GENERAL ANESTHESIA

By DR. ANINDYA
2nd YEAR PG OMFS
General anesthetics (GAs) are drugs which:

 Reversible loss of all sensations and consciousness.

 Loss of memory and awareness with insensitivity to

painful stimuli, during a surgical procedure.

Areflexia
 Definition

 GENERAL ANESTHESIA:
 It is a controlled state of unconsciousness, accompanied by partial or complete loss of protective reflexes,
including the inability to independently maintain an airway or respond purposefully to verbal command.
 CONCIOUS SEDATION:
 It is a state of mind obtained by IV administration of combination of anxiolytics, sedatives and hypnotics
&/or analgesic that render the patient relaxed, yet allows the patient to communicate, maintain patent
airway and ventilate adequately.
 DEEP SEDATION:
 It is a depressed level of consciousness with some blunting of protective reflex, although it remains
possible to arouse the patient.
 IATRO SEDATION:
 A general term used for any technique of anxiety reduction in which no drugs are given
 Relief of anxiety through the doctor’s behavior - it is one of the form of psychosedation
 HISTORICALBACK GROUND
 Ether synthesized in 1540 by cordus
 General anesthesia was absent until the mid-1800s.
 Ether used as anesthetic in 1842 by dr. Crawford W.Long
 1846 – Oliver Wendell Sr. “Anesthesia”
meaning:
Insensibility during surgery produced by inhalation of ether.
 William T. G. Morton (dentist) was the first to publicly
demonstrate the use of ether during surgery(1846).
 Chloroform used as anesthetic in 1853 by dr. John snow
 1860 – Albert Niemann  Cocaineas.
 Endotracheal tube discovered in 1878
 Thiopental first used in 1934
 Curare first used in 1942 - opened the “Age of anesthesia”
 PROPERTIES OF AN IDEAL ANAESTHETIC
 For the patient –
Should be pleasant,
Non irritating,
Should not cause nausea or vomiting.
Induction and recovery should be fast with no after effects.
 For the surgeon –
Should provide adequate analgesia,
Immobility and muscle relaxation.
It should be noninflammable and nonexplosive so that cautery
may be used.
For the anaesthetist –
Its administration should be easy, controllable and
versatile.

Margin of safety should be wide - no fall in BP.

Heart, liver and other organs should not be
affected.

It should be potent so that low concentrations are

needed and oxygenation of the patient does not
suffer.

Rapid adjustments in depth of anaesthesia should

be possible.

It should be cheap, stable and easily stored.

It should not react with rubber tubing or soda

lime.
 BALANCED ANESTHESIA

It is a term used to describe the multidrug approach to managing the patient needs. Balanced
anesthesia takes advantage of drug’s beneficial effects while minimizing each agent’s adverse qualities.

Intraoperatively, an ideal anesthetic drug:

• would induce anesthesia smoothly, rapidly

• permit rapid recovery as soon as administration ceased.

A ‘balanced anesthesia’ is achieved by a combination of I.V and inhaled anesthesia and Preanesthetic
medications
SIGNS & STAGES OF ANAESTHESIA (GUEDEL’S Signs)
 Guedel (1920) described four stages with ether anaesthesia, dividing the III stage into 4
planes.
 The order of depression in the CNS is: Cortical centers→basal ganglia→spinal cord→medulla
• analgesia and amnesia, the patient is conscious and conversational. Starts from
beginning of anaesthetic inhalation and lasts upto the loss of consciousness
• Pain is progressively abolished
Stage of • Reflexes and respiration remain normal

Analgesia • Use is limited to short procedures

• From loss of consciousness to beginning of regular respiration

• Patient may shout, struggle and hold his breath; muscle tone increases, jaws are tightly
closed, breathing is jerky; vomiting, involuntary micturition or defecation may occur
Stage of
• . Heart rate and BP may rise and pupils dilate due to sympathetic stimulation
Delirium • No operative procedure carried out
• Can be cut short by rapid induction, premedication
 • Extends from onset of regular respiration to cessation of spontaneous breathing.
• This has been divided into 4 planes which may be distinguished as:
• Plane 1 roving eye balls. This plane ends when eyes become fixed.
• Plane 2 loss of corneal and laryngeal reflexes.
Surgical • Plane 3 pupil starts dilating and light reflex is lost.

anaesthesia • Plane 4 Intercostal paralysis, shallow abdominal respiration, dilated pupil.

• Cessation of breathing to failure of circulation and death.

