General Anesthesia

SURGERY II
FACILITATOR: Editha I. Chan-Francisco, MD, DPBA, FPSA
DATE: June 7, 2016
GENERAL ANESTHESIA (GA) • IV access
• Patient positioning
• A state wherein unconsciousness, amnesia, analgesia, • Patient monitoring
immobility, and attenuation of autonomic response to
noxious stimuli are achieved by administration of drugs. MODE OF ADMINISTRATION
• Inhalation
• Intravenous

INHALATIONAL ANESTHESIA
• The patient must receive an adequate:
o Concentration of oxygen to prevent hypoxia
o Concentration of anesthetic drug to ensure
unconsciousness
o Flow of fresh gas to prevent hypercarbia

STAGES OF ANESTHESIA

• Stage 1: Analgesia
INDICATIONS o Period between the initial administration of the
• Infants and young children induction agents and loss of consciousness
• Extensive and prolonged surgery • Stage 2: Excitement
• Patients with mental diseases o Period following loss of consciousness and
• Surgery for which local anesthesia is neither practical nor marked by excited and delirious activity
satisfactory • Stage 3: Surgical Anesthesia
• Patients with history of toxic or allergic reaction to local o Skeletal muscle relaxation, regular breathing,
anesthetics cessation of eye movements
• Patients on anti-coagulant therapy o 4 planes:
§ Eyes initially rolling, then becoming fixed
ADVANTAGES § Loss of corneal and laryngeal reflexes
• Reduces intraoperative patient awareness and recall § Pupils dilate and loss of light reflex
• Proper muscle relaxation for prolonged periods of time § Intercostal paralysis, shallow abdominal
• Control of the airway, breathing, and circulation respiration
• Can be administered without moving patient from the • Stage 4: Medullary Depression
supine position o Too much medication relative to the amount of
• Can be adapted easily to procedures of unpredictable surgical stimulation
duration or extent
• Can be administered rapidly and is reversible GENERAL INHALATIONAL ANESTHESIA
• GAS vs. VAPOUR
DISADVANTAGES • GAS LAWS (these govern the physicochemical activity of
• Requires increased complexity of care and associated inhaled anesthetics)
costs o Boyle’s Law
• Requires some degree of preoperative patient preparation § At a constant temperature, volume is
• Can induce physiologic fluctuations that require active inversely proportional to pressure
intervention o Charles Law
• Complications like nausea or vomiting, sore throat, § At a constant pressure, temperature and
headache, shivering, and delayed return to normal mental volume are directly proportional
functioning o Gay-Lussac’s Law
• Associated with malignant hyperthermia § At a constant volume, temperature and
pressure are directly proportional
OVERVIEW OF THE CONDUCT OF o Dalton’s Law
GENERAL ANESTHESIA § In a mixture of non-reacting gases, the
total pressure is equivalent to the sum of
• GA is a complex procedure involving:
all the partial pressures of each gas
o Pre-operative evaluation
o Henry’s Law
o Preparation for anesthesia
§ Governs solubility of gases
o Induction of anesthesia
§ Solubility depends on the partial
o Airway Management
pressure of the gas
o Maintenance of anesthesia
o Avogadro’s Law
o Emergence from anesthesia
§ Equal volumes contains equal number of
o Post-operative pain relief
molecules
o Graham’s Law
PREPARATION FOR ANESTHESIA
§ Law of diffusion across a semi-permeable
• Preoperative medications
membrane which is inversely proportional
• Preparation of the anesthesia machine and vaporizers, to the molecular weight of the agent
circuits and ventilators

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 UPTAKE AND DISTRIBUTION CLINICAL PHARMACOLOGY OF INHALATIONAL
ANESTHETICS

• Gasseous Anesthetics – gases at room temperature

o Cyclopropane
o Nitrous Oxide
• Volatile Anesthetics – administered as inhaled gases
(vapors), but liquid at room temperature
o Halothane
o Isoflurane
o Enflurane
o Sevoflurane
o Desflurane

NITROUS OXIDE (MAC 105)

