General Anesthesia

General Anesthesia
Controlled by a reversible irregular
paralysis of cells of the central
nervous system
ALL modalities of sensations are lost,
including consciousness
Depression must be REVERSIBLE,
since full recovery is very importnant

ARMAMENTARIUM

GAS MACHINES

PURPOSE
General anaesthesia has many
purposes including:
Analgesia loss of response to pain,
Amnesia loss of memory,
Immobility loss of motor reflexes,
Unconsciousness loss of
consciousness,
Skeletal muscle relaxation.

Sequence of Depression in CNS

when G.A. is administered
1. Cerebrum
Cerebral cortex memory,
judgement, consciousness

2. Cerebellum
Basal Ganglia muscle coordination

3. Spinal Cord
Motor and sensory impulses

4. Medullary Centers
Medullary centers

CEREBRUM
Most highly developed area of the
CNS
First to be depressed
Produces loss of memory,
impairment of judgement, obtunding
of the special senses,
unconsciousness
Patient will still react, however, to
painful stimuli with somewhat
coordinated muscular movements

CEREBELLUM & BASAL

GANGLIA
Patient loses muscles coordination
and mat exhibit only purposeless
movements in response to painful
stimuli.

 As the amount of anesthetic agent

increased, the irregular descending
depression will manifest itself as the
medullary centers of respiration and
circulation are bypassed and he
spinal cord are depressed.

SPINAL CORD
Patient has now lost the ability to
convey motor & sensory impulses
and thus cannot respond to painful
stimuli by any muscular movements

MEDULLARY CENTERS
Depressed until, if the depression is
allowed to continue, respiration and
then the circulation will cease.

THEORIES OF
GENERAL
ANESTHESIA

ANOXIC THEORIES
Use ANOXIA as their basis no doubt
predicated on the intimate
relationship commonly exhibited
between he effects of anoxia an
those of anesthetics
In effect, they stated the various
anesthetic agents inhibited the
oxidative of the cells on the CNS

LIPID THEORY
States that there is a parallelism
between the oil-water distribution
coefficient of an anesthetic agent
and its potency.
Evidence for this theory has been
strengthen with the fact that the lipid
solubility coefficient of anesthetic
agents compares favorably with their
anesthetic potency.

 Suggests that the anesthetic acts

nonspecifically on the lipid portions
of the neuronal membrane to cause
a general disturbance that causes
the ion channels to change structure
thereby changing their function
Interactions here cause a physical
change in the membrane

SURFACE TENSION THEORY

It is based on the ability of the
anesthetic agents to lower surface
tension, on which their potency
depends
This property enables the agents
possesing it to interfere with the
permeability, polarization and
metabolic processes of the cells

ADSORPTION THEORY
Based on the concept of surface
tension
It assumes that anesthetic agent
thus retarded the adsorption of other
substances.
The theory was substantiatedby the
finding of much lower concentrations
of anesthetic agent were needed to
influence the activity of enzymes in
cellular structures with large surface
area than were needed in structure

CELLULAR PERMEABILITY
THEORY

Is an extension of the adsorption

theory.
It states that reversible paralysis is
produce by a reversible decreased of
cell lipid membrane.
The decreased permeability for fat
soluble substance seems to be
increased.

COAGULATION THEORY
It is the earliest of all the theories of
anesthesia
Anesthesia results from the
reversible coagulation of proteins
which is indeed true for a limited
number of agents.

DEHYDRATION THEORY
Based on the assumption that
anesthesia is produced by
dehydration of the cells in the CNS.
It supposes that he brain loses some
of its water content under anesthesia

MICROCRYSTAL THEORY
Based on the molecular properties of
anesthetic agent and aqueous
molecular structure of nervous
tissue.
The theory involves the interaction of
molecules of the anesthetic agent
and water molecules of the brain,
which is 78% water rather than lipid
molecules

 It suggests that consciousness is loss

when submicroscopic crystals are
formed in the aqueous part of the
brain subtance.

