GENERAL ANESTHESIA

Dr. Emilzon Taslim, Sp. An. M.Kes

Medical Faculty University of Andalas
M. Djamil Hospital

ANESTHESI
A
GENERAL
LOCAL
Intravenous
Inhalation
Intramuscular

Topical

COMBINATION

Spinal +
Infiltration propofol
Block
peripheral
nerve
Spinal
Epidural
Caudal

General anesthesia
A reversible state of unconsciousness

produced by anesthetic agent, with loss of

sensation of pain over the whole body.
Reversible irregular CNS depression.
General anesthetic drugs are administered
by inhalation, intravenously,
intramuscularly, orally, rectally.

The order of descending

depression of the CNS
Cortical and psychic centers
Basal ganglia and cerebellum
Spinal cord
Medullary centers

GENERAL ANESTHESIA

TRIAS ANESTHESIA
Hypnotic
Analgesic
Relaxation

BALANCED ANESTHESIA

Balance anesthesia
Anesthesia
component

Drugs

Hypnotic

Pentothal, Propofol, Enflurane,

Isoflurane, Sevoflurane

Analgesic

Pethidine, Morphine, Fentanyl,

Sufentanil, Remifentanil

Relaxation

Succ choline, Atracurium,

Cisatracurium, Pancuronium

Anesthetic drugs
Volatile anesthetic inhalation :

Halogen hydrocarbon (halothane)

Halogen ether: enflurane, isoflurane,
desflurane, sevoflurane
Gas anesthetic inhalation : cyclopropane,
N2O, ethylene.
Intravenous : thiopental, propofol, ketamine,
etomidate, diazepam, midazolam

Concept balanced anesthesia

Component VIMA
anesthesia

TIVA

Hypnotic

Sevo, Iso, Enf, Hal,

Desfluran

Propofol, Pento,
Ket, Mid

Analgesic

Fentanyl, alf, suf

,Mo, pethidine,
remifentanil

Fentanyl, alf, suf

,Mo, pethidine,
remifentanil

Relaxation

Depol & non depol

Depol & non

depol

Indication general anesthesia

Infant and young children.
Adult who prefer general anesthesia.
Extensive surgical procedures
Patient with mental disease
Prolonged surgery
Patient with a history of toxic or allergic

reaction to local anesthetic drugs

Patient on anticoagulant treatment

General anesthesia
Induction inhalation, maintenance

anesthesia with inhalation anesthetic

(VIMA)
Induction intravenous , maintenance
anesthesia with intravenous anesthetic
(TIVA)
Induction intravenous, maintenance
anesthesia with inhalation anesthetic

General anesthesia technique

Spontaneous breathing
Controlled ventilation
Face mask
Intubation
LMA (Laryngeal Mask Airway)
COPA (Cuffed Oro Pharyngeal Airway)
LSA (Laryngeal Seal Airway)

Concentration
of
Anesthetic
Agent

Inspired Alveolar Arterial

Gas
Gas
Blood

Brain

Brain

Venous Alveolar Inspired

Blood
Gas
Gas

Gambar : Perbedaan tekanan zat anestesi inhalasi pada saat induksi dan pemulihan.

Techniques of general inhalation

anesthesia
Open-drop technique
Insufflation
Ayre T-piece system
System with non-rebreathing valve
Semiclosed
Closed

Breathing circuit system

Open system
Semi open system
Semi closed system
Closed system

Flow Rate Definition :

Metabolic-flow : 250
ml/minute
Minimal-flow

: 250 -

500

ml/minute
Low-flow
ml/minute

: 500 - 1000

Advantageous Low-flow
anesthesia
Less of anesthesia gas consumption
Less of pollution
Heat loss decrease
Cost effective

THE EQUIPMENT

Component anesthesia machine

Gas sources : Oxygen, N2O
Reducing valve or pressure regulator
Flow meter
Vaporizer for halothane, enflurane,

isoflurane, desflurane or sevoflurane.

CO2 absorption system (soda lime or bara
lime)

 SEE THE MOVIE

Gases Vapors

Diffusion

Inspired Mixture

COMP.
%

C.O.
% B.W.

M.G.

20

55

Circulation

V.R.G.
Brain
Heart
Splanc
Kidney

75

R.Heart

V.P.G.