• Pupil is widely dilated, muscles are totally flabby, pulse is thready or
Medullary imperceptible and BP is very low

paralysis
 Stages of
anesthesia
Guedel (1920) described four stages with ether
anesthesia, dividing the III stage into 4 planes.
The order of depression in the CNS is:
1. Cortical centers
2. Basal ganglia
3. Spinal cord
4. Medulla
 Mechanisms of GA

 The unitary theory of anesthesia – Meyer-Overton rule (1901)

 Lipid : water partition coefficient

 GA (gases) are highly lipid soluble and therefore can easily enter in neurones
 After entry causes disturbances in physical chemistry of neuronal membranes –
fluidization theory
 Finally, obliteration of Na+ channel and refusal of depolarization

 The unitary theory has been discarded now!

Modern theory on Mechanism of General Anesthesia

 Major targets – ligand gated ion channels

 Important one – GABAA receptor gated Cl¯ channel

• GABAA receptors - 4 transmembrane (4-TM) ion channel

– 5 subunits arranged around a central pore: 2 alpha, 2 beta, 1 gamma

– Each subunit has N-terminal extracellular chain which contains the ligand-
binding site

– 4 hydrophobic sections cross the membrane 4 times: one extracellular and

two intracellular loops connecting these regions, plus an extracellular C-
terminal chain
 GABAA Receptor gated Cl¯ Channel

 Normally, GABAA receptor mediates the effects of gamma-amino

butyric acid (GABA), the major inhibitory neurotransmitter in the
brain

 GABAA receptor found throughout the CNS

 most abundant, fast inhibitory, ligand-gated ion channel in the
mammalian brain
 located in the post-synaptic membrane
 Ligand binding causes conformational changes leading to opening of
central pore and passing down of Cl- along concentration gradient
 Net inhibitory effect reducing activity of Neurones

 General Anaesthetics bind with these channels and cause opening

and potentiation of these inhibitory channels – leading to inhibition
and anesthesia
 General Anesthesia

Inhalational Intravenous

Volatile Slower
Gas Inducing agents
liquids acting

Nitrous oxide Dissociative Opioid analgesia Benzodiazepines

Ether anesthesia Thiopentone sod.
Zenon
Halothane Methohexitone sod.
Diazepam
Enflurane Ketamine Propofol
Fentanyl
Lorazepam
Etomidate
Isoflurane
Midazolam Droperidol
Desflurane

Sevoflurane

Methoxyflurane
 Inhalation anesthetics
• Common features of inhaled anesthetics
– Modern inhalation anesthetics are nonflammable, nonexplosive agents.
– Decrease cerebrovascular resistance, resulting in increased perfusion of the brain
– Cause bronchodilation, and decrease both minute ventilation and hypoxic
pulmonary vasoconstriction

• MAC (potency): The alveolar concentration of an anesthetic gas

needed to eliminate movement among 50% of patients challenged
by a standardized painful stimulus (skin incision).
– MAC is the ED50 of the anesthetic.

– the inverse of MAC is an index of potency of the anesthetic.

uptake and distribution of inhalation anesthetics
 The movement of these agents from the lungs to the different body compartments depends
upon their solubility in blood and tissues as well as on blood flow.

 Because gases move from one compartment to another within the body according to partial
pressure gradients, a steady state (SS) is achieved when the partial pressure in each of these
compartments is equivalent to that in the inspired mixture.
 Anesthetic concentration in the inspired air (Alveolar wash-in):
 replacement of the normal lung gases with the inspired anesthetic mixture.
 The time required for this process is
 directly proportional to the functional residual capacity of the lung,
 inversely proportional to the ventilatory rate; it is independent of the physical properties of the gas.

 Anesthetic uptake:
 is the product of gas solubility in the blood, cardiac output, and the alveolar to venous partial pressure gradient of the anesthetic.
 Solubility in the blood: called the blood/gas partition coefficient.
 The solubility in blood is ranked in the following order: halothane > enflurane > isoflurane > sevoflurane > desflurane > n2o.
 An inhalational anesthetic agent with low solubility in blood shows fast induction and also recovery time (e.g., N2O), and an agent
with relatively high solubility in blood shows slower induction and recovery time (e.g., halothane).

