GENERAL ANAESTHESIA

Presented by Dr. Vishal Dewalwar Lecturer

Definition
A controlled state of unconsciousness in which there is a loss of protective reflexes, including the ability to maintain an airway independently and to respond appropriately to physical stimulation. or verbal command.

Surgery Before Anesthesia

Fun and Frolic led to early Anaesthesia

History of Anaesthesia
Joseph Priestly discovered N2O in 1773 Sir Humphrey Davy experimented with N2O, reported loss of pain, euphoria Horace Wells in 1844 demonstrated N2O for tooth extraction

 William Morton, dentist first demonstration of successful surgical anesthesia with ether in 1846 Dr. John Snow administered chloroform to Queen Victoria (1853) popularized anesthesia for childbirth in UK

Goals of Anaesthesia
Hypnosis (unconsciousness) Amnesia Analgesia Immobility/decreased muscle tone
(relaxation of skeletal muscle)

Inhibition of nociceptive reflexes Reduction of certain autonomic reflexes

(gag reflex, tachycardia, vasoconstriction)

Preanaesthetic evaluation
The main purpose of preoperative visit is to assess the patients fitness for anaesthesia. This visit allows the most suitable anaesthetic technique to be determined, any potential interaction between concurrent diseases, drugs and anaesthesia to be anticipated and also provides reassurance to the patient.

Anaesthetic History
Previous anaesthesia and major surgeries Past and present medical history - CVS, RS - Pregnancy Drug and allergies Personal history - Habits Smoking, Alcohol, Drugs

Physical Examination
Cardiovascular System - Cardiac arrhythmias - Blood pressure - Peripheral veins Respiratory System - Asthma - COPD`s

 Nervous system - motor or sensory impairment Musculoskeletal system - TMJ - Cervical spondilitis

 Airway - assessment is made in 3 stages 1. Observation of patients anatomy 2. Bedside tests 3. X- rays

1. Observation of patients anatomy - Trismus - Retrognathia - Position, no. and health of teeth - Size of tongue - Deviated larynx or trachea - Midline or lateral swelling of neck

2. Bedside tests

a. Mallampati`s criteria
- view of pharyngeal structures is noted and graded as I-IV

b. Thyromeatal distance

- distance between bony point of the chin and the prominence of thyroid cartilage
- a distance less than 7cm suggests difficult intubation

3. X - rays - Lateral and AP neck X - rays are advised

- measurements can be made on lateral X - ray of head and neck

Preanaesthetic medication
It refers to the drugs administered to facilitate the induction and maintenance of anaesthesia. The 6 A`s premedication 1.Anxiolysis 2.Amnesia 3.Anti-emetic 4.Antacid 5.Anti-autonomic 6.Analgesic

Aims
1. Relief of anxiety and apprehension preoperatively and to facilitate smooth induction. 2. Amnesia for pre and post operative events. 3. Supplement analgesic action of anaesthetics and potentiate them so that less anaesthetic is needed.

3. Decrease secretions and vagal stimulation caused by anaesthetics. 4. Antiemetic effect extending to the postoperative period.

5. Decreases acidity and volume of gastric acid so that it is less damage if aspirated.

Anticholinergics
ATROPINE
Atropine is the prototype drug of anticholinergic class and is highly selective for muscarinic receptors.

ACTION:-Blocks the muscarinic effects of acetylcholine as it has

the same affinity for muscarinic receptors as acetylcholine but poor intrinsic activity. USES :- 1. Preanasesthetic medication 2.Organophosphorous poisoning 3.Bradyarrhythmias 4.Motion sickness 5.Colic and dysmenorrehea

6.Peptic ulcer

7.Parkinson`s disease
8.To produce mydriasis and cycloplegia

SIDE EFECTS :-1.Dry mouth, dysphagia, constipation, paralytic ileus

2.Urinary retention 3.Blurred vision and precipitates of glaucoma

4.Allergic dermatitis
PRECAUTIONS:-1.In elderly it precipitates glaucoma and urinary retention(if enlarged prostate). 2.In chronic lung diseases it dries up secretions. DOSE :-ATROPINE SULPHATE 0.6mg/ml inj. i.m.,i.v.

H2 BLOCKER
RANITIDINE It is introduced as a non-imidazole H2 blocker. ACTION:-1. Abolishes histamine stimulated gastric acid secretion and flushing.

