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The AutonomicThe Autonomic
Nervous System AndNervous System And
Its Implications InIts Implications In
AnaesthesiaAnaesthe...
 IntroductionIntroduction
 AnatomyAnatomy
 PhysiologyPhysiology
 Drugs acting on ANSDrugs acting on ANS
 Tests for au...
INTRODUCTIONINTRODUCTION
Anesthesiologists manipulate the physiology andAnesthesiologists manipulate the physiology and
ph...
ANATOMYANATOMY
 ComprisesComprises all afferent fibresall afferent fibres from the CNSfrom the CNS
except those supplying...
Sympathetic Nervous SystemSympathetic Nervous System
 Originates from theOriginates from the Thoraco-lumbarThoraco-lumbar...
 PairedPaired sympathetic chains havingsympathetic chains having 22 paired ganglia22 paired ganglia
 UnpairedUnpaired prevertebral ganglia in the abdomen andprevertebral ganglia in the abdomen and
pelvispelvis
 CeliacCel...
 Terminal or collateral gangliaTerminal or collateral ganglia
 Small and few in numberSmall and few in number
 PresentP...
PARASYMPATHETIC NERVOUSPARASYMPATHETIC NERVOUS
SYSTEMSYSTEM
 75% from75% from vagusvagus
 Arises fromArises from III, VI...
Preganglionic fibresPreganglionic fibres
arise fromarise from
CENTRALCENTRAL
 Edinger WestpalEdinger Westpal nucleus –nuc...
ENTERIC NERVOUS SYSTEMENTERIC NERVOUS SYSTEM
 FoundFound within the wallswithin the walls
of the GIT, pancreasof the GIT,...
PHYSIOLOGYPHYSIOLOGY
 EitherEither sympathetic or parasympathetic systemsympathetic or parasympathetic system
dominatesdo...
Target organTarget organ SNSSNS ReceptorReceptor PNSPNS
1.1. Hair follicleHair follicle
smooth musclesmooth muscle
2.2. Ir...
Target organTarget organ SNSSNS ReceptorReceptor PNSPNS
6. Sweat gland6. Sweat gland
7. Apocrine gland7. Apocrine gland
8....
Target organTarget organ SNSSNS ReceptorReceptor PNSPNS
9. Lungs9. Lungs
-Bronchi-Bronchi
-Blood vessels-Blood vessels
10....
Target organTarget organ SNSSNS ReceptorReceptor PNSPNS
15.Bladder15.Bladder
- Detrusor- Detrusor
- TrigoneTrigone
16. Ure...
Target organTarget organ SNSSNS ReceptorReceptor PNSPNS
19.Veins19.Veins
20.Blood20.Blood
21.Basal metab21.Basal metab
22....
Dominance at specific siteDominance at specific site
Parasympathetic :Parasympathetic :
 Ciliary muscleCiliary muscle
 I...
ANS of HeartANS of Heart
NeurotransmittersNeurotransmitters
 AcetylcholineAcetylcholine – Secreted by– Secreted by
**all preganglionic fibresall p...
 Acetylcholine receptors are of 2 types:Acetylcholine receptors are of 2 types:
-- MuscarinicMuscarinic: action similar t...
Action of Important Drugs on ANSAction of Important Drugs on ANS
Site of actionSite of action
1.Sympathetic1.Sympathetic
a...
Site of actionSite of action
3.Alpha receptors3.Alpha receptors
AgonistAgonist
Stimulate alpha1Stimulate alpha1
-methoxami...
Site of actionSite of action
4.Beta receptors4.Beta receptors
5.Domaninergic5.Domaninergic
receptorsreceptors
AgonistAgoni...
TESTS FOR AUTONOMICTESTS FOR AUTONOMIC
INTEGRITYINTEGRITY
Autonomic functions can be evaluated by:Autonomic functions can ...
HistoryHistory
CVSCVS (postural/orthostatic hypotension)(postural/orthostatic hypotension)
 Fainting episodesFainting epi...
CNSCNS (affection of fibres supplying iris)(affection of fibres supplying iris)
 Night-blindnessNight-blindness
Chronic d...
Non – invasive testsNon – invasive tests
Tests for cardiac vagal functionTests for cardiac vagal function
 Respiratory si...
Respiratory sinus arrhythmiaRespiratory sinus arrhythmia
 TestsTests parasympatheticparasympathetic functionfunction
 De...
Postural stress: Supine to standingPostural stress: Supine to standing
 Tests theTests the sympatheticsympathetic functio...
Cold Pressure testCold Pressure test
 Tests theTests the peripheral sympatheticperipheral sympathetic
vasoconstrictorsvas...
Isometric Hand grip ExerciseIsometric Hand grip Exercise
 Tests theTests the efferent sympatheticefferent sympathetic fun...
Vasalva ManouverVasalva Manouver
 Tests bothTests both sympathetic and parasympatheticsympathetic and parasympathetic fun...
 HR increasesHR increases 10to15secs after initiating blowing(PhaseII) and10to15secs after initiating blowing(PhaseII) an...
 To test cardiac vagal function a ratio has been devisedTo test cardiac vagal function a ratio has been devised
 Vasalva...
EPINEPHRINE TESTEPINEPHRINE TEST ––
 3 drops in eye at I min. interval 3 times3 drops in eye at I min. interval 3 times
...
EPHEDRINE TESTEPHEDRINE TEST ––
 Give 25mg imGive 25mg im
 Normal subjects = HR increasesNormal subjects = HR increases
...
Power Spectral Analysis of HRPower Spectral Analysis of HR
variabilityvariability
 Slower periodic oscillations in heart,...
 This frequency domain reveals aThis frequency domain reveals a consistant peakconsistant peak/ power at the breathing/ p...
INVASIVE TESTSINVASIVE TESTS
 Done to locateDone to locate precise siteprecise site of pathologyof pathology
 Done forDo...
OTHER TESTSOTHER TESTS
 Measurement of skinMeasurement of skin temperaturetemperature
 Tests forTests for sudomotorsudom...
ANAESTHESIA AND AUTONOMICANAESTHESIA AND AUTONOMIC
NERVOUS SYSTEMNERVOUS SYSTEM
GENERAL ANAESTHESIAGENERAL ANAESTHESIA
Pre...
 Pentazocine increases plasma catecholaminesPentazocine increases plasma catecholamines
 Fentanyl causes vagal bradycard...
Inhalational AgentsInhalational Agents ––
 Halothane, enflurane, isoflurane reduce pre-ganglionicHalothane, enflurane, is...
SPINAL ANAESTHESIASPINAL ANAESTHESIA
 Causes sympathetic blockade, hypotension andCauses sympathetic blockade, hypotensio...
• In low SAB sacral parasympathetic and lumbar plusIn low SAB sacral parasympathetic and lumbar plus
lower thoracic sympat...