 Wash out:
 when the administration of anesthetics discontinued, the body now becomes the “source” that derives the anesthetic into the
alveolar space. The same factors that influence attainment of steady-state with an inspired anesthetic determine the time course of
clearance of the drug from the body. Thus N2O exits the body faster than halothane.
 Inhalation sedation
 Indication  Contraindication
 Uncooperative patient  Patient with extreme anxiety
 Mildly apprehensive patient  Nasal obstruction, sinus problem, common cold
 Medically compromised patient  URTI
 Patient with gaging reflex  Serious psychiatry disorder
 COPD patient

o Advantage  Disadvantage
o Easy to administer  Expensive equipment
o Rapid onset  Occupational hazards from Nitrous
o Rapid uptake Oxide leakage
o Wide margin of safety
o Nausea-Vomiting uncommon
 Nitrous oxide (N2O) “laughing gas”
 It is a potent analgesic but a weak general anesthetic.
 Rapid onset and recovery:
 Does not depress respiration, and no muscle relaxation.
 No effect on CVS or on increasing cerebral blood flow

 The least hepatotoxic, Teratogenic, bone marrow depression.

 Second gas effect:

N2O can concentrate the halogenated anesthetics in the alveoli when they are
concomitantly administered because of its fast uptake from the alveolar gas.

 Diffusion hypoxia:
speed of N2O movement allows it to retard oxygen uptake during recovery.
Ether

 Known as diethyl ether.

 Prepared by Cordus in1540 – sweet oil of vitriol
 Blood gas partition coefficient is 15
 Guedel stage of anesthesia is described on ether anesthesia
 On induction – analgesia > excitement > anesthesia
 Increase CSF pressure, blood glucose level
 Postoperative nausea and vomiting in 50 % of patient
 Halothane (2-bromo-2-chloro-1,1,1-trifluoroethane)

 Synthesized in 1951
 Blood gas partition coefficient 2.5

 ADVANTAGE  DISADVANTAGE
 Potent anesthetic, rapid induction & recovery  Weak analgesic (thus is usually coadministerd with
N2O, opioids)
 Neither flammable nor explosive, sweet smell, non
irritant  Is a strong respiratory depressant
 Low incidence of post operative nausea and  Is a strong cardiovascular depressant
vomiting.
 Hypotensive effect
 Not hepatotoxic in pediatric patient, and combined
 Cardiac arrhythmias: if serious hypercapnia develops
with its pleasant odor, this makes it suitable in
due to hypoventilation and an increase in the plasma
children for inhalation induction
concentration of catecholamines
 Malignant hyperthermia
It is an autosomal dominant genetic disorder of skeletal muscle that occurs in susceptible individuals undergoing general anesthesia with volatile agents and muscle relaxants (eg,
succinylcholine).

The malignant hyperthermia syndrome consists of the

• rapid onset of tachycardia

• hypertension,

• severe muscle rigidity,

• hyperthermia,

• hyperkalemi

• acid-base imbalance.

Rx Dantroline
 ENFLUREN

 ADVANTAGE  DISADVANTAGE
 Less potent than halothane, but produces rapid induction  CNS excitation at twice the MAC, Can induce
and recovery seizure
 ~2% metabolized to fluoride ion, which is excreted by
the kidney
 Has some analgesic activity
 Differences from halothane:
 Fewer arrhythmias,
 less sensitization of the heart to catecholamines
 greater potentiation of muscle relaxant
 ISOFLUREN
 ADVANTAGE
 A very stable molecule that undergoes little
metabolism
 Not tissue toxic
 Does not induce cardiac arrhythmias
 Does not sensitize the heart to the action of
catecholamines
 Produces concentration-dependent hypotension
due to peripheral vasodilation
 It also dilates the coronary vasculature, increasing
coronary blood flow and oxygen consumption by
the myocardium, this property may make it
beneficial in patients with IHD.
Desflurane:

• Rapidity of induction and recovery: outpatient surgery

• Less volatility (must be delivered using a special vaporizer)

• Like isoflurane, it decreases vascular resistance and perfuses all major tissues very well.

• Irritating cause apnea, laryngospasm, coughing, and excessive secretions

Sevoflurane:

• Has low pungency, not irritating the airway during induction; making it suitable for induction
in children

• Rapid onset and recovery:

• Metabolized by liver, releasing fluoride ions; thus, like enflurane, it may prove to be
nephrotoxic.

Methoxyflurane

• The most potent and the best analgesic anesthetic available for
clinical use. Nephrotoxic and thus seldom used.
Intravenous sedation

 Advantage  Disadvantage
 Highly effective technique  Venepuncture is necessary
 Rapid onset of action  Venepuncture complications
 Patent vein is a safety factor  Infiltration

 Control of salivary secretion  Hematoma

 Nausea vomiting less common  thrombophlebitis

 Intensive monitoring required
 Delayed recovery
 Intravenous anesthetics
28
Barbiturates (thiopental, methohexital)
 Potent anesthetic but a weak analgesic
 High lipid solubility;
 Quickly enter the CNS and depress function, often in less than one
minute.
 Redistribution occur very rapidly as well to other body tissues,
including skeletal muscle and ultimately adipose tissue (serve as a
reservoir).