ADMINISTRATIO
N OF GENERAL
ANESTHESIA

To obtain general
anesthesia

What must be maintained

for a satisfactory result of
GA?
Sufficient concentration of the
anesthetic agent.
Enough oxygen to supply the
patients metabolic needs
An efficient elimination of Carbon
Dioxide

ROUTES OF
ADMINISTRA
TION

Inhalation Route
Anesthetic agent is given as GAS,
VAPOR, or LIQUID
vaporized through a mask so that it is
eventually taken into the lungs then
transmitted into the blood stream

Inhalation Route
Transmission is dependent on a
gradient or pressures between the
concentration of anesthetic in the
lungs and that in the blood stream

5 Different Methods of
Inhalation Route
1. OPEN DROP
A suitable mask or gauze stucture is
needed for penetration and vaporization
of volatile anesthetic agent
No other cloth or confining covering is
used

2. SEMI-OPEN DROP
Same as the open drop method except
that a confining wrapper or covering is
used to uncrease the concentration of
anesthetic vapor more readily within
the area.
Confining wraper or covering also
prevents the entrance of atmospheric
air and the exit of carbon dioxide

3. INSUFFALATION
Done by vaporizing a volatile
anesthetic agent by air or oxygen
under pressure.
Resultant mixture is brought by a
catheter into the upper respiratory
passeges

4. SEMI-CLOSED
Done by using an anesthetic apparatus
where in controlled amounts of
anesthetic agent and oxygen are
delivered by meanes of gauges,
vaporizers, breathing tube and masks.
Exhalation are blown into the
atmosphere, which maintains
equilibrium of gasses, reduces
mechanical dead space and affords an
efficient elimination of carbon dioxide.

5. CLOSED
Done in the same manner as that of
the semi-closed to a closed system
Difference with semi closed is that the
exhalations are confined to a closed
system
Anesthetic machine and the external
part of the respiratory system are in
one continuous circuit where
exhalations or inhalations are routed
through a chemical compound (soda
lime)

 May be accomplished by
using:
CIRCLE FILTER - gasses
pass over the canister with
soda only during inhalation
To-and-fro System gasses
pass over the soda lime
during both exhalation and
inhalation

ROUTES OF
ADMINISTRATION (cont.)
Quizon, Lhajean May

INTRAVENOUS ROUTE
Most direct route
for inducing
unconsciousness
Anesthetic agent:
carried directly into
the venous
circulation

2 techniques:
a. INTERMITTENT TECHNIQUE
An intravenous agent is
injected slowly into the
bloodstream until desired plane
of anesthesia is reached
Patient watched carefully as
the signs of anesthesia are
observed
Additional intravenous agent is
administered when necessary
to maintain the proper level of
anesthesia

b. CONTINUOUS DRIP
TECHNIQUE
Employs the anesthetic
agent in a much weaker
concentration and allows it
to drip constantly into the
venous circulation
Rate of the drip is
increased or decreased as
desired to maintain the
proper plane of anesthesia

Inhalation and Intravenous

Most frequent routes used to secure
anesthesia for dental and oral
surgery
Afford the anesthesia a fairly
accurate control of the degree of
depression of the central nervous
system

RECTAL ROUTE
Anesthesia is administered
rectally in a single dose and
is absorbed onto the
bloodstream to elicit it
effects
Anesthetist does not have
minute to minute control
over the depth of anesthesia
Often used when basal
narcosis is needed and is
supplemented by
inhalational anesthesia

INTRAMUSCULAR ROUTE
Anesthetic drug or agent is
injected into the muscle tissues
and then absorbed into the
bloodstream to produce the
desired effect
Provides the anesthetist little
control of the drug one it is
administered
Used primarily for premedication
90 positioned

INTRAORAL ROUTE
Patient is instructed to
swallow a previously
calculated dose
Provides the anesthetist
little control of the drug
one it is administered
Used primarily for
premedication purposes
Method of choice of most
dentists for premedication
for the reason of
convenience of the
administration

