Various type of anaestheisa used in plastic surgery

1. ANAESTHESIA IN PLASTIC
SURGERY
Dr Saurabh Garg

2. Anaesthesia
 Derived from Greek word ANAISTHESIS
which means No Sensation
 It include
 Analgesia
 Amnesia (loss of memory)
 Sedation or Unconsciousness
 Paralysis (muscle relaxation)

4. MAC

5. Local Anaesthetics
 These agent block the conduction of nerve
impulse reversible
 Classified in 2 groups
On the basis of the type of linkage between
aromatic and amine portions
 Amide
 Ester

6. Amide Group
 Moderate to fast Onset
 Low chances of allergic reaction
 Systemic toxicity high
 It Includes
 Lidocaine
 Bupivacaine
 Ropivacaine
 Mepivacaine
 Prilocaine

7. Ester Group – Not Commonly
Used
 Slow Onset
 High chances of allergic reaction
 It Includes
 Cocaine
 Procaine
 Chloroprocaine
 Tetracaine
 Benzocaine

8. Classification – Based On
Duration
 Short Acting
 Chloroprocaine (Shortest Acting 15-25mins)
 Procaine (15-30 mins)
 Intermediate Acting (30-60 mins)
 Lignocaine
 Prilocaine
 Cocaine
 Long Acting (2-3 hours)
 Bupivacaine, Ropivacaine

9. Mechanism of Action
 Blocks the sodium channel from intracellular
side

10. Role of Adrenaline
 Most Commonly Used 1 in 200000
Advantages
 Increase the duration
 Reduce the systemic absorption
 Decrease bleeding
 Improve quality of block

11. Role of Soda Bicarb
 Soda Bicarb
(1 ml of 8.4% to 10ml Lignocaine)
 Enhance the onset of action
 Increases duration of action
 Decreases pain of injection
 Improve quality of block

12. Max Dose
Max Dose Duration of
action
Max Dose Duration of
action
Plain Plain With ADR With ADR
Lignocaine 3mg/kg 30mins – 2 hrs 7mg/kg Upto 3 hrs
Bupivacaine 2mg/kg 2-4 hrs 3mg/kg 3-4 hrs
Ropivacaine 3mg/kg 2-6 hrs NA NA

17. Dose Formula
Max Safe dose Body Weight (kg) 1
of LA(mg/kg) 10 Concentration
%(mg/ml)
mg kg 1
kg 10 mg/ml

18. For 60 Kg Person
Lignocaine (2%) - 3 x 60/10 x ½ = 9ml
Lignocaine (2%) – 7 x 60/10 x ½ = 21ml
with Adr
Bupivacaine (0.25%) – 2 x 60/10 x 1/0.25 = 48ml
Rupivacaine (0.2%) – 3 x 60/10 x 1/0.2 = 90ml

19. Adverse Effects
 Cardiac Toxixity
 CNS Toxicity
 Allergic Reaction
 Toxicity is proportional to dose of drug

20. Cardiac Toxixity
 Hypotension – All are vasodilators – except
Cocaine, Ropivacaine & Levobupivacaine
 Bradycardia
 Arrythmias
 Cardiac Arrest
Bupivacaine has high cardiac toxicity among all
 Slow reversible block of sodium channels
 High negative inotropic effect & conductive block

21. CNS Toxixity
Circumoral and/or tongue numbness
Lightheadedness & Dizziness
Disorientation
Drowsiness
Unconsciousness

22. Management of CVS & CNS
Toxicity
 Stop LA Injection
 Secure ABC
 Seizures: Diazepam/Phenytoin
 Hypotension: Vasopressors
 Lipid Emulsion :
 20% intralipid
 Bolus 1.5 mL/kg over 1 min
 Continous infusion 0.25 – 0.5 mL/kg for 10 min
 Repeat bolus once or twice if persistent
cardiovascular collapse
 Act by creating Lipid Sink – Absorb the lipophilic LA

23. Allergic reactions
 Rare
 May range from allergic dermatitis to anaphylaxis
 Occur most often by ester-type drugs
 Management
 Mild – Antihistaminic – Chlorpheniramine (10-
20mg)
 Moderate – Severe
 IV Fluids (25-50ml/kg crystalloids)
 Antihistaminic (Chlorpheniramine 10-20mg IM/IV)
 Steroids (Hydrocortisone100-300mg IM/IV)
 Adrenaline (0.5ml 0f 1:1000 Solution IM)