Features of Autonomic Imbalance afterFeatures of Autonomic Imbalance after
Spinal AnaesthesiaSpinal Anaesthesia
CVSCVS
 H...
Autonomic reflexes duringAutonomic reflexes during
Anaesthesia and SurgeryAnaesthesia and Surgery
Oculocardiac reflexOculo...
Abdominal reflexAbdominal reflex ::
 Due to stimulation of ANS by traction orDue to stimulation of ANS by traction or
pre...
Recto – laryngeal reflexRecto – laryngeal reflex ::
 Caused by dilation of anal sphincter under GACaused by dilation of a...
ANS DYSFUNCTIONANS DYSFUNCTION
PRIMARY –PRIMARY –
 Idiopathic orthostatic hypotensionIdiopathic orthostatic hypotension
...
SECONDARY TO SYSTEMICSECONDARY TO SYSTEMIC
DISORDERSDISORDERS
 AgeingAgeing
 Diabetes MellitusDiabetes Mellitus
 Chroni...
AGINGAGING
 20% of people over 65yrs have20% of people over 65yrs have postural hypotensionpostural hypotension
 Symptom...
ALCOHOLISMALCOHOLISM
 Acute, chronic or alcohol withdrawal causes orthostaticAcute, chronic or alcohol withdrawal causes ...
TETANUSTETANUS
 Sympatho adrenalSympatho adrenal
hyperactivity is thehyperactivity is the
chief cause of deathchief cause...
PHEOCHROMOCYTOMAPHEOCHROMOCYTOMA
 Catecholamine secreting tumourCatecholamine secreting tumour
 Hypertension, hypermetab...
GUILLIAN BARREGUILLIAN BARRE
SYNDROMESYNDROME
• ANS involvementANS involvement
secondary tosecondary to axonalaxonal
degen...
 Neuronal degenerationNeuronal degeneration
 Metabolically related neuronalMetabolically related neuronal
dysfunctiondys...
AUTONOMIC CHANGES IN SPINALAUTONOMIC CHANGES IN SPINAL
CORD TRANSECTIONCORD TRANSECTION
 Affects motor, sensory and ANS d...
 Management of Anaesthesia :Management of Anaesthesia :
• AirwayAirway managementmanagement
• Avoidance ofAvoidance of hy...
ANAESTHESIA IN PATIENTS WITH ANSANAESTHESIA IN PATIENTS WITH ANS
DYSFUNCTIONDYSFUNCTION
 UnderstandUnderstand the impactt...
GENERAL ANAESTHESIAGENERAL ANAESTHESIA
 InductionInduction ––
 Thiopentone given slowly with proper iv fluidThiopentone ...
 IPPV produces exaggerated reduction inIPPV produces exaggerated reduction in
BPBP
 Blood loss should be replaced prompt...
REGIONAL ANAESTHESIAREGIONAL ANAESTHESIA
 Risk of hypotension with SAB andRisk of hypotension with SAB and
epiduralsepidu...
ANS IN INTENSIVE CAREANS IN INTENSIVE CARE
 Mechanical IPPVMechanical IPPV causes increased intra thoraciccauses increase...
ANS IN CHRONIC PAINANS IN CHRONIC PAIN
LUMBAR SYMPATHETIC BLOCKLUMBAR SYMPATHETIC BLOCK
 Used to alleviate theUsed to alleviate the rest pain of chronic PVDrest...
COELIAC PLEXUS BLOCKCOELIAC PLEXUS BLOCK
 Used for intractable pain caused byUsed for intractable pain caused by
cancer o...
COMPLEX REGIONAL PAIN SYNDROMECOMPLEX REGIONAL PAIN SYNDROME
 Consequence of limb trauma with orConsequence of limb traum...
CONCLUSIONCONCLUSION
 ANS plays a very dominant role in maintainingANS plays a very dominant role in maintaining
haemodyn...
THANKTHANK
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THANKTHANK
YOU…YOU…
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  1. 1. The AutonomicThe Autonomic Nervous System AndNervous System And Its Implications InIts Implications In AnaesthesiaAnaesthesia Guided byGuided by :: Dr. BakshiDr. Bakshi MadamMadam Presented by :Presented by : Dr. Neha SoaresDr. Neha Soares Dated : 26Dated : 26thth July 2007July 2007
  2. 2.  IntroductionIntroduction  AnatomyAnatomy  PhysiologyPhysiology  Drugs acting on ANSDrugs acting on ANS  Tests for autonomic integrityTests for autonomic integrity  Anaesthesia and ANSAnaesthesia and ANS a) Generala) General b) Regionalb) Regional  Autonomic reflexes during anaesthesia andAutonomic reflexes during anaesthesia and surgerysurgery  ANSANS dysfunctiondysfunction  Anaesthesia in patients with ANS dysfunctionAnaesthesia in patients with ANS dysfunction  ANS in intensive careANS in intensive care  ANS and chronic painANS and chronic pain
  3. 3. INTRODUCTIONINTRODUCTION Anesthesiologists manipulate the physiology andAnesthesiologists manipulate the physiology and pharmacology of the autonomic nervous system.pharmacology of the autonomic nervous system.
