ANESTHESIOLOGY 2

GENERAL
ANAESTHESIA

General anesthesia is a procedure

performed by anesthetics before the
patient gets some types of surgery, to
make patient sleep (unconscious) and
prevent him from feeling pain.
General anesthesia works by interrupting
nerve signals in the brain and body. It
prevents it brain from processing pain and
from remembering what happened during
the surgery

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 STAGES OF GENERAL ANESTHESIA

Analgesia state: Patient is conscious and

Stage I
rational, with decreased perception of pain.

Delirium stage: Patient is unconscious; body

Stage II responds reflexively; irregular breathing
pattern with breath holding.

Surgical anesthesia: Increasing degrees of

Stage III
muscle relaxation; unable to protect airway.

Medullary depression: There is depression of

Stage IV
cardiovascular and respiratory centers.

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 Side effects of general anesthesia

• Temporary confusion and memory loss, although this is more

common in older adults

• Dizziness

• Difficulty passing urine

• Bruising or soreness from the IV drip

• Nausea and vomiting

• Shivering and feeling cold

•Sore throat due to the breathing tube

 Endotracheal Intubation

Endotracheal intubation is the procedure to

insert a flexible tube into
the airway (trachea) through the mouth or
the nose. Endotracheal intubation is
performed during general anesthesia prior
to a surgery or in critically ill patients to
assist breathing.
The modified Mallampati classification for
difficult laryngoscopy and intubation

The modified Mallampati classification is a simple

scoring system that relates the amount of mouth opening
to the size of the tongue and provides an estimate of
space available for oral intubation by direct
laryngoscopy. According to the Mallampati scale, class I
is present when the soft palate, uvula, and pillars are
visible; class II when the soft palate and the uvula are
visible; class III when only the soft palate and base of the
uvula are visible; and class IV when only the hard palate
is visible.
 How is endotracheal intubation done?
An anesthetic team performs the endotracheal intubation in three stages with different
medications at each stage. Commonly used practice is the rapid sequence intubation
protocol, performed as follows:

• Pretreatment:
o Saturation of the lungs with oxygen with an oxygen mask (bag-valve mask) to
provide continued oxygen in circulation during the procedure.
o Administration of IV medications to control pain and reflex response to
intubation, such as elevated blood pressure and heart rate, intracranial
hypertension, coughing and gagging.

• Induction: Administration of a rapid-acting, short-duration anesthetic agent to induce

unconsciousness.

• Paralysis: Administration of medications to induce temporary paralysis to prevent

muscle contraction during the procedure.
The anesthesiologist inserts the endotracheal tube through the mouth into the airway
with the aid of a lighted device (laryngoscope) and secures it in place.
 What equipment is required for
endotracheal intubation?
• Laryngoscope: A device made of metal or plastic, with a
handle and a curved blade with a light on it. The blade is
inserted behind the tongue into the top of the throat to
visualize the epiglottis, which is a cartilage at the entrance of
the trachea.

• Endotracheal tube: A thin flexible tube with an inflatable

balloon (cuff) that is placed inside the airway and inflated to
prevent gases leaking past the cuff and allows positive
pressure ventilation and prevents material like gastric fluid
from entering the trachea.

• Stylet: A thin malleable rod or wire which is placed inside the

tube to make insertion easier. The stylet can bend to fit the
curvature of the airway and minimize trauma.

• Syringe: To inflate the balloon in the tube.

 What equipment is required for
endotracheal intubation?

• Suction catheter: A tube to suction out secretions and prevent

aspiration.

• Carbon dioxide detector: A device used to confirm the correct

position of the tracheal tube by measuring the exhaled carbon
dioxide.

• Oral airway: A device that conforms to the tongue shape is

placed in the mouth to keep the airway clear.

• Nasal airway: A device to keep the nasopharyngeal airway clear.

• Bag-valve-mask: A mask used for preoxygenation.

• Nasal cannula: A tube with two prongs that fit into the nostrils, to
provide supplemental oxygen.
 What medications are required for
endotracheal intubation?
Pretreatment
Pretreatment medications are administered two to three minutes before
intubation. Commonly used pretreatment medications for sedation
and pain relief (analgesia) include:

Sedatives

Fentanyl

Fentanyl is the primary pretreatment sedative agent used prior to

intubation. Fentanyl has immediate onset, lasting up to an hour.

• Other effects: Reduces hypertensive response

• Risks: High doses can cause hypotension and chest wall rigidity
 What medications are required for
endotracheal intubation?
Esmolol

Esmolol is a beta-blocker that may be combined with

reduced dosage of fentanyl or lidocaine, to
reduce hypertension. Esmolol has onset within seconds and
the effects last up to 10 minutes.

Dexamethasone

A study has reported that intravenous dexamethasone is

effective in reducing the incidence of postoperative

•Sore throat and hoarseness

•Nausea and vomiting

Dexamethasone is a steroid and cannot be used in patients

with diabetes mellitus, pregnancy or other contraindications
to corticosteroids.
 What medications are required for
Atropine endotracheal intubation?
Atropine is typically administered for pediatric patients. Atropine has an
onset of up to four minutes and lasts for up to four hours.

•Effects: Reduces secretion of saliva and bronchial secretions

•Risks: Increase in heart rate (tachycardia)

Muscle relaxants

Some muscle relaxants may be used in small doses (high doses are
paralytic) as pretreatment medications, especially if succinylcholine is
used for neuromuscular blockade. Muscle relaxants used as
pretreatment medications include:

•Vercuronium (Norcuron)

•Rocuronium (Zemuron)
Induction

The selection of the agent for induction of anesthesia is based on

the patient’s condition. Commonly used anesthetic agents include:

Etomidate (Amidate) - is a rapid-onset anesthetic agent that

produces unconsciousness within 30 seconds that lasts for under
10 minutes. Etomidate is useful for patients with multiple trauma
and reduced blood pressure (hypotension).