• The only inorganic anesthetic gas in clinical use
• Sweet-smelling and non-flammable of low potency
• Limited blood and tissue solubility
• Often administered as an adjuvant in combination with
PHARMACOKINETICS OF
other volatile anesthetics or opioids
INHALATIONAL ANESTHETICS
a. Factors affecting Inspiratory Concentration (FI) HALOTHANE (MAC 0.75)
b. Factors affecting Alveolar Concentration (FA) • Halogenated alkane
c. Factors affecting Arterial Concentration (Fa) • Non-flammable and non-explosive
d. Factors affecting Elimination
• Immune-mediated hepatitis
• Colorless and pleasant-smelling
Factors affecting Inspiratory Concentration (FI)
1. Fresh gas flow rate • Most potent bronchodilator
2. Volume of the breathing system • Sensitizes myocardium to the effect of catecholamines ->
3. Any absorption by the machine or breathing circuit PVC’s, tachydysrrhythmias
• Potent uterine relaxation
The higher the fresh gas flow rate, the smaller the breathing
system volume, and the lower the circuit absorption, the closer ISOFLURANE (MAC 1.2)
the inspired gas concentration will be to the fresh gas • Halogenated methyl ethyl ether
concentration. • Coronary vasodilation is characteristic
• “Coronary Steal” Phenomenon
Factors affecting Alveolar Concentration (FA) • Less myocardial depression
1. Uptake • High degree of solubility
2. Ventilation • Negligible amount of organic fluoride
3. Concentration
ENFLURANE (MAC 1.7)
The alveolar concentration (FA) ultimately is the principal • Halogenated ether
factor in determining onset of action. • Non-flammable, clear, strong smell, airway irritant
• Seizure-like activity on EEG at high concentration
Factors affecting Arterial Concentration (Fa) • Inorganic fluoride may cause toxicity
• Ventilation/perfusion mismatch
o Increases alveolar partial pressure and decreases SEVOFLURANE (MAC 1.8)
arterial partial pressure • Completely fluorinated methyl isopropyl ether
• Rapid induction and emergence
Factors affecting Elimination
• Relatively stable CV effect
• The most important route for elimination of inhalation • Non-arrythmogenic
anesthetics is the alveolus
• Minimal odor and pungency
• Potent bronchodilator
PHARMACODYNAMICS OF INHALATIONAL • Highly dependent on liver metabolism
ANESTHETICS
DESFLURANE (MAC 6)
MINIMUM ALVEOLAR CONCENTRATION (MAC) • Completely fluorinated methyl ethyl ether – resist
• Is the FA of an anesthetic at 1 atm and 37C that prevents biodegradation
movement in response to a surgical stimulus in 50% of • Fast induction and emergence (lowest blood:gas
patients solubility)
• Can be used in low flow technique
• Requires a heated and pressurized vaporizer
MINIMUM ALVEOLAR CONCENTRATION (MAC)
• Pungent
NITROUS OXIDE 105
HALOTHANE 0.75
INTRAVENOUS ANESTHETICS
ISOFLURANE 1.2
• Barbiturates
ENFLURANE 1.7
• Propofol
SEVOFLURANE 1.8 • Ketamine
DESFLURANE 6

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 THE CONTINUUM OF DEPTH OF ANESTHESIA
Minimal Sedation/
Moderate Sedation Deep Sedation General Anesthesia
Anxiolysis
Normal response to Purposeful response to Purposeful response Unarousable even with
RESPONSIVENESS verbal stimulation verbal or tactile following repeated or painful stimulus
stimulation painful stimulation
Unaffected No intervention Intervention may be Intervention often
AIRWAY
required required required
SPONTANEOUS Unaffected Adequate May be inadequate Frequently inadequate
VENTILATION
CARDIOVASCULAR Unaffected Usually maintained Usually maintained May be impaired
FUNCTION

Barbiturates – Thiopental • May be beneficial to certain types of surgery, i.e.,

• Inhibits excitatory synaptic transmission to the GABA neurosurgery
receptors • Pollution is reduced
• Rapid onset, apnea
• Anticonvulsant DISADVANTAGES
• Causes hypotension and myocardial depression • Secure, reliable IV access is required
• Ideal for short diagnostic procedures • Risk of awareness if IV infusion fails
• Poor analgesic property • Cost of electronic infusion pumps
• May cause profound hypotension
NOTE (Batch 2016): It has a very fast onset BUT it can produce
apnea, so always have some provision for ventilation when you use
it. EMERGENCE FROM ANESTHESIA
• After the surgical procedure, the anesthesiologist has to
Associated with Lethal injection which is a combination of Potassium reverse the process of anesthesia, often referred to as
& Thiopental
“waking the patient up”
o Thiopental: to put the patient to sleep
o Potassium: to make the heart stop. • No absolute protocol
• Main priorities:
Propofol o Recovery of consciousness
• Total Intravenous anesthetic o Maintenance of a patent airway
• Alkylated phenol that inhibit synaptic transmission at the
GABA receptor OTHER DRUGS USED IN ANESTHESIA
• Short duration, rapid recovery • Sedative-Tranquilizer
• Low incidence of nausea and vomiting • Narcotic analgesic
• Bronchodilator effect • Anticholinergics
• Muscle relaxants
NOTE (Batch 2016):
Propofol is the newest agent