  4. 4. ANATOMYANATOMY  ComprisesComprises all afferent fibresall afferent fibres from the CNSfrom the CNS except those supplying skeletal muscles.except those supplying skeletal muscles.  Includes :Includes : 1)1) sympatheticsympathetic nervous systemnervous system 2)2) parasympatheticparasympathetic nervous systemnervous system 3)3) entericenteric nervous systemnervous system
  5. 5. Sympathetic Nervous SystemSympathetic Nervous System  Originates from theOriginates from the Thoraco-lumbarThoraco-lumbar spinalspinal cord (T1 to L2/L3)cord (T1 to L2/L3)  Composed of 2 neurons:Composed of 2 neurons: a)a) prepre-ganglionic-ganglionic b)b) postpost-ganglionic-ganglionic
  6. 6.  PairedPaired sympathetic chains havingsympathetic chains having 22 paired ganglia22 paired ganglia
  7. 7.  UnpairedUnpaired prevertebral ganglia in the abdomen andprevertebral ganglia in the abdomen and pelvispelvis  CeliacCeliac  Superior mesentericSuperior mesenteric  Inferior mesentericInferior mesenteric  Aortico renalAortico renal • terminal/collateral gangliaterminal/collateral ganglia
  8. 8.  Terminal or collateral gangliaTerminal or collateral ganglia  Small and few in numberSmall and few in number  PresentPresent near targetnear target organorgan  Eg. Nerves supplying adrenal medullaEg. Nerves supplying adrenal medulla and other chromaffin tissueand other chromaffin tissue  CompriseComprise preganglionicpreganglionic fibres itself thatfibres itself that pass to target tissue without synapsingpass to target tissue without synapsing
  9. 9. PARASYMPATHETIC NERVOUSPARASYMPATHETIC NERVOUS SYSTEMSYSTEM  75% from75% from vagusvagus  Arises fromArises from III, VII, IX, X cranialIII, VII, IX, X cranial nerves,nerves, S2-3S2-3 and occasionally S1and4and occasionally S1and4  Occur proximal to or within the innervatedOccur proximal to or within the innervated organorgan  Hence,Hence, pre-ganglionic fibres very longpre-ganglionic fibres very long  PNS more targetedPNS more targeted
  10. 10. Preganglionic fibresPreganglionic fibres arise fromarise from CENTRALCENTRAL  Edinger WestpalEdinger Westpal nucleus –nucleus – # oculomotor nerve# oculomotor nerve #synapses in ciliary ganglia#synapses in ciliary ganglia #Innervates smooth muscles#Innervates smooth muscles of iris and ciliary musclesof iris and ciliary muscles  Medulla OblongataMedulla Oblongata –– #Facial nerve#Facial nerve #Glossopharyngeal nerve#Glossopharyngeal nerve #Vagus nerve#Vagus nerve PERIPHERALPERIPHERAL  Sacral segments/ Pelvic nervesSacral segments/ Pelvic nerves
  11. 11. ENTERIC NERVOUS SYSTEMENTERIC NERVOUS SYSTEM  FoundFound within the wallswithin the walls of the GIT, pancreasof the GIT, pancreas and gall-bladderand gall-bladder  High degree ofHigh degree of autonomyautonomy  Peristalsis andPeristalsis and digestion persists evendigestion persists even if sphincter functionif sphincter function impaired followingimpaired following SAB/transections.SAB/transections.  Submucous(Submucous(Meissner’sMeissner’s plexus)plexus)  Myenteric(Myenteric(Auerbach’sAuerbach’s plexus)plexus)
  12. 12. PHYSIOLOGYPHYSIOLOGY  EitherEither sympathetic or parasympathetic systemsympathetic or parasympathetic system dominatesdominates a particular organ function, hencea particular organ function, hence providing the resting toneproviding the resting tone  Few organs have only sympathetic innervation –Few organs have only sympathetic innervation – blood vessels, spleen, piloerector muscles,blood vessels, spleen, piloerector muscles, adrenal medulla, uterusadrenal medulla, uterus  Some organs have only parasympatheticSome organs have only parasympathetic innervation – stomach, pancreasinnervation – stomach, pancreas  Sympathetic deals with FIGHT OR FLIGHTSympathetic deals with FIGHT OR FLIGHT  Parasympathetic deals with discrete adjustmentsParasympathetic deals with discrete adjustments in relaxed homeostasisin relaxed homeostasis
  13. 13. Target organTarget organ SNSSNS ReceptorReceptor PNSPNS 1.1. Hair follicleHair follicle smooth musclesmooth muscle 2.2. Iris –radial msIris –radial ms 3.3. Iris- circular msIris- circular ms 4.4. Ciliary msCiliary ms 5.5. Glands – nasalGlands – nasal parotid,lacrimalparotid,lacrimal submandibularsubmandibular gastric,pancraeticgastric,pancraetic ContractionContraction PiloerectionPiloerection MydriasisMydriasis NoneNone SlightSlight MydriasisMydriasis SlightSlight increaseincrease Alpha1Alpha1 Alpha 1Alpha 1 BetaBeta Alpha 1Alpha 1 NoneNone NoneNone MiosisMiosis Accomoda-Accomoda- tiontion CopiousCopious IncreaseIncrease Action of SNS and PNS on various organsAction of SNS and PNS on various organs
  14. 14. Target organTarget organ SNSSNS ReceptorReceptor PNSPNS 6. Sweat gland6. Sweat gland 7. Apocrine gland7. Apocrine gland 8. Heart8. Heart -Rate-Rate -Force of contractn-Force of contractn -Coronaries-Coronaries CopiousCopious IncreaseIncrease ThickThick odoriferousodoriferous IncreaseIncrease IncreaseIncrease DilatedDilated ConstrictedConstricted Alpha 1Alpha 1 Beta 1Beta 1 Beta 1Beta 1 Beta 2Beta 2 AlphaAlpha Sweating ofSweating of PalmsPalms NoneNone DecreaseDecrease DecreaseDecrease xcept atriaxcept atria
  15. 15. Target organTarget organ SNSSNS ReceptorReceptor PNSPNS 9. Lungs9. Lungs -Bronchi-Bronchi -Blood vessels-Blood vessels 10. Gut lumen10. Gut lumen SphincterSphincter 11.Pancreas11.Pancreas 12.Liver12.Liver 13.Gall bladder13.Gall bladder 14.Kidney14.Kidney DilationDilation ConstrictedConstricted DecreasedDecreased IncreasedIncreased DecreasedDecreased GlucoseGlucose releasedreleased RelaxedRelaxed Output andOutput and renin lessrenin less Beta 2Beta 2 Alpha2Alpha2 Alpha2Alpha2 Alpha2Alpha2 Alpha1Alpha1 Beta1Beta1 ConstrictnConstrictn DilationDilation IncreasedIncreased peristalsisperistalsis RelaxedRelaxed
  16. 16. Target organTarget organ SNSSNS ReceptorReceptor PNSPNS 15.Bladder15.Bladder - Detrusor- Detrusor - TrigoneTrigone 16. Ureter16. Ureter 17. uterus, vas17. uterus, vas deferens,deferens, prostrateprostrate 18.Arterioles18.Arterioles -viscera,skin-viscera,skin -muscle-muscle RelaxedRelaxed ContractedContracted ContractedContracted ContractedContracted ConstrictedConstricted ConstrictedConstricted DilatedDilated BetaBeta Alpha1Alpha1 Alpha1Alpha1 Alpha1Alpha1 AlphaAlpha beta2beta2
