
general anesthesia and clinical practice for inhalation inductions across
various surgical procedures.

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Stage 1 - Analgesia or Disorientation

• can be initiated in a preoperative anesthesiology holding area,

where the patient is given medication and may begin to feel its
effects but has not yet become unconscious.
• This stage is also known as the "induction stage." Patients are
sedated but conversational.
• Breathing is slow and regular.
• At this stage, the patient progresses from analgesia free of
amnesia to analgesia with concurrent amnesia.
• This stage comes to an end with the loss of consciousness.

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Stage 2 - Excitement or Delirium
• It is marked by disinhibition, delirium, uncontrolled movements, loss of
eyelash reflex, hypertension, and tachycardia.
• Airway reflexes remain intact and are often hypersensitive to
stimulation.
• Airway manipulation during this stage of anesthesia should be avoided
• including both the placement and removal of endotracheal tubes and
deep suctioning maneuvers.
• At this stage, there is a higher risk of laryngospasm
• Fast-acting agents help reduce the time spent in stage 2 as much as
possible and facilitate entry to stage 3(i.e. may not be observed while
using IV anesthetic agents)

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Stage 3 – Surgical Anesthesia:
• The targeted anesthetic level for general anesthesia procedures.
• Ceased eye movements and respiratory depression are the hallmarks of this
stage.
• Airway manipulation is safe at this level.
• There are 4 "planes" described for this stage.
Plane 1
• there is still regular spontaneous breathing, constricted pupils, and central
gaze. However, eyelid, conjunctival, and swallow reflexes usually disappear in
this plane.
Plane 2
• there are intermittent cessations of respiration along with the loss of corneal
and laryngeal reflexes. Halted ocular movements and increased lacrimation
may also occur
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Plane 3
• marked by complete relaxation of the intercostal and abdominal
muscles and loss of the pupillary light reflex.
• This plane is called "true surgical anesthesia" because it is ideal for
most surgeries.
Plane 4
• marked by irregular respiration, paradoxical rib cage movement,
and full diaphragm paralysis resulting in apnea

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Stage 4 - Overdose
• This stage occurs when too much anesthetic agent is given relative to
the amount of surgical stimulation, which results in the worsening of an
already severe brain or medullary depression.
• This stage begins with respiratory cessation and ends with potential
death.
• Skeletal muscles are lax, and pupils are fixed and dilated at this stage.
• Blood pressure is typically significantly lower than normal, with weak
and thready pulses
• Without cardiovascular and respiratory support, this stage is lethal.

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Balanced Anesthesia
• Anesthesia with a single agent can often require doses that produce
execissive hemodynamic depression.
• Alternatively, a balanced anesthesia can be used to more selectively
direct different components of anestehsia.
• It is the concept of using the combination of drugs and techniques to
provide
• Analgesia
• Amnesia
• Muscle Relaxation
• Abolition of autonomic reflexes with
maintainance of homeostasis

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Physiologic Signs of Loss of Conciousness
• Following administration of IV hypnotic drug to induce GA the following
signs are observed
• If asked to count backwards from 100, the patient typically does not get
beyond 85 to 90.
• This transition into unconsciousness can be followed easily by asking the
patient to perform smooth pursuit of the anesthesiologist’s finger.
• the lateral excursions of the eyes during smooth pursuit decrease,
nystagmus may appear, blinking increases, and the eyes fix abruptly in the
midline.
• The oculocephalic reflex and the corneal reflex are lost, but the pupillary
response to light can remain intact.
• The patient typically becomes apneic, atonic, and unresponsive at the point
when the oculocephalic reflex is lost
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• The oculocephalic reflex is assessed by turning the patient’s head from side to side, while lifting
the eyelids.
• Before administration of the induction anesthetic, when the reflex is intact in a patient with no
neurologic deficits, the eyes move in the direction opposite the motion of the head. When the
reflex is lost, the eyes stay fixed in the midline.
• The oculocephalic reflex requires the circuits of cranial nerves III, IV, VI, and VIII to be intact. The
motor nuclei associated with cranial nerves III and IV are located in the midbrain, whereas the
nucleus of cranial nerve VI is located in the pons.
• An easier way to assess the reflex is to allow a drop of sterile water to fall on the cornea.
• the reflex is intact if the eyes blink consensually, is impaired if there is a blink in one eye and not
the other, and is absent if there is no blink.
• The afferent component of the corneal reflex travels to the sensory nucleus of the cranial nerve V
through the ophthalmic branch, whereas the efferent component arises from the motor nucleus
of the cranial nerve VII.
• The nuclei for these nerves associated with the oculocephalic reflex and the corneal reflex lie in
close proximity to the arousal centers in the midbrain, pons, hypothalamus, and basal forebrain

