General Anesthesia

Riyadh Firdaus
General Anesthesia
 General Anesthesia in RSCM
from July, 2006 to June, 2007:
9871 cases of anesthesia procedure
5547 cases performed by general anesthesia
technique
2006
Approx. 700 cases of out-patients anesthesia
procedure
80 cases of sedation and analgesia
performed for MRI, CT, and endoscopic
procedure
Data from Koordinator Pelayanan Departemen Anestesiologi dan Terapi Intensif RSCM
Predicted incidence of complications of anaesthesia
Predicted incidence of complications of anaesthesia

Anaesthesia, 2003, 58, pages 962984

Predicted incidence of complications of anaesthesia

Anaesthesia, 2003, 58, pages 962984

Predicted incidence of complications of anaesthesia

Anaesthesia, 2003, 58, pages 962984

Predicted incidence of complications of anaesthesia

Anaesthesia, 2003, 58, pages 962984

Clinical indicators and other complications
in the recovery room

Anaesthesia, 1999, 54, pages 11431149

Clinical indicators and other complications
in the recovery room

Anaesthesia, 1999, 54, pages 11431149

Clinical indicators and other complications
in the recovery room

Anaesthesia, 1999, 54, pages 11431149

Question ?
refreshing presentation
 The purpose of the grading system is simply to
assess the degree of a patients "sickness" or
"physical state" prior to selecting the anesthetic
or prior to performing surgery.
Describing patients preoperative physical status
is used for recordkeeping, for communicating
between colleagues, and to create a uniform
system for statistical analysis.
The grading system is not intended for use as a
measure to predict operative risk.
 Normal healthy patient
No organic, physiologic, or psychiatric
disturbance; excludes the very young and very
old; healthy with good exercise tolerance
 Patients with mild systemic disease
No functional limitations; has a well-controlled
disease of one body system; controlled
hypertension or diabetes without systemic
effects, cigarette smoking without chronic
obstructive pulmonary disease (COPD); mild
obesity, pregnancy
 Patients with severe systemic disease
Some functional limitation; has a controlled
disease of more than one body system or one
major system; no immediate danger of death;
controlled congestive heart failure (CHF), stable
angina, old heart attack, poorly controlled
hypertension, morbid obesity, chronic renal
failure; bronchospastic disease with intermittent
symptoms
 Patients with severe systemic disease that is a
constant threat to life
Has at least one severe disease that is poorly
controlled or at end stage; possible risk of
death; unstable angina, symptomatic COPD,
symptomatic CHF, hepatorenal failure
 Moribund patients who are not expected to
survive without the operation
Not expected to survive > 24 hours without
surgery; imminent risk of death; multiorgan
failure, sepsis syndrome with hemodynamic
instability, hypothermia, poorly controlled
coagulopathy
 A declared brain-dead patient who organs are
being removed for donor purposes
 Any patient for whom an emergency operation
is required.
Example: an otherwise healthy 39-year-old
female who requires a dilation and curettage
for moderate but persistent bleeding. ASA class
1E
General Anesthesia ?
 Minimal Sedation (Anxiolysis)
a drug-induced state during which patients
respond normally to verbal commands
 Moderate Sedation/Analgesia
(Conscious Sedation)
a drug-induced depression of
consciousness during which patients
respond purposefully* to verbal
commands, either alone or accompanied
by light tactile stimulation.