  17. 17. Target organTarget organ SNSSNS ReceptorReceptor PNSPNS 19.Veins19.Veins 20.Blood20.Blood 21.Basal metab21.Basal metab 22.Adrenal medulla22.Adrenal medulla secretionsecretion 23. Mental activity23. Mental activity 24.Fat cell24.Fat cell ConstrictedConstricted Coag,lipid,Coag,lipid, glucose ^glucose ^ 100% rise100% rise IncreasedIncreased IncreasedIncreased LipolysisLipolysis Alpha2Alpha2
  18. 18. Dominance at specific siteDominance at specific site Parasympathetic :Parasympathetic :  Ciliary muscleCiliary muscle  IrisIris  Salivary glandsSalivary glands  SA nodeSA node  GITGIT  UterusUterus  Urinary bladderUrinary bladder Sympathetic :Sympathetic :  ArteriolesArterioles  VeinsVeins  Sweat glandsSweat glands  SpleenSpleen
  19. 19. ANS of HeartANS of Heart
  20. 20. NeurotransmittersNeurotransmitters  AcetylcholineAcetylcholine – Secreted by– Secreted by **all preganglionic fibresall preganglionic fibres *Postganglionic parasympathetic*Postganglionic parasympathetic fibrespostganglionic sympathetic fibresfibrespostganglionic sympathetic fibres of sweat gland,piloerctor muscle andof sweat gland,piloerctor muscle and blood vesselsblood vessels  NorepinephrineNorepinephrine – Secreted by all– Secreted by all postganglionic sympatheticpostganglionic sympathetic fibresfibres
  21. 21.  Acetylcholine receptors are of 2 types:Acetylcholine receptors are of 2 types: -- MuscarinicMuscarinic: action similar to that: action similar to that produced byproduced by parasympatheticparasympathetic systemsystem -- NicotinicNicotinic: action on: action on skeletal andskeletal and ganglionicganglionic synapses onlysynapses only  Adrenergic receptors are of 2 tyes:Adrenergic receptors are of 2 tyes: -- AlphaAlpha: alpha1(smooth muscle: alpha1(smooth muscle vasoconstriction)vasoconstriction) alpha2 (presynapses)alpha2 (presynapses) -- BetaBeta: beta1 (cardiac tissue): beta1 (cardiac tissue) beta2 (smooth muscle relaxation inbeta2 (smooth muscle relaxation in somesome organs)organs)
  22. 22. Action of Important Drugs on ANSAction of Important Drugs on ANS Site of actionSite of action 1.Sympathetic1.Sympathetic andand parasympatheticparasympathetic gangliaganglia 2.Endings of post2.Endings of post ganglionic nonganglionic non adrenergicadrenergic NeuronsNeurons AgonistAgonist 1.Stimulate post-1.Stimulate post- ganglionganglion- nicotin- nicotin 2.2.InhibitACh’trsInhibitACh’trse-e- PhysostigminePhysostigmine NeostigmineNeostigmine ParathionParathion Release NARelease NA -TyramineTyramine -EphedrineEphedrine -AmphetamineAmphetamine AntagonistAntagonist HexamethoniumHexamethonium MecamylamineMecamylamine TrimethaphanTrimethaphan High conc.Ach,High conc.Ach, AnticholinestrsesAnticholinestrses CurareCurare Block NA synthBlock NA synth -metyrosine-metyrosine Stop NA storageStop NA storage -reserpine,guane-reserpine,guane thidinethidine
  23. 23. Site of actionSite of action 3.Alpha receptors3.Alpha receptors AgonistAgonist Stimulate alpha1Stimulate alpha1 -methoxamine-methoxamine -phenylephrine-phenylephrine Stimulate alpha2Stimulate alpha2 -clonidine-clonidine AntagonistAntagonist Stop NAStop NA breakdownbreakdown -MA inhibitors-MA inhibitors FalseFalse transmitterstransmitters -methydopa-methydopa -phenoxybenza-phenoxybenza minemine -phentolamine-phentolamine -prazocin-alpha1-prazocin-alpha1 -yohimbin-alpha2-yohimbin-alpha2
  24. 24. Site of actionSite of action 4.Beta receptors4.Beta receptors 5.Domaninergic5.Domaninergic receptorsreceptors AgonistAgonist -isoproterenol-isoproterenol -dobutamine-dobutamine -salbutamol-salbutamol (beta2)(beta2) DA1 – dopamineDA1 – dopamine DA2DA2 -bromocriptine-bromocriptine AntagonistAntagonist -propanolol-propanolol -metoprolol-metoprolol -esmolol-esmolol -Butoxamine-Butoxamine (beta2)(beta2) DA1 –DA1 – metoclopramidemetoclopramide DA2-haloperidolDA2-haloperidol
  25. 25. TESTS FOR AUTONOMICTESTS FOR AUTONOMIC INTEGRITYINTEGRITY Autonomic functions can be evaluated by:Autonomic functions can be evaluated by:  HistoryHistory  Non-invasive testsNon-invasive tests  Invasive testsInvasive tests
  26. 26. HistoryHistory CVSCVS (postural/orthostatic hypotension)(postural/orthostatic hypotension)  Fainting episodesFainting episodes  DizzinessDizziness  HeadacheHeadache  Diminution of visionDiminution of vision GenitourinaryGenitourinary  ImpotencyImpotency  Incontinence of urineIncontinence of urine  Retention of urineRetention of urine  Frequency in urinationFrequency in urination GlandsGlands  Decreased salivation with difficulty in eatingDecreased salivation with difficulty in eating  Decreased lacrimation causing eye irritationDecreased lacrimation causing eye irritation  Impaired sweating causing temperature elevationImpaired sweating causing temperature elevation
  27. 27. CNSCNS (affection of fibres supplying iris)(affection of fibres supplying iris)  Night-blindnessNight-blindness Chronic diseasesChronic diseases  Diabetes mellitusDiabetes mellitus  Chronic renal failureChronic renal failure  HypertensionHypertension Family historyFamily history Personal historyPersonal history  Chronic alcoholismChronic alcoholism  Drugs like Antihypertensive antidepressants,Drugs like Antihypertensive antidepressants, tranquilizers , diureticstranquilizers , diuretics
  28. 28. Non – invasive testsNon – invasive tests Tests for cardiac vagal functionTests for cardiac vagal function  Respiratory sinus arrhythmiaRespiratory sinus arrhythmia  Vasalva ratio(Phase IV/II)Vasalva ratio(Phase IV/II)  Bradycardia duringBradycardia during phenylephrine challengephenylephrine challenge  Absence of tachycardia withAbsence of tachycardia with atropineatropine Tests for sympathetic functionTests for sympathetic function I) CARDIACI) CARDIAC  Tachycardia during standing orTachycardia during standing or head-up tilthead-up tilt  Tachycardia during vasalvaTachycardia during vasalva strain(PhaseII)strain(PhaseII) II) PERIPHERALII) PERIPHERAL  Blood pressure overshootBlood pressure overshoot after vasalva releaseafter vasalva release  BP increase with coldBP increase with cold pressure testpressure test  Diastolic BP rise withDiastolic BP rise with isometric handgripisometric handgrip  Systolic and diastolic BPSystolic and diastolic BP response to uprightresponse to upright positionposition