Mode of Action
First type of body
tissue to be
depressed = brain
Brain: more readily
susceptible to the
depressant action of
anesthetic agents
: receive a
proportionately
higher percentage of
circulating blood
volume

General anesthetic
agents:
Depress brain tissues in
advance of other body
tissues
Selectively depress
specific cells of brain so
that the ital functions
are lost in a
predetermined manner
Dissolved in the
circulating blood and
transported by this
means to the circulatory
system

 What happens when in

the circulatory system?
During each circuit of
the blood a certain
proportion of the
dissolved agent is:
Carried to the brain
Carried to the other
tissue
Being excreted

Remained in the
circulating blood to
reinitiate the previous
action
This action continues
with the direction of
diffusion:

Higher concentration in
the bloodstream lower
concentration in the
tissues

When concentration in
bloodstream tissues=
direction of diffusion is
reversed
Result:

Exertion of a
depressant action
Reversal of the
temporary paralysis
Return of the ell to the
normal

Why would the

concentration in the
bloodstream fall?

Detoxification
Elimination
Reduced administration

 Control of the anesthetic in the

bloodstream depends on :
Rate of uptake of the anesthetic agent
Excretion from the circulating blood

Excretion via: lungs kidneys and

liver

GENERAL ANESTHESIA IN DENTAL

PROCEDURES
Patients level of fear is usually a more important
factor than the nature of the procedure
High levels of preoperative anxiety lengthy and
complex procedures and need for a pain free
operative period ay be indications for general in
anesthesia in healthy adults and young children
At least 3 professionals are required:
Operating dentist
A professional responsible for observing and
monitoring the patient
Assistant of the operating dentist

INDICATIONS FOR GENERAL

ANESTHESIA
1.
2.
3.
4.

Children who are too young to cooperate

Lancing abscesses
Adults who are abnormally fearful of needle
Extraction of teeth in the early stage of
suppurative infection
5. Multiple uncomplicated extractions
6. In its analgesic stage for preparation of
sensitive teeth for fillings
7. Treatment of peridental disease

CONTRAINDICATIONS FOR GENERAL

ANESTHESIA
1.
2.
3.
4.

Presence of persistent thymus glands in children(status lypmhaticus)

Exopthalmic goiter diabetes or other disturbance of endocrine function
Abnormally high blood pressure
Uncompensated valvular lesions of the heart myocarditis pronounced
cardiac arrhythmia
5. Inflammations of the respiratory system including pulmonary
tuberculosis
6. Grave primary or secondary anemia
7. Patients addicted to the excessive use of alcohol tobacco coal tar
derivatives and narcotic drugs
8. Advanced pregnancy
9. Obesity
10.Children with greatly enlarged tonsils
11.Operations requiring prolonged anesthesia
12.Senility

Yasi anaesthetic agent

STAGES OF ANESTHESIA
Kamran

 TheGuedel's classificationbyArthur
Ernest Guedeldescribed four stages
of anaesthesia in 1937.Despite
newer anaesthetic agents and
delivery techniques, which have led
to more rapid onset and recovery
from anaesthesia, with greater safety
margins, the principles remain.

 Stage 1
Stage 1 anaesthesia, also known as the "induction", is the
period between the initial administration of the induction
agents and loss of consciousness. During this stage, the
patient progresses from analgesia without amnesia to
analgesia with amnesia. Patients can carry on a
conversation at this time.

 Stage 2
Stage 2 anaesthesia, also known as the "excitement
stage", is the period following loss of consciousness and
marked by excited and delirious activity. During this stage,
respirations and heart rate may become irregular. In
addition, there may be uncontrolled movements,vomiting,
breath holding, and pupillary dilation. Since the
combination of spastic movements, vomiting, and irregular
respirations may lead to airway compromise, rapidly acting
drugs are used to minimize time in this stage and reach
stage 3 as fast as possible.

 Stage 3
Stage 3, "surgical anaesthesia".
During this stage, the skeletal
muscles relax, vomiting stops, and
respiratory depression occurs . Eye
movements slow, then stop, the
patient is unconscious and ready for
surgery.