25. Topical/ Surface Anaesthesia
 It Includes topical application
 Mucous Membranes – Mouth, Pharynx & Larynx
 4% Xylocaine spray
 Tetracaine & benzoczine lozenges
 For Nasal Mucosa
 4 % Lidocaine – 0.05 % Oxymetazoline combination
 For Catheterization
 2% Xylocaine Jelly

26. Skin Surface Application
 Eutectic mixture of local anesthetics (EMLA)
 2.5% lidocaine & 2.5% prilocaine
 5% lidocaine - prilocaine cream
 Eutectic mixtures exist as liquids that melt at
lower temperatures than their single
components

27. Regional Anasthesia
Peripheral
Nerve
Blocks
Ganglion
or Plexus
Block
Bier’s
Block
Epidural Spinal

28. Peripheral Nerve Blocks
 Head & Neck
 Upper Limb
 Lower Limb
 Trunk

29. Head & Neck Nerve Blocks

30. Supraorbital & Supratrochlear Nerve Block
 Both are branch of
frontal nerve
 This block is used for
forehead
anaesthesia

31. Supraorbital Nerve Block
•Palpate the supra orbital
notch with one finger &
distract the brow laterally
with thumb
•Needle is inserted in
middle 1/3rd of brow or in
vertical plane of medial
limbus or approx 27 mm
from glabellar midline
•Needle is directed toward
the notch

32. Supratrochlear Block
 1 cm medial to the
point of supraorbital
block or 17 mm
lateral from from
glabellar midline

33. Infratrochlear Nerve
 Branch of nasociliary nerve
 Supply medial upper eyelid,
medial canthus, medial
nasal skin, and lacrimal
apparatus
 Infratrochlear nerve is
blocked by injecting 1–2 ml
of local anesthetic solution
at the junction of the orbit
and the nasal bones

34.  All three of these nerves by simply injecting 2–
4 ml of local anesthetic solution from the
central brow proceeding to the medial brow

35. Infra Orbital Nerve Block
Infraorbital nerve block will
anaesthetize the lower
palpebral area, lateral nasal
area, infraorbital cheek and
suprerior labial regior
Techniques
1. Intra Oral Approach
2. Facial Approach

36. Intra Oral Approach
The lip is elevated needle is inserted in
the mucosa opposite to the upper
second premolar approximately 0.5 cm
from the buccal surface
Needle is advance upward toward
medial limbus
Other hand must constantly palpate the
inferior orbital rim to prevent inadvertent
injection into the orbit

37. Facial Approach
Infraorbital foramen is palpated
first – present 5-9mm below
infraorbital rim in a vertical
place of medial limbus in
forward gaze
Needle is directed towar the
medial limbus & advanced
untill foramen is entered or
bony contact felt
Other hand must constantly
palpate the inferior orbital rim
to prevent inadvertent injection

38. Infra Alveolar Nerve Block
Branch of Mandibular Nerve (V3)

39.  Use the non-dominant
hand to retract the buccal
soft tissue
 Thumb in coronoid notch
of mandible
 Index finger on posterior
border of extraoral
mandible

40.  Approach area of injection from contralateral
premolar region

41.  Area of injection
 6-10 mm above the
occlusal table of the
mandibular teeth
 Just lateral to the
pterygomandibular raphe

42. Mental Nerve Block
 The lower lip is retracted
 the needle is introduced
through the mucosa in the
gb sulcus opposite to
second premolar
 The needle is directed
downward and Slightly
posteriorly toward the
mental foramen

43. Greater Palatine Nerve Block
 Branch of the
maxillary division of
the trigeminal nerve
 Anesthetize all
maxillary teeth
posterior to canine
and corresponding
alveolus & palate

44. Technique
 Area of insertion is 1cm
medial from upper 2nd
molar on the hard
palate
 Depth is usually less
than 10mm

45. Nasal Blocks
 External
 Internal

46. Dorsal Nasal Nerve Block
 External branch of Ant Ethmoid Nerve
(Nasociliary Nerve)
 Supply lateral nasal wall, ala, vestibule, tip &
anterior sseptum
 Block at 5-10mm lateral to distal end of nasal
bone