38

L.Heart

FA

Solubilities

Ventilation

Blood Carriage

Tissue Uptake

Figure : Schematic diagram of uptake and distribution of inhalation anesthetics. The inspired concentration. F1 or fraction
inspired, of anesthetic is under direct control of the anesthetist. F1 is delivered to the alveoli by the minute volume of
ventilation (M.V.V.). The alveolar concentration, FA or fraction in alveoli, regulates tension (partial pressure) of anesthetic
agent in arterial blood. The four tissue groups or compartments (COMP), the vesel rich group (V.R.G.) tend toward
equilibration with anesthetic tension in arterial blood but reach that equilibrium at rates determined by the volume of blood
flow to each tissue. The brain is the site of action. C.O. = cardiac output and B.W. = body weight, both expressed in percent.
SPLANC = splanchnic circulation.

Pa

Uptake and distribution

Respiration factor
Circulation factor
Anesthetic gas factor
Tissue factor

Respiration factor
Inspiration concentration
Ventilation effect

Circulation Factor
Solubility (partition coefficient)
Cardiac output
The difference of gas partial pressure

alveoli and vein

Partition coefficient of anesthetic

Anesthetic Blood/gas Brain/blood Tissue/blood
Ether
Halothane
Enflurane
Isoflurane
N2O

12.1
2.3
1.8
1.4
0.47

1.1
2.6
2.6
3.7
1.1

0.9
2.5
1.7
4.0
1.2

Anesthetic gas factor

MAC (Minimal Alveolar concentration)
MAC 50, MAC 95
MAC Ei 50, MAC Ei 95
MAC BAR 50, MAC BAR 95

MAC inhalation anesthetic

MAC =minimal alveolar concentration, in 1

atmosphere, 50% patient without movement

in noxious stimuli
MAC Ei = concentration of volatile agent
permitting laryngoscopy and intubation
without untoward movement.
MAC BAR = concentration of volatile
agent required to block adrenergic response
to skin incision

MAC inhalation anesthetic, 40

years old.
Volatile anesthetic

MAC

Halothane
Enflurane
Isoflurane
Desflurane
Sevoflurane
N2O

0,72
1.68
1.12
6.0
2.05
105.2

Factors influencing or not

influencing MAC
MAC decreased MAC
unchanged

MAC increased

Increasing age
CNS depressant:
alcohol,
barbiturate,
lidocaine,
benzodiazepine,
narcotic

Alcoholism
chronic
Hyperthermia > 42
Hypercarbia
Anemia

Duration of
anesthesia
Gender
Species
Hypertension
Hypocarbia

Tissue factor
Tissue rich vessel : brain, heart, endocrine,

kidney.
Intermediate : muscle, skin.
Fat.
Tissue poor vessel : ligament, tendon.

General anesthesia planning

Pre operative visit
Premedication
Anesthesia technique : General, Regional
Intraoperative
Postoperative

Anesthesia technique :
General anesthesia
Airway controlled
Induction
Maintenance anesthesia
Analgesia
Muscle relaxation

Intraoperative
Monitoring
Patient position
Crystalloid and colloid
Special technique

Postoperative
Post operative pain treatment
Send patient to Ward or ICU

INTRAVENOUS
ANESTHETIC

Intravenous anesthetic
Pentothal
Propofol
Etomidate
Midazolam
Diazepam

Ideal intravenous anesthetic

Water soluble
Non irritation
No anta analgesic effect
Rapid and smooth Induction
Cardiovascular stable in clinically dose

Thiopentone
Blood pressure decrease
Heart rate increase or decrease
Peripheral vasodilatation
Heart contraction depressed
Larynx spasm, bronchus spasm
Respiratory depression until apnoea
Dose 4-6 mg/kg BW

Relative contraindication
thiopentone
Asthma bronchiale

Severe liver disease

Severe kidney disease
Severe anemia
Hypotension
Shock

Ketamine

Dissociative anesthetic
Delirium
Hallucination
Increase blood pressure : systolic 23% from base
line
Increase heart rate
Arrhythmias
Hypersecretion
Dose 1-3 mg/kg I.v or 9-11 mg/kg I.m

Indication and Contraindication

Ketamine
Indication : short surgery
Contraindication : Hypertension systolic >

160 mmHg
Arrhythmias
Heart failure
Pharynx and larynx surgery without
intubation.

Propofol
New intravenous anesthetic
Fast onset, short duration of action
Accumulation minimal
Fast recovery
Rapid metabolism
No complication at site of injection
Dose 2-2.5 mg/kg BW

Pharmacology Propofol
No histamine release/reaction anaphylactoid

(chremophor El change with soya bean oil).