It has been divided into 4

planes:
eyes initially rolling, then becoming
fixed
loss of corneal and laryngeal reflexes
pupils dilate and loss of light reflex
intercostal paralysis, shallow
abdominal respiration

 Stage 4
Stage 4 anaesthesia, also known as "overdose", is the
stage where too much medication has been given relative
to the amount of surgical stimulation and the patient has
severe brain stem or medullary depression. This results in a
cessation of respiration and potential cardiovascular
collapse. This stage is lethal without cardiovascular and
respiratory support.

Phases of General Anesthesia:

1.Preanesthesia
2.Induction
3.Maintenance

 Preanesthesia:
The stage from full consciousness to a state of sedation or
tranquilization with varying degrees of muscle relaxation
and immobilization

Reasons for preanesthesia:

Induce sedation
Calm patient
Reduce general anesthetic drug requirements
Provide analgesia and muscle relaxation
Decrease airway secretion, salivation, gastric fluid
volume and acidity
Suppress vomiting or regurgitation
Obtund autonomic reflexes
Promote smooth and rapid induction and recovery
phases

Preanesthesia Drugs:
Anticholinergics e.g. Atropine,
glycopyrrolate
Tranquilizers e.g. Acepromazine
Sedatives e.g. Diazepam

Induction:
The stage following the preanesthetic stage
characterized by a loss of consciousness and
complete muscular relaxation and
immobilization.
Typically a very short phase (5-10 minutes)
Often associated with an excitement phase
prior to achievement of general anesthesia
Both injectable and inhalant drugs are
available

Induction drugs
Barbituates e.g. Thiopental,
thiamylal, methohexital
Alkylphenol e.g. Propofol
Inhalant gases e.g. Isoflurane,
halothane

Maintenance:
A plane of general anesthesia that is achieved
prior to surgical intervention.
Associated with the greatest physiological impact
(hypothermia, hypotension, depression of
cardiopulmonary parameters).

Maintenance Drugs:
Examples:
Inhalant gases (isoflurane, halothane)
Barbituates (pentobarbital)
Neuroleptanalgesics (fentanyl-fluanisone,
Hypnorm
Tribromoethanol (Avertin)
Drug combinations (e.g.ketamine, xylazine
and acepromazine)

NOUGHANCHI
SABET,MAHDIEH
Signs of anesthesia
DDB

Respiratory signs
Preparatory stage:
Rate &volume: usually normal or depressed
Character: normal
Rhythm: not significant

Chemanesia stage:
Rhythm : irregular or uncertain
Depend on patients preoperative emotional & physical
state as well as preanesthetic medication

 Surgical stage:
Rhythm: regular rhythmic onset of respiration

Inhalation_ volume: greater than normal

Rate: slightly increased caused by the

shortening
of the pause that follows expiratory phase

Intravenous_ volume and rate :

slightly decreased and depressed
with a prolongation of the pause that follows
expiration

Optic (eye) signs

Subdivided into:
a) Lid reflex
b) Eyeball movements
c) Tearing
d) Pupillary reactions

a. Lid reflex :
Earliest to be eliminated
Absent by the time patient enters coordinated
plane of 2nd stage (except Vinethene)

b . Eyeball movement :
Inhalation : more active than when intravenous
agents are administered
Chemanesia stage : in both coordinated and
uncoordinated planes , the eyeballs oscillate
because of an imbalance in the tone of the ocular
muscles

 c. Tearing :
Surgical stage:
Lighter plane : eyeball is moist
tearing is sometimes evident
(particularly in
second stage)
Depressed plane : eyeball loses
its luster
(more so with administration of
agents than with
intravenous agents.)

d.Pupilary reactions:
Maybe the extreme interest during the various
stages of anesthesia.
Pupils ability to dilate and contract is altered by
various drugs and conditions.
Iris:
Circular fibers or sphincter papillae :
parasympathetic
_
contraction
Radiating fibers or dilator papillae : sympathetic _
dilation