  29. 29. Respiratory sinus arrhythmiaRespiratory sinus arrhythmia  TestsTests parasympatheticparasympathetic functionfunction  Determines the max. to min. heart rate variation inDetermines the max. to min. heart rate variation in forceful breathingforceful breathing  Patient in sitting or lying down positionPatient in sitting or lying down position  6 breaths/min.(5secs inspiration,5secs expiration)6 breaths/min.(5secs inspiration,5secs expiration)  Record mx. and min. HR and RR intervalRecord mx. and min. HR and RR interval  Av. variation should be >10 beats/minAv. variation should be >10 beats/min  E : I ratio = longest RR interval in expiration/shortest RRE : I ratio = longest RR interval in expiration/shortest RR interval in inspirationinterval in inspiration  In <40yrs age,In <40yrs age, E:I<1.2 is abnormalE:I<1.2 is abnormal
  30. 30. Postural stress: Supine to standingPostural stress: Supine to standing  Tests theTests the sympatheticsympathetic functionfunction  Commonly performed bed-side testCommonly performed bed-side test  Note HR and BP in supine position afterNote HR and BP in supine position after 10mins rest10mins rest  Note changes in HR and BP after assumingNote changes in HR and BP after assuming standing posture unaided after 50 secsstanding posture unaided after 50 secs  Drop of systolic BP >20mm of Hg and/orDrop of systolic BP >20mm of Hg and/or diastolic BP >10 mm of Hg is abnormaldiastolic BP >10 mm of Hg is abnormal  Absence of tachycardia when standing isAbsence of tachycardia when standing is abnormal (Marrey’s Law of baro receptorabnormal (Marrey’s Law of baro receptor stimulation)stimulation)
  31. 31. Cold Pressure testCold Pressure test  Tests theTests the peripheral sympatheticperipheral sympathetic vasoconstrictorsvasoconstrictors  Record BP 1min after immersing hand inRecord BP 1min after immersing hand in ice cold waterice cold water  Both systolic and diastolic BP shouldBoth systolic and diastolic BP should increase by 10mm of Hgincrease by 10mm of Hg
  32. 32. Isometric Hand grip ExerciseIsometric Hand grip Exercise  Tests theTests the efferent sympatheticefferent sympathetic functionfunction  Sustained isometric contraction at 30% ofSustained isometric contraction at 30% of patients max. strength should increase BP bypatients max. strength should increase BP by 10-15mm of Hg10-15mm of Hg
  33. 33. Vasalva ManouverVasalva Manouver  Tests bothTests both sympathetic and parasympatheticsympathetic and parasympathetic functionfunction  Subject sits quietly or lies supine, blows into a mouth-Subject sits quietly or lies supine, blows into a mouth- piece with an open glottis, holds airway pressure ofpiece with an open glottis, holds airway pressure of 40mm of Hg for 15secs(PhaseII40mm of Hg for 15secs(PhaseII) and then releases the) and then releases the pressurepressure
  34. 34.  HR increasesHR increases 10to15secs after initiating blowing(PhaseII) and10to15secs after initiating blowing(PhaseII) and before release of pressurebefore release of pressure  This implies that theThis implies that the sympathetic response is intactsympathetic response is intact  On release of strain(PhaseIV), preload and cardiac outputOn release of strain(PhaseIV), preload and cardiac output restored,restored, BP overshootBP overshoot….this implies that the peripheral….this implies that the peripheral sympathetic vasoconstriction is intactsympathetic vasoconstriction is intact  Baroreceptors stimulated, reflexBaroreceptors stimulated, reflex bradycardiabradycardia…this implies that the…this implies that the parasympathetic system is intactparasympathetic system is intact
  35. 35.  To test cardiac vagal function a ratio has been devisedTo test cardiac vagal function a ratio has been devised  Vasalva ratio = longest RR interval[max HR] in Phase IV(x)/Vasalva ratio = longest RR interval[max HR] in Phase IV(x)/ shortest RR interval[min HR] in Phase II(y)shortest RR interval[min HR] in Phase II(y)  Vasalva ratio <1.2 is abnormalVasalva ratio <1.2 is abnormal
  36. 36. EPINEPHRINE TESTEPINEPHRINE TEST ––  3 drops in eye at I min. interval 3 times3 drops in eye at I min. interval 3 times  Check pupil sixe at 15, 30 and 45 minsCheck pupil sixe at 15, 30 and 45 mins  Normal pupil = no effectNormal pupil = no effect  Sympathetically denervated pupil = dilationSympathetically denervated pupil = dilation COCAINE TESTCOCAINE TEST ––  Method same as aboveMethod same as above  Normal pupil = dilationNormal pupil = dilation  Sympathetic denervated pupil = no change in sizeSympathetic denervated pupil = no change in size HISTAMINE TESTHISTAMINE TEST ––  0.05ml of 1:1000 histamine injected intracutaneously0.05ml of 1:1000 histamine injected intracutaneously  Normal response – triple response with 1cm whealNormal response – triple response with 1cm wheal  Familial dysautonomia and peripheral neuropathy –Familial dysautonomia and peripheral neuropathy – absent whealabsent wheal
  37. 37. EPHEDRINE TESTEPHEDRINE TEST ––  Give 25mg imGive 25mg im  Normal subjects = HR increasesNormal subjects = HR increases  Sympathetic denervation = no change in HRSympathetic denervation = no change in HR ATROPINE TESTATROPINE TEST ––  Give 0.8mg imGive 0.8mg im  Normal subjects = HR increases by 20Normal subjects = HR increases by 20 beats/minbeats/min  Sympathetic denervation = no changeSympathetic denervation = no change NEOSTIGMINE TESTNEOSTIGMINE TEST ––  Give 1mg imGive 1mg im  Normal subjects = HR decreasesNormal subjects = HR decreases  Parasympathetically denervated = no changeParasympathetically denervated = no change
  38. 38. Power Spectral Analysis of HRPower Spectral Analysis of HR variabilityvariability  Slower periodic oscillations in heart, can be decomposedSlower periodic oscillations in heart, can be decomposed into a series of sine waves with diff. amplitudes andinto a series of sine waves with diff. amplitudes and frequenciesfrequencies
  39. 39.  This frequency domain reveals aThis frequency domain reveals a consistant peakconsistant peak/ power at the breathing/ power at the breathing frequencyfrequency 0.2 to 0.3Hz0.2 to 0.3Hz… this implies… this implies intact parasympatheticintact parasympathetic innervaton ofinnervaton of SA nodeSA node  There is another peak at low frequenciesThere is another peak at low frequencies 0.05 to 0.150.05 to 0.15 Hz…due to changingHz…due to changing cardiaccardiac sympatheticsympathetic activityactivity  This low frequency component is augmented by increased sympatheticThis low frequency component is augmented by increased sympathetic drive eg.head up tilt, mental arithmatics and is reduced in quadriplegics duedrive eg.head up tilt, mental arithmatics and is reduced in quadriplegics due to interrupted sympathetic pathways.to interrupted sympathetic pathways.