47. Nasopalatine nerve
 Branch of the maxillary
division
 mucous membrane of the
nasal septum maxillary
anterior teeth (central
incisors, lateral incisors,
and the canine) &
adjacent palate

48.  Target Area –Incisive
papilla - Projection on
the palate behind
incisors
 Needle is inserted just
lateral to papilla
 Alternative Technique
 Injection between the
base of the columella
and nasal tip

49. Ear Block

50. Great Auricular
1.5cm behind
ear at level of
tragus
Auriculotemporal
1.5 cm anterior
to tragus

51. Auricular branch of the vagus
nerve Block

52. Field Block

53. Greater & Lesser Occipital
Nerve
 Landmarks
 External occipital
protuberance
 Mastoid Process
 Draw a line between these
two point
 GON lies at 1/3 rd of line
closer to the occiput
 LON lies at 2/3 rd along the
line closer to the mastoid
process

54. Scalp
 The “scalp block” is classically blockade of
seven nerves
 Greater occipital
 Lesser occipital
 Great auricular
 Auriculotemporal nerve
 Supraorbital
 Supratrochlear nerves
 Zygomaticotemporal nerve

55. Upper Limb Blocks
 Digital Blocks
 Wrist Block
 Elbow Blocks
 Brachial Plexus blocks

56. Digital Blocks
 Web Block Techniques
 The hand is pronated and rested on a flat surface
 Hold the syringe perpendicular to the digit and
insert the needle into the web space, just distal to
the metacarpal-phalangeal (MP) joint

58. Transthecal or Flexor tendon
Sheath Block
 The hand is supinated
and rested on a flat
surface
 Locate the flexor tendon
sheath by palpating it at
the distal palmar crease
 Insert the needle at a 45-
degree angle just distal
to the distal palmar
crease
 The needle is advanced
to the level of the flexor
tendon sheath – Free
Flow of LA

59. Other Techniques
 3 Sided Block
 4 Sided Block

60. Wrist Block
 Median Nerve
 Between the tendons of
palmaris longus and flexor
carpi radialis

61.  Oppose the thumb to the tip of
the little finger, press hard and
flex the wrist
 PL Tendon felt in the centre of
wrist
 For FCR flex wrist against
resistance and slightly radially
deviate

62. Ulnar Nerve
 Needle inserted under the
tendon of the flexor carpi
ulnaris muscle
 Just above the pisiform
bone

63. Radial Nerve
 Field block at
subcutaneous level
in & around
anatomical snuff
box
 Fan Technique

64. Elbow Block
 Rarely used

65. Lower Limb Block
 Femoral Nerve Block
 Lateral Cutaneous Nerve Block
 Popliteal Block
 Ankle block

66. Femoral Nerve Block
 Supine with both legs
extended
 Femoral crease and
the femoral artery
pulse.
 Immediately lateral to
the femoral artery

67. USG Guided Block
 Decreased Incidence of vascular puncture.
 Less local anesthetic needed

68. Lateral Femoral Cutaneous
Nerve
 Position – Supine
 Landmarks
 ASIS
 Inguinal Ligament
 Needle entry Point
 2cm below & medial to
ASIS
5-10 ml of rupivacaine or
bupivacaine

69. Popliteal Block
 Two Approach
 Posterior Approach
 Lateral Approach

70. Posterior Approach
 Prone position
 7 cm above the popliteal crease at the
midpoint between the two tendons.

71. Lateral Approach
 The landmarks
 VL, BF & Popliteal
Fossa Crease
 8 cms above crease
between VL & BF
groove POI
8 cms

72.  The needle is inserted in a horizontal plane
and perpendicular to the groove till it hit femur
 After femur contact, the needle is then
withdrawn to skin level, redirected 30º
posterior to the angle at which the femur was
contacted, and advanced toward the nerve
 The depth of the sciatic nerve is typically 1 to 2
cm beyond the skin-femur distance.