Keramine (Ketalar) - has both anesthetic and analgesic effect with

a rapid onset of under one minute and durationi of about 10
minutes.

Propofol (Diprivan) - has a rapid onset and short duration about 15

minutes.
 Paralysis
Succinylcholine (Anectine)
Succinylcholine is a neuromuscular blocking drug that
has been a choice paralytic agent for decades. It has a
rapid onset of one minute and ultrashort activity
duration of about six minutes. Succinylcholine is a
pregnancy category C medication.

Reversal of paralysis

Sugammadex sodium (Bridion)

Sugammadex sodium is a medication that reverses
the effects of longer-acting paralytic agents.
•Aspiration: When a person is intubated, What are the risks of intubation?
they may inhale vomit, blood or other fluids.

•Endobronchial intubation: The tracheal tube may go down one of two bronchi, a pair of tubes
that connect your trachea to your lung. This is also called mainstem intubation.

•Esophageal intubation: If the tube enters your esophagus (food tube) instead of your trachea, it
can result in brain damage or even death if not recognized soon enough.

•Failure to secure the airway: When intubation doesn’t work, healthcare providers may not be
able to treat the person.

•Infections: People who’ve been intubated may develop infections, such as sinus infections.

•Injury: The procedure can potentially injure your mouth, teeth, tongue, vocal cords or airway.
The injury may lead to bleeding or swelling.

•Problems coming out of anesthesia: Most people recover from anesthesia well, but some have
trouble waking or have medical emergencies.

•Tension pneumothorax: When air gets trapped in your chest cavity, this can cause your lungs to
collapse.
 REGIONAL
ANESTHESIA

• Regional anesthesia is used

to numb only the portion of the
body that will undergo the
surgery. Usually an injection of
local anesthetic is given in the
area of nerves that provide
feeling to that part of the body.

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 THERE ARE SEVERAL FORMS OF REGIONAL ANESTHETICS:

• Spinal anesthetic. A spinal anesthetic is used for lower abdominal, pelvic, rectal, or
lower extremity surgery. This type of anesthetic involves injecting a single dose of the
anesthetic medicine into the area that surrounds the spinal cord. The injection is
made into the lower back, below the end of the spinal cord, and causes numbness in
the lower body. This type of anesthesia is most often used in orthopedic procedures of
the lower extremities.

• Epidural anesthetic. The epidural anesthetic is similar to a spinal anesthetic and is

commonly used for surgery of the lower limbs and during labor and childbirth. This
type of anesthesia involves continually infusing an anesthetic medicine through a thin
catheter (hollow tube). The catheter is placed into the space that surrounds the spinal
cord in the lower back, causing numbness in the lower body. Epidural anesthesia may
also be used for chest or abdominal surgery. In this case, the anesthetic medicine is
injected at a higher location in the back to numb the chest and abdominal areas.
 LOCAL ANESTHESIA

Local anesthesia refers to using a drug called an

anesthetic to temporarily numb a small area of your
body. Your doctor might use a local anesthetic before
doing a minor procedure, such as a skin biopsy. You
might also receive local anesthesia before a dental
procedure, such as a tooth extraction. Unlike general
anesthesia, local anesthesia doesn’t make you fall
asleep.

Local anesthetics work by preventing the

nerves in the affected area from
communicating sensations of pain to your
brain. It’s sometimes used with a sedative.
This helps you relax.

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HOW LONG DOES THE
LOCAL ANESTHESIA LAST?

Most often, the effects of local anesthesia wear off

quickly. The effect of commonly used local anesthetic
drugs, like lignocaine, wears off in about an hour. Your
doctor may combine a local anesthetic with other drugs
like steroids, clonidine, or epinephrine (adrenaline). This
prolongs the anesthesia.
It's important to take care of the numbed part carefully.
After dental treatment, for example, your mouth will be
numb, and you might burn yourself by drinking hot
coffee.
When the local anesthesia is needed to work longer, your
doctor will use slow-release forms of the drugs or apply
continuous infusion of the local anesthetic drugs.
 WHAT ARE TYPES OF LOCAL ANESTHESIA?
Local application. You can apply local anesthetic ointment to open sores or mouth
ulcers. Anesthetic eye drops numb the eye for your doctor to remove eyelashes or
particles.
Local injection. Your doctor injects a local anesthetic drug under the skin or deeper.
You won't feel the needle pricks as your doctor sews a wound. Your doctor also uses
such injections to take a biopsy or do a spinal tap to get cerebrospinal fluid (CSF) for
testing.
Nerve blocks. Local anesthetic drugs are injected near nerves to block the pain from
the area supplied by the nerve. Your doctor uses nerve blocks for dental treatment
and eye operations. Spinal anesthesia, used for doing cesarean section, is also a type
of nerve block.
Two kinds of local anesthetic drugs are used nowadays. The commonly used drugs
are amides like lignocaine, prilocaine, and bupivacaine. The other group is esters like
cocaine, procaine, and amethocaine.
Local anesthetics with epinephrine (e.g., bupivacaine, lidocaine, mepivacaine) may
be used during pregnancy. Special considerations should be given to pregnant dental
personnel whose job duties can involve direct exposure to nitrous oxide and radiation.
Pitch Deck 20
THANK YOU

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