GENERAL ANESTHESIA

OUTLINE
I. Case
II. Preoperative Evaluation and Preparation ● Medical history and physical examination are cornerstones
of an effective preoperative evaluation
A. Patient History → To ensure that patient is in optimal condition to undergo a
B. Physical Examination surgical procedure
→ To identify specific characteristics that may influence the
C. Laboratory Workups and Imaging proposed anesthetic plan
D. ASA Status Classification
E. Preoperative Assessment
F. Premedication and Preparation Prior to Surgery A. PATIENT HISTORY
Parts of a Medical History
G. Informed Consent ● History of Present Illness
H. Postoperative Assessment Note → Information on the condition for which the surgery was
planned for
III. Equipment
→ Any other accompanying symptoms of the patient’s condition
A. Ancillary Equipment ● Past Medical History
B. Anesthesia Machine → Childhood and adult illnesses
▪ Giving emphasis to pulmonary function, kidney disease,
C. Delivery of Inhalational Anesthesia endocrine and metabolic diseases, is important as these
may typically increase risk of complications. 
D. Patient Monitoring ▪ History of obstructive sleep apnea or symptoms
IV. Intraoperative Management pointing to it (i.e. snoring, pause in breathing while asleep)
should be asked
A. Preparation of Anesthesia Table − Perioperative pulmonary complications (e.g. post-
operative respiratory depression and respiratory failure)
B. Anesthesia of Choice are commonly associated
C. Airway Management ▪ History of asthma
− Those with asthma have greater risk for bronchospasm
D. Fluid Management during airway manipulation
V. Postoperative Management ▪ Active cardiopulmonary disease
− This may postpone or may require the patient’s
A. Post Anesthesia Care Unit (PACU) condition to be improved prior the scheduled procedure
▪ History of fever and benign febrile convulsions
B. Monitoring/Follow-ups − Some anesthetics (e.g. Propofol) are contraindicated
C. Postoperative Nausea and Vomiting Management and should NOT be given to those patients with history
of benign febrile convulsions and seizures
D. Diet/Nutrition and Fluid Therapy ▪ History of Malignant Hyperthermia
E. Post-op Pain Management ▪ History of Gastroesophageal Reflux Disease (GERD)
− Increased risk of aspiration of gastric contents during
F. Addressing Possible Complications and Adverse Effects surgery
→ Immunization history
G. Discharge Criteria from PACU → Past surgical procedures, its outcomes and complications
→ Responses and reactions to previous anesthetics
I. CASE → All medications taken by the patient in the recent past
A 17 year old was booked for excision with frozen section of ▪ Anticoagulation medications (e.g. warfarin) should be
a 4 x 6 cm. mass on the subscapular area, left. The mother noticed discontinued or temporarily replaced 5 days prior to
surgery to avoid excessive blood loss
this mass a year ago, but she took it for granted because it was
→ All pertinent drug, contact, and food allergies
small, measuring around 1 x 2 cm, and painless. However, a ▪ Allergy to egg may contraindicate the use of propofol as it
month ago, the mass was noted to be fast growing and painful. contains egg in its composition
Discuss your perioperative anesthetic management. → If the patient is female, should also include the Obstetric
and Sexual history of the patient
II. PREOPERATIVE EVALUATION AND ▪ Women in their 2nd and 3rd trimesters are in increased risk
of aspiration of gastric contents during surgery
PREPARATION ● Family History
● Important part of every surgery, as it serves to do the ff:
→ Possible genetic predisposition to the patient’s condition and
→ To identify patients whose outcomes will be improved by a → Familial diseases (Hypertension, Diabetes Mellitus, etc.)
specific medical treatment → Adverse reactions of family members to previous anesthetics
→ To discriminate the patients with poor conditions that the ● Personal and Social History
proposed surgery will only hasten their deaths
→ Lifestyle and diet
● In this phase, physicians should be able to establish rapport
→ Possible tobacco, alcohol, and illicit drug use
with the patient, establish co-existing disease if present, give
● Complete Review of Systems
the appropriate therapy, and plan the perioperative
management based on the patient’s status.