Perivascular injection, tissue necrosis
negative.
Injection intra artery : tissue necrosis
negative.

Effect Propofol to CNS

Hypnotic effect 1,8 time pentothal
Airway depression > pentothal
Anti emetic effect
No anti convulsant effect

Comparative properties of
intravenous anesthetics
Aqueous
solution
Available in
solution
Pain on
injection
Venous
thrombosis

Thiopen Ketamin Propof

Diazep Midaz

Comparative properties of
intravenous anesthetics
Rapidly
acting
Smooth
induction
Respiratory
depression
Cardiovascul
ar depression

Thiopen Ketamin Propof

Diazep Midaz

++

+/-

++

++

+/-

+/-

Comparative properties of
intravenous anesthetics
Rapid
recovery
Smooth
recovery
Suitable for
infusion
Interaction
with relaxant

Thiopen Ketamin Propof

Diazep Midaz

+/-

+/-

Drug

Resume: Effect anesthetic non

volatile to organ system

Thiopentone
Diazepam
Midazolam
Meperidine
Morphine
Fentanyl
Ketamine
Propofol

HR

MAP

Vent

Bdil

0/

*
*

0
0
*
*
0

0

Resume: Effect anesthetic non

volatile to CNS

Drug

CBF

CMRO2

ICP

Thiopentone
Diazepam
Midazolam
Meperidine
Morphine
Fentanyl
Ketamine
Propofol

INHALATION
ANESTHETIC

Choice of anesthetic inhalation

Cardio pulmonal effect
Product degradation with soda lime
What metabolites ?
How much metabolism?

Ideal anesthetic inhalation

Pleasant odor and non irritation
Low solubility
No organ toxic
Side effect cardiovascular and respiration minimal
CNS effect reversible without stimulant activity
Effective in high O2 concentration
Boiling pressure and boiling point can delivered by

vaporizer standard

New Trend in General Anesthesia

VIMA
Fast-Track Anesthesia
Low-flow Anesthesia
Low-cost Anesthesia
Single-breath induction (Rapid induction)

Physicochemical properties
Halothane
Odor
+
Irritating to
Resp system Solubility
2,35
MAC
0,76
Metabolism 17-20%
Metabolites F, Cl,
Br, TFA
BCDFE,
CDE, CTE,
DBE

Enfl
+
1,91
1,68
2,4%
F,
CDA

Isofl
+
1,4
1915
<0,2%
F,
TFA

Desfl
+
0,42
6,0
0,02%
F,
TFA

Sevo
+
0,63
2,05
<5%
F,
HFIP

Interaction with Sodalime

Anesthetic

degradation
Product

organ Toxicity clinical

Relevancy

Halothane

BCDFE

Nephrotoxic

Non identified
to data

Enflurane

CO

Isoflurane

CO

Desflurane

CO

Sevoflurane

Compound A
Compound B

Nephrotoxic

Non identified
to date

WHY VIMA???
intravenous induction, ex: Propofol : rapid

and smooth induction, but need vein access

first, hypotension, apnoe.
Pediatric anesthesia commonly by VIMA.
More advantages than intravenous
induction, maintenance inhalation .

Cardiovascular effect of Volatile

inhalational anesthetics

Variable

Halothane Enflurane Isoflurane

Blood pressure
Vascular resistance
Cardiac output
Cardiac contraction
CVP
Heart rate
Sensitization of the
heart to epinephrine

0
0
0

0?

0 = No change (<10%)
= increase

= Variable
change

= 10-20%
decrease

= 20-40%
decrease

Clinical pharmacology of Inhalational

anesthetics : Respiratory
N2O

Tidal

volume
Resp rate
PaCO2

resting

Halo

Enflur

Isoflu

Sevoflu

Clinical pharmacology of Inhalational

anesthetics : CNS

CBF
ICP
CMRO2
Seizure

N2O

Halo

Enflur

Isoflu

Sevoflu

Clinical pharmacology of Inhalational

anesthetics

HBF
Nondep
blockade
Metabolism

N2O

Halo

Enflur Isoflu

Sevoflu

0.2

2-3

0.004 15-20 2.5

N2O
1.5 time heavier than air
Must be give with O2 100%
Weak anesthetic
Analgesic N2O 20% equal with 15 mg

morphine
Dont use in closed system
At the end of anesthesia, to prevent
diffusion hypoxia O2 100%