2. Inhibits gastric H2 receptors, this reduces basal, 24 hours

and nocturnal acid secretion. 3. Has mucosal protective action.

USES:-

1.Preaneasthetic medication.
2.Peptic ulcer. 3.Esophagitis.

4.Stress ulcer

5.Zollinger- Ellision syndrome

6.Gastro oesophageal reflux disease(GERD).

SIDE EFFECTS :- 1.Blood dycrasias. 2.Skin rash.

3.Leucopenia
DOSE :-300mg/day or 150mg BD 50mg i.m. or slow i.v.every 6 to 8 hrs. TRADE NAME :- ULTEC,ZENTAC,RANITINE,ACILOC.

ANTIEMETIC
ONDANSETRON It is the prototype of a new class of anti emetic drugs developed to control cancer chemotherapy/radiotherapy induced vomitting and later found to be highly effective in postoperative nausea and vomiting as well. USES:1.Preaneasthetic medication.

2.It is given before starting chemotherapy

especially CISPLASTIN. SIDE EFFECTS:- 1.GI:diarrohea .

2.Skin:rashes

3.Miscellaneous;headache, blurred vision,

hypokalemia, anaphylactoid reaction.

DOSE

: 4-8mg BD or TDS orally or i.v.

TRADE NAME:-EMESET,VOMIZ,OSETRON

INTRAVENOUS ANAESTHETICS
INTRAVENOUS

Inducing agents
Thiopentone sodium Propofol

Slower acting drugs

Benzodiazepines Diazepam Midazolam Dissociative anaesthesia

Ketamine

Inducing agents
These are drugs which on i.v. injection produce loss of consciousness. They are generally used for induction because of rapidity of onset of action.

THIOPENTONE SODIUM

It is an ultra short acting barbiturate highly soluble in water.

It must be prepared freshly before injection. ACTION :- Its undissociated form has high lipid solubility & enters brain almost instantaneously to produce unconsciousness in 15-20 sec & last till 10-20 min.

USES

:- 1.Inducing agent along with anaesthetic.

2. Rapid control of convulsions. 3. Gradual i.v. infusion of subanaesthetic doses can be

used to facilitate verbal communication with psychiatric

patient.

ADVERSE EFFECTS:- 1. Laryngosparm when respiratory secretions

or other irritants are present.

2. Shivering & delirium. 3. Post operative pain. CONTRAINDICATION:- Acute intermittent porphyria. N.B. :- Succinylcholine & thiopentone react

chemically should not be mixed in the

same syringe. DOSE :- 3-5 mg/kg as a 2.5% solution.

TRADE NAME

:- PENTOTHAL, INTRAVAL SODIUM.

PROPOFOL

It is an oily liquid introduced recently as a 1% emulsion for i.v. induction & short duration anaesthesia.
ACTION :- Unconsciousness after propofol injection occurs in

15-45sec & lasts for 15min.

USES :- 1.Inducing agent; particularly for out patient surgery.

2. In subaneasthetic doses; used for sedation in

intensive care units. SIDE EFFECTS :- 1. Pain during injection. 2. Dose dependent respiratory depression. DOSE :- 2mg/kg bolus i.v. for induction

9mg/kg/hr for maintenance.

SLOWER ACTING DRUGS

BENZODIAZEPINES In addition to preanaesthetic medication; BZDs are now frequently used for inducing, maintaining and supplementing anaesthesia.

ACTION

:-Injected i.v. produce sedation, amnesia and then

unconsciousness in 10-15 minutes. If no other

anaesthetic or opioid is given, the patient becomes responsive in 1 hr but amnesia persists for 2-3 hr

and sedation for 6 hr or more.

USES :-1. Sedative and Hypnotic.

2. Muscle Relaxant 3. Preanaesthetic Medication 4. Alcohol Withdrawal 5. Anxiety Neurosis 6. Petit-mal, Psychomotor and Status Epilepticus. SIDE EFFECTS:- 1. Drowsiness 2. Ataxia 3. Respiratory Depression

4. Hypotension

MIDAZOLAM

Water Soluble
Non Irritating Faster and Shorter Acting 3 Times more potent than Diazepam

KETAMINE It induces a so called Dissociative Anaesthesia- profound analgesia, immobility, amnesia with light sleep and feeling of dissociation from ones own body and the surroundings.