 Thiopental has minor effects on the CVS but it may cause sever
hypotension in hypovolemic or shock patient
 All barbiturates can cause apnea, coughing, chest wall spasm,
laryngospasm, and bronchospasm
29 Intravenous anesthetics/Propofol
Phenol derivative
It is an IV sedative-hypnotic used in the induction and or maintenance of anesthesia.
Onset is smooth and rapid (40 seconds)
It is occasionally accompanied by excitatory phenomena, such as muscle twitching, spontaneous
movement, or hiccups.
Rate of Infusion – 30 mg/kg/min – amnesic
- 10 to 50 mg/kg/min – sedative dose
Full orientation occur with in 5 to 10 minute after stopping of infusion.

 Decrease BP without depressing the myocardium, it also reduce intracranial pressure.

 It is widely used and has replaced thiopental as the first choice for anesthesia induction and
sedation, because it produces a euphoric feeling in the patient and does not cause post
anesthetic nausea and vomiting.
 Poor analgesia
30
Intravenous anesthetics/Etomidate
 Is used to induce anesthesia, it is a hypnotic agent but lacks
analgesic activity.
 Induction is rapid, short acting
 It is only used for patients with coronary artery disease or
cardiovascular dysfunction,
 No effect on heart and circulation
 Adverse effects: a decrease in plasma cortisol and
aldosterone levels which can persist for up to eight hours.
This is due to inhibition of 11-B-hydroxylase

3/21/2016
 ketamine
31

 Ketamine (phencyclidine derivative)

 Non-barbiturate hypnotic
 1-2mg/kg – IV or 8-10 mg/kg - IM
 A short acting anesthetic (up to 15 min) induces a
dissociated state in which the patient is unconscious but
appear to be awake and does not fell pain.
 Profound analgesia, less vomiting
 Provides sedation, amnesia, and immobility
 Interacts with NMDA receptor,
 ketamine
32
 Sympathomimetic effect:
 stimulates the central sympathetic outflow, causes stimulation of the heart and
increased BP and COP.

This property is especially beneficial

1. in patients with either hypovolemic or cardiogenic shock,
2. as well as in patients with asthma. Ketamine is therefore used when
circulatory depression is undesirable. BP is often increased.
 It increases cerebral blood flow and induces postoperative
hallucinations “nightmares” particularly in adults,
 No M. relaxation
 Adjuvants/Opioids (fentanyl, sufentanil)
33
Benzodiazepine (midazolam, lorazepam and diazepam)
 Are used in conjunction with anesthetics to sedate the patient.
Opioids:
 Analgesic, not good amnesic, used together with anesthetics.
 They are administered either I.V, epidurally, or intrathecally
 All cause hypotension, respiratory depression and muscle rigidity as well as post
anesthetic nausea and vomiting, antagonized by naloxone.
Neuroleptanesthesia:
Is a state of indeffernce and immobilization (analgesia and amnesia) produced
when patient become analgesic, deeply seated and partially or wholly amnesic but yet
remain capable of obeying commands and answering simple question.
it occurs while fentanyl is used with droperidol and N2O, Is suitable for burn
dressing, endoscopic examination
 Properties of Intravenous Anesthetic Agents
34 Drug Induction and Main Unwanted Notes
Recovery Effects
thiopental Fast onset Cardiovascular and Used as induction agent
(accumulation respiratory depression declining. ↓ CBF and O2
occurs, giving slow consumption
recovery) Hangover Injection pain
etomidate Fast onset, fairly Excitatory effects Less cvs and resp
fast recovery during induction depression than with
Adrenocortical thiopental, Injection site pain
suppression
propofol Fast onset, very fast cvs and resp Most common induction
recovery depression agent. Rapidly metabolized;
Pain at injection site. possible to use as
continuous infusion. Injection
pain. Antiemetic
ketamine Slow onset, after- Psychotomimetic Produces good analgesia
effects common effects following and amnesia. No injection
during recovery recovery, Postop site pain
nausea, vomiting，
salivation
midazolam Slower onset than Minimal CV and resp Little resp or cvs depression.
other agents effects. No pain. Good amnesia.
 Non-barbiturate induction drugs effects on
35 BP and HR

Drug Systemic BP Heart Rate

propofol ↓ ↓

etomidate No change or slight No change

↓
ketamine ↑ ↑
 Pre-anesthetic evaluation

Use pre-anesthetic medication

↓
Induce by I.V thiopental or suitable alternative
↓
Use muscle relaxant
↓
Intubate
↓
Use, usually a mixture of N2O and a halogenated
hydrocarbon→maintain and monitor.
↓