  40. 40. INVASIVE TESTSINVASIVE TESTS  Done to locateDone to locate precise siteprecise site of pathologyof pathology  Done forDone for researchresearch purposepurpose  Intraneural recordingIntraneural recording of post-ganglionicof post-ganglionic sympathetic activitysympathetic activity  ElicitingEliciting axon reflexaxon reflex by intradermal injection ofby intradermal injection of acetyl-cholineacetyl-choline  Response of ANS to infusion ofResponse of ANS to infusion of pressor drugspressor drugs ::  injection or epinephrine(1 : 1000) in conjunctival sacinjection or epinephrine(1 : 1000) in conjunctival sac  Cocaine (4 to 10%) topical applicationCocaine (4 to 10%) topical application  Ephedrine testEphedrine test  Atropine testAtropine test  Neostigmine testNeostigmine test
  41. 41. OTHER TESTSOTHER TESTS  Measurement of skinMeasurement of skin temperaturetemperature  Tests forTests for sudomotorsudomotor functionfunction  Weight of sweatWeight of sweat  Galvanic skin resistance testGalvanic skin resistance test  Tests forTests for lacrimallacrimal functionfunction  Tests forTests for bladder and GITbladder and GIT dysfunctiondysfunction  LaboratoryLaboratory teststests  Measure plasma levels of catecholamines and other vasoactiveMeasure plasma levels of catecholamines and other vasoactive hormones like renin, angiotensin and vasopressinhormones like renin, angiotensin and vasopressin  Measurement of forearm blood flow with plethysmographyMeasurement of forearm blood flow with plethysmography  Cerebral EEG blood flow studiesCerebral EEG blood flow studies SELECTION OF TESTSSELECTION OF TESTS :: To assess ANS involvement, 5 simple non-invasive tests areTo assess ANS involvement, 5 simple non-invasive tests are sufficientsufficient To assess definitive abnormality, 2 or more specific tests areTo assess definitive abnormality, 2 or more specific tests are recommendedrecommended
  42. 42. ANAESTHESIA AND AUTONOMICANAESTHESIA AND AUTONOMIC NERVOUS SYSTEMNERVOUS SYSTEM GENERAL ANAESTHESIAGENERAL ANAESTHESIA Pre medicationPre medication ::  Agents used to decrease secretions likeAgents used to decrease secretions like atropine,glycopyrolate areatropine,glycopyrolate are anti cholinergicsanti cholinergics  Antiemetic metoclopramide is aAntiemetic metoclopramide is a dopaminergicdopaminergic anti emeticanti emetic  Opiods cause respiratory depression byOpiods cause respiratory depression by inhibiting Ach release from CNSinhibiting Ach release from CNS  Morphine releases histamine, venous pooling,Morphine releases histamine, venous pooling, reduced peripheral vascular resistancereduced peripheral vascular resistance
  43. 43.  Pentazocine increases plasma catecholaminesPentazocine increases plasma catecholamines  Fentanyl causes vagal bradycardia during intubationFentanyl causes vagal bradycardia during intubation  Beta antagonistsBeta antagonists reduce stress response during intubationreduce stress response during intubation  Alpha2 agonist,Alpha2 agonist, clonidine,clonidine, reduces dose of induction agent andreduces dose of induction agent and stress response duringstress response during Induction agents – All induction agents except ketamine reduce sympathetic activity Arterial pressure drops Baroreceptor mediated tachycardia may/may not occur Ketamine stimulates the sympathetic system Etomidate is a potent inhibitor of adrenergic steroidogenesis
  44. 44. Inhalational AgentsInhalational Agents ––  Halothane, enflurane, isoflurane reduce pre-ganglionicHalothane, enflurane, isoflurane reduce pre-ganglionic sympathetic activity and hence decrease plasmasympathetic activity and hence decrease plasma catecholaminescatecholamines  Cyclopropane and diethyl ether increase sympatheticCyclopropane and diethyl ether increase sympathetic activity by central action and by action on vasomotoractivity by central action and by action on vasomotor neurons in spinal cordneurons in spinal cord Muscle RelaxantsMuscle Relaxants ––  Pancuronium releases adrenaline and raises HR and BPPancuronium releases adrenaline and raises HR and BP Autonomic changes like decreasingAutonomic changes like decreasing arterial BP,HR and plasmaarterial BP,HR and plasma catecholamines and cortisol indicatecatecholamines and cortisol indicate increasing depth of anaesthesiaincreasing depth of anaesthesia
  45. 45. SPINAL ANAESTHESIASPINAL ANAESTHESIA  Causes sympathetic blockade, hypotension andCauses sympathetic blockade, hypotension and bradycardia depending on the level of blockadebradycardia depending on the level of blockade
  46. 46. • In low SAB sacral parasympathetic and lumbar plusIn low SAB sacral parasympathetic and lumbar plus lower thoracic sympathetics are blocked,lower thoracic sympathetics are blocked, uninhibited vagaluninhibited vagal parasympathetics acting on splanchnic bed and visceraparasympathetics acting on splanchnic bed and viscera  In high SAB,In high SAB, all sympathetics are blockedall sympathetics are blocked, vagal, vagal parasympathetics to thoracic and abdominal visceraparasympathetics to thoracic and abdominal viscera become over active and cause severe bradycardia andbecome over active and cause severe bradycardia and even asystoleeven asystole  InIn saddle blocksaddle block sacral parasympathetic is blocked,sacral parasympathetic is blocked, thoracolumbar sympathetic is intact…causing minimalthoracolumbar sympathetic is intact…causing minimal physiologic disturbancephysiologic disturbance
  47. 47. Features of Autonomic Imbalance afterFeatures of Autonomic Imbalance after Spinal AnaesthesiaSpinal Anaesthesia CVSCVS  HypotensionHypotension  BradycardiaBradycardia GITGIT  Increased peristalsisIncreased peristalsis  Intestines usually activeIntestines usually active RSRS  In high SAB(upper 5 or 6 thoracic sympathetic)In high SAB(upper 5 or 6 thoracic sympathetic)  Some bronchial spasm due to increased vagal activitySome bronchial spasm due to increased vagal activity EPIDURAL ANAESTHESIAEPIDURAL ANAESTHESIA  Less hypotensionLess hypotension  SegmentalSegmental type of anaesthesia is possibletype of anaesthesia is possible  Onset of action is slowerOnset of action is slower  Hence compensatory mechanisms initiated well in advanceHence compensatory mechanisms initiated well in advance