 Preparation stage :

normal unless premedication

is given .
Morphine _ constricts
Atropine _ dilates
Chemanesia stage : pupil reacts to sympathetic stimulation
and also to the excitation of the antagonistic cortical centers
of the parasympathetic fibers.
Surgical stage : greately constricted particularly when
morphine has been used for medication.
Miosis is also characteristic of the more potent inhalation
agents (probabely due to the paralysis of the antagonistic
cortical centers of theparasympathetic fibers.As a result ,the
fibers accompanying the oculomotor nerve are no longer
inhibited and have a decided predominance over the
dilation fibers of the cervical sympathetic system.)
Moderate or depressed plane: pupil begins to dilate.

Muscular signs :
Degree of skeletal muscle not required or
desired
manifestation:

degree of relaxation of skeletal

muscle

absence or presence of certain

reflexes (pharyngeal reflex,laryngeal
reflex,swallowing reflex,and the vomiting
reflex.)

NEUROLEPTANALGESIA
In 1949 Laborit challenged the idea that general
anesthesia can protect an organism from surgical
pain by depression of cortical and subcortical
centers alone. He introduced a concept based on
selective blocking of the cerebral cortex and
other cellular , autonomic, and endocrine
mechanisms activated as a response to stress.
Drug combinations consisting of chlorpromazine ,
promethazine and meperidine were used to
produce this state.
Marked circulatory depression often resulted from
this induced homeostatic imbalance, which may
explain why yhe technique never become
popular.

 Recently compounds have been made available that depress

subcortical and central autonomic activity with a minimum of
toxic effects. These butyrophenone derivatives are potent
psychosedatives and are also alpha_adrenergic blocking agents.
When they are combined with a potent narcotic, a state, not
unlike that of laborit , of neuroleptanalgesia may be produced in
which the patient lies at rest and is completely passive.With the
possible exception of respiratory depression , vital signs are
remarkably stable.
The search for improved means of selectively blocking afferent
systems involved in surgical led to increased stress led to
increased emphasis on analgesia.Fentanyl , a meperidine
derivative, has been found to produce analgesia (it is reported
to be 150 times as potent as morphine) without certain of the
central nervous system that are blocked by orthodox
anesthesia.
The most popular drug combination used to produce neurolept
analgesia today consist of a fixed mixture of 2.5 mg. droperidol
( inapsine) and 0.05 mg. fentanyl (sublimaze ) per ml.

 Introduction is carried out by administering 1 to 2

ml. per 20 pounds of body weight intravenously.
During maintenance phase additional fentanyl is
administered whenever signs if surgical stress
occur.
Nitrous oxide and oxygen mixture is administered
after completion if the intravenous injection , or
the surgery maybe performed under regional
analgesia if practical . Anesthesia is terminated by
discontinuing the nitrous oxide and oxygen and
allowing the patent to breathe room air ,which
results in immediate awakening of the patient.

Advantages of
neuroleptanalgesia:
1. Simple , safe,nonexplosive,economical
2. Low toxicity of agent used
3. Profound analgesia produced without
cardiovascular and cortical depression
4. Total amnesia for the
induction,maintenance, and early
recovery phases
5. Nausea and vomiting rarely seen

Disadvantages of
neuroleptanalgesia:
1. Profound respiratory depression possible
after completion of intravenous injection
2. Poor skeletal muscle relaxation
3. Possible lead-pipe chest wall rigidity , which
may be easily overcome by administrating
neumuscular blocking agents and then
providing artificial ventilation
4. Not suitable for outpatients because of the
long action of droperidol (6 hours and more)

Dissociative anesthetics:
a unique anesthesia characterized by analgesia and
amnesia with minimal effect on respiratory function.
The patient does not appear to be anesthetized and
can swallow and open eyes but does not process
information. This form of anesthesia may be used to
provide analgesia during brief, superficial operative
procedures or diagnostic processes. Ketamine
hydrochloride is a phencyclidine derivative used to
induce dissociative anesthesia. Ketamine is used for
trauma patients with very unstable, low blood
pressure or for elderly patients. Emergence may be
accompanied by delirium, excitement, disorientation,
and confusion.