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• Apnea, is most likely due to the inhibitory effects of the anesthetic on
the dorsal and ventral respiratory groups in the medulla and pons,
respectively.
• Atonia can effect onthe motor pathways between the primary motor
areas and the spinal cord.
• The most likely brainstem sites are the pontine and medullary
reticular nuclei.

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• Loss of the oculocephalic reflex, the corneal reflex, apnea, and atonia
occur concomitantly with loss of consciousness on induction of
general anesthesia because of the actions of the hypnotic drug in the
brainstem after an intravenous bolus.
• Blood containing the anesthetic reaches the brainstem through the
basilar artery, which supplies the posterior cerebral arteries that
provide the posterior input to the circle of Willis.
• Before terminating in the posterior cerebral arteries, the basilar
artery runs on the dorsal surface of the brainstem and gives off
multiple penetrating arteries that perfuse the brainstem nuclei with
the anesthetic leading to the observed physiological effects.

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Phases of Emergence from GA
E

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What is awareness
• It is the ability to recall events occurring under general anesthesia.
• Patients may be awake but paralyzed during operation.
• They might or might not experience pain.
• As a result of this patients might have psychological trauma for many years
after the event.
• As the depth of anesthesia increase, there will be
• loss of consciousness,
• loss of recall and
• loss of reflex.
• It is important to find the right depth to prevent over dose or inadequate
anesthesia causing awareness.
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Under general anesthesia patient may experience
• unconsciousness, non paralysis and painlessness
• unconsciousness, paralysis and painlessness
• consciousness, paralysis and painlessness
• consciousness, paralysis and in pain
• consciousness, non paralysis and in pain
• And This can be assessed Using different parameters

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How to Assess Depth of Anesthesia
Depth of anesthesia can be assessed by
• CLINICAL PARAMETERs
• Heart rate
• Blood pressure
• Sweating
• Lacrimation
• ECG
•

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These clinical parameters are the least informative as they affected by other
factors such as:
• hypovolemia
• hypoxia
• sepsis
• hypoglycemia
• Isolated fore arm technique
• ECG monitoring
• MAC-minimum alveolar concentration

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Monitored Anesthesia Care (MAC)
• Monitored anesthesia care is a specific anesthesia service in which
an anesthesiologist has been requested to participate in the care
of a patient undergoing a diagnostic or therapeutic procedure
• and includes all the usual aspects of anesthetic care—a
preprocedure evaluation, intraprocedure care, and postprocedure
management.
• Monitored anesthesia care is provided by a qualified
anesthesiologist,
• thus can safely encompass the complete spectrum of sedation
from light sedation/analgesia to conversion to general anesthesia
if required.
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Introduction to Regional
Anesthesia

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DEFINITION

• Rendering a specific area of the body(e.g. foot, arm, lower

extremities,…)insensitive to stimulus of surgery or other instrumentation.

• Produces transient loss of sensory, motor, and autonomic function when the

drugs are injected or applied in proximity to neural tissue.

• Reversible loss of sensation in a portion of the body.

