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General Considerations General anesthesia (GA) is the state produced when a patient receives medications for amnesia, analgesia, muscle

paralysis, and sedation. An anesthetized patient can be thought of as being in a controlled, reversible state of unconsciousness. Anesthesia enables a patient to tolerate surgical procedures that would otherwise inflict unbearable pain, potentiate extreme physiologic exacerbations, and result in unpleasant memories. The combination of anesthetic agents used for general anesthesia often leaves a patient with the following clinical constellation: 1. Unarousable even secondary to painful stimuli 2. Unable to remember what happened (amnesia) 3. Unable to maintain adequate airway protection and/or spontaneous ventilation as a result of muscle paralysis 4. Cardiovascular changes secondary to stimulant/depressant effects of anesthetic agents

General anesthesia
General anesthesia uses intravenous and inhaled agents to allow adequate surgical access to the operative site. A point worth noting is that general anesthesia may not always be the best choice; depending on a patient’s clinical presentation, local or regional anesthesia may be more appropriate. Anesthesia providers are responsible for assessing all factors that influence a patient's medical condition and selecting the optimal anesthetic technique accordingly. Attributes of general anesthesia include the following:

Advantages o Reduces intraoperative patient awareness and recall[2] o Allows proper muscle relaxation for prolonged periods of time o Facilitates complete control of the airway, breathing, and circulation o Can be used in cases of sensitivity to local anesthetic agent o Can be administered without moving the patient from the supine position o Can be adapted easily to procedures of unpredictable duration or extent o Can be administered rapidly and is reversible Disadvantages o Requires increased complexity of care and associated costs o Requires some degree of preoperative patient preparation o Can induce physiologic fluctuations that require active intervention o Associated with less serious complications such as nausea or vomiting, sore throat, headache, shivering, and delayed return to normal mental functioning o Associated with malignant hyperthermia, a rare, inherited muscular condition in which exposure to some (but not all) general anesthetic agents results in acute and potentially lethal temperature rise, hypercarbia, metabolic acidosis, and hyperkalemia

a source of pressurized oxygen (most commonly piped in). capnography. an effective suction device. Mortality attributable to general anesthesia is said to occur at rates of less than 1:100. this means the availability of a properly serviced and maintained anesthetic gas delivery machine. This may be as simple as needles and syringes. standard ASA (American Society of Anesthesiologists) monitors. monitoring technology.[4] Beyond this. and a recovery room staffed by properly trained individuals completes the picture. and safety systems. a cardiac defibrillator. The most efficient method is for the patient to be reviewed by the person responsible for giving the anesthetic well in advance of the surgery date.10-20% Nausea . pulse oximetry. and development of an effective and safe anesthetic plan. discussion of any previous personal or familial adverse reactions to general anesthetics.000. An array of routine and emergency drugs. attention to any new or ongoing medical conditions. the risk caused by anesthesia to a patient undergoing routine surgery is very small. even in previously healthy patients.30% Preparation for General Anesthesia Safe and efficient anesthetic practices require certified personnel. ECG. including Dantrolene sodium (the specific treatment for malignant hyperthermia). In most circumstances. Minor complications occur at predicable rates. Preparing the patient The patient should be adequately prepared. It also serves to relieve anxiety of the unknown surgical environment for patients and their families. airway management equipment. temperature. appropriate medications and equipment. and an optimized patient. The frequency of anesthesia-related symptoms during the first 24 hours following ambulatory surgery is as follows:[3] • • • • Vomiting . if the drugs are to be administered entirely intravenously. some equipment is needed to deliver the anesthetic agent.25% Incisional pain . Preoperative evaluation allows for proper laboratory monitoring.[5] . Overall. this process allows for optimization of the patient in the perioperative setting. blood pressure. Minimum requirements for general anesthesia Minimum infrastructure requirements for general anesthesia include a well-lit space of adequate size. assessment of functional cardiac and pulmonary states.10-40% Sore throat . including heart rate. as well as highly educated anesthesia providers.With modern advances in medications. and inspired and exhaled concentrations of oxygen and applicable anesthetic agents.