Advantages N2O
Rapid induction and recovery
No sensitized myocardium with

catecholamine
No irritation respiratory tract
Odor pleasant
Strong analgesic

Disadvantages N2O
Weak anesthetic
No muscle relaxation effect
Need high concentration oxygen
Possibility aplasia bone marrow

Halothane
A clear, colorless, potent volatile liquid.
Metabolism 17-20%

Advantages Halothane
Rapid, smooth induction and recovery.
Pleasant
Non irritating, no secretion
Bronchodilator
Nonemetic
Non flammable and non explosive

Disadvantages Halothane
Myocardial depressant
An arrhythmia producing drug
Sensitizes the myocardial conduction

system to the action of catecholamines

A potent uterine relaxant
Possible toxic to the liver
Shivering during recovery period.

Enflurane
A clear, colorless, stable volatile liquid with

a pleasant ether-like odor.

A potent inhalation anesthetic
CNS excitation
Use of epinephrine : saver than halothane.

Advantages Enflurane
Pleasant
Rapid induction and recovery
Non-irritating : no secretion
Bronchodilator
Good muscle relaxation
Nonemetic
Non flammable and non explosive
Compatible with epinephrine

Disadvantages Enflurane
Myocardial depressant
Shivering on emergence
CSF production increase
CNS excitation, in high dose and

hypocarbia.

Isoflurane
A stabe, volatile liquid
A isomer enflurane
Inhalation anesthetic choice for

neurosurgical patient, kidney, liver.

Advantages Isoflurane
Rapid induction of anesthesia and swift

recovery
Nonirritating : no secretion
Blood pressure remain stable
Indicated in poor-risk patient

Disadvantages Isoflurane
Less than halothane and enflurane

Sevoflurane
Inhalation

anesthetic with low solubility

(0,63), low MAC (2,05), pleasant odor, no
airway irritation, rapid uptake and
elimination , cardio vascular stable.
Rapid induction, with technique single
breath induction, induction time 23 seconds.

Sevoflurane
Drugs of choice for Neuro anesthesia :

WCA 2000 Montreal, Canada.

Drugs of choice for Pediatric Anesthesia :
ESA Barcelona, 1998. ASPA, Singapore,
2000., ESA Sweden 2001.
In Sectio Caesarea equal with Isoflurane
and spinal anesthesia
Reduce sphlannic blood flow, hepatic blood
flow lesser than other anesthetic inhalation.

NARCOTIC ANALGESIC

Narcotic analgesic ideal :

Wide margin of safety

Fast onset of action
Short duration of action
Easier analgesia controlled
Strong analgesic
no histamine release
Non active metabolite

Opiate in Anesthesia
1.
2.
3.
4.
5.
6.
7.

Premedication
Induction Anesthesia
Narcotic anesthesia
A part of balanced anesthesia
Adjuvant in regional anesthesia
Neurolept anesthesia
Post operative pain relief

Drugs

Protein binding

Morphine
Pethidine
Fentanyl
Sufentanil
Alfentanil

++
+++
+++
++++
++++

Lipid solubilit

+
++
++++
++++
+++

Note : + = very low; ++ = low; +++ = high

++++ = very high

Narcotic effect :

Bradycardia : central vagotonic

effect & SA & AV node depression
Respiratory depression : respiratory
rate, rhythm, Response CO2, Minute
Volume, Tidal Volume
Muscle stiffness
Nausea vomiting cause by
stimulation CTZ, GIT mobility,
decrease gastric mobility, increased

Clinical Doses of Narcotics

Drug

i.v dose

Onset
(min)

Approximate
duration

Morphine
Meperidine
Fentanyl
Sufentanil
Alfentanil

0.05-0.3 mg/kg
0.5-1 mg/kg
1-5 ug/kg
10-40 ug/kg
30-80 ug/kg

5-10
5-10
2
<1
<1

3-5 h
2-3 h
45 min 2 h
< 30 min
< 60 min

MUSCLE RELAXANT

Muscle relaxant
Very useful in general anesthesia.
laryngoscopy and intubation more easier

and avoid injury

Muscle relaxation very useful during
surgery and controlled ventilation

Ideal muscle relaxant

Non depolarization
Rapid onset, short duration of action
Rapid recovery, high potency
non cumulative, metