General anesthesia

General anesthesia uses intravenous and inhaled agents to allow adequate

surgical access to the operative site. General anesthesia may not always
be the best choice; depending on a patient’s clinical presentation, local or
regional anesthesia may be more appropriate.

Anesthetist are responsible for assessing all factors that influence a

patient's medical condition and selecting the optimal anesthetic technique
accordingly.

Advantages of general anesthesia include the following:

 Reduces intraoperative patient awareness

 Allows proper muscle relaxation for prolonged periods of time
 Facilitates complete control of the airway, breathing, and
circulation
 Can be used in cases contraindicated to regional anesthesia

Disadvantages of general anesthesia include the following:

 Associated with complications such as nausea or vomiting, sore

throat, headache and shivering.
 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

Preparing the patient

 The patient should be adequately prepared. 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.
 Preoperative evaluation allows for proper laboratory monitoring,
attention to any new or ongoing medical conditions, discussion of
any previous personal or familial adverse reactions to general
anesthetics, assessment of functional cardiac and pulmonary states,
and development of an effective and safe anesthetic plan. It also
serves to relieve anxiety of the unknown surgical environment for
patients and their families. Overall, this process allows for
optimization of the patient in the perioperative setting.

Monitoring During Anesthesia

People receiving anesthesia must be carefully monitored, because the drugs
used for anesthesia affect the central nervous system, cardiovascular
system, and respiratory system (airway and lungs). Anesthesia suppresses
many of the body's normal automatic functions. So it may significantly
affect breathing, heartbeat, blood pressure, and other body functions.
Instruments commonly used for monitoring during anesthesia include:

 An inflatable blood pressure cuff. This is usually strapped around

upper arm.
 A pulse oximeter, a small instrument that is attached to finger, toe,
or earlobe to measure the level of oxygen in blood.
 An electrocardiogram (ECG) to monitor heart activity. Small wires
(leads) are placed on the skin of chest and held in place by small
adhesive patches.
 A temperature probe. A monitor connected to skin to measure skin
temperature.
 An oxygen analyzer and carbon dioxide analyzer on the
anesthesia machine. These instruments measure the amount of
oxygen and carbon dioxide gases inhaled and exhaled in your breath.

Premedication

 Premedication is the first stage of a general anesthetic.

 This stage, which is usually conducted in the surgical ward or in a
preoperative holding area, originated in the early days of anesthesia
 The goal of premedication is to have the patient arrive in the
operating room in a calm and relaxed .
 The most commonly used premedication is midazolam, a short-
acting benzodiazepine. For example, midazolam syrup is often
given to children to facilitate calm separation from their parents
prior to anesthesia. When a history of gastroesophageal reflux
exists, H2 blockers and antacids may be administered.
 Drying agents (eg, atropine) are now only administered routinely in
anticipation of a fiberoptic endotracheal intubation.

Induction
The patient is now ready for induction of general anesthesia, a critical
part of the anesthesia process.

It is the transformation of a waking patient into an anesthetized one.

This stage can be achieved by intravenous injection of induction agents

(drugs that work rapidly, such as propofol) or by the slower inhalation of
anesthetic vapors delivered into a face mask, or by a combination of both.

In addition to the induction drug, most patients receive an injection of an

opioid analgesic, such as fentanyl (a synthetic opioid many times more
potent than morphine). Induction agents and opioids work synergistically
to induce anesthesia. In addition, anticipation of events that are about to
occur, such as endotracheal intubation and incision of the skin, generally
raises the blood pressure and heart rate of the patient. Opioid analgesia
helps control this undesirable response.

The next step of the induction process is securing the airway. it may
demand the insertion of a prosthetic airway device such as a laryngeal
mask airway or endotracheal tube. Various factors are considered when
making this decision. The major decision is whether the patient requires
placement of an endotracheal tube. Potential indications for endotracheal
intubation under general anesthesia may include the following:

 Potential for airway contamination (full stomach)

 Surgical need for muscle relaxation
 Predictable difficulty with endotracheal intubation or airway access
(eg, lateral or prone patient position)
 Surgery of the mouth or face
 Prolonged surgical procedure

Not all surgery requires muscle relaxation.

If surgery is taking place in the abdomen or thorax, an intermediate or

long-acting muscle relaxant drug is administered in addition to the
induction agent and opioid. Therefore, the patient's lungs must be
ventilated under pressure, necessitating an endotracheal tube.

Maintenance phase
At this point, the patient must be kept anesthetized with a maintenance
agent.

For the most part, this refers to the delivery of anesthetic gases into the
patient's lungs. These may be inhaled as the patient breathes
spontaneously or delivered under pressure by each mechanical breath of a
ventilator.

When surgery time end , anesthetic vapors have been decreased or even
switched off entirely to allow time for them to be excreted by the lungs.

Excess muscle relaxation is reversed using specific drugs and an adequate

long-acting opioid analgesic to keep the patient comfortable in the
recovery room.

If a ventilator has been used, the patient is restored to breathing by

himself, and, as anesthetic drugs dissipate, the patient regain his
consciousness.

Extubation (Removal of the endotracheal tube or other artificial airway

device) is only performed when the patient has regained sufficient control
of his airway reflexes.

Traditional opioid analgesics

Morphine, Pethidine, and hydromorphone are widely used in anesthesia

as well as in emergency departments, surgical wards, and obstetric suites.

In addition, Anesthetist have a range of synthetic opioids, which, in

general, cause less fluctuation in blood pressure and are shorter acting.
These include fentanyl, sufentanil, and remifentanil.

Muscle relaxants

Succinylcholine, a rapid-onset, short-acting depolarizing muscle

relaxant, has traditionally been the drug of choice when rapid muscle
relaxation is needed.

Other relaxants have durations of action ranging from 15 minutes to 1

hour.

Pancuronium (50 min. duration) was often associated with changes in

heart rate or blood pressure. Newer muscle relaxants are devoid of these
adverse properties.
Atracurium(25 min. duration) associated with histamine release .

Muscle relaxants generally are excreted by the kidney, but some

preparations are broken down by plasma enzymes and can be used safely
in patients with partial or complete renal failure.

Anesthetic vapors

These are highly potent which are delivered from vaporizers and directly
to the patient. They may be mixed with nitrous oxide, a useful anesthetic
gas.

The prototype of modern anesthetic vapors is halothane. It is no longer

used in routine clinical practice. In the 1980s, it was displaced by
isoflurane and enflurane, agents that were cleared from the lungs faster
and thus were associated with more rapid anesthetic emergences.

In the late 1990s, desflurane and sevoflurane came into use. These
inhaled anesthetics are associated with a more rapid emergence.

Recovery

Recovery from anesthesia may be defined as a state of consciousness of

an individual when he is awake or easily arousable . Awakening results
from elimination of anesthetic agents from the brain .Recovery from
intravenous (IV) opioids and hypnotics may be more variable and
difficult to quantify than recovery from inhalational and neuromuscular
blocking agents. Patients should not leave the operating room unless they
have stable hemodynamic parameters, a patent airway, have adequate
ventilation, and oxygenation.

Post Operative Care

Postoperative care is the care received after a surgical procedure. The

type of postoperative care needed depends on the type of surgery done.

Postoperative care begins at the end of the operation and continues in

the recovery room and throughout the hospitalization and outpatient
period. Critical immediate concerns are airway protection, pain control,
mental status, and wound healing. Other important concerns are
preventing urinary retention, constipation, deep venous thrombosis
(DVT), and BP variability (high or low). For patients with diabetes, blood
glucose levels are monitored closely by fingerstick testing every 1 to 4 h
until patients are awake and eating because better glycemic control
improves outcome.

Post-operative complications

Post-operative nausea and vomiting

Pulmonary complication (atelectasis )

Cardiovascular Complication (Hypotension or Hypertension , Myocardial

Infarction , Arrhythmia)

Pain at site of surgery

Deep Venous Thrombosis

Pulmonary Embolism

Bleeding

Wound Infection

Intensive care unit (ICU)

An intensive care unit (ICU), is a special department of a hospital or

health care facility that provides intensive treatment medicine.

Intensive care units refer to patients with severe and life-threatening

illnesses and injuries, which require constant, close monitoring and
support from specialist equipment and medications in order to ensure
normal bodily functions. They are staffed by highly trained doctors and
nurses who specialise in caring for critically ill patients. ICUs are also
distinguished from normal hospital wards by a higher staff-to-patient
ratio and access to advanced medical resources and equipment that is not
routinely available elsewhere. Common conditions that are treated within
ICUs include acute (or adult) respiratory distress syndrome (ARDS),
trauma, multiple organ failure and sepsis.
Patients may be transferred directly to an intensive care unit from an
emergency department if required, or from a ward if they rapidly
deteriorate, or immediately after surgery if the surgery is very invasive
and the patient is at high risk of complications .

Common equipment in an ICU includes mechanical ventilators to assist

breathing through an endotracheal tube or a tracheostomy tube; cardiac
monitors including those problems; equipment for the constant
monitoring of bodily functions; a web of intravenous lines, feeding
tubes, nasogastric tubes, suction pumps, drains, and catheters; and a
wide array of drugs to treat the primary condition(s) of hospitalization.
Medically induced comas, analgesics, and induced sedation are common
ICU tools needed and used to reduce pain and prevent secondary
infections.

Anesthetic Plan :
1- Effect of co-morbid disease (HT,DM,IHD)
2-Effect of Surgery
3-Effect of Anesthetic drugs
4-Effect of Patient Physiology (Morbid
Obesity,Geriatric,Pregnant women)