73. USG guided popliteal block
 Sciatic nerve is lateral
to popliteal artery

74. Ankle Block
 Block of the four distal
branches of the sciatic
nerve
 Deep and superficial
peroneal,
 Tibial
 Sural
 One cutaneous
branch of the femoral
nerve(saphenous)

75. Deep Peroneal Nerve
 Immediately lateral to
EHL tendon needle is
advanced through the
skin till bone
 A “fan” technique is
utilized for LA injection

76. Posterior Tibial Nerve
 Block by injecting just
behind the medial
malleolus by Fan
Technique

77. Superficial Peroneal, Sural and
Saphenous Nerves
 All three nerves are
blocked by
circumferential injection
of local anesthetic
subcutaneously at the
level of the medial and
lateral malleolus

78. Tumescent Anaesthesia
 Tumescent lidocaine solution contains
 20-30 ml of 2% lidocaine (Max)
 1 ml adrenaline 1:1000
 10 ml (10 mEq) of 8.4 % sodium bicarbonate
 Added to 1000 ml NS
 American Society for Dermatologic Surgery
recommended that the maximal safe dosage
of tumescent lidocaine for liposuction totally by
local anesthesia is 55 mg/kg

79. Biers Block
 Indications
 Short operative procedures for the extremities (30-45
mins)
 Effect came in 3-4 mins
 For surgies below elbow or below knee
 Drugs used
 1-2 % Lignocaine – 10-15ml
 0.5 % Lignocaine – 30-40ml

80. Insert IV
Cannula 20-22
G in Hand
Apply double
pneumatic
Tourniquet in arm
Elevate arm for 1
min
Apply Esmarch
bandage from
distal to proximal
direction

81. Inflate cuff 100
mmhg above
systolic BP
Remove the
Esmarch bandage
Limb should be
pale with absent
pulsations
Inject 10-15ml of
1-2% Lignocaine
or 30-40ml of
0.5%

82. If patient
have
tourniquet
pain
Inflate the
proximal cuff &
deflate the
distal cuff
Inject 10-15ml
of 1-2%
Lignocaine or
30-40ml of
0.5%

83. MAC (Monitored Anaesthesia
Care)
 Conscious Sedation
 Minimal depressed level of consciousness
 Patient independently maintain airway
 Responds to physical & verbal stimuli
 Goals
 To reduce pain & minimize discomfort
 To minimize the anxiety
 To improve patient safety
 Used alone or supplement LA or Regional

84. Drugs Used
 Propofol
 Initial Bolus – 0.5mg/kg then 10mg intermittent
bolus if required
 Alternative – Continuous infusion at 4ml/kg/hr
 Benzodiazepines
 Anxiolytic & hypnotic property
 Midazolam is preferred (Optimal dose 3mg)

85.  Ketamine
 Weak sedation & good analgesia
 Dose -0.5 – 1mg/kg
 Bad dream & hallucination usually doesnot occur
at this dose

86. Pedicloryl
 Infants – 25-30mg/kg
 1-5 Years – 250-500mg
 > 5 Years – 500-1000mg

87. General Anasthesia

88. 88
General Anaesthesia (GA)
ANALGESIA
AMNESIA
SEDATION/
UNCOUNCIOUSNESS
Muscle
Relaxation
 Four Components
 Analgesia
 Amnesia
 Sedation/Unconsciousn
ess
 Muscle Relaxation

89. 89
Postoperative Analgesia
• Oral pain relief medications
• Paracetamol and NSAIDS such as
ibuprofen.
Minor surgical
procedures
• Addition of mild opiates such as
Tramadol
Moderate
surgical
procedures
• Combination of modalities
• Patient Controlled Analgesia System
(PCA) involving morphine
Major surgical
procedures

90. Patient Controlled Analgesia
 Basic Concept
 when I feel pain, I press a button
 PCA involve on demand, intermittent self
administration of analgesic by a patient
 Dose is predetermined
 Drugs used
 Morphine
 Fentanyl

92. Morphine Fentanyl
Loading Dose 2mg/ml 20-25mcg/ml
Bolus 1mg/ml 10mcg/ml
Locking Period 8 mins 6 mins
Max Dose & Duration 15 -20 mg /4hrs 200-250mcg/4hr

93. Thanks