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Types of Regional Anesthesia

• Central neuraxial blocks

• Peripheral nerve block

• Local infiltration

• Topical anesthesia

• Intravenous regional anesthesia (bier's block)

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Peripheral Nerve Blocks
Upper Extremity Blocks
• Interscalene, supraclavicular, suprascapular, Axillary, Infraclavicular, Distal Extremity Blocks(median, radial and ulnar
nerve blocks at the elbow and wrist), wrist block, Digital Block, Intravenous regional block
Lower Extremity Blocks
• Lumbar plexus block, Inguinal Perivascular block(3 in 1), psoas compartment block, sciatic block , femoral block,
lateral femoral cutaneous nerve block, Obturator block , Popliteal and saphenous block, adductor canal block ,,
ankle block
Head and Neck Blocks
• Retroorbital(peribulbar block), cervical plexus block, satellite ganglion block
Airway Blocks
• Glossopharyngeal block, superior laryngeal nerve block, trans laryngeal block
Truncal Blocks
• Pecs and pecto intercostal blocks, serratus anterior block , intercostal block , paravertebral block, erector spinae
plane block, rectus sheath block, Tap block, subcostal tap block, quadratus lumborum blocks

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NEURAXIAL BLOCKS

1. Spinal
2. Caudal
3. Epidural

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Spinal Anesthesia

• Is the injection of small amounts of local anesthetics into the

subarachnoid space ( CSF ) at the level below ( L2 ) ,where the
spinal cord ends to produce a reversible loss of sensation and
motor function.

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Anatomy of vertebrae
• 33 Vertebrae
◦ 7 Cervical
◦ 12 Thoracic
◦ 5 Lumbar
◦ 5 Sacral
◦ 4 Coccygeal

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• Dura Mater
◦ Outer most layer
◦ Fibrous
• Arachnoid
◦ Middle layer
◦ Non-vascular
• Pia
◦ Inner most layer
◦ Highly vascular
• Sub Arachnoid Space
◦ Lies between the arachnoid
and pia

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• 5 ligaments hold the spinal column together;
1. supraspinous,
2. interspinous,
3. ligament flavumm.
4. Anterior &
5. posterior ligaments

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Anatomical Layers
• Skin
• Subcutaneous fat
• Supraspinous
• Interspinous
• Ligamentum flavum
• Epidural space
• Dura matter
• Subdural space
• Arachnoid matter
• Sub-arachnoid space
• Pia

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12/23/2024 INTRODUCTION TO ANESTHESIA 83
• Generally Spinal anesthesia is used for surgical procedures below
the umbilicus.
✓Involves Injection of local anesthetics below spinal cord at subarachnoid
space(in to CSF) as a result it is also know as subarachnoid, intradural,
intrathecal injection
✓Depending on local anesthesia used it can last up to 3 hours
✓Patient selection is vital
✓Preoperative assessment should be done.

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• The spinal cord is continuous with the brainstem proximally and terminates
distally in the conus medullaris as

• the filum terminale (fibrous extension) and

• the cauda equina (neural extension).

• This distal termination varies from L3 in infants to the lower border of L1 in

adults because of differential growth rates between the bony vertebral canal
and the central nervous system.

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Epidural Anesthesia(extradural)
• Local anesthesia injected into extra dural space.
• Needs more drug than spinal due to large area
• Relative to spinal anesthesia, it
➢ Has Slow onset
➢Requires large dose
➢block can be any where from cervical- caudal

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Caudal Anesthesia
• Most commonly used for pediatric patients.
• It may also be used in anorectal surgery in adults.
• The caudal space is the sacral portion of the epidural space.
• Involves needle and/or catheter penetration of the sacrococcygeal
ligament covering the sacral hiatus that is created by the unfused
S4 and S5 laminae.

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Drugs Used for Regional Anesthesia
Physiochemical Properties of Local Anesthetics
The typical local anesthetic molecule structure consists of 3 parts
1.Aromatic group
• a lipophilic (membrane-liking) character to its portion of the molecule
• usually unsaturated benzene ring.
2.Intermediat bond-
• hydrocarbon containing chain, either an ester(-co) or amide(-HNC) linkage
• used to classify local anesthetics.
3. Tertiary amine- base (proton acceptor).
• Relatively hydrophilic,.
• Local anesthetics block voltage-gated sodium channels and thereby
interrupt initiation and propagation of impulses in axons