  48. 48. Autonomic reflexes duringAutonomic reflexes during Anaesthesia and SurgeryAnaesthesia and Surgery Oculocardiac reflexOculocardiac reflex ::  Pressure over eyeballs or traction of externalPressure over eyeballs or traction of external ocular musclesocular muscles  Causes bradycardia, asystole, cardiacCauses bradycardia, asystole, cardiac dysrhytthmia, ventricular fibrillationdysrhytthmia, ventricular fibrillation  Light plane on anaesthesia, hypoxia,Light plane on anaesthesia, hypoxia, hypercarbia aggravate this reflexhypercarbia aggravate this reflex  Prophylaxis with anticholinergics..still aProphylaxis with anticholinergics..still a controversycontroversy
  49. 49. Abdominal reflexAbdominal reflex ::  Due to stimulation of ANS by traction orDue to stimulation of ANS by traction or pressure during surgeries within the abdominalpressure during surgeries within the abdominal cavitycavity  Circulatory effect – bradycardia, hypotentionCirculatory effect – bradycardia, hypotention  Respiratory effect – apnea, tachypnea,Respiratory effect – apnea, tachypnea, laryngospasmlaryngospasm These are :These are : • Peritoneal and mesentericPeritoneal and mesenteric reflexreflex • Coeliac plexusCoeliac plexus reflex – traction of stomach,gallreflex – traction of stomach,gall bladder, hilum of liver or retraction of duodenumbladder, hilum of liver or retraction of duodenum • Brewer LuckhardtBrewer Luckhardt reflex/ Diaphragmatic tractionreflex/ Diaphragmatic traction reflexreflex • Reflexes associated with pelvic nerveReflexes associated with pelvic nerve
  50. 50. Recto – laryngeal reflexRecto – laryngeal reflex ::  Caused by dilation of anal sphincter under GACaused by dilation of anal sphincter under GA  Afferent is via pelvic and sacral nerve toAfferent is via pelvic and sacral nerve to vagalvagal motormotor nucleusnucleus  Efferent is viaEfferent is via recurrent laryngealrecurrent laryngeal nervenerve  Causes laryngeal spasm and apneaCauses laryngeal spasm and apnea Recto – cardiac reflexRecto – cardiac reflex ::  Anal sphincter dilation causes bradycardia, hypotensionAnal sphincter dilation causes bradycardia, hypotension Preventions :Preventions :  These autonomic reflexes can be prevented by adequateThese autonomic reflexes can be prevented by adequate depth of anaesthesiadepth of anaesthesia  Atropine prophylaxis maybe givenAtropine prophylaxis maybe given  Ask surgeon to avoid manipulations, proceed gently andAsk surgeon to avoid manipulations, proceed gently and slowlyslowly
  51. 51. ANS DYSFUNCTIONANS DYSFUNCTION PRIMARY –PRIMARY –  Idiopathic orthostatic hypotensionIdiopathic orthostatic hypotension  Shy Dragger syndromeShy Dragger syndrome FAMILIAL – Riley Day syndrome Leesch Neehan syndrome •Genetic disorder of purine metabolism in males •Sympathetic response to stress is enhanced Gill Familia dysautonomia
  52. 52. SECONDARY TO SYSTEMICSECONDARY TO SYSTEMIC DISORDERSDISORDERS  AgeingAgeing  Diabetes MellitusDiabetes Mellitus  Chronic alcoholismChronic alcoholism  Chronic renal failureChronic renal failure  Neurological diseasesNeurological diseases  Tabes dorsalisTabes dorsalis  SyringomyeliaSyringomyelia  amyloidosisamyloidosis  Chagas diseaseChagas disease  HypertensionHypertension  TetanusTetanus  PheochromocytomaPheochromocytoma  Spinal cord injurySpinal cord injury  Guillian BarreGuillian Barre syndromesyndrome  CarcinomatosisCarcinomatosis
  53. 53. AGINGAGING  20% of people over 65yrs have20% of people over 65yrs have postural hypotensionpostural hypotension  Symptoms – dizziness, faintness, loss of consciousnessSymptoms – dizziness, faintness, loss of consciousness  Selective/Selective/ early parasympatheticearly parasympathetic involvementinvolvement  Delayed/ slow sympathetic involvementDelayed/ slow sympathetic involvement  Blunting of – Vasalva maneuverBlunting of – Vasalva maneuver Respiratory cycleRespiratory cycle HR changes to changes in BPHR changes to changes in BP Resting and exercise induced NE responseResting and exercise induced NE response
  54. 54. ALCOHOLISMALCOHOLISM  Acute, chronic or alcohol withdrawal causes orthostaticAcute, chronic or alcohol withdrawal causes orthostatic intoleranceintolerance  Poor nutrition impairs SNSPoor nutrition impairs SNS  Baroreceptors less sensitiveBaroreceptors less sensitive  Vasalva ratio and cardiac acceleration following ivVasalva ratio and cardiac acceleration following iv atropine is diminished in presence of neurologicalatropine is diminished in presence of neurological impairmentimpairment
  55. 55. TETANUSTETANUS  Sympatho adrenalSympatho adrenal hyperactivity is thehyperactivity is the chief cause of deathchief cause of death  Direct effect ofDirect effect of tetanus toxin on SNStetanus toxin on SNS causes rise in plasmacauses rise in plasma catecholaminescatecholamines
  56. 56. PHEOCHROMOCYTOMAPHEOCHROMOCYTOMA  Catecholamine secreting tumourCatecholamine secreting tumour  Hypertension, hypermetabolism, hyperglycemiaHypertension, hypermetabolism, hyperglycemia  Preop alpha blockers are given toPreop alpha blockers are given to  Restore blood volumeRestore blood volume  Assess end organ damageAssess end organ damage  Treat cardiac arrhythmiasTreat cardiac arrhythmias
  57. 57. GUILLIAN BARREGUILLIAN BARRE SYNDROMESYNDROME • ANS involvementANS involvement secondary tosecondary to axonalaxonal degenerationdegeneration • Variable BP, facialVariable BP, facial flushing, urinaryflushing, urinary retention, tachy –retention, tachy – brady arrhythmiasbrady arrhythmias • Neuropathic lesions inNeuropathic lesions in afferent limb ofafferent limb of baroreceptor may leadbaroreceptor may lead toto SIADH,SIADH, hyponatremiahyponatremia
  58. 58.  Neuronal degenerationNeuronal degeneration  Metabolically related neuronalMetabolically related neuronal dysfunctiondysfunction  Afferent, central and efferentAfferent, central and efferent pathways involvedpathways involved  Vagal neuropathyVagal neuropathy occurs beforeoccurs before systemic neuropathysystemic neuropathy  Symptomatic posturalSymptomatic postural hypotension implies poorhypotension implies poor prognosisprognosis  Esophageal gastric hypomotility,Esophageal gastric hypomotility, bradycardia, silent myocardialbradycardia, silent myocardial infarcts, impaired ventilatoryinfarcts, impaired ventilatory control, unexplained cardiocontrol, unexplained cardio respiratory arrests may occurrespiratory arrests may occur
  59. 59. AUTONOMIC CHANGES IN SPINALAUTONOMIC CHANGES IN SPINAL CORD TRANSECTIONCORD TRANSECTION  Affects motor, sensory and ANS depending on level of transectionAffects motor, sensory and ANS depending on level of transection  Acute effects/Acute effects/ Spinal ShockSpinal Shock ::  Flaccid paralysisFlaccid paralysis  Total absence of sensationTotal absence of sensation  Loss of temperature regulationLoss of temperature regulation  Loss of spinal reflexes below level of injuryLoss of spinal reflexes below level of injury  Decreased systolic BPDecreased systolic BP  BradycardiaBradycardia  Abnormal ECG, ST-T changes, VPCsAbnormal ECG, ST-T changes, VPCs
