General Anesthesia
Dr. Rasha S Bondok
Professor Of Anesthesia
Ain-Shams University
ANESTHESIA
The word Anesthesia in 1846 from the
Greek refers to the inhibition of sensation.
Listed in Baileys English Dictionary 1721.
When the effect of ether was
discoveredanesthesia was used as a
name for the new phenomenon.
Historical Perspective
Until the Mid-1840s, the only two
anesthetic agents regularly used in
industrialized countries
were opium and alcohol.
Original discoverer of
general anesthetics: Ether
Crawford Long: 1842
Chloroform introduced
James Simpson: 1847
Nitrous oxide
Horace Wells- Dentist-the first
person to use nitrous oxide to
pull teeth in 1845.
Historical Perspective
In 1846. A dentist named Dr.
William Morton put on a
demonstration at
Massachusetts General
Hospital when he removed a
tumor from the jaw of a
patient. Prior to the operation,
he used a sponge soaked with
ether to render his patient
unconscious.
Ether no longer used in
modern practice, yet
considered to be the first
ideal anesthetic.
Anesthetic techniques
General anesthesia
Regional anesthesia
Local anesthesia
Conscious Sedation
(monitored anesthesia
care)
Monitored Anesthesia Care
Infiltration of the surgical site with a local
anesthesia is performed by the surgeon
The anesthesiologist may supplement the
local anesthesia with intravenous drugs
ccc(rapid acting & short duration eg
Propofol +/-Fentanyl - Dexmedetomidine)
that provide systemic analgesia and
sedation and depress the response of the
patients autonomic nervous system and
maintain respiration
What is General Anesthesia
No universally accepted definition
Usually thought to consist of:
Reversible, drug-induced
loss of consciousness +
Amnesia
Analgesia
Lack of Movement
Hemodynamic Stability
What is Anesthesia
Sensory:
-Absence of intraoperative pain
Cognitive:
-Absence of intraoperative awareness
-Absence of recall of intraoperative events
Motor:
-Absence of movement
-Adequate muscular relaxation
Autonomic:
-Absence of hemodynamic response
-Absence of tearing, flushing, sweating
Goals of General Anesthesia
Hypnosis (unconsciousness)
Amnesia
Analgesia
Immobility/decreased muscle tone
(relaxation of skeletal muscle)
Inhibition of nociceptive reflexes
Reduction of certain autonomic reflexes
(gag reflex, tachycardia, vasoconstriction)
Phases of General Anesthesia
Induction- initial entry to surgical
anesthesia
Maintenance- continuous monitoring and
medication
Maintain depth of anesthesia, ventilation, fluid balance,
hemodynamic control, hoemostasis
Emergence- resumption of normal CNS
function
Extubation, resumption of normal respiration
Anesthetic Techniques
Inhalation anesthesia
Anesthetics in gaseous state are taken up
by inhalation
Total intravenous anesthesia
Inhalation plus intravenous (Balanced
Anesthesia)
Most common
Anesthetics divide into 2
classes
Inhalation
Anesthetics
Gases or Vapors
Usually
Halogenated
Intravenous
Anesthetics
Propofol
Thiopental
sodium
Ketamine
Inhalation Anesthetics
Nitrous oxide
Halogenated
anesthetics:
Halothane
Isoflurane
Sevoflurane
Desflurane
General Anesthesia
Induction
Maintenance
Induction
intravenous
inhalational
Faster onset
where IV
access is
difficult
avoiding the
excitatory
phase of
anaesthesia
Anticipated
difficult
intubation
patient
preference
(children)
Maintenance
In order to prolong anaesthesia for the
required duration
breathe to a carefully controlled mixture of
oxygen, nitrous oxide, and a volatile
anaesthetic agent
transferred to the patient's brain via the
lungs and the bloodstream, and the
patient remains unconscious
Maintenance
Inhaled agents are supplemented
by intravenous anaesthetics, such
as opioids (usually fentanyl or
morphine)
What is Balanced Anesthesia?
Use specific drugs for each component
1. Sensory
N20, Opioids, ketamine for analgesia
2. Cognitive
Produce amnesia, and preferably
unconsciousness
inhaled agent
IV hypnotic (propofol, midazolam,
diazepam, thiopental)
3. Motor
Muscle relaxants
Scope of Anesthesia
Anesthesiologists care for the surgical patient
all through the preoperative, intraoperative, and
postoperative period .
Important patient care decisions reflect:
The preoperative evaluation,
Creating the anesthesia plan,
Preparing the operating room,
Managing the intraoperative anesthetic.
General Anesthesia
Preoperative evaluation (medical deseases; bleeding
eplipsy, aneth. Complictions)
Intraoperative management
(deleverin anesth,
mentainig vital signs)
Postoperative management (pain, ponv, discharge)
Examples of patients who may not comply
with dental treatment in the dental chair and
may require GA include:
Patients with severe learning difficulties
Patients with anxiety and phobias
Patients with severe psychiatric disorders
Patients with physical disability and movement disorders
Patients with significant co-morbidity, such as those with
congenital disorders, in whomsedation may not be safe
and perioperative monitoring is required.