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GENERAL ANESTHESIA
B. PHYSICAL EXAMINATION
● Measurement of vital signs
● Examination of heart, lungs, and musculoskeletal system
● Focused physical examination of left subscapular area using
inspection and palpation
→ Check for evidence of infection or any anatomic
abnormalities that can complicate the surgical procedure
Examination of Airway
● Patient’s airway must be examined by the anesthesiologist.
Before any procedure, the following must be checked:
→ Patient’s dentition – loose or chipped teeth, caps, bridges,
dentures
→ Facial abnormalities – can affect the fit of the anesthetic
mask
→ Micrognathia, prominent upper incisors, large tongue, limited
movement of TMJ/cervical spine, and short or thick neck –
can result to difficulties in using direct laryngoscopy for
tracheal intubation
● MALLAMPATI CLASSIFICATION OF AIRWAY
→ Indirect way of assessing how difficult intubation will be using
visual assessment of the distance from the tongue to the roof
of the mouth
→ Estimates the amount of space there is to work with
Figure 1. Mallampati Classification of Airway
Dr. So:
● Prior to intubation, the anesthesiologist must explain and
emphasize possible damage to dental prosthesis.
● Pag yung patient niyo kunwari may Swarovski na jacket,
dapat i-explain nyo na may possibility ma-damage or else
baka i-sue kayo ng patient.
Screen for Sleep Apnea
● Sleep apnea – sleep disorder that causes breathing to
repeatedly stop and start must be ruled out since it poses a risk
to patients
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● Majority of sleep apnea patients are undiagnosed; thus, it is
important to ask questions like:
→ Do you snore nightly?
→ Has anyone ever said that you stop breathing in your sleep?
→ Do you feel tired and groggy on awakening?
→ Do you fall asleep easily during the day?
→ Do you frequently have headaches in the morning?
● Typical patients with sleep apnea:
→ Overweight males
→ > 40 years old
C. LABORATORY WORKUPS AND IMAGING
● Chest X-ray
→ Most commonly used in patients who will undergo thoracic,
esophageal, or cardiac surgery
→ May reveal rib destruction, calcifications
● Thorax CT Scan
Used in observing the relationship of the mass with the
adjacent structures (lungs, soft tissues, mediastinum,
other skeletal components
● Magnetic Resonance Imaging (MRI)
→ Has superior soft tissue contrast resolution and multiplanar
capabilities
→ Shows clear recognition between the fibrous and fat
component
→ Characterizes the composition, size, location, and relation of
the tumor with the adjacent areas
● Biopsy
→ Performed only when diagnosis cannot be made from the
imaging results
→ Excision Biopsy
▪ Used when the initial diagnosis points out that the mass is
benign
▪ Any lesion < 2.0 cm can be excised as long as the wound
is small enough to close primarily
→ Core Needle Biopsy
▪ Advantage: prevents the contamination of the wound
● Blood Glucose Measurement (Hba1c)
→ Determines the adequacy of long-term blood glucose control
of the patient
● Hematocrit and Hemoglobin Concentration,
Urinalysis, Serum Electrolyte Measurement, and
Coagulation Studies
→ Usually conducted by physicians, but are considered
as not cost-effective in asymptomatic patients
→ Results rarely affects the management of the patient’s
condition
D. ASA PHYSICAL STATUS CLASSIFICATION
● American Society of Anesthesiologists’ Physical Status
Classification
→ Used to define relative risk prior to conscious sedation and
surgical anesthesia
→ Simple, time-honored, reproducible, and strongly associated
with perioperative risk
● In the case, patient can be classified as Class 1 since he/she
has no significant functional limitation
GENERAL ANESTHESIA
→ Consultant’s
recommendation
● Anesthetic plan is briefly described
→ Contains the following:
▪ Type of anesthesia (general or regional) or sedation
▪ Use of invasive monitoring and other techniques
▪ Statement on the informed consent from the patient or
guardian
→ Discussion includes the plan and alternative plans with their
advantages, disadvantages, and risks
▪ Documentation of discussion must indicate that the details
were presented, understood, and accepted by the patient

