Prior to anesthesia, the patient's

blood pressure was 1186/117 mm Hg,

while her heart rate was 97 beats per
minute, respiratory rate was 10
breaths per minute, and oxygen
saturation was 98%. Fentanyl (50
mcg) and midazolam (2.5 mg)was
administered intravenously.

Pt name :- ATIENZA JOCELYN D.

AGE/SEX :- 50/F
Hosp no. :- 717969
WT. :- 140lbs
ASA :- 1
MAL :- II

Pre-op diagnosis :- sebaceous cyst

on the upper back.
Procedure :- excision of sebaceous
cyst.

GENERAL ANESTHETICS
• General anaesthetics (GAs) are
drugs which produce reversible loss
of all senations and consciousness.
Or,
• General anaesthetics (GAs) are a
class of drugs used to depress the
CNS to a sufficient degree to
permit the performance of surgery
and other noxious or unpleasant
procedures.

• Triad of General Anesthesia :-

–need for unconsciousness
–need for analgesia
–need for muscle relaxation

MECHANISM OF ACTION OF
ANAESTHESIA :-

The mechanism of action of GAs

is not precisely known. A wide
variety of chemical agents
produce general anaesthesia.
Therefore, GA action had been
related to some common
physicochemical property of the
drugs.

● Minimal alveolar concentration

(MAC) is the lowest
concentration of the
anaesthetic in pulmonary
alveoli needed to produce
immobility in response to a
painful stimulus (surgical
incision) in 50% individuals.

● Many inhalational
anaesthetics, barbiturates,
benzodiazepines and propofol
potentiate the action of the
inhibitory transmitter GABA at
 the GABAA receptor.
● Certain fluorinated
anaesthetics and barbiturates
in addition inhibit the
neuronal cation channel
gated by nicotinic cholinergic
receptor. As such, the
receptor operated ion
channels appear to be a major
site of GA action. Unlike local
anaesthetics which act
primarily by blocking axonal
conduction, the GAs appear
to act by depressing synaptic
transmission.

Four stages of general Anesthesia :-

Inhalational Anesthetic Agents :-

Inhalational anesthesia refers to
the delivery of gases or vapors
from the respiratory system to
produce anesthesia.

Nitrous Charac Nitrous Nitrous

Oxide terized Oxide Oxide
by inert System Side
nature ic Effects
with Effects Manufa
minimal Minimal
 Effects Manufa
minimal Minimal cturing
metabo effects impuriti
lism on es toxic
Colorle heart Hypoxi
ss, rate c
odorles and mixture
s, blood s can
tastele pressur be
ss, and e May used
does cause Large
not myocar volume
burn dial s of
Simple depres gases
linear sion in can be
compo sick used
und, patient Beginni
not s Little ng of
metabo effect case:
lized. It on second
is the respirat gas
only ion effect
anesth Safe, End of
etic efficaci case:
agent ous diffusio
that is agent n
inorgan hypoxia
ic Inhibits
Major methio
differen nine
ce is synthet
low ase
potenc (precur
y MAC sor to
value is DNA
105% synthe
Weak sis)
anesth Inhibits
etic, vitamin
powerf B-12
 B-12
ul metabo
analges lism
ic Dentist
Needs s, OR
other person
agents nel,
for abuser
surgica s at
l risk
anesth
esia
Low
blood
solubili
ty
(quick
recover
y)
Halotha Haloge
ne n Halotha Halotha
substit ne ne Side
uted System Effects
ethane ic “Haloth
Volatile Effects ane
liquid :- Hepatit
easily Decrea is” --
vaporiz ses 1/10,00
ed, respirat 0
stable, ory cases
and drive fever,
nonfla Depres jaundic
mmabl ses e,
e Most myocar hepatic
potent dium-- necrosi
inhalati lowers s,
onal BP and death
anesth slows metabo
etic conduc lic
MAC of tion breakd
MAC of tion breakd
0.75% Mild own
Efficaci periphe produc
ous in ral ts are
depres vasodil hapten
sing ation -protei
consci n
ousnes conjug
s. ates-
Inhibits Malign
sympat ant
hetic Hypert
respon hermia
se to --
painful 1/60,00
stimuli 0 with
Inhibits succiny
sympat lcholine
hetic to
driven 1/260,0
baroref 00
lex without
respon halotha
se ne in
(hypov 60%,
olemia) succiny
lcholine
in 77%.
Rapid
rise in
body
temper
ature,
muscle
rigidity,
tachyc
ardia,
rhabdo
myolysi
s,
 acidosi
s,
hyperk
alemia.
most
commo
n
masset
er
rigidity

Enflura Stable, Enflura

ne nonfla Enflura ne Side
mmabl ne Effects
e liquid System Metabo
Pungen ic lism
t odor Effects one-
MAC Potent tenth
1.68% inotropi that of
c and halotha
chrono ne--
tropic does
depres not
sant release
and quantit
decrea y of
ses hepatot
systemi oxic
c metabo
vascula lites
r Metabo
resista lism
nce-- release
lowers s
blood fluoride
pressur ion--
e and renal
conduc toxicity
tion
•Sevoflurane and Desflurane :-

Low solubility in blood

produces rapid induction and
emergence Minimal systemic effects
mild respiratory and cardiac
suppression
Few side effects
Expensive

Intravenous Anesthetic Agents :-

INDUCING AGENTS : These

are drugs which on i.v. injection
produce loss of consciousness in
one arm-brain circulation time (-11
sec); are generally used for induction
because of rapidity of onset of
action.
Anaesthesia is then usually
maintained by an inhalational agent..