and Mallampati presentations (see below). no one scoring system is near 100% sensitive or 100% specific. practitioners rely on several criteria and their experience to assess the airway. neck anatomy. can be taken to prepare for fiberoptic bronchoscopy.[6] However. By combining all factors. which identifies patients in whom the pharynx is not well visualized through the open mouth. The Mallampati assessment is ideally performed when the patient is seated with the mouth open and the tongue protruding without phonating. if necessary. . mouth. neck. or various other difficult airway interventions. In many patients intubated for emergent indications. Mallampati classification. or throat Facial trauma Interdental fixation Hard cervical collar Halo traction Various scoring systems have been created using orofacial measurements to predict difficult intubation. including mouth opening. this type of assessment is not possible. loose or problematic dentition. As a result. an appropriate plan for intubation can be outlined and extra steps. High Mallampati scores have been shown to be predictive of difficult intubations.Physical examination associated with preoperative evaluations allow anesthesia providers to focus specifically on expected airway conditions. A crude assessment can be performed with the patient in the supine position to gain an appreciation of the size of the mouth opening and the likelihood that the tongue and oropharynx may be factors in successful intubation (see image below). Airway management • • • • • • • • • • • Possible or definite difficulties with airway management include the following: Small or receding jaw Prominent maxillary teeth Short neck Limited neck extension Poor dentition Tumors of the face. The most widely used is the Mallampati score. video laryngoscopy. limitations in neck range of motion.

[10] The Process of Anesthesia Premedication: This is the first stage of a general anesthetic. Exceptions may include the following: • • • • Anticoagulants to avoid increased surgical bleeding Oral hypoglycemics (For example. herbal preparations. including interactions with vitamins. noncardiac surgery identified risk factors for postoperative intubation. Good information on the exact content of these supplement preparations is often hard to obtain. Severity of surgery is also an identified risk factor. Pedialyte. when morphine and . active congestive heart failure. which is usually conducted in the surgical ward or in a preoperative holding area. traditional remedies. water. metformin is an oral hypoglycemic agent that is associated with the development of metabolic acidosis under general anesthesia.[9] ) Recent catastrophes under anesthesia have focused attention on the interaction between nonprescribed medications and anesthetic drugs. and food supplements. beta blocker therapy should be continued perioperatively for high-risk patients undergoing major noncardiac surgery. some patients may require unanticipated early postoperative intubation. no other liquids) should be avoided for 2-4 hours prior to the induction of anesthesia. Independent predictors include patient comorbidities such as chronic obstructive pulmonary disease. A large-scale study of 109. Half of unanticipated tracheal intubations occurred within the first 3 days after surgery and were independently associated with a 9-fold increase in mortality.In addition to intubation during surgery. and hypertension. The reason for this is to reduce the risk of pulmonary aspiration during general anesthesia when a patient loses his or her ability to voluntarily protect the airway.[8] Patients should continue to take regularly scheduled medications up to and including the morning of surgery. originated in the early days of anesthesia.636 adult patients undergoing nonemergent. • This stage. Other requirements The need for coming to the operating room with an empty stomach is well known to health professionals and the lay public.[7] When suspicion of an adverse event is high but a similar anesthetic technique must be used again. or Gatorade ONLY.) Monoamine oxidase inhibitors Beta blocker therapy (However. • • Published guidelines recommend that solid food (including gum or candy) should be avoided for 6 hours prior to the induction of anesthesia. obtaining records and previous anesthetic records from previous operations or from other institutions may be necessary.[8] Clear fluids (ie. insulin-dependent diabetes.

Most patients do not want to have any recollection of entering the operating room. Drying agents (eg. contemporary practice dictates that adult patients and most children aged at least 10 years be induced with intravenous drugs. A irway equipment. generally raises the blood pressure and heart rate of the patient. allows for elective inhalation induction of anesthesia in adults. Many synthetic and naturally occurring opioids with different properties are available. such as fentanyl (a synthetic opioid many times more potent than morphine). When a history of gastroesophageal reflux exists. this being a rapid and minimally unpleasant experience for the patient. This stage can be achieved by intravenous injection of induction agents (drugs that work rapidly. a short-acting benzodiazepine. such as propofol). Various factors are considered when making this decision. gastroesophageal [GE] reflux. The major decision is whether the patient requires placement of an endotracheal tube. scopolamine) are now only administered routinely in anticipation of a fiberoptic endotracheal intubation. • • • • • In many ways. nonsteroidal anti-inflammatory drugs or acetaminophen can be administered preemptively. relaxed frame of mind. The mnemonic DAMMIS can be used to remember what to check ( D rugs. a critical part of the anesthesia process.• • • scopolamine were routinely administered to make the inhalation of highly pungent ether and chloroform vapors more tolerable. I V. checking all the systems before taking off. a well-tolerated anesthetic vapor. Induction: The patient is now ready for induction of general anesthesia. by the slower inhalation of anesthetic vapors delivered into a face mask. M onitors. atropine. H2 blockers and antacids may be administered. S uction). The role of the anesthesia provider is analogous to the role of the pilot. In addition to the induction drug. anticipation of events that are about to occur. In anticipation of surgical pain. or it may demand the insertion of a prosthetic airway device such as a laryngeal mask airway or endotracheal tube. Potential indications for endotracheal intubation under general anesthesia may include the following: o Potential for airway contamination (full stomach. most patients receive an injection of an opioid analgesic. induction of general anesthesia is analogous to an airplane taking off. midazolam syrup is often given to children to facilitate calm separation from their parents prior to anesthesia. For example. This may be a simple matter of manually holding the patient's jaw such that his or her natural breathing is unimpeded by the tongue. M achine. Opioid analgesia helps control this undesirable response. However. The next step of the induction process is securing the airway. In addition. Induction agents and opioids work synergistically to induce anesthesia. The most commonly used premedication is midazolam. sevoflurane. The goal of premedication is to have the patient arrive in the operating room in a calm. or by a combination of both. It is the transformation of a waking patient into an anesthetized one. such as endotracheal intubation and incision of the skin. gastrointestinal [GI] or pharyngeal bleeding) . For the most part.