F. PREMEDICATION

● In the past, every patient received premedication before

arriving in the preoperative area in anticipation of surgery.
→ Belief that all patients benefit from sedation and
Fig 2. ASA Physical Status Classification
anticholinergics, and most patients would benefit from a
preoperative opioid.
Dr. So:
● Some patients arrived in a nearly anesthetized state after such
● Emphasized that in emergency situations, letter E is
premedication
added to the classification number
● Goals of preoperative medication depend on many factors:
● E.g. A normal healthy patient rushed to the emergency
→ Health and emotional status of the patient
room is classified as 1E
→ Proposed surgical procedure
→ Anesthetic plan
E. PREOPERATIVE ASSESSMENT NOTE ● Instead of giving pre medications blindly, the choice of
anesthetic premedication must be:
→ individualized and,
→ must follow a thorough preoperative evaluation.
● Anxiety is a normal response to impending surgery.
● One of the major goals of administering preoperative medication
is to diminishing anxiety
→ Especially in children aged 2-10 years since they are usually
experiencing separation anxiety on being removed from their
parents
● In the case presented
→ Preoperative interview with the anesthesiologist will decide if
the patient will need a sedative drug or the interview itself will
effectively allays fears.
→ In a situation where the patient still feel anxious after the
interview benzodiazepine is usually administered
preoperatively.
▪ On account of their good anxiolytic actions, their excellent
tolerability and only few side effects benzodiazepines are
most frequently used for this purpose (Broscheit, 2008).
▪ Midazolam
− a short acting benzodiazepine frequently used as
premedication to reduce preoperative anxiety
− Induces meaningful anterograde amnesia.
− Usually taken orally, 45 minutes prior to procedure.
● Another goal is to provide relief of preoperative pain or
perioperative amnesia.
Figure 3. Sample preoperative assessment note ● Since the patient is experiencing pain, small doses of opioid
(typically fentanyl) will often be given.
● Required for all patients who will undergo surgery ● Most anesthetic agents have a side effect of nausea and
● Added to the patient’s permanent medical record vomiting, to prevent this 5-HT3s is usually given as a
● Includes the following: prophylaxis. (Ondansetron is usually administered according to
→ Medical history → Laboratory test results Doc So)
→ Anesthetic history → Imaging interpretation
● Another drug that can reduce postoperative shivering, nausea,
→ Current medications → Electrocardiograms
→ Physical examination → ASA physical status vomiting, and emergence delirium is Clonidine which is an
class alpha 2 adrenergic agonist.

