Practical Points in Anesthesia

by Frederick-Emil Neef

It may happen to the conscientious anesthetist, who desists from giving more of the anesthetic until he has regained his bearings, that the patient suddenly shows signs of awakening, and vomiting begins. This is a disagreeable, but generally not a serious interruption. The anesthetist is absolute master of the situation. Although the patient’s face turns somewhat blue during the vomiting efforts, the anesthetist should not attempt to push the jaw forward or exert traction on the tongue. The face is merely turned to the side and kept in position by placing the hand on the cheek. The mouth and pharynx are cleansed gently with a piece of gauze and the anesthetic is continued, drop by drop. It is often surprising in such cases how rapidly the patient can be brought back into the proper plane of anesthesia. There need be no fear that the patient will fully awake.

Obstructed Breathing.

Many anesthesias are unsatisfactory because the breathing is obstructed. To my mind the prime cause of obstructed breathing is too great a concentration of the anesthetic. The importance of avoiding the crowding of the anesthetic is the secret of a good narcosis.

Concentrated Anesthetic

The irritability of the air passages varies greatly in different individuals. Concentrated vapor may cause reflex spasm of the larynx and, consequently, obstructed breathing. This is the condition that leads to what is ordinarily called respiratory collapse. It is due to crowding—undue concentration—rather than excessive quantity of the anesthetic. If there were no superior laryngeal and trifacial nerves to warn the inexperienced or inattentive by closing the larynx to more of the anesthetic, real respiratory paralysis, which is apt to be fatal, and is due to direct toxic action of the anesthetic on the respiratory centre, might be more common.

“Have I crowded the anesthetic?” is the first question that should be considered when there are signs of obstructed breathing. The jaw is rigid, the patient is almost awake, and yet the mask is lifted to admit more air. Paradoxical as it may seem, the jaw begins to relax, the breathing becomes free and the anesthesia at once more profound. The reason is simple. As long as the spasm of the larynx persists the anesthetic cannot readily pass the barrier to exert its physiological action. As soon as the spasm is overcome by admitting air the anesthetic can be freely inhaled. By observing the precaution to dilute the anesthetic generously with air pharyngeal irritation and laryngeal spasm can be avoided and an undisturbed narcosis secured.

Valve-action of the Lips

Sometimes, however, the obstruction is purely mechanical. It may be due to compression of the trachea by a shoulder brace. In aged individuals, after removing the tooth plate, progressively increasing cyanosis may be due to valve-action of the lips. Expiration is unhindered, but inspiration becomes impossible on account of collapse of the lips and cheeks. The difficulty is overcome by turning the head to one side and placing a spindle of gauze in the dependent angle of the mouth to keep the lips apart.

Recession of the Tongue

There are other cases in which the base of the tongue drops back into the oropharynx, and hinders breathing. There is a peculiar, noisy, “fluttering” respiration which indicates this condition. The jaw-grip, that is, pushing the jaw forward, is often insufficient. Most of us have been taught to use the wedge, mouth-gag and tongue forceps at once in such an emergency, but it is certainly desirable to escape this maneuver whenever possible. A naso-pharyngeal catheter, or breathing tube of soft rubber, passed through the nostril into the pharynx sometimes instantly relieves the obstruction.