  60. 60.  Management of Anaesthesia :Management of Anaesthesia : • AirwayAirway managementmanagement • Avoidance ofAvoidance of hypovolemiahypovolemia  Anaesthesia is given so that pt. toleratesAnaesthesia is given so that pt. tolerates tubetube  Muscle relaxant is used as neededMuscle relaxant is used as needed
  61. 61. ANAESTHESIA IN PATIENTS WITH ANSANAESTHESIA IN PATIENTS WITH ANS DYSFUNCTIONDYSFUNCTION  UnderstandUnderstand the impactthe impact Reduced ANS activity on CVSReduced ANS activity on CVS responses to change inresponses to change in o body positionbody position o positive airway pressurepositive airway pressure o acute blood lossacute blood loss o effects due to negativeeffects due to negative inotropic anaesthetic agentsinotropic anaesthetic agents  PosturePosture – shift patient to OT– shift patient to OT and induce in supine positionand induce in supine position  PreloadingPreloading should be doneshould be done properlyproperly  Pre medicationPre medication ––  Atropine may fail to produceAtropine may fail to produce tachycardiatachycardia  Ranitidine and metoclopramideRanitidine and metoclopramide to avoid regurg and aspirationto avoid regurg and aspiration  Narcotics and other respiratoryNarcotics and other respiratory depressants are avoideddepressants are avoided  MonitoringMonitoring ––  Pulse oxPulse ox  Continuous arterial BPContinuous arterial BP  ECGECG  CVPCVP  TemperatureTemperature  Urine outputUrine output
  62. 62. GENERAL ANAESTHESIAGENERAL ANAESTHESIA  InductionInduction ––  Thiopentone given slowly with proper iv fluidThiopentone given slowly with proper iv fluid replacementreplacement  Diazepam and fentanyl may also be usedDiazepam and fentanyl may also be used  Ketamine produces accentuated BP responseKetamine produces accentuated BP response  Rapid sequence intubationRapid sequence intubation as patients haveas patients have gastro-paresisgastro-paresis  Maintenance on spontaneous breathing withMaintenance on spontaneous breathing with N2O and O2, withN2O and O2, with minimal halothaneminimal halothane  If needed, cardio stable muscle relaxants likeIf needed, cardio stable muscle relaxants like Vec should be usedVec should be used
  63. 63.  IPPV produces exaggerated reduction inIPPV produces exaggerated reduction in BPBP  Blood loss should be replaced promptly asBlood loss should be replaced promptly as compensatory tachycardia is absentcompensatory tachycardia is absent  Volatile anaesthetics produce excessiveVolatile anaesthetics produce excessive myocardial depression and hypotensionmyocardial depression and hypotension  Maintain fluid balanceMaintain fluid balance  Avoid hypothermiaAvoid hypothermia (pts may become(pts may become poikilothermic due to sympatheticpoikilothermic due to sympathetic dysfunction)dysfunction)  Vasopressors should be used with cautionVasopressors should be used with caution
  64. 64. REGIONAL ANAESTHESIAREGIONAL ANAESTHESIA  Risk of hypotension with SAB andRisk of hypotension with SAB and epiduralsepidurals  Post spinal urinary retention may occurPost spinal urinary retention may occur  Pre opPre op presence ofpresence of impotenceimpotence must bemust be brought to notice to avoidbrought to notice to avoid medico legalmedico legal implicationsimplications
  65. 65. ANS IN INTENSIVE CAREANS IN INTENSIVE CARE  Mechanical IPPVMechanical IPPV causes increased intra thoraciccauses increased intra thoracic pressure, decreased cardiac filling and hence,pressure, decreased cardiac filling and hence, decreased cardiac outputdecreased cardiac output  All reflex mechanisms fail hence cardiac output fallsAll reflex mechanisms fail hence cardiac output falls drasticallydrastically  Suction careSuction care
  66. 66. ANS IN CHRONIC PAINANS IN CHRONIC PAIN
  67. 67. LUMBAR SYMPATHETIC BLOCKLUMBAR SYMPATHETIC BLOCK  Used to alleviate theUsed to alleviate the rest pain of chronic PVDrest pain of chronic PVD  Preganglionic sympathetics are from lowerPreganglionic sympathetics are from lower thoracic chain and pre ganglionic somatic fibresthoracic chain and pre ganglionic somatic fibres are from 1are from 1stst and 2and 2ndnd lumbar nerveslumbar nerves  Post ganglionic fibres are vasoconstrictor toPost ganglionic fibres are vasoconstrictor to arterioles, pilomotor and sudomotor to skinarterioles, pilomotor and sudomotor to skin  Hence, its block causes absence of sweatingHence, its block causes absence of sweating and warm dry skinand warm dry skin
  68. 68. COELIAC PLEXUS BLOCKCOELIAC PLEXUS BLOCK  Used for intractable pain caused byUsed for intractable pain caused by cancer of pancreas, stomach, gall bladdercancer of pancreas, stomach, gall bladder and liverand liver SUPERIOR HYPOGASTRIC PLEXUSSUPERIOR HYPOGASTRIC PLEXUS BLOCKBLOCK  Relates pain from pelvic organsRelates pain from pelvic organs  Used in cancer pain due toUsed in cancer pain due to cervical,prostate,testicular cancers and incervical,prostate,testicular cancers and in radiation injuryradiation injury
  69. 69. COMPLEX REGIONAL PAIN SYNDROMECOMPLEX REGIONAL PAIN SYNDROME  Consequence of limb trauma with orConsequence of limb trauma with or without obvious nerve lesionswithout obvious nerve lesions  Characterised by motor, sensory and ANSCharacterised by motor, sensory and ANS symptomssymptoms  ANS features include abnormal skin bloodANS features include abnormal skin blood flow, temperature and sweatingflow, temperature and sweating PHANTOM LIMBPHANTOM LIMB Ectopic discharge ofEctopic discharge of epinephrine from a stump neuromaepinephrine from a stump neuroma isis an important peripheral mechanisman important peripheral mechanism Sympathetic block, sympathectomies or beta blockersSympathetic block, sympathectomies or beta blockers increase blood flow and reduce intensity of burning painincrease blood flow and reduce intensity of burning pain Decreased blood flow causes phantom limb painDecreased blood flow causes phantom limb pain
  70. 70. CONCLUSIONCONCLUSION  ANS plays a very dominant role in maintainingANS plays a very dominant role in maintaining haemodynamic stabilityhaemodynamic stability  Influences the outcome after anaesthesia and surgeryInfluences the outcome after anaesthesia and surgery
  71. 71. THANKTHANK YOU…YOU… THANKTHANK YOU…YOU…

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