ANESTHESI DAN TERAPI INTENSIVE

RS dr SAIFUL ANWAR/FKUB
 “General Anesthesia is a drug-induced loss of
consciousness during which patients are not
arousable, even by painful stimulation. The ability to
independently maintain ventilatory function is often
impaired. Patients often require assistance in
maintaining a patent airway, and positive pressure
ventilation may be required because of depressed
spontaneous ventilation or drug-induced depression
of neuromuscular function. Cardiovascular function
may be impaired.”

CONTINUUM OF DEPTH OF SEDATION: DEFINITION OF GENERAL ANESTHESIA

AND LEVELS OF SEDATION/ANALGESIA*.
Approved by ASA House of Delegates on October 13, 1999, and amended on
October 27, 2004
Anaesthesia Episode
Artificial Trauma
Assesment
Inform Consent (patient Right)
Pre-medication (alleviate Distress)
Induction (Artificial Coma)
Intubation (Artificial Apnoe)
Relaxation (Artificial Paralyze)
Maintenance/Bleeding (Haemodynamic Stability)
Emergence
Post Operative

Recovery of all the System

(Back to “normal”)
● General anaesthesia is a complex procedure involving :
● Pre-anaesthetic assessment
● Administration of general anaesthetic drugs
● Cardio-respiratory monitoring
● Analgesia
● Airway management
● Fluid management
● Postoperative pain relief

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● Mallampati Score
● The patient is asked to maximally open his mouth and
protrude his tongue while in the sitting position

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Class 1 Faucial pillars, uvula, soft palate seen

Class 2 Uvula masked by tongue base
Class 3 Only soft and hard palate visualized
Class 4 Only hard palate
Physical status classification
● Class I : A normal healthy patients
● Class II: A patient with mild systemic disease (no functional
limitation) ex. Current smoker, well controlled HT
● Class III: A patient with severe systemic disease (some
● functional limitation) ex. Poorly controlled HT
● Class IV: A patient with severe systemic disease that is a
constant threat to life (functionality incapacitated)
ex. Sepsis, ESRD
● Class V: A moribund patient who is not expected to survive
without the operation ex. Internal bleeding
● Class VI: A brain-dead patient whose organs are being
removed for donor purposes
● Class E: Emergent procedure
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● Surgical stress – evokes HPA axis and
sympathetic system.
● Tissue damage during surgery induces
coagulation factors and activates platelets
leading to hypercoagulability of blood.
● Anesthesia decreases the components of
surgical stress response.
Anesthetics are associated with
● Decrease in systemic blood pressure –
myocardial depression and direct
vasodilatation.
● Blunting of baroreceptor control and
decreased central sympathetic tone.
Hallmark of anesthesia:
● Amnesia / unconsciousness
● Analgesia
● Muscle relaxation
Preanesthetic medication:
It is the use of drugs prior to anesthesia to make it
more safe and pleasant.
● To relieve anxiety – benzodiazepines.
● To prevent allergic reactions – antihistaminics.
● To prevent nausea and vomiting – antiemetics.
● To provide analgesia – opioids.
● To prevent bradycardia and secretion – atropine.
● Stage 1 (amnesia)
● From induction of anesthesia to loss of consciousness (loss of
eyelid reflex)
● Pain perception threshold is not lowered.

● Stage 2 (delirium/excitement)
● Characterized with uninhibited excitation, agitation,
delirium, irregular respiration and breath holding
● Pupils are dilated and eyes are divergent
● Responses to noxious stimuli: vomiting, laryngospasm,
hypertension, tachycardia, and uncontrolled movements

Morgan, et al. Clinical Anesthesiology, 4th ed. 2006

Ezekiel. Handbook of Anesthesiology, 2005
● Stage 3 (surgical anesthesia)
● characterized by central gaze, constricted pupils, and regular
respirations
● Painful stimulation does not elicit somatic reflexes or
deleterious autonomic responses.