ACTION:- It acts within a minute and recovery starts after 10-15

minutes, but patient remains amnesic for 1-2 hrs.

USES :-1.Recommended for Operations on head and neck. 2.In patients who have bled. 3.In Asthmatics (relieves bronchopasm). 4.In burn dressings.

SIDE EFFECTS

:- 1. Emergence Delirium 2. Hallucinations 3. Involuntary Movements

DOSE

:- 1-4(average 2)mg/kg i.v. or 6.5-13(average10)mg/kg i.m.

TRADE NAME

:-

KETAMIN, KETLAR.

SKELETAL MUSCLE RELAXANTS Skeletal muscle relaxants are drugs that act peripherally at the neuro muscular junction/muscle fibre itself or centrally in the cerebrospinal axis to reduce muscle tone and/or cause paralysis.

Peripherally acting
muscle relaxants *Non Depolarizing blockers Pancuronium d-Tubocurarine *Depolarizing blockers Succinylcholine

Centrally acting
muscle relaxants *Mephenesin group Chlorzoxazone *Benzodiazepines Diazepam and others *GABA Derivative Baclofen

Comparative features of central and peripheral muscle relaxants:-

Centrally acting
1.Decrease muscle tone without reducing voluntary action.

Peripherally acting
1.Cause muscle paralysis, Voluntary movements lost.

2.Selectively inhibit polysynaptic

reflexes in CNS. 3.Cause CNS depression. 4.Given orally sometimes parenterally.

2.Block neuromuscular
transmission. 3.No effect on CNS. 4.Practically always given i.v.

5.Used in chronic spastic condition, 5.Used for short term purposes

acute muscle spasms,tetanus. (surgical procedures).

MECHAISM OF ACTION NON-DEPOLARIZING BLOCKERS(COMPETITIVE)They combine with the receptors on the motor end-plate and thus block the action of acetylcholine by competitive blockade.

DEPOLARIZING BLOCKERS(NON-COMPETITIVE)Depolarize muscle end-plates by opening Na-channels & thus act as partial agonist of acetylcholine.

SUCCINYLCHOLINE Commonly used muscle relaxant for passing tracheal tube. Induces rapid, complete and predictable paralysis with spontaneous recovery in 5min.

DOSE

:- 50mg/ml injection, 2ml ampule.

TRADE NAME:- MIDARINE.

PANCURONIUM Synthetic steroidal compound. Provides good cardiovascular stability. Seldom induces flushing, bronchospasm or cardiac arrhythmias. Relatively inexpensive.

Reversal often required due to its long duration of action.

DOSE :- 2mg/ml in 2ml amp. TRADE NAME:- PAVULON, PANCONIUM.

ATRACURIUM 4 times less potent than pancuronium & shorter acting. Inactivation in plasma by spontaneous non-enzymatic degradation (HOFFMANN ELIMINATION). DOSE

:- 10mg/ml injection in 2.5ml vial.

TRADE NAME:- TRACRIUM.

ANALGESICS
DICLOFENAC SODIUM
It is non-opioid analgesic , anti-pyeretic non-steroidal anti-inflammatory drug. ACTION USES

:- It inhibits synthesis and has short lasting antiplatelet action. :-1. Post-traumatic and postoperative inflammatory conditions-affords quick relief of

pain and edema.

2. Rheumatoid & osteoarthritis, bursitis. 3. Ankylosing spondylitis.

 SIDE EFFECTS :-1.Epigastric pain, nausea.

2.Headache, dizziness,rashes.

DOSE

:- 50 mg TDS
75 mg deep i.m.

TRADE NAME :- VOVERAN, DICLONAC.

PENTAZOCINE It is the first opioid agonist antagonist to be used as an analgesic. ACTION :- 1. Raises pain threshold & modifies emotional reaction to pain. 2.Inhibits transmission of impulses across the pain pathways in CNS.

USES

:-1. Potent analgesic with low addiction

liability.

SIDE EFFECTS :- 1. Respiratory depression. 2. Hallucinations and unpleasant dreams. 3. Pulmonary & systemic hypertension.

 DOSE

:- 50-100 mg orally. 30-60 mg i.m. , s.c.

TRADE NAME :- FORTWIN, MERIWYN, SOSEGON.

THANK

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