1. Thiopentone sod. It is an ultrashort

acting thiobarbiturate, highly soluble
in water yielding a very alkaline
solution, which must be prepared
freshly before injection.

2.Propofol :- Rapid onset and short

duration of action Myocardial
depression and peripheral
vasodilation may occur-- baroreflex
not suppressed Not water soluble--
painful (50%) Minimal nausea and
vomiting Unconsciousness after
propofol injection occurs in 1545
sec and lasts -15 min. It distributes
rapidly (distribution t1/2 2-4 min)
and elimination is much shorter than
thiopentone due to rapid
metabolism. It is particularly suited
for out patient surgery because
residual impairment is less marked
and incidence of post operative
nausea and vomiting is low.
Dose:2mg/kg bolus i.v. for induction;
9 mg/kg/hr for maintenance.

3.Etomidate :- Structure similar to

ketoconozole Direct CNS depressant
(thiopental) and GABA agonist.
Little change in cardiac function in
healthy and cardiac patients Mild
dose-related respiratory depression
Decreased cerebral metabolism.

Slower Acting Drugs :-

● Benzodiazepines Produce
sedation and amnesia
Potentiate GABA receptors
Slower onset and emergence

● Diazepam :- Often used as

 premedication or seizure
activity, rarely for induction
Minimal systemic effects--
respirations decreased with
narcotic usage Not water
soluble-- venous irritation
Metabolized by liver-- not
redistributed

● Lorazepam Slower onset of

action (10-20 minutes)-- not
used for induction Used as
adjunct for anxiolytic and
sedative properties Not water
soluble-- venous irritation

● Midazolam More potent than

diazepam or lorazepam
Induction slow, recovery
prolonged May depress
respirations when used with
narcotics Minimal cardiac
effects Water soluble

● Ketamine Interrupts cerebral

association pathways --
“dissociative anesthesia”,
Stimulates central sympathetic
pathways Ketamine Systemic
and Side Effects Characteristic
of sympathetic nervous system
stimulation-- increase HR, BP.

~ PREANAESTHETIC MEDICATION :-

Preanaesthetic medication refers to

the use of drugs before anaesthesia
to make it more pleasant and safe.
1. Opioids Morphine (10 mg) or
pethidine (50-100 mg), i.m. allay
anxiety and apprehension of the
operation, produce pre and
postoperative analgesia, smoothen
induction, reduce the dose of
anaesthetic required and
supplement poor analgesic
(thiopentone, halothane) or weak
(N20) anaesthetics. Postoperative
restlessness is also reduced.

2. Antianxiety drugs
Benzodiazepines like diazepam (5-10
mg oral) or lorazepam (2 mg i.m.)
have become popular drugs for
preanaesthetic medication because
they produce tranquility and
smoothen induction; there is loss of
recall of intaoperative events
(specially with lorazepam) with little
respiratory depression or
postoperative vomiting. They
counteract CNS toxicity of local
anaesthetics and are being used
along with pethidine/fentanyl for a
variety of minor surgical and
endoscopic procedures. Midazolam is
a good amnesic with potent and
shorter action; it is also better
suited for injection

3. Sedative-hypnotics Barbiturates
like pentobarbitone, secobarbitone or
butabarbitone (100 mg oral) have
been used night before (to ensure
sleep) and in the morning to calm
the patient.
4. Anticholinergics Atropine or
hyoscine (0.6 mg i.mJi.v.) have been
used, primarily to reduce salivary
and bronchial secretions. The main
aim of their use now is to prevent
vagal bradycardia and hypotension
(which occur reflexly due to certain
surgical procedures), and prophylaxis
of laryngospasm which is
precipitated by respiratory
secretions.

5. H2 blockers Patients undergoing

prolonged operations, caesarian
section, obese patients are at
increased risk of gastric regurgitation
and aspiration pneumonia. Ranitidine
(150 mg) or famotidine (20 mg)
given night before and in the
morning benefit by raising pH of
gastric juice. Prevention of stress
ulcers is another advantage. Now
routinely used before prolonged
surgery.

6. Antiemetics Metoclopramide
10-20 mg i.m. preoperatively is
effective in reducing post operative
vomiting. By enhancing gastric
emptying it reduces the chances of
reflux and its aspiration.
Extrapyramidal effects and motor
restlessness can occur. Combined
use of metoclopramide and H2
blockers is more effective.
COMPLICATIONS OF GENERAL
ANAESTHESIA

A. During anaesthesia
1. Respiratory depression and
hypercarbia.
2. Salivation, respiratory secretions
-less now as non-irritant
anaesthetics are mostly used.
3. Cardiac arrhythmias, asystole.
4. Fall in BP
5. Aspiration of gastric contents:
acid pneumonitis.
6. Laryngospasm and asphyxia.
7. Delirium, convulsions. Excitatory
effects are generally seen with i.v.
anaestheticsspecially if
phenothiazines or hyoscine have
been given in premedication. These
are suppressed by opioids.
8. Fire and explosion - rare now due
to use of noninflammable agents.

B. After anaesthesia
1. Nausea and vomiting.
2. Persisting sedation: impaired
psychomotor function. 3.
Penumonia, atelectasis.
4. Organ toxicities: liver, kidney
damage.
5. Nerve palsies - due to faulty
positioning.
6. Emergence delirium.