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In modern medical practice, general anaesthesia (AmE: anesthesia) is a state of total unconsciousness resulting from general anaesthetic drugs. A variety of drugs are given to the patient that have different effects with the overall aim of ensuring unconsciousness, amnesia and analgesia. The anaesthetist (AmE: anesthesiologist) selects the optimal technique for any given patient and procedure. The biological mechanism of action of general anesthetics is not well understood.
1 Overview 2 Preanaesthetic evaluation
3 General anaesthesia
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3.1 Induction of anaesthesia 3.2 Maintenance 3.3 Muscle relaxation / Neuromuscular blockade 3.4 Airway management 3.5 Monitoring
4 Stages of anaesthesia
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4.1 Stage 1 4.2 Stage 2 4.3 Stage 3 4.4 Stage 4
5 Postoperative care
5.1 Post-operative analgesia 5.2 Shivering
6 Mortality rates 7 See also
Key factors of this determination are the patient's age. For example. weight. Truthful and accurate answering of the questions is important so that the anaesthetist can select the proper anaesthetic drugs and procedures. and fasting time. current medications. . failure to disclose such usage can endanger the patient. neck flexibility and head extension observed. a heavy drinker or drug user who does not disclose their chemical uses could be undermedicated. The condition of teeth and location of dental crowns and caps are checked. which could then lead to anaesthesia awareness or dangerously high blood pressure. the anaesthetist will review this information with the patient either during the pre-operative evaluation or on the day of the surgery. then alternative placement methods such as fibreoptic intubation may be required. Premedication Anaesthesiologists may prescribe or administer a sedative pre-medication by injection or by mouth anywhere from a couple of hours to a couple of minutes before induction. If an endotracheal tube is indicated and airway management is deemed difficult. 8 Notes 9 External links Overview General anaesthesia is a complex procedure involving: Preanaesthetic assessments Administration of general anaesthetic drugs Cardiorespiratory monitoring Analgesia Airway management Fluid management Postoperative pain relief Preanaesthetic evaluation Prior to surgery. An important aspect of this assessment is that of the patient's airway. medical history. Patients are typically required to fill out this information on a separate form during the preoperative evaluation. involving inspection of the mouth opening and visualisation of the soft tissues of the pharynx. Commonly used medications such as Viagra can interact with anaesthesia drugs. after induction of anaesthesia. Depending on the existing medical conditions reported. the anaesthetist interviews the patient to determine the best combination of drugs and dosages and the degree to which monitoring is required to ensure a safe and effective procedure. previous anaesthetics.
and totally unaware of events. Though for a propofol-based anaesthetic. General anaesthesia can be induced by intravenous (IV) injection. Usually this is achieved by allowing the patient to breathe a carefully controlled mixture of oxygen. Commonly used IV induction agents include propofol. or due to patient preference (e. General anaesthesia is traditionally described as comprising of 3 components: hypnosis. sodium thiopental. causing immobility and allowing easy surgical access. Relaxation implies abolition of reflex muscle tone. where difficulty maintaining the airway is anticipated. The inhalation agents are transferred to the patient's brain via the lungs and the bloodstream.g. Inhaled agents are frequently supplemented by intravenous anaesthetics. supplementation by inhalation agents is not required. and the patient remains unconscious. or breathing a volatile anaesthetic through a facemask (inhalational induction). General anaesthesia General anaesthesia implies loss of consciousness and of protective reflexes. At the end of surgery the volatile or .The most common drugs used for pre-medication are narcotics (opioids such as fentanyl) and sedatives (most commonly benzodiazepines such as midazolam). relaxation and analgesia. through an IV. and ketamine. taking about 10–20 seconds to induce total unconsciousness. anaesthesia must be maintained. children). The most commonly-used agent for inhalational induction is sevoflurane because it causes less irritation than other inhaled gases. unconscious. and a volatile anaesthetic agent or by having a carefully controlled infusion of medication. Onset of anaesthesia is faster with IV injection than with inhalation. etomidate. nitrous oxide. Analgesia refers to use of one or more of a wide range of pain reducing drugs from paracetamol to morphine. and thus reduces complications related to induction of anaesthesia. or specific block of nerve/muscle function. In order to prolong anaesthesia for the required duration (usually the duration of surgery). Hypnosis or sleep refers to being deeply asleep. This has the advantage of avoiding the excitatory phase of anaesthesia (see below). Induction of anaesthesia The general anaesthetic is administered in either the operating theatre itself or a special ante-room. usually propofol. Maintenance The duration of action of IV induction agents is generally 5 to 10 minutes. in the hope of reducing heart rate and blood pressure responses to surgery. and perhaps local anaesthetics to block pain impulse transmission along nerves. after which time spontaneous recovery of consciousness will occur. An inhalational induction may be chosen by the anesthesiologist where IV access is difficult to obtain. such as opioids (usually fentanyl or a fentanyl derivative) and sedative-hypnotics (usuallypropofol or midazolam).