Withdraw the drugs → recover

 Meet the patient personally.
 Choose the right technique by the preferences,
case and patient.
 Goal
 Increase Quality of preoperative care
1. Patient’s History
 Reduce Morbidity and mortality of surgery
2. History of use of anesthetics
 Reduce Cost of preoperative care or drugs
 Reduce Anxiety 3. Pre-operative labs
4. Physical examination &
Problem Identification
5. Risk Assessment
6. Plan of Anesthetic
Use the ASA and GOLDMAN Management
scale for anaesthetic risk. 7. Pre-anaesthetic Instructions
Physical Examination:

 General examination
 Airway assessment
 Respiratory system
 Cardiovascular system
 System related problems identified from the history
MALLAMPATI TEST

DOCTOR
PATIENT
Mallampati Classification

Class I = visualize the soft palate, uvula, anterior and posterior pillars.

Class II = visualize the soft palate and uvula.

Class III = visualize the soft palate and the base of the uvula.

Class IV = soft palate is not visible at all.

ULBT (Upper Lip Bite Test)

 Class 1:
Lower incisors can bite upper lip
above vermillion line.

 Class 2:
Lower incisors can bite upper lip
below vermillion line.

 Class 3:
Lower incisors cannot bite the upper lip.
 Interincisor distance (IID)

 Generally greater than 2.5 to 3

fingerbreadths (depending on
observers fingers)
 Less than or equal to 4.5 cm is

considered a potentially
difficult intubation.
Thyromental distance(TMD)

Upright, neck extension, mouth closed, Distance < 6.5cm difficult

intubation
Sternomental Distance(SMD)

Extended head and neck, mouth closed, distance

<12.5cm is a difficult intubation
 medical status mortality
ASA I Normal healthy patient without organic, biochemical, or psychiatric 0.06-0.08%
disease

ASA II Mild systemic disease with no significant impact on daily activity Unlikely to have an
e.g. mild diabetes, controlled hypertension, obesity . impact
0.27-0.4%

ASA III Severe systemic disease that limits activity e.g. angina, COPD, prior Probable impact
myocardial infarction 1.8-4.3%

ASA IV An incapacitating disease that is a constant threat to life e.g. CHF, Major impact
unstable angina, renal failure ,acute MI, respiratory failure requiring 7.8-23%
mechanical ventilation

ASA V Moribund patient not expected to survive 24 hours e.g. ruptured 9.4-51%
aneurysm
 GOLDMAN RISK ASSESMENT SCALE (1977)
Factors Value
History Age > 70 years (5 point)
Myocardial infection with in 6 month (10 points)
Cardiac Exam Signs of CHF: ventricular gallop or JVD (11 points)
Significant aortic stenosis (3 points)
Electrocardiogram Arrhythmia other than sinus or premature atrial contractions (7 points)
5 or more PVC's per minute (7 points)
General Medical PO2 < 60; PCO2 > 50; K < 3; HCO3 < 20; BUN > 50; Creat > 3; elevated SGOT;
Conditions chronic liver disease; bedridden (3 points)
Operation Emergency (4 points)
Intraperitoneal, intrathoracic or aortic (3 points)

0-5 Points: Class I 1% Complications

6-12 Points: Class II 7% Complications

13-25 Points: Class III 14% Complications

26-53 Points: Class IV 78% Complications

Age up to 49 yrs CBC

Age 50-64yrs CBC,ECG

Age > 65 yrs CBC, ECG, CXR

Urine analysis, LFT, BUN/ Cr, Electrolyte,Blood Sugar

 MINIMUM FASTING PERIOD,
INGESTED MATERIAL APPLIED TO ALL AGES (hr)
Clear liquids 2

Breast milk 4

Infant formula 6

Nonhuman milk 6

Light meal (toast and clear 6

liquids)
PRE-ANAESTHETIC
MEDICATIONS
PREANAESTHETIC MEDICATION

 “Itis the term applied to the administration

of drugs prior to general anaesthesia so as
to make anaesthesia safer for the patient”

 Ensurescomfort to the patient & to

minimize adverse effects of anesthesia
PRE-ANAESTHETIC MEDICATIONS

Serve to
 Relief of apprehension or anxiety
 Sedation
 Analgesia
 Amnesia of perioperative events
 Antisialogogue effect
 Reduction of stomach acidity
 Prevention of nausea and vomiting
 Vagolytic action
 Facilitation of anesthetic induction
 Prophylactic against allergies
Preanesthetic Medicine:
• Benzodiazepines; midazolam or diazepam: Anxiolysis & Amnesia.
• Barbiturates; pentobarbital: sedation
• Diphenhydramine: prevention of allergic reactions: antihistamines
• H2 receptor blocker- ranitidine: reduce gastric acidity.
 Provide relief from apprehension & anxiety
Post-operative amnesia

 Benzodiazepine
 anxiolytics but no analgesia – should not be given with opioids

 Midazolam
 Iv – 0.05-0.1 mg/kg (2 to 5 mg in 0.5 mg increment) – return to normal within 4
hr
 Intra-nasal dose – 0.6 mg/kg

 Diazepam
 Gold standard
 Oral doses – 5-10 mg
 With opioid can produce respiratory and cardiovascular depression

 Flumezanil
 Drug antagonized the sedative and amnestic effect of midazolam
 0.1 -0.5 mg
 Short acting – preferably given in infusion form
SEDATIVES-HYPNOTICS
 Barbiturates
 Priorly used but now generally no use
 Replaced by benzodiazepine
 Doses – 50-200 mg orally
 Action within 15 to 20 minute – duration last – 2 to 4 hr

 Butyrophenon
 Mainly antiemetic but can produce sedation
 Doses – IV/IM – 2.5 to 7.5 mg

 Phenothiazine
 Sedation, anticholinergic and antio emetic effect
 Always used with opioids
 Lytic cocktail – 50 mg pethidine + 25 mg promethazine + 10 mg chlorpromazine

 Promethazine
 Antisialogogue + antihistaminic + sedative
 Doses – Orally – 10 – 25 mg

 Trimeperezine tartrate
 Doses – 3-4 mg/kg – 2 hr preoperatively
 ANALGESIC AGENT
 Morphine
 Well absorbed after IM injection
 Onset – 15 to 30 minute
 Peak effect – 45 to 90 minute
 Lasting for 4 hr
 May cause – orthostatic hypotension, respiratory distress, addiction

 Fentanyl (preferred most now a days/ given just before induction)

 50 to 125 times potent than morphine
 Respiratory depression is high
 Dose – 1-2umg/kg
 Onset – 30 to 60 second
 Route – intranasally, orally, transdermally

 Pethidine
 Doses – 50 to 100 mg – IM / IV – single dose lasts for 2 to 4 hour

 Buprenorphine
 Highly potent drug
 3 to 6 umg/kg – IM/IV
 Respiratory depression
 ANTICHOLINERGIC AGENTS
 Actions
 Vagolytic
 Increase heart rate by blocking acetylcholine on muscarinic
receptor in SA node
 Atropine is more effective than glycopyrolate / scopolamine
 Useful in preventing intraoperative bradycardia resulting from
vagal stimulation or carotid sinus stimulation
 Atropine (0.5mg IM) also helps in preventing vasovagal attack  Side Effects
 Pupillary dilatation

 Antisialogogue  Tachycardia, cardiac arrhythmia

 Induce drying of salivary, gastric, tracheobronchial and sweat gland
secretion  Delirium, confusion, restlessness
 Glycopyrolate (0.1-0.3 mg IM) is more potent – long acting drying
effect  Increase body temperature
 Should be given 30 minute prior to the procedure

 Sedation and amnetia

 Atropine and scopolamine cross blood-brain barrier
 Atropine cause delirium in elderly
 Scopolamine has good sedative and amnesic effect
 Antiemetics-
- Metoclopramide (10mg i.m.) used as antiemetic & as prokinetic gastric emptying agent
prior to emergency surgery – 30-60 minute prior to surgery

- Domperidone (10mg oral) more preferred (does not produce extrapyramidal side effects)

- Ondansetron (4-8mg i.v.), a 5HT3 receptor antagonist, found effective in preventing post-
anaesthetic nausea & vomiting

Drugs reducing acid secretion -

- Ranitidine (150-300mg oral) or Famotidine (20-40mg oral) given night before & in morning along with
Metoclopramide reduces risk of gastric regurgitation & aspiration pneumonia

- Proton pump inhibitors like Omeprazole (20mg) with Domperidone (10mg) is preferred nowadays
 For OUT PATIENT DENTAL SURGERY
 Atropine/ Glycopyrolate – 30 min prior to surgery
 Diazepam (0.25mg/kg) – orally night before procedure
 For longer procedure – Midazolam (0.05-0.1mg/kg) – IM- 30 min prior to surgery
 If pt. having pain – fentanyl (100mg) may be added to midazolam