• • • For the most part. an intermediate or long-acting muscle relaxant drug is administered in addition to the induction agent and opioid. including the muscles of breathing. would be inadequate for manipulation of the bowel. good communication (eg. A level of anesthesia that is satisfactory for surgery to the skin of an extremity. At that point during a surgical procedure. However.• • • Surgical need for muscle relaxation Predictable difficulty with endotracheal intubation or airway access (eg. urinary catheter insertion. o o Maintenance phase: At this point. These devices have yet to become universally accepted as vital equipment. the drugs used to initiate the anesthetic are beginning to wear off. using a fiberoptic bronchoscope or other advanced airway tool. are likely to be difficult to intubate are usually intubated electively at the beginning of the procedure. This requires a very light level of anesthesia. Therefore. a considerable period of time may elapse between the completion of the induction of anesthetic and the incision of the skin. necessitating an endotracheal tube. This paralyzes muscles indiscriminately. During the period of skin preparation. saves everyone's time. These may be inhaled as the patient breathes spontaneously or delivered under pressure by each mechanical breath of a ventilator. understanding that anesthesia is a continuum of different depths is important. and the patient must be kept anesthetized with a maintenance agent. This prevents a situation in which attempts are made to manage the airway with a lesser device. corresponding to anesthetic depth. The maintenance phase is usually the most stable part of the anesthesia. and marking incision lines with a pen. the patient's lungs must be ventilated under pressure. but new processed EEG machines give the anesthesia provider a simplified output in real time. Persons who. Traditionally. for example. swift intubation of the patient can be very difficult. for anatomic reasons. ultimately. this refers to the delivery of anesthetic gases (more properly termed vapors) into the patient's lungs. As the procedure progresses. only for the anesthesia provider to discover that oxygenation and ventilation are inadequate. In complex plastic surgery. lateral or prone patient position) o Surgery of the mouth or face o Prolonged surgical procedure Not all surgery requires muscle relaxation. warning of the start of new stimuli. for example. When the anesthesia provider and surgeon are not accustomed to working together. this has been a matter of clinical judgment. This maximizes patient safety and. such as moving the head of an intubated patient or commencing surgery) facilitates preemptive deepening of the anesthetic. Appropriate levels of anesthesia must be chosen both for the planned procedure and for its various stages. If surgery is taking place in the abdomen or thorax. . if not impossible. the level of anesthesia is altered to provide the minimum amount of anesthesia that is necessary to ensure adequate anesthetic depth. the patient is not receiving any noxious stimulus. which must be converted rapidly to a deeper level just before the incision is made.

excessive depth results in slower awakening and more adverse effects. . tachycardia. This is only performed when the patient has regained sufficient control of his or her airway reflexes. clear-headed recovery. anesthetic vapors have been decreased or even switched off entirely to allow time for them to be excreted by the lungs. Excessive anesthetic depth. the patient is restored to breathing by himself. inadequate anesthesia is easy to spot. and. coughs. If a ventilator has been used. This requires experience and judgment. water-soluble barbiturates such as thiopental. propofol can be administered by slow intravenous infusion instead of vapor to maintain the anesthesia. and thiamylal. is associated with decreased heart rate and blood pressure. o The use of propofol is associated with less postoperative nausea and vomiting and a more rapid. • • • • In advance of that time. if carried to extremes. has displaced barbiturates in many anesthesia practices. Induction agents • • For 50 years. and capillary dilation to decide whether the patient requires a deeper anesthetic. Experience and close communication with the surgeon enable the anesthesia provider to predict the time at which the application of dressings and casts will be complete. a nonbarbiturate intravenous anesthetic.• • • • If muscle relaxants have not been used. methohexital. then clearly the patient is unable to demonstrate any of these phenomena. and. the patient emerges to consciousness. the most commonly used induction agents were rapidly acting. as anesthetic drugs dissipate. o In addition to being an excellent induction agent. Short of these serious misadventures. the way in which they are sequenced depends partially on the personal preference of the person administering them. These drugs are not commonly in use today. the anesthesia provider must rely on careful observation of autonomic phenomena such as hypertension. Emergence is not synonymous with removal of the endotracheal tube or other artificial airway device. Propofol. or obstructs his airway if the anesthetic is too light for the stimulus being given. In these patients. sweating. on the other hand. The patient moves. can jeopardize perfusion of vital organs or be fatal. Anesthesia Drugs in Common Use Numerous choices exist for every aspect of anesthetic care. Excess muscle relaxation is reversed using specific drugs and an adequate longacting opioid analgesic to keep the patient comfortable in the recovery room. If muscle relaxants have been used. As the surgical procedure draws to a close. The specialty of anesthesiology is working to develop reliable methods to avoid cases of awareness under anesthesia. the patient's emergence from anesthesia is planned.

They may be mixed with nitrous oxide. in general. a rapid-onset. Muscle relaxants • • • • Succinylcholine. cause less fluctuation in blood pressure and are shorter acting. which. In addition. can be a medium for rapid bacterial growth. such as pancuronium or curare. Other relaxants have durations of action ranging from 15 minutes to more than 1 hour. These include fentanyl. sufentanil. and obstetric suites. It is no longer used in routine clinical practice. . and hydromorphone are widely used in anesthesia as well as in emergency departments. were often associated with changes in heart rate or blood pressure. which. which are delivered with precision from vaporizers and directly into the patient's inhaled gas stream. and remifentanil. if not handled using meticulous aseptic precautions. anesthesia providers have at their disposal a range of synthetic opioids. This is how all anesthetics were once given and is a common and useful technique in uncooperative children. agents that were cleared from the lungs faster and thus were associated with more rapid anesthetic emergences. Sevoflurane is most commonly used for this purpose. Muscle relaxants generally are excreted by the kidney. It is reemerging as a choice in adults. surgical wards. but some preparations are broken down by plasma enzymes and can be used safely in patients with partial or complete renal failure. it was displaced by isoflurane and enflurane. a much weaker but nonetheless useful anesthetic gas. The prototype of modern anesthetic vapors is halothane. o Traditional opioid analgesics • • Morphine. o For decades. has traditionally been the drug of choice when rapid muscle relaxation is needed. In the 1980s.• Among its disadvantages are the facts that it often causes pain on injection and that it is prepared in a lipid emulsion. Anesthesia can also be induced by inhalation of a vapor. meperidine. short-acting depolarizing muscle relaxant. o The search for a drug that replicates its onset and offset speed without its adverse effects is the holy grail of muscle relaxant research. Newer muscle relaxants are devoid of these adverse properties. Anesthetic vapors • • These are highly potent chlorofluorocarbons. anesthesia providers have used it extensively despite numerous predictable and unpredictable adverse effects associated with its use. Older drugs in this class.

Pasien dengan penyakit sistemik sedang hingga berat yang menyebabkan keterbatasan fungsi 4. desflurane and sevoflurane came into use. American Society of Anesthesiologists (ASA) membuat klasifikasi pasien menjadi kelas-kelas: 1. Pasien normal dan sehat fisis dan mental 2. ASA SCORE Berdasarkan status fisis pasien. These inhaled anesthetics are much more maneuverable than their predecessors and are associated with a more rapid emergence. Intense commercial interest is present in anesthesia drug research.• In the late 1990s. and the continuous introduction of new and better drug products for many years to come seems inevitable. Pasien yang tidak dapat hidup/bertahan dalam 24 jam dengan atau tanpa operasi 6. Pasien mati otak yang organ tubuhnya dapat diambil E Bila operasi yang dilakukan darurat (emergency) maka penggolongan ASA diikuti huruf E (misalnya 1E atau 2E) . Pasien dengan penyakit sistemik berat yang mengancam hidup dan menyebabkan ketidakmampuan fungsi 5. Pasien dengan penyakit sistemik ringan dan tidak ada keterbatasan fungsional 3.