Advantages of dissociative anesthesia:

1. Pleasant induction possible by the
intravenous or intra muscular route.
2. With margin of safety
3. May be used asan induction technique
prior to the administration of inhalation
agents
4. Produces good analgesia

5. Pharyngeal and larengeal reflexes

active, the patient maintaining own
airway in a patent state

Disadvantages of dissociative
anesthesia:
1. Heightened muscular tone andactive oral
and pharyngeal reflexes
2. Recovery time longer ,which discourages
use in ambulatory patients
3. Irrational behaviour occasionally seen
during recovery
4. Actives pharyngeal reflexes, possible
laryngospasm
5. Vivid dreams during emergence

COMMON SIDE EFFECTS

Regalado, Liel Marie

Common side effects

Nausea and vomiting after surgery (also called postoperative nausea and vomiting)
How common is it?
Post-operative nausea and vomiting (PONV for short) is one of the most common side-effects that
occurs in the first 24 hours after your surgery. It affects 20-30% of patients. However, nearly half of
all patients who do not have PONV in the hospital, experience nausea and/or vomiting in the first
few days after discharge.
Who is at risk?
For adults, there are many factors that increase the risk of having PONV. Firstly - being female, not
smoking (the only benefit from smoking, but definitely not worth it!) and having a history of
motion sickness or PONV after a previous surgery.
Then some anesthetic drugs and painkillers - most commonly those gases that keep you asleep,
the morphine-like painkillers (calledopioidsin medical terms) and laughing gas (callednitrous
oxidein medical terms). The morphine-like painkiller used for pain relief after surgery (commonly
used by the acute pain service) do a good job in relieving pain, but are a common reason for
nausea on the first and second day after surgery.
Lastly, some surgeries are known to carry a high risk for PONV. These include surgery on the ear or
intestines and laparoscopic surgery (key-hole surgery) for operations on the female organs.

 Sore throat
How common?
Sore throat and hoarseness in the first hours to days after anesthesia occurs in up to
40% of patients (13).
Who is at risk?
The following increase your risk:. Being female; younger than 50 years old and
having a general anesthetic lasting more than 3 hours.
Can it be prevented and/or treated?
Having a regional anesthetic (link bold word to regional anesthesia) will completely
prevent this problem. However, if you need a general anesthetic, your anesthetist
may chose a smaller size for the device used to help you breath during surgery. Some
drugs have also been proven to be beneficial, such as a freezing medication or an
anti-inflammatory medication. In addition, the use of some over the counter
substances such as Tantum or Strepsils can help alleviate acute sore throat pain.

 Teeth damage
How common is it?
Teeth damage is a rare but very unfortunate complication of general
anesthesia, roughly occurring in 1:2000-cases. The most frequently
injured teeth are the upper front ones (the upper incisors) (25;26).
Who is at risk?
Patients mostly at risk for dental injury are those with poor dental health
and where the anesthetist have had difficulty to get the breathing tube
down (called a difficult intubation).
Can it be prevented?
Although the anesthetists are always very careful, prevention of dental
damage is not always possible. Several devices have been used such as
mouth-guards and bite-blocks but provide no guarantee. Moreover, these
devices may make it more difficult to place to place the breathing tube.

 Shivering/Chills
How common is it?
Shivering after an anesthetic is an occurs in the early recovery phase
after anesthesia in approximately 25-50% of patients.
Who is at risk?
Cooling down is the most common cause. Other causes including
include pain, fever and stress after surgery. It seems to be more
common in males and after longer surgeries, but it is quite rare in
elderly patients.
Can it be prevented and/or treated?
While we try to reduce the drop in body temperature, is itit is
impossible to completely prevent it. There are also a few drugs that
can be used either to prevent and/or to treat post-operative
shivering.

Goals of General Anesthesia

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)

Desired Effects Of General Anesthesia

(Balanced Anesthesia)

Rapid induction
Sleep
Analgesia
Secretion control
Muscle relaxation
Rapid reversal