● Stage 4 (impending death/overdose)

● characterized by onset of apnea, dilated and nonreactive
pupils, and hypotension
● may progress to circulatory failure

Morgan, et al. Clinical Anesthesiology, 4th ed. 2006

Ezekiel. Handbook of Anesthesiology, 2005
Molecular mechanism of the GA :
● GABA –A : Potentiation by Halothane,
Propofol, Etomidate
● NMDA receptors : inhibited by Ketamine
The main target of inhalation anesthetics is
the brain.
There are two types of anesthetics :
● Inhalational --- for maintenance
● Intravenous --- for induction and short
procedures
Inhalation anesthetics:
● Advantage of controlling the depth of
anesthesia.
● Metabolism is very minimal.
● Excreted by exhalation.
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Inhalational anesthetics :
Non-halogenated gas:
● Nitrous oxide
Halogenated hydrocarbons:
● Halothane
● Enflurane
● Isoflurane
● Desflurane
● Sevoflurane
● Methoxyflurane – nephrotoxicity.
 The important characteristics of
Inhalational anesthetics which govern
the anesthesia are :
● Solubility in the blood
(blood : gas partition co-efficient)
● Solubility in the fat (oil : gas partition
co-efficient)
Blood : gas partition co-efficient:
● It is a measure of solubility in the blood.
● It determines the rate of induction and
recovery of Inhalational anesthetics.
● Lower the blood : gas co-efficient – faster the
induction and recovery – Nitrous oxide.
● Higher the blood : gas co-efficient – slower
induction and recovery – Halothane.
BLOOD GAS PARTITION CO-EFFICIENT
 Agents with low solubility in
blood quickly saturate the
blood. The additional anesthetic
molecules are then readily
transferred to the brain.

BLOOD GAS PARTITION COEFFICIENT

Oil: gas partition co-efficient:
● It is a measure of lipid solubility.
● Lipid solubility - correlates strongly with the
potency of the anesthetic.
● Higher the lipid solubility – potent
anesthetic. e.g., halothane
● MAC value is a measure of inhalational
anesthetic potency.
● It is defined as the minimum alveolar
anesthetic concentration ( % of the inspired
air) at which 50% of patients do not respond
to a surgical stimulus.
● MAC values are additive and lower in the
presence of opioids.
 OIL GAS PARTITION CO-EFFICIENT
Higher the Oil: Gas
Partition Co-efficient
lower the MAC .
E.g., Halothane

0.8

1.4 220
Inhalation MAC value Oil: Gas
Anesthetic % partition
Nitrous >100 1.4
oxide
Desflurane 7.2 23

Sevoflurane 2.5 53

Isoflurane 1.3 91

Halothane 0.8 220

Nitrous oxide:
● Safest inhalational anesthetic.
● Weak anesthetic but a good analgesic.
● No toxic effect on the heart, liver and
kidney.

● Caution about diffusional hypoxia

megaloblastic anemia.
Halothane:
● It is a potent anesthetic.
● Induction is pleasant.
● It sensitizes the heart to catecholamines.
● It dilates bronchus – preferred in asthmatics.
● It inhibits uterine contractions.
● Halothane hepatitis and malignant
hyperthermia can occur.
Enflurane:
● Sweet and ethereal odor.
● Generally do not sensitizes the heart to
catecholamines.
● Seizures occurs at deeper levels
–contraindicated in epileptics.
● Caution in renal failure due to fluoride.
Isoflurane:
● It is commonly used with oxygen or nitrous
oxide.
● It do not sensitize the heart to
catecholamines.
● Its pungency can irritate the respiratory
system.
Desflurane:
● It is delivered through special vaporizer.
● It is a popular anesthetic for day care
surgery.
● Induction and recovery is fast, cognitive
and motor impairment are short lived
● It irritates the air passages producing cough
and laryngospasm.
Sevoflurane:
● Induction and recovery is fast.
● It is pleasant and acceptable due to lack of
pungency.
● It do not cause air way irritancy.
● Concerns about nephrotoxicity.
Anesthetic B:G PC O:G PC Features Notes

Halothane 2.3 220 PLEASANT Arrhythmia

Hepatitis
Hyperthermia
Enflurane 1.9 98 PUNGENT Seizures
Hyperthermia
Isoflurane 1.4 91 PUNGENT Widely used