abdomen and thorax without the need for very deep anaesthesia. Acetylcholine. and is also used to facilitate endotracheal intubation. In the 1990s a novel method of maintaining anaesthesia was developed in Glasgow. TCI is not permitted in the United States. At present. and allowing pharmacologic principles to more precisely guide amount of infusion of the drug.e. drugs like ephedrine and phenylephrine to treat low blood pressure. and drugs like epinephrine or diphenhydramine to treat allergic reactions. This device intermittently sends short electrical pulses through the skin over a peripheral nerve while the contraction of a muscle supplied by that nerve is observed. Other medications will occasionally be given to anaesthetized patients to treat side effects or prevent complications. and absence of a trigger for malignant hyperthermia. Monitoring of paralysis is most easily provided by means of a peripheral nerve stimulator. Purported advantages include faster recovery from anaesthesia. the airway usually needs to be protected by means of an endotracheal tube. this involves using a computer controlled syringe driver (pump) to infuse propofol throughout the duration of surgery. The effects of muscle relaxants are commonly reversed at the termination of surgery by anticholinesterase drugs. As the muscles of the larynx are also paralysed. removing the need for a volatile anaesthetic. Sometimes glucocorticoids or antibiotics are given to prevent inflammation and infection. Muscle relaxation allows surgery within major body cavities.g. which has now been superseded by drugs with fewer side effects and generally shorter duration of action. reduced incidence of post-operative nausea and vomiting. UK. . i. introduced in the 1940s. These medications include antihypertensives to treat high blood pressure. e. respectively. Muscle relaxants work by preventing acetylcholine from attaching to its receptor. Called TCI (target controlled infusion). the diaphragm and intercostal muscles of the chest requires that some form of artificial respiration be implemented.intravenous anaesthetic is discontinued. Recovery of consciousness occurs when the concentration of anaesthetic in the brain drops below a certain level (usually within 1 to 30 minutes depending upon the duration of surgery). The first drug used for this purpose was curare. Paralysis of the muscles of respiration. drugs like albuterol to treat asthma or laryngospasm/bronchospasm. the natural neurotransmitter substance at the neuromuscular junction. Muscle relaxation / Neuromuscular blockade "Paralysis" or temporary muscle relaxation with a neuromuscular blocker is an integral part of modern anaesthesia. causes muscles to contract when it is released from nerve endings.
although there are alternative devices such as face masks or laryngeal mask airways. desflurane.). A blood pressure machine takes blood pressure readings at regular. 4. halothaneetc.Examples of skeletal muscle relaxants in use today are pancuronium. maintenance of and emergence from general anaesthesia. some form of "breathing tube" is inserted in the airway after the patient is unconscious. vecuronium. or muscle relaxants. an endotracheal tube is often used (intubation). Agent concentration measurement . Continuous pulse oximetry (SpO2): The placement of this device (usually on one of the fingers) allows for early detection of a fall in a patient's haemoglobin saturation with oxygen (hypoxemia). mivacurium. This involves placing a blood pressure cuff around the patient's arm. Monitoring Monitoring involves the use of several technologies to allow for a controlled induction of. To enable mechanical ventilation.g.usually at the wrist or in the groin. the critically ill. or when large blood losses are expected. To maintain an open airway and regulate breathing within acceptable parameters. there is loss of protective airway reflexes (such as coughing). sevoflurane. and succinylcholine. rocuronium. and most common. atracurium. This may also help the anaesthetist to identify early signs of heart ischemia. . Airway management With the loss of consciousness caused by general anaesthesia. This method is reserved for patients with significant heart or lung disease. The first. loss of airway patency and sometimes loss of a regular breathing pattern due to the effect of anaesthetics. The second method is called invasive blood pressure (IBP) monitoring. 3. opioids. 6. 1. This warns if the fraction of inspired oxygen drops lower than room air (21%) and allows the anaesthetist to take immediate remedial action. is called non-invasive blood pressure (NIBP) monitoring. forearm or leg. isoflurane. Continuous Electrocardiography (ECG): The placement of electrodes which monitor heart rate and rhythm. 2.indicates failure of circuit to achieve a given pressure during mechanical ventilation. Circuit disconnect alarm . Low oxygen alarm .Common anaesthetic machines have meters to measure the percent of inhalational anaesthetic agent used (e.Almost all circuits have a backup alarm in case the oxygen delivery to the patient becomes compromised. 5. Blood Pressure Monitoring (NIBP or IBP): There are two methods of measuring the patient's blood pressure. The invasive blood pressure monitoring technique involves placing a special type of plastic cannula in the patient's artery . preset intervals throughout the surgery. major surgery such as cardiac or transplant surgery.