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GENERAL ANESTHESIA
● For prevention of allergic reactions antihistamines are usually
given.
● Not all patients require preoperative medication since levels of
preoperative anxiety do not harm patients.
● Some will feel more uncomfortable when they are put into an
altered state of consciousness.
The effects of some sedatives may extend into the postoperative
period and prolong recovery time if the surgical procedure is brief
G. INFORMED CONSENT
● Premedication should never be given before informed consent
has been obtained.
● Since the patient is a minor, consent must be obtained from the
parents.
● There are two types of informed consent
→ Written Consent
→ Oral consent.
● Oral consent is not advised since it is more susceptible to
misunderstanding and possible legal suits because the patient
may deny its existence or content.
● The consent form should contain:
→ All the necessary information regarding the nature of the
patient’s illness,
→ Procedures to be done to him or her
→ Rationale behind, alternative treatment options, and side
effects of treatments.
● Although these are already written on the consent form,
→ the physician should still explain these to both the patient
and the parents and address any concerns.
● Furthermore, to make sure that everything is clear to the
decision-maker
→ he/she should be asked to repeat what he/she has
understood from the physician’s explanation
● Hence, the person giving the consent, should be the one who is
able to make a sound medical decision regarding treatments or
procedures to be done to the patient.
● Most importantly, the physician may express his/her opinion
about the most appropriate treatment when asked however,
he/she should not, in any way, coerce the patient/parents to
make a particular decision.
● The final decision should be respected by the physician.
Figure 4. Algorithm for navigating the process of informed consent.
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H. FLUID THERAPY
● To reduce the risk of vomiting during the procedure, patients
undergoing surgical procedures must also refrain from these
things prior to surgery
→ Solid food- 8 hours
→ Clear fluid- 2 hours
→ Cow’s milk- 6 hours
→ Mother’s milk- 4 hours
I. POSTOPERATIVE ASSESSMENT NOTE
● Until normal vital signs have been measured and the patient’s
condition is deemed stable
→ the anesthesiologist should remain with the patient in the
post anesthesia care unit (PACU).
● Before discharge from the PACU, a note should be written by
the anesthesiologist to document:
→ The general condition of the patient
→ The patient’s recovery from anesthesia
→ Any apparent anesthesia related complications and any
measures undertaken to treat such complications
→ The immediate postoperative condition of the patient
→ The patient’s disposition (discharge to an outpatient area, an
inpatient ward, an intensive care unit, or home)
● In all patients, recovery from anesthesia should be assessed at
least once within 48 hours after discharge from the PACU.
● Postoperative notes should document
Figure 5. Elements required by the Center for Medicare and Medicaid
Services in all postoperative notes.
III. EQUIPMENT
A. ANCILLARY EQUIPMENT
ENDOTRACHEAL TUBES
● Used during the conduct of general anesthesia to deliver
oxygen to the patient
● Intubation is a recommended procedure in patients with
airways in less accessible positions (e.g., prone position)
● A different internal diameter and cut length is needed for
patients of different age groups
Figure 6. Size guidelines for oral endotracheal tubes
GENERAL ANESTHESIA
● To optimize gas through, adult endotracheal tubes have a Gas Supply
cuff inflation system, which have a cuff, pilot balloon, valve, ● Two sources of gas supply:
and inflating tube → Pipeline gas supply – transports oxygen, nitrous oxide,
and air from a central supply source to the operating room
Table 1. Components of an ET tube ▪ Forward flow is maintained by valves that prevent
Component Description
backflow
Cuff ● Creates a tracheal seal and permits
▪ A filter is in place that prevents small debris from
positive-pressure ventilation
flowing into the anesthesia machine
Pilot Balloon ● Estimates cuff inflation levels
Valve ● Prevents air loss after inflation of the → Cylinder gas supply – used as a backup in case there is
cuff by preventing backflow of air pipeline gas supply failure
Inflating Tube ● Connects the valve and the cuff ▪ Gas cylinders are attached to the anesthesia machine
via hanger-yoke assemblies that utilize the pin index
safety system to prevent the backward flow of gases
LARYNGOSCOPE
▪ Color-coded for easy identification
● Facilitates the intubation of the
trachea and the examination of Flow Control Circuits
the larynx
→ Tongue – displaced
horizontally
→ Hyoid bone and attached
tissues – moved anteriorly
→ Epiglottis - elevated
● Can have either a straight
(Miller) or curved (Macintosh)
blade
→ Straight blades are generally
preferred in neonates and
Figure 7. Laryngoscope
children
positioning

B. THE ANESTHESIA MACHINE

● Uses composite systems to deliver medical gases from a gas

supply to the patient
● Comprised of a high-pressure, intermediate-pressure, and
low-pressure circuit
→ High: Gas supply cylinders and cylinder primary pressure
regulators
→ Intermediate: From the regulated cylinder supply sources
to the flow control valves
→ Low: From the flow control valves to the common gas
outlet

Figure 8. Diagram of a two-gas anesthesia machine

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