General anesthesia

Definition of anesthesia

• It is a reversable blocking of pain feeling in

whole body or in a part of it using
pharmacology or other methods
 Anesthesia- division
• Local- regional anesthesia, patient is
conscious or sedated
• General- anesthesia interact with whole
body, function of central nervous system is
depressed:
– Intravenous
– Inhalation (volatile)
– Combined, balanced
 TIVA

Total
Intra
Venous
Anaesthesia
 VIMA

Volatile
Induction
and
Maintain
Anaesthesia
 Parts of general anesthesia

• Hypnosis- pharmacological sleep,

reversable lack of consciousness
• Analgesia-pain management
• Areflexio-lack of reflexes
• Relaxatio musculorum- muscle relaxation,
pharmacological reversable neuromuscular
blockade
Parts of general anesthesia must be
in balance

Hypnosis
(anesthesia) Analgesia

Lack of reflexes (muscle relaxation)

• General anesthesia

Lack of consciousness
1
features
Pain management

2 Lack of reflexes
Neuromuscular blockade
3
4
 Stages of general anesthesia

• Stadium analgesiae (analgesia and

sedation stage)
• Stadium excitationis (excitation stage)
• Stadium anaesthesiae chirurgicae
(anesthesia for surgery)
• Stadium paralysis respirationis
(intoxication, respiratory arrest)
 I. Analgesia stage

• Patient consciouss
• Spontaneus respiration
• Reflexes present
• Possible small surgery procedures like
dressing change in burns
 II. Excitation stage

• Possible uncontrolled movements,

vomitings
• Increase in respiratory rate
 III. Anesthesia for surgery

• It begins with lack of lid reflex

• 4 substages
• Airway opening necessary
• Possible surgery except for abdominal
opening if no relaxants are used
• Possible endotracheal intubation
 IV. intoxication, overdosing

• Respiratory arrest
• If anesthesia not discontinued possible
cardiac arrest
 Estimation of the risk of anesthesia (American
Society of Anesthesiologists scale)

• ASA 1: healthy patient.

• ASA 2: patient with stable, treated illness like arterial
hypertension, diabetes melitus, asthma bronchiale,
obesity
• ASA 3: patient with systemic illness decreasing
suffitiency like heart ilness, late infarct
• ASA 4: patient with serious illness influencing his state
like renal insuficiency, unstable hypertension,
circulatory insuficiency
• ASA 5: patient in life treatening illness
• ASA 6: brain death- potential organ donor
 Premedication

Main reasons for premedication:

• Anxiolysis- lack of threat
• Sedation – calming down
• Amnesia – lack of memories of
perioperative period
• Methods of general anesthesia

OPEN

SEMIOPEN

SEMICLOSED

CLOSED
• METHODS OF GENERAL ANESTHESIA

OPEN- old

SEMIOPEN – used mostly in pediatric anesthesia

SEMICLOSED- most common

CLOSED- modern anesthesia

• Methods of general anesthesia

CIRCLE SYSTEM
*HIGH-FLOW
FRESH GAS FLOW  3 l/min.
*LOW-FLOW
FGF ok. 1l/min.
*MINIMAL-FLOW
FGF ok. 0,5 l/min.
 Stages of general anesthesia

• Introduction to anesthesia (induction)

• Maintaining of anesthesia (conduction)
• Recovery from anesthesia
 Anesthesia agents
1. Inhalation anesthetics (volatile anesthetics)
- gases : N2O, xenon
- Fluids (vaporisers)
2. Intravenous anesthetics
- Barbiturans : thiopental
- Others : propofol, etomidat
3. Pain killers
- Opioids: fentanyl, sufentanil, alfentanil, remifentanil, morphine
- Non Steroid Anti Inflamatory Drugs: ketonal, paracetamol
4. Relaxants
- Depolarising : succinilcholine
- Non depolarising : atracurium, cisatracurium, vecuronium, rocuronium
5. adiuvants
-benzodiazepins: midasolam, diazepam
 Volatile
vs
intravenous anesthesia
 Mechanism of action of
inhaled anesthetics

• Reaction depends on concentration. This depends

on alveolar (first compartment), blood and brain
(central compartment) concentration , (third
compartment- other tissue like muscles, fat-
accumulation effect):
– Minute ventilation
– Lung blood perfusion
– Solubility in tissues
 MAC-minimal alveolar
concentration

