An elderly man with type 2 diabetes mellitus and ischemic pain in a lower extremity is scheduled for femoral-to-popliteal artery bypass surgery. He has a history of hypertension and coronary artery disease with symptoms of stable angina. He can walk only half a block before pain in his legs forces him to stop. He has a 50-pack-year smoking history but stopped 2 years ago. Medications include atenolol, atorvastatin, and hydrochlorothiazide.
The nurse in the preoperative holding area obtains the following vital signs: temperature 36.8°C (98.2°F), blood pressure 168/100 mm Hg, heart rate 78 bpm, oxygen saturation by pulse oximeter 96% while breathing room air; he reports pain 5/10 in the right lower leg after walking into the hospital. What anesthetic agents will you choose for his anesthetic plan? Why? Does the choice of anesthetic make a difference?
For centuries, humans relied on natural medicines and physical methods to control surgical pain. Historical texts describe the sedative effects of cannabis, henbane, mandrake, and opium poppy. Physical methods such as cold, nerve compression, carotid artery occlusion, and cerebral concussion were also employed, with variable effectiveness. Although surgery was performed under ether anesthesia as early as 1842, the first public demonstration of surgical general anesthesia in 1846 is generally accepted as the start of the modern era of anesthesia. For the first time, physicians had a reliable means to keep their patients from experiencing pain during surgical procedures.
The neurophysiologic state produced by general anesthetics is characterized by five primary effects: unconsciousness, amnesia, analgesia, inhibition of autonomic reflexes, and skeletal muscle relaxation. None of the currently available anesthetic agents used alone can achieve all five of these desired effects well. An ideal anesthetic drug should also induce rapid, smooth loss of consciousness, be rapidly reversible upon discontinuation, and possess a wide margin of safety.
The modern practice of anesthesiology relies on the use of combinations of intravenous and inhaled drugs (balanced anesthesia techniques) to take advantage of the favorable properties of each agent while minimizing their adverse effects. The choice of anesthetic technique is determined by the type of diagnostic, therapeutic, or surgical intervention that the patient needs. For minor superficial surgery or invasive diagnostic procedures, oral or parenteral sedatives can be combined with local anesthetics in a technique termed monitored anesthesia care (MAC) (see Box: Sedation & Monitored Anesthesia Care, and Chapter 26). This approach can provide profound analgesia, while retaining the patient’s ability to maintain a patent airway and to respond to verbal commands. For more invasive surgical procedures, anesthesia may begin with a preoperative benzodiazepine, be induced with a rapidly acting intravenous drug (eg, propofol or thiopental), and be maintained with inhaled agents (eg, volatile agents, nitrous oxide), intravenous drugs (eg, propofol, opioid analgesics), or both.
Sedation & Monitored Anesthesia Care
Many diagnostic and minor therapeutic surgical procedures can be performed without general anesthesia ...