It’s the drug used by Michael Jackson to OD. MUSCLE RELAXANT

• Mechanism of neuromuscular transmission
This agent has a continuum of effect which means that at different o Role of ACTH
dosages you will have different effect. It can be a sedative (can o Action Potential
provide very good sedation at 1- 2mg/kg) and it can provide a
hypnotic effect at around 3-4mg/kg body weight. At 5-6mg, it can • Neuromuscular blocking drugs (NMDBs) are used to
cause hypoventilation to apnea and 10mg/kg it can already be used o Improve conditions for tracheal intubation
as an anesthetic.
o Provide immobility during surgery
o Facilitate mechanical anesthesia
It is good for asthmatic patients because of its bronchodilator effect.
TYPES OF MUSCLE RELAXANTS USED IN ANESTHESIA
Ketamine
• DEPOLARIZING
• Dissociative anesthesia
o Succinylcholine
• Sympathetic stimulation, increase heart rate and blood
§ (Batch 2016)It is very short acting (usually 10
pressure minutes) and very fast. 

• Bronchodilator § It acts like acetylcholine but is not hydrolyzed
• May have eyes open or some involuntary muscle by acetylcholinesterase. It stays in the receptor
movement for a long time, and while at the receptor it
• Hallucinations during emergence keeps the muscle depolarized. Therefore,
there is no way to stimulate the muscle.
NOTE (Batch 2016): When patients have dissociative anesthesia § Patient given succinylcholine will manifest
they will have hallucinations. They cannot discern reality from what is contraction of the whole body at first then after
imaginary. that the body will be relaxed. 

• NON-DEPOLARIZING
This is useful in patients with hypovolemia, because it may sustain a o Pancuronium
good blood pressure and heart rate because of its sympathetic o Rocuronium
stimulation.
o Vecuronium
It cannot be used in eye operations.
o Atracurium
o Cisatracurium
It is used in combination with amnesic drug like midazolam so that o Mivacurium
the patient will not be able to recall the hallucinations.
NOTE (Batch 2016): Non- depolarizing drug works as a
Total Intravenous Anesthesia (TIVA) : ADVANTAGES competitive inhibitor of acetylcholine. The acetylcholine cannot
• The potential toxic effects of inhalational anesthetics are bind to the receptor because these drugs will be the one to
avoided bind at the receptor.
• A better quality of recovery is claimed

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 Mallampati Classification
AIRWAY MANAGEMENT
• To maintain an open airway and enable mechanical
ventilation, an endotracheal tube or laryngeal mask
airways are often used
ANATOMY OF THE AIRWAY

Nerve Supply and Innervation

Vagus

Recurrent Superior
Laryngeal Nerve Laryngeal Nerve

Motor innervation External (motor

Internal (sensory
to all except innervation to the
cricothyroid cricothyroid) innervation)

Effects of Laryngeal Nerve Injury on the Voice

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 Video Laryngoscopy (Glidescope)
LARYNGOSCOPY AND INTUBATION
• (Batch 2016): Minimizes trauma caused by endotracheal
• Indications for intubation: tube insertion
o Head and neck surgery • Indicated for Mallampati class IV
o Intrathoracic and intraperitoneal surgery • Monitors insertion through the screen, and not directly
o Surgery with the patient in lateral or prone position observed
o Obstructed airway
o Full stomach
o Procedures requiring the anesthesiologist to be
remote from the patient
o Severely ill patient
o Operation in which major hemorrhage is
anticipated
o Complicated techniques of anesthesia
o Major pediatric surgery
o Non-surgical conditions like resuscitation and
laryngeal obstruction
• Advantages
o Ensures patent airway
o Decreases anatomic dead space
o Decreases possibility of aspiration
o Ventilation can be assisted or controlled USING THE GLIDESCOPE
o Suctioning of the lungs is facilitated

• Disadvantages
o Increases resistance to respiration
o Trauma

TECHNIQUES IN LARYNGOSCOPY
• Direct laryngoscopy
• Indirect laryngoscopy
• Video Laryngoscope (Glidescope)

Direct laryngoscopy
• (Batch 2016) By the use of laryngoscope
• If you are right handed, you hold the laryngoscope with your left
hand and insert the endotracheal tube with your right hand and
vice versa

LARYNGEAL MASK AIRWAY

Indirect laryngoscopy

Technique used in the indirect examination of the larynx,

patient’s tongue held in left hand, vocal cords visible in mirror.
END OF TRANSCRIPTION.

5 | DLSHSI COLLEGE OF MEDICINE Batch 2018