Carbon dioxide measurement (capnography). and the patient's breathing becomes regular. and to aid early detection of malignant hyperthermia. It has been divided into 4 planes: 1.7. pupils dilate and loss of light reflex 4. Temperature measurement to discern hypothermia or fever. vomiting. rolling eye balls. and surgery can begin. It also reduces the likelihood of a patient receiving significantly more amnesic drugs than actually necessary to do the job. 9. loss of corneal and laryngeal reflexes 3. vomiting.measures the amount of carbon dioxide expired by the patient's lungs. EEG or other system to verify depth of anaesthesia may also be used. shallow abdominal respiration. rapidly acting drugs are used to minimize time in this stage and reach stage 3 as fast as possible. and pupillary dilation. Eye movements slow. During this stage. respirations and heart rate may become irregular. intercostal paralysis. and irregular respirations may lead to airway compromise. breath holding. the skeletal muscles relax. During this stage. This reduces the likelihood that a patient will be mentally awake. "surgical anesthesia". then stop. also known as the "induction". which have led to more rapid onset and recovery from anaesthesia. Stage 2 Stage 2 anaesthesia. the principles remain. also known as the "excitement stage". is the period following loss of consciousness and marked by excited and delirious activity. Patients can carry on a conversation at this time. although unable to move because of the paralytic agents. Stage 1 Stage 1 anaesthesia. In addition. Since the combination of spastic movements. It allows the anaesthetist to assess the adequacy of ventilation 8. Despite newer anaesthetic agents and delivery techniques. Stages of anaesthesia The four stages of anaesthesia were described in 1937. the patient progresses from analgesia without amnesia to analgesia with amnesia. During this stage. there may be uncontrolled movements. is the period between the initial administration of the induction medications and loss of consciousness. with greater safety margins. Stage 3 Stage 3. dilated pupils Stage 4 . ending with fixed eyeballs 2.
they make no more morphine requests. catecholamine release. shivering has been shown to increase oxygen consumption. Parenteral methods include patient-controlled analgesia (PCA) involving a strong opiate such as morphine. The PCA device then "locks out" for a preset period.g. and organ failure (e. heart. There are a number of techniques used to reduce this occurrence. such as increasing the ambient temperature in theatre. kidneys. 5 minutes. Moderate levels of pain require the addition of mild opiatessuch as tramadol. one milligram of morphine). to activate a syringe device. blood pressure and intra-ocular pressure. to allow the drug to take effect. sepsis.g. Minor surgical procedures are amenable to oral pain relief medications such as paracetamol and NSAIDs such as ibuprofen. cardiac output.g. the patient presses a button and receives a preset dose or "bolus" of the drug (e. is the stage where too much medication has been given and the patient has severe brain stem or medullary depression. heart rate. transdermal or parenteralmedication. using conventional or forced warm air blankets and using warmed intravenous fluids. If the patient becomes too sleepy or sedated. oral. Major surgical procedures may require a combination of modalities to confer adequate pain relief. This stage is lethal without cardiovascular and respiratory support. lungs. e. Here. Postoperative Post-operative care analgesia The anaesthesia should conclude with a pain-free awakening and a management plan for postoperative pain relief. fentanyl or oxycodone. These include major haemorrhage.Stage 4 anesthesia. This confers a fail safe aspect which is lacking in continuous opiate infusion techniques. Mortality rates Overall. This results in a cessation of respiration and potential cardiovascular collapse. liver). Common causes of death directly related to anaesthesia include: aspiration of stomach contents suffocation (due to inadequate airway management) allergic reactions to anaesthesia (specifically and not limited to anti-nausea agents) and other genetic predispositions human error . also known as "overdose". Shivering Shivering is a frequent occurrence in the post-operative period. Death during anaesthesia is most commonly related to surgical factors or pre-existing medical conditions. This may be in the form of regional analgesia. Apart from causing discomfort and exacerbating post-operative pain. the mortality rate for general anaesthesia is about three to five deaths per million anaesthetic administrations.
with at least one death per 10. a careful effort was made to understand the causes and improve the results. up until about 1980.S. It is generally believed that anaesthesia is now at least ten times safer than it was then. However. After becoming something of a public scandal. The death rate for dental anaesthesia is reported to be one out of 350.. the data are not even collected). there is some controversy about this. In the U.S. the data is not made public (in fact. anaesthesia held significant risk.000 times administered.. equipment failure In the U.00[8 . so the truth is uncertain.
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