Sevoflurane 0.62 53 PLEASANT Ideal

Desflurane 0.42 23 IRRITANT Cough

Nitrous 0.47 1.4 PLEASANT Anemia

Parenteral anesthetics (IV):
● These are used for induction of anesthesia.
● Rapid onset of action.
● Recovery is mainly by redistribution.
● Also reduce the amount of inhalation
anesthetic for maintenance.
● E.g., includes thiopental, midazolam
propofol, etomidate, ketamine.
Thiopental (Pentothal):
● It is an ultra short acting barbiturates.
● Consciousness regained within 10-20 mins by
redistribution to skeletal muscle.
● It do not increase ICT.
● It is eliminated slowly from the body by
metabolism and produce hang over.
● It can be used for rapid control of seizures.
Propofol (Diprivan):
● Most commonly used IV anesthetic.
● Unconsciousness in ~ 45 seconds and
lasts ~15 minutes.
● Anti-emetic in action.
● Suited for day care surgery - residual
impairment is less marked.
Etomidate:
● It is a short acting anesthetic.
● It suppress the production of steroids from
the adrenal gland and no repeated injections.
● It is a pro-convulsant and emetic.
● CVS stability is the main advantage over
anesthetics.
Ketamine : Dissociative anesthesia
● Produce - profound analgesia, cataleptic
state, immobility, amnesia with light sleep.
● Acts by blocking NMDA receptors
● Heart rate and BP are elevated due to
sympathetic stimulation.
● Respiration is not depressed and reflexes are
not abolished.
Ketamine:
● Emergence delirium, hallucinations and
involuntary movements occurs in 50% cases
during recovery.
● It is useful for burn dressing and trauma
surgery.
● Dangerous for hypertensive and IHD.
Neuroleptanalgesia :
● It is characterized by general quiescence,
psychic indifference and intense analgesia
without total loss of consciousness.
● Combination of Fentanyl and Droperidol as
Innovar
Neuroleptanalgesia :
● It is associated with decreased motor
functions, suppressed autonomic reflexes,
cardiovascular stability with mild amnesia.
● It causes drowsiness but respond to
commands.
● Used for endoscopies, angiography and
minor operations.
Anesthetic Duration Analgesia Muscle Others
I.V mins relaxation

Thiopental 5 - 10 --- --- Respiratory

depression

Propofol 5-10 --- --- Respiratory

depression

Ketamine 5-10 +++ --- Hallucinatio

ns

Midazolam 5-20 --- +++ Amnesia

Fentanyl 5-10 +++ --- Respiratory

depression
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 Opioid

● Tramadol
● Morfin
● Fentanyl
● Sufenta
● To maintain an open airway and
enable mechanical ventilation, an
endotracheal tube or laryngeal mask
airways are often used.

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⦿ ECG
⦿ Pulse oximetry (SpO2)
⦿ Blood Pressure Monitoring (NIBP or IBP)
⦿ Agent concentration measurement
⦿ Low oxygen alarm
⦿ Carbon dioxide measurement (capnography)
⦿ Temperature measurement
⦿ Circuit disconnect alarm

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 Balanced anesthesia

Regimen for balanced anesthesia

1. Pre-anesthetic medication (anxiolytics, analgesics,
anti-mascarinics),
2. Induction (Thiopental, BDZ, NMB),
3. Maintenance (halothane or nitrous oxide),
4. Recovery (AChE inh, analgesics).
● Patients
children, mentally changed patients
● Intervention
long procedure, Extensive procedure
● Local anesthesia
Allergy
 INDUCTION Individual variable response to drugs
Depression of the CNS / respiratory /
cardiovascular systems
Hypersensitivity reactions

Problems in Ventilation:
•Hypoxemia
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•Hypercarbia
•Obstruction
•Difficult ventilation

Aspiration
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 INTUBATION

Physiologic Responses
•Hypertension, Tachycardia
•Laryngospasm
•Bronchospasm
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Airway Trauma
•Injury to teeth and airway tissues
•Tracheal and laryngeal trauma
•Post-intubation hoarseness and sore
throat
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•Difficult intubation

Tracheal Tube Positioning

•Endobronchial Intubation
•Esophageal Intubation
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•Inadequate insertion depth
 MAINTENANCE Individual Variable response
Hypersensitivity reactions
Depression of the CNS / respiratory /
cardiovascular systems
Inadequate depth of anesthesia
www.introtoccnursing.com www.flatrock.org.nz Awareness

EXTUBATION

Aspiration
Laryngospasm
Airway trauma
Residual Neuromuscular Blockade
Delayed Emergence
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