 For MAJOR MAXILLOFACIAL SURGERY

 Atropine / Glycopyrolate + Pethidine + Promethazine – 30 min prior to surgery
 Promethazine act for drying secretion + Sedation + prevent Histamine release

 For PEDIATRIC / CHILD PATIENT

 Vagus activity more predominant with small air passage
 Presence of secretion may cause deleterious effect
 Anticholinergic mandatory IM/IV
 Syrup TRIMEPERAZINE / Promethazine (0.6mg/kg) – to sedate
 Ketamine can also be given
 CONCURRENT DRUG THERAPY
To be continued To be modified To be discontinued

Antiarrythmics Insulin Diuretic- on the day of surgery

Antiasthmatic Oral-anticoagulant Oral hypoglycemic

Antibiotics Steroid cover Aspirin – 1 wk prior

Antiepileptic Mono Amine Inhibitor – 2 wk prior to

surgery

B-blocker Oral contraceptive – 1 mnth cycle

Ca channel blocker

Eye drops

Sedative/anxiolytic

immunosuppressant
 Anesthesia & Resuscitation equipment  Oxygen therapy Equipment
 Anesthesia machine  Oxygen cylinder
 Breathing circuit  Oxygen flowmeter
 Anesthetic mask  Oxygen mask
 Laryngoscope  Nasal catheter/ prongs
 Endotracheal tube  Intravenous infusion equipment
 Airways  Scalp needle
 Magill’s forceps  Intravenous cannula
 Mouth prop  Bivalve (three way)
 Resuscitation bag  Infusion set
 Monitoring equipment  Intravenous fluids
 Blood pressure monitor
 Cardioscope
 Pulse oximeter
 Capnometer
 Respiratory gas monitor
 Anesthesia Machine
 To deliver a desired concentration of a mixture of anesthetic agents in an
inhalation form with oxygen and/or air – act as a vehicle to carry this
mixture to the outlet of the equipment.
 Consist of
 Cylinder of gases
 Flow meter
 Vaporizer
 Oxygen flush / emergency oxygen knob
 Working platform and tray

 Two type
 Intermediate flow (Walton 5 machine)
 Continuous flow (Boyle machine)
 Intermediate machine
 Gas flows on patient demand through DEMAND VALVE
– now a days obsolete

 Continuous flow machine

 Oxygen/ nitrous oxide – individual flow meter
 Vaporizer – meant for setting desired percentage of
anesthetic agent

 Disadvantage
 Delivery of hypoxic gas mixture
 Lead to – brain damage / coma/ cardiac arrest/ death
 To avoid newer anesthetic machine has – hypoxic gas
mixture alarm
 Component
 Reservoir bag
 Excursion (rhythmical inflation + deflation) – allows visual monitoring of patient breathing

 Long corrugated breathing tube

 Flexible
 Prevent kinking
 Plastic body – light weight – less drag on mask

 Expiratory valve
 Spring loaded valve (Heidbrink Valve)
 Non-rebreathing valve

 Types
 Magill’s system – a single corrugated tubing
 Bain’s system – coaxial tubing
 Closed circuit – double tubing – inspiratory / expiratory
Anesthetic mask

 Allows administration of gases from

breathing unit
 Type
 Face mask
 Nasal mask
 Parts
 Connector / mount
 Body
 Edge / seal
 Size
 1,2,3,4,5
AIRWAY TUBES
 Oropharyngeal airway

 Nasopharyngeal airway

 LMA (Laryngeal Mask Airway)

 Esophageal tracheal combi-tube

 Endotracheal tube

 Nasotracheal tube

 Flexo-matalic tube

 Ring Adair Ellwyn (RAE)

 South pole
 North pole
 Tracheal intubation
 Intubation after induction of GA
 Oral – OROTRACHEAL intubation
 Nasal – NASOTRACHEAL intubation

 Awake intubation
 Blind oral
 Blind nasal
 Retrograde – rail road technique
 Fiberoptic scope
 Consisting of
 Self inflating bag
 Non-breathing valve
 facemask

 Verities
 With reservoir bag
 Without reservoir bag
 Size
 Infant
 Child
 adult
 Monitoring Equipment
 Blood pressure monitor
 Generally monitor on the right / left upper arm
 Types-
 Simple sphygmomanometer / aneroid dial
 Noninvasive automatic blood pressure monitor
 Invasive blood pressure monitor

 Cardioscope
 Help to monitor
 ECG
 Heart rate, rhythm
 Type of arrhythmia
 It may be either 3 lead or 12 lead
 Pulse oximeter
 Non invasive equipment to monitor the oxygen saturation
of the patient
 A small probe attached on any of the finger/ toes/ ear
lobule
 It is important because hypoxia can occur from anesthetic
gas mixture/ breathing circuit got disconnected
 Hypoxia can lead to brain death , coma and even cardiac
arrest
 Capnometer/ capnograph
 Equipment that continuously record CO2 tension
(in mm Hg or %) of expired gas

 Value – 35-45 mm Hg

 Also known as End Tidal CO2 monitor.