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Advantages and Disadvantages of Neuraxial Blockade

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INDICATION OF REGIONAL
ANESTHESIA
• Any surgery below the umbilicus
• Appendectomy
• Gyne/obs surgery
• Hemorrhoidectomy
• Orthopedic surgery fixation
• surgery involving extremities
• Pain control during labor

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Contraindications for Neuraxial
Blockade
Absolute Contraindications
• There are few absolute contraindications to neuraxial blockade.
• Some of the most important include
• patient refusal
• localized sepsis
• allergy to any of the drugs planned for administration.
• A patient’s inability to maintain stillness during needle puncture, which
can expose the neural structures to traumatic injury
• as well as raised intracranial pressure, which may theoretically
predispose to brainstem herniation

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Relative Contraindications
• Neurologic
• Myelopathy or Peripheral Neuropathy
• Spinal Stenosis
• Spine Surgery
• Multiple Sclerosis
• Spinal Bifida
• Cardiac
• Aortic Stenosis or Fixed Cardiac Output
• Hypovolemia
• Hematologic
• Thromboprophylaxis
• Inherited Coagulopathy
• Systemic Infection

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MANAGEMENT OF REGIONAL
ANESTHESIA
• PREOPERATIVE
• Preoperative assessment
• Acquisition of Informed Consent
• Prophylactic transfusion of Fluids( preload) for patients with
Hypovolemia/ at an increased risk of Hypovolemia prior to
administration of spinal and epidural block
• Preparing drugs and equipment's for general anesthesia as
well.

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• INTRAOPERATIVE
• close monitoring of the patient
• Maintaining Sterility during the procedure
• Assessment of the degree of block

•POSTOPERATIVE
• Close monitoring and supervision
• Identification and early treatment of Complications

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Complications
Neurologic • Infection
• Paraplegia • Bacterial Meningitis
• Cauda Equina Syndrome • Epidural Abscess
• Epidural Hematoma • Aseptic Meningitis
• Nerve Injury • Backache
• Arachnoiditis
• Post Dural Puncture Headache • Nausea and Vomiting
• Transient Neurologic Symptoms • Urinary retention
Cardiovascular • Pruritis
• Hypotension
• Bradycardia
• Shivering
• Cardiac Arrest • Wrong Route Administration
• Respiratory • Local Anesthesia Systemic Toxicity
• Respiratory Depression • Total and High Spinal

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SIGNS AND SYPTOMS OF TOXICITY(LAST)

• Systemic reactions to local anesthetics primarily involve the CNS and the CVS.
• In general, the CNS is more susceptible to the actions of systemic local anesthetics.
• The initial symptoms of CNS toxicity
• feelings of lightheadedness and dizziness , Metallic taste , Perioral tingling
• followed by visual and auditory disturbances such as difficulty focusing and tinnitus.
• Other subjective CNS symptoms include disorientation and occasional feelings of
drowsiness.
• Objective signs of initial CNS toxicity are usually excitatory in nature and include shivering,
muscular twitching, and tremors initially involving muscles of the face and distal parts of the
extremities.
• Ultimately, generalized convulsions of a tonic-clonic nature occur.
• CVS Toxicity
Ventricular Arrythmia , Ventricular
•12/23/2024 I N T Fibrillation
R O D U C T I O N finally
T O A N ECardiac
S T H E S I A Arrest 100
PREVENTION OF TOXICITY

• Calculating Maximum Safe dose before administration of drug

• Aspiration through the needle/catheter before injection
• Administering a test dose containing adrenaline before injection
of drug
• Slow injection of drug

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TREATMENT OF TOXICITY

• Administration of 100% oxygen Via facemask to correct Hypercapnia

and acidosis as well as Hypoxemia which if not treated could further
exacerbate CNS Toxicity
• Circulatory Support
• Management of convulsion( using Midazolam, Thiopentone, Propofol)
• Intubation of the airway and mechanical ventilation in severe cases
• In case of severe cardiovascular depression or cardiac arrest
• Initiate BLS Or ACLS ( initiate Cardiopulmonary Resuscitation)
• Followed by rapid bolus of Intralipid 20%, 1.5 mL/ kg (approximately
100 mL in adults), followed if necessary by an infusion of 0.25
mL/kg/min over the next 10 minutes.( in case of cardiotoxicity)
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Peripheral nerve blocks
• An understanding of regional anesthesia anatomy and techniques
of the well required well-rounded anesthesiologist.
• The selection of a regional anesthetic technique is a process that
begins with a thorough history and physical examination.