• Concentration in which 50% of anesthetised

patients do not react on skin incision
• Corelation with solubility in fat tissue
• The lower MAC is the higher strenght of
action is
Inhalation agents
 Division of inhalation agents
1. Gases:
• N2O – old, weak, used as adiuvant
• Xenon – lately introduced
2. Vapors (fluids):
• Halothan
• Enfluran
• Isofluran
• Sevofluran
• Desfluran
 Features of ideal volatile
anesthetic
• Not disturbing smell
• Fast acting, titrable
• Low solubility in blood- fast transport to brain
• Stable when stored, not reacting with other
chemicals
• Non- flamable, non- explosive
• Low methabolism in body, fast elimination, no
accumulative effect
• No depressing effect on circulatory and respiratory
systems
 Nitrous oxide, laughing gas

• Old
• Weak
• Used as adiuvant
• Will be removed form medical use up to
2010- destroyes ozone lawyer
 Halothan

• Used for many years with good effect

• First non-flamable volatile fluid anesthetic
• MAC high
• Depression of circulatory system
• May destroy liver
• Now-a-days used only in pediatric
anesthesia
 Isofluran

• Disturbing smell
• May interact with heart contractivity
• Increases relaxation of muscles
 Sevofluran
• Not disturbing smell- may be used for VIMA
• Low solubility in blood- fast acting
• Does not disturbs airway
• May depress circulatory system
• Methabolised to Compound A- may be renal toxic
(but not confirmed in humans)
• May be used in one-day surgery
• Modern, and more and more widely used volatile
anesthetic
 Desfluran
• Very disturbing smell- can not be used for
VIMA
• Is not methabolised
• Very fast acting
• May be used for one-day surgery
• Expensive, difficult to store (boiling temp.
about 20 C)
• Modern and widelly used
Intravenous anesthesia
 TCI

Target
Controlled
Infusion
 Defining TCI
When applied to anaesthesia

• TCI is an infusion system which allows the

anaesthetist to select the target blood
concentration required for a particular
effect …

… and then to control depth of anaesthesia

by adjusting the requested target
concentration
 What is TCI?
• Instead of setting ml/h or a dose rate (mg/kg/h),
the pump can be programmed to target a
required blood concentration.
• Effect site concentration targeting is now
included for certain pharmacokinetic models.
• The pump will automatically calculate how
much is needed as induction and maintenance to
maintain that concentration.
Intravenous anesthetics
 Thiopental

• Old, one of the first used intravenous

anesthetics
• Depressing effect on circulatory system
• May be used in patients with ASA 1
 Ketamine
• Only intravenous anesthetic which has good analgesia
effect
• Does not depress circulatory nor respiratory function
• Used in children, and in emergency and diseaster medicine
• Gives night mare dreams in adult patients
 Etomidat

• Has no depressing effect on circulatory

system- may be used in patients with
circulatory insufficiency
• May give musle contractions
• Depressing effect on epirenals function
• Can not be given in repeated bolus nor
continuous infusion
 Propofol
• Very good anesthetic for induction and
maintaince of anesthesia with no
accumulation effect
• Titrable
• May be used in short procedures – titrated
do not effect circulatory and respiratory
system in important manner
• Good for sedation, brain protecting effect
• May be used in TCI
Pain killers
 Opioids
• fentanyl, alfentanil, sufentanil, remifentanil
• May be used for induction and maintain of
anesthesia in repeated bolus or continuous
infusion technique
• Sedative effect
• In high doses may be used alone for so called
opioid anesthesia- formerly used in
cardioanesthesia- very stable circulatory effect
 Compications of use

• Respiratory depression !!!!

• Muscle rigidity in high doses
• Post-Operative Nausea and Vomitings
• Accumulation effect after prolonged
administration (except for remifentanil)
 Remifentanil – modern opioid
analgesic

• T1/2 3-5 min !!

• Methabolised by non-specific tissue
esterases- methabolism is not altered by
renal or liver function
• No accumulation effect after prolonged
infusion !!
 NSAID

• Used as adiuvants in short, not very painful

procedures
• Used for „preemptive analgesia” –
reduction of consumption of opioids by
blocking COX
Benzodiazepines
 Benzodiazepiny

• Used in anesthesia:
– Diazepam
– Midazolam
• Used as adiuvants for premedication
Muscle relaxants
 Division of relaxants depending
on mechanism of action
1.nondepolarising- combine with receptor for Ach
like antagonists- they are fake mediators – do not
cause muscle contractation but block access to
receptors for Ach
2.depolarising- they combine with receptors for Ach
and cause contractation of muscle but they stay
connected with receptor blocking access to it for
Ach. They act like agonists.
 Nondepolarising agents
-d-tubocurine – oldest deliverate of curarine
-alcuronium
-pancuronium – cheap and still used
-pipercuronium
-vercuronium
-atracurium
-cisatracurium
-mivacurium
-rocuronium
 Division of nondepolarising
relaxants due to
Chemical structure:

Aminosteroids: Benzylizochinolons:
Pankuronium (Pavulon) Miwakurium (Mivacron)
Pipekuronium (Arduan) Cisatrakurium (Nimbex)
Rapakuronium (Raplon) Atrakurium (Trakurium)
Rokuronium (Esmeron)
Wekuronium (Norcuron)
 Division of nondepolarising
relaxants due to
time of action:

• Short acting < 3 min: still searching

• Midle time <60 min: mivacurium,
atracurium, cisatracurium, rocuronium,
vecuronium
• Long acting > 60 min: pancuronium,
pipecuronium
 Atracurium

• Elimination non-enzymatic, independent of

renal and liver function, Hoffman
elimination- hydrolisis
• Releases histamine
• Acts about 30 min
 Cisatracurium

• One of stereoisomers of atracurium,

• Do not release histamine
• Acts about 60 min
 Mivacurium

• Releases histamine
• Acts about 15-20 min – used for short
procedures
• Methabolised by plasma esterases
 Rocuronium

• Fast acting- time to 100% supresion 60 sec.

• Do not release histamine
• Acts about 60 min
• Is methabolised in liver- disfunction of liver
may alter elimination
 Reverse of neuromuscular blockade

• Neostigmine, piridostigmine- blockers of

acetylocholinesterase
• Must be given toghether with atropine to
avoid bradycardia caused by activation of
perisympatic system
 Depolarising agents
Only one: chlorsuccinilocholine
- It is methabolised by pseudocholinesterase
- Causes many complications, has many
contraindications
- Indications:
Rapid sequence induction: full stomach, suspected difficult
intubation because it acts very fast < 30 seconds and short < 3
min
Monitoring during general
anesthesia
 Obligatory

• Clinical observation
• Circulatory system function: ECG, blood
pressure - Non-Invasive-Blood Pressure
• Respiratory function: SpO2 (pulsoxymetry),
EtCO2
• Neuromuscular function- ie accelerometry
TOF Guard
 Additional- advanced

• Invasive Blood Pressure

• Haemodynamic monitoring ie Doppler
transesophageal probe
• EEG monitoring for deepness of anesthesia
ie BIS (Bispectral Index), AEP - Auditory
Evoced Potentials, Entropy
 Complications of general
anesthesia

• Respiratory: residual relaxants/opioids

action
• Circulatory
• Neurological: residual anesthetics/opioids
action
• Post-Operative Nausea and Vomitings
Mortality connected with anesthesia

• 0,05 - 4/10000 GA
• 2 - 16 % of surgical patients
• 80 % is caused by human
mistake
 Major causes of deaths

• Airway obstruction
• Difficult and unefficient intubation
• Insufficient ventillation
 Other causes of mortality and morbidity

• Anoxia
• Haemodynamic instability
• Aspiration
• Toxity of drugs – mostly inhalation
agents
• Anaphylaxia and drug interations
Airway management and
artificial ventillation
 AIRWAY MANAGEMENT

Respiratory Distress vs. Respiratory Failure

Distress Failure
-Increased work of breathing-Increased work of breathing
-Relative hypoxia/hypercapnea
-Profound hypoxia/hypercapnea
-Compensating -Decompensating

It’s a constant reassessment process…

 Contraindications for face mask
and bag ventillation

• Hernia hiatus aesophagus

• gastric reflux
• injury of face or neck
• brochial-esophagaeal connection
• injury of trachea cartiladges
• full stomach patient, vomitings
 Indications for ET
(endotracheal intubation)

• Airway obstruction
• Cardio Pulmonary Resuscitation
• Artificial ventilation
• Anesthesia
• Brain injury, facial injury, facial burn,
airway burn
 Complications of ET
• Injuries:
- theeth injury, mouth injury
- laryngs rupture
- aspiration
- bleeding
• oesophagus intubation
• one bronchus intubation
• Reactions: vomitings, coughing, apnea,
laryngospasm, bradycardia, hypertension
 Alternative airway management

• Laryngeal mask- for short, not major

operations ecxept for head and neck surgery
• for elective surgery- patient must be
prepared for anesthesia