* Reflex withdrawal from a painful stimulus is not considered a

purposeful response
 Deep Sedation/Analgesia
a drug-induced depression of
consciousness during which patients
cannot be easily aroused but respond
purposefully* following repeated or
painful stimulation.
 General Anesthesia
a drug-induced loss of consciousness
during which patients are not arousable,
even by painful stimulation.
 General Anesthesia
The ability to independently maintain
ventilatory function is often impaired.
Patients often require assistance in
maintaining a patent airway.
Positive pressure ventilation may be
required because of depressed
spontaneous ventilation or drug-induced
depression of neuromuscular function.
Cardiovascular function may be impaired
General Anesthesia
Pre-anesthesia Visit
 Preprocedure evaluation
Relevant history
(major organ systems, sedationanesthesia history,
medications, allergies, last oral intake)
Focused physical examination
(especially to include heart, lungs, airway)
Laboratory testing
guided by underlying conditions and possible effect
on patient management
Findings confirmed immediately before
anesthesia
Airway Assessment Procedures
History
Previous problems with anesthesia or
sedation
Stridor, snoring, or sleep apnea
Advanced rheumatoid arthritis
Chromosomal abnormality (e.g., trisomy 21)
Airway Assessment Procedures
Habitus
Significant obesity (especially involving the
neck and facial structures)
Airway Assessment Procedures
Head and Neck
Short neck,
limited neck extension,
decreased hyoidmental distance ( 3 cm in an adult),
neck mass,
cervical spine disease or trauma,
tracheal deviation,
dysmorphic facial features (e.g., Pierre-Robin
syndrome)
Airway Assessment Procedures
Mouth
Small opening ( 3 cm in an adult);
edentulous;
protruding incisors;
loose or capped teeth;
dental appliances;
high, arched palate;
macroglossia;
tonsillar hypertrophy;
nonvisible uvula
Airway Assessment Procedures
Jaw
Micrognathia,
retrognathia,
trismus,
significant malocclusion
Question ??
 Patient counseling
Risks, benefits, limitations, and
alternatives
Informed consent
Fasting
 Preprocedure fasting
Elective proceduressufficient time for
gastric emptying
Urgent or emergent situationspotential
for pulmonary aspiration
considered in determining target level of
sedation, delay of procedure, protection of
trachea by intubation
 Fasting
Summary of American Society of
Anesthesiologists Preprocedure
Fasting Guidelines
Ingested Material Minimum Fasting Period
Clear liquids :2h
Breast milk :4h
Infant formula :6h
Nonhuman milk :6h
Light meal :6h
 ASA Fasting Guidelines
These recommendations apply to healthy
patients who are undergoing elective
procedures.
They are not intended for women in labor.
Following the Guidelines does not
guarantee a complete gastric emptying
has occurred.
The fasting period apply to all ages.
 Scandinavian guidelines for pre-
operative fasting in elective patients
Patients (adults as well as children) may drink clear
fluids up to 2 h prior to general or regional anaesthesia
Patient should not take solid food 6 h prior to induction
of anaesthesia
Breast-feeding should be stopped 4 h prior to induction
of anaesthesia. The same applies to formula milk
Adults may drink up to 150 ml of water with pre-
operative oral medication up to 1 h before induction of
anaesthesia, and children up to 75 ml.
Use of chewing gum and any form of tobacco should
be discouraged during the last 2 h prior to induction of
anaesthesia
Apply to C-Section
 Fasting
Examples of clear liquids include water, fruit juices
without pulp, carbonated beverages, clear tea, and black
coffee.
Since nonhuman milk is similar to solids in gastric
emptying time, the amount ingested must be considered
when determining an appropriate fasting period.
A light meal typically consists of toast and clear liquids.
Meals that include fried or fatty foods or meat may
prolong gastric emptying time.
Both the amount and type of foods ingested must be
considered when determining an appropriate fasting
period.
 Monitoring
(Data to be recorded at appropriate intervals
before, during, andafter procedure)
Pulse oximetry
Pulmonary ventilation
Exhaled carbon dioxide monitoring considered
when patients separated from caregiver
Blood pressure and heart rate at 5-min intervals
Electrocardiograph
 Training
Pharmacology of sedative and analgesic
agents
Pharmacology of available antagonists
Advanced life support skills
 Emergency Equipment
Oxygen delivery equipment
Suction, appropriately sized airway
equipment, means of positive-pressure
ventilation
Intravenous equipment, pharmacologic
antagonists, and basic resuscitative
medications
Defibrillator
 Emergency Equipment
Intravenous equipment
Gloves
Tourniquets
Alcohol wipes
Sterile gauze pads
Intravenous catheters [24-22-gauge]
Intravenous tubing
Intravenous fluid
Assorted needles for drug aspiration, intramuscular injection
[pediatric: intraosseous bone marrow needle]
Appropriately sized syringes
Tape
 Emergency Equipment
Basic airway management equipment
Source of compressed oxygen (tank with regulator or
pipeline supply with flowmeter)
Source of suction
Suction catheters
Yankauer-type suction
Face masks
Self-inflating breathing bag-valve set
Oral and nasal airways
Lubricant
 Emergency Equipment
Advanced airway management equipment
Laryngeal mask airways
Laryngoscope handles (tested)
Laryngoscope blades [pediatric]
Endotracheal tubes
Cuffed 6.0, 7.0, 8.0 mm ID
[Uncuffed 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0 mm
ID]
Stylet (appropriately sized for endotracheal
tubes)
 Emergency Equipment
Pharmacologic Antagonists
Naloxone
Flumazenil
 Emergency Equipment
Emergency medications
Epinephrine
Ephedrine
Vasopressin
Atropine
Nitroglycerin (tablets or spray)
Amiodarone
Lidocaine
Glucose, 50% [10 or 25%]
Diphenhydramine
Hydrocortisone, methylprednisolone, or
dexamethasone
Diazepam or midazolam
Induction Maintenance Stop

the General Anesthesia

 Recovery and discharge
1. Medical supervision of recovery and discharge after anesthesia is
the responsibility of the ansesthesiologist or a licensed
physician.
2. The recovery area should be equipped with, or have direct access to,
appropriate monitoring and resuscitation equipment.
3. Patients should be monitored until appropriate discharge criteria
are satisfied.
4. Level of consciousness, vital signs, and oxygenation should be
recorded at regular intervals.
5. A nurse or other individual trained to monitor patients and recognize
complications should be in attendance until discharge criteria are
fulfilled.
6. An individual capable of managing complications (e.g.,
establishing a patent airway and providing positive pressure
ventilation) should be immediately available until discharge criteria
are fulfilled.
One Day Care ?
 Guidelines for discharge
1. Patients should be alert and oriented; infants and patients
whose mental status was initially abnormal should have returned to
their baseline status.
2. Vital signs should be stable and within acceptable limits.
3. Use of scoring systems may assist in documentation of fitness
for discharge.
4. Sufficient time (up to 2 h) should have elapsed after the last
administration of reversal agents (naloxone, flumazenil) to
ensure that patients do not become resedated after reversal effects
have worn off.
5. Outpatients should be discharged in the presence of a
responsible adult who will accompany them home and be able to
report any postprocedure complications.
6. Outpatients and their escorts should be provided with written
instructions regarding postprocedure diet, medications,
activities, and a phone number to be called in case of emergency.
Question ???
 Special Situations
Severe underlying medical problems
consult with appropriate specialist if
possible
Thank you