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• The risk–benefit ratio often favors regional anesthesia in patients
with multiple comorbidities for whom a general anesthetic carries
a greater risk.
• In addition, patients intolerant to systemic analgesics (e.g., those
with obstructive sleep apnea or at high risk for nausea) may
benefit from the opioid-sparing effects of a regional analgesic.

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Block Techniques
FIELD BLOCK TECHINQUE
• A field block is a local anesthetic injection that targets terminal
cutaneous nerves
• Field blocks are used commonly by surgeons to minimize
incisional pain and may be used as a supplementary technique or
as a sole anesthetic for minor, superficial procedures.

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Paresthesia technique
• Formerly the mainstay of regional anesthesia, this technique is
now rarely used for nerve localization.
• Using known anatomic relationships and surface landmarks as a
guide, a block needle is placed in proximity to the target nerve or
plexus.
• When a needle makes direct contact with a sensory nerve, a
paresthesia (abnormal sensation) is elicited in its area of sensory
distribution.

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Nerve stimulation Technique
• For this technique, an insulated needle concentrates electrical
current at the needle tip, while a wire attached to the needle hub
connects to a nerve stimulator—a battery-powered machine that
emits a small amount (0–5 mA) of electric current at a set interval
(usually 1 or 2 Hz).

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Ultrasound Technique
• Ultrasound for peripheral nerve localization is becoming
increasingly popular; it may be used alone or combined with
other modalities such as nerve stimulation.
• Ultrasound uses high-frequency (1-20MHz) sound waves emitted
from piezoelectric crystals that travel at different rates through
tissues of different densities, returning a signal to the transducer

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Upper Extremity Blocks
• Interscalene
• supraclavicular
• Suprascapular
• Axillary
• Infraclavicular
• Distal Extremity Blocks(median, radial and ulnar nerve blocks at the elbow
and wrist),
• wrist block,
• Digital Block,
• Intravenous regional block

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 Upper extremity
block anatomy
Anatomy of
Brachial Plexus

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Lower Extremity Blocks
• Lumbar plexus block
• Inguinal Perivascular block(3 in 1),
• psoas compartment block,
• sciatic block,
• femoral block,
• lateral femoral cutaneous nerve block,
• Obturator block ,
• Popliteal and saphenous block,
• adductor canal block
• ankle block

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Lower extremity block anatomy
Anatomy of Lumbar Plexus

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 Local Infiltration
• Is a technique of producing loss -of- sensation restricted to a
superficial, localized area in the body.
• Epinephrine added to the solution can prolong the anesthetic
effects, but this added epinephrine can cause ischemia in some
areas (finger tips,penis…)

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Topical Anesthesia
• Topical anesthetic is a local that is used to numb the surface of
the body part.
Indications
• Venipuncture and intra arterial catheterization
• Bronchoscopy
• Ophthalmology procedures
• Urologic and gynecologic examination

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 References
• Michael Gropper Lars Eriksson Lee Fleisher Jeanine Wiener-Kronish Neal
Cohen Kate Leslie. Miller’s Anesthesia. 9th ed. Elsevier Saunders,2019.
• Bruce F. Cullen, M. Christine Stock, Rafael Ortega, Sam R. Sharar,
Natalie F. Holt, Christopher W. Connor, Naveen Nathan, Barash, Cullen,
and Stoelting's Clinical Anesthesia.9th ed. Wolters Kluwer,2024.
• Ehab Farag, Loran Mounir-Soluman, David L. Brown. Brown’s Atlas of
Regional Anesthesia. 6th ed. Elsevier, 2021.

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THANK YOU

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