 Help anesthesiologist to decide

 Pt breathing adequately
 Whether tube is in trachea or oesophagus
 Breathing circuit is in position or not
Oxygen Therapy Equipment

 Oxygen Cylinder
 Oxygen flowmeter
 Oxygen Mask
 Nasal Catheter
Intravenous Infusion Equipment

 Scalp needle
 Intravenous cannula
 Bivalve ( three way)
 Infusion set
 IV fluid
Induction of anesthesia
 the period of time from the onset of administration of the anesthetic to the development
of effective surgical anesthesia in the patient.
 It depends on how fast effective concentrations of the anesthetic drug reach the brain.
 During induction it is essential to avoid the dangerous excitatory phase (stage II delirium)
that was observes with the slow onset of action of some earlier anesthetics.
 GA is normally induced with an I.V thiopental, which produces unconsciousness within 25
seconds after injection. At that time, additional inhalation or IV drugs comprising the
selected anesthetic combination (skeletal M. relaxants) may be given to produce the
desired depth of surgical stage III anesthesia.

 Inhalation induction: For children without IV access, non pungent agents, such as
halothane or sevoflurane, are used to induce GA.
Maintenance of anesthesia

 Anesthesia is usually maintained by the administration of volatile anesthetics,

because these agents offer good minute-to-minute control over the depth of
anesthesia.
 Opioids such as fentanyl are often used for pain along with inhalation agents,
because the later are not good analgesics.
 Usually: N2O + volatile agent (halothane, isoflurane)
 Less often N2O + I.V Opioid analgesic (fentanyl, morphine, pethidine + N.M
blocking agents
Recovery

 the time from discontinuation of administration of the anesthesia until

consciousness and protective physiologic reflexes are regained.

 It depends on how fast the anesthetic drug diffuses from the brain.

 For most anesthetic agents, recovery is the reverse of induction; that is,
redistribution from the site of action (rather than metabolism) underlies
recovery.
 N.M blocking agents and Opioids induced respiratory
depression have either worn off or have been adequately
reversed by antagonists.
 Regained consciousness and protective reflex restored
 Relief of pain: NSAIDs
 Postoperative vomiting: metoclopramide, prochlorperazine
Complications Cause Management
Coughing Irritation of airways, secretion By deepening of anesthesia / induce muscle relaxant

Hiccup Afferent impulse from abdominal/ Deepen anesthesia / induce muscle relaxant
thoracic viscous via vagus
Wheezing Reflex under light anesthesia, ETT Rule out mechanical obstruction
inserted too far, aspiration Deepen the level of anesthesia
Aminophyline IV 250-500 mg
Adrenaline IV 1-3 ml (1:10000)
Salbutamol IV 250mg / 2.5mg inhalation
Cyanosis Misplaced ETT Properly position ETT
Disconnection Connect circuit properly
Airway obstruction Check gas supply
Oxygen supply failure Monitor ET CO2 SaO2
Hypertension Light anesthesia Use vasodilator
Hypoventilation Deep anesthesia level
Hypercarbia Ventilate properly
Hypotension Due to anesthetic drug Volume load
Blood loss IV Atropine
B-blockers IV Vasopressor (dopamine)
hypoxemia Failed oxygen delivery Ventilate with self inflating bag
Obstructed airway Rule out disconnection
Esophageal intubation Check ETT position
Complications Management

Nausea & Vomiting Keep patient supine

Promethazine 12.5 mg- 25 mg IM/IV
Metaclopromide 10-20 mg orally
Ranitadine 50 mg IV

Postoperative Passage of urine

hypertension Oxygenate properly
Chlorpromazine 2-5 mg IV
Sodium nitro preside infusion

Respiratory inadequacy Ventilate adequately with 100% oxygen

Asses neuromascular block – IV Atropine/ Neostigmine (not more than 5 mg)
Naloxane administer if narcotics used (0.4 mg dilute to 4 ml – 0.1 mg increament)

Respiratory obstruction Clear the airway

Ventilate with bag and mask
Oxygenate
If require intubate SOS / Tracheostomy

Postoperative shivering Oxygenation

Warm the patient
Stop any blood infusion
Thank You!