Pre-Operative Evaluation
I- History
Indication for surgery
Surgical/anesthetic hx: previous
anesthetics/complications, previous
intubations,
Medications, drug allergies
I- History
Medical history
CNS: seizures, CVA, raised ICP, spinal
disease, arteriovenous malformations
CVS: CAD, HTN, valvular disease,
dysrhymias, PVD, conditions requiring
endocarditis prophylaxis, exercise tolerance,
Resp: smoking, asthma, COPD, recent
URTI, sleep apnea
GI: GERD, liver disease
Renal: insufficiency, dialysis
I- History
Hematologic: anemia, coagulopathies,
easy bruising, bleeding tendency.
MSK: conditions associated with difficult
intubations arthritis,oesteoperosis,
cervical tumours, cervical
infections/abscess, trauma to C-spine,
Down syndrome.
Endocrine: diabetes, thyroid, adrenal
disorders
Other: morbid obesity, pregnancy,
ethanol/other drug use
II- Examination
Physical exams of all systems.
Airway assessment to determine the
likelihood of difficult intubation
Upper Airway
Cervical spine mobility
Temporomandibular mobility
Tracheal mobility
Prominent central incisors
Diseased or artificial teeth
Ability to visualize uvula
Thyromental distance
Mallampati Classification
Size of Tongue Versus Pharynx
The size of the tongue versus the oral cavity can be visually graded
by assessing how much the pharynx is obscured by the tongue.
This is the basis for the Mallampati Classification.
Class I
Class II
Soft
palate,anterior
and posterior
tonsillar pillars
and uvula visible
Class III
Only soft
Tonsillar pillars
and base of uvula
palate visible
hidden by base of
tongue
Class IV
Soft palate
not visible
What Laboratory tests are
needed?
CXR
ECG - Hx of
CAD,Age > 50,
HTN, chest pain,
CHF, diabetes
CBC
LFT- liver disease,
Jaundice
RFT HTN, DM,
renal
Coagulation profile
On anticoagulants renal liver disease
INR should be 1.4 if urgent surgery and INR
1.4 correct with FFP
Antiviral markers
ASA Classification
The American Society of Anesthesiologists(ASA)
physical status classification serves as a guide, to allow
to predict patient anesthetic/surgical risks -the higher
ASA class, the higher the risks.
ASA Classification
Class 1Healthy patient, no medical problems 0.060.08%
Class 2 Mild systemic disease (HTN DM) 0.2-0.4%
Class 3Severe systemic disease, but not incapacitating
MI COPD - 1.8- 4.3%
Class 4 Severe systemic disease that is a constant
threat to life. (RF Res F HF )7.8 23%
Class 5 Moribund, not expected to live 24 hours
irrespective of operation.
Premedication
Sedatives and hypnotics- Diazepam Midazolam - Narcotics
Purpose: to sedate the patient and reduce anxiety
Antiacid or an H2 receptor-blocking drug such as ranitidine (Zantac)
Purpose: to decrease gastric acid production and make the gastric
contents less acidic
If aspiration occur this premedication decreases the resultant pulmonary
damage
Given 60-90 minutes before surgery, or may be given i.v. After the patient
arrives in the surgical suite
NPO for a minimum of 6 hours before elective surgery
Medications
Beta blockers as propranolol/carvidalol ,
corticosteroids should continue till morning
of peration
ACEI (antihypertensive), oral
hypoglycemics, Monoaminooxidase
inhibitors, should be discontinued the
night prior surgery
Plavix should be discontinued 10 days
prior surgery
Warfarin (oral anticoagulants)should be
discontinued 4-5 days prior surgery
Intraoperative management
Equipment Check
Suction
Airway
Laryngoscope
Endotracheal Tube
Apply Standard ASA
Monitors - Pulse
oximetry SpO2, EKG,
NIBP, RR, ET CO2
Put pt in optimal
intubating position.
Preoxygenate
Induction - IV anesthetic
(propofol), Narcotics, Muscle
relaxant
Mask ventilate & / or intubation
POST-OPERATIVE CARE
I.
ROUTINE CARE
II. SPECIAL CONSIDRATIONS
ICU care & Possible mechanical Ventilation
Hemodynamic Instability
Analgesia
Tracheostomy
POST-OPERATIVE CARE
ICU Care & Possible Mechanical Ventilation
Patient should be kept in the intensive care unit for
24-48 hours
Prolonged Surgery
Airway Oedema
Co-existing diseases
Risk of bleeding and/or neck hematoma
POST-OPERATIVE CARE
Analgesia
Non Steroidal Anti-inflammatory Agents should be
used as opioids cause respiratory depression in
spontaneously breathing patients
When patient is on ventilator opioid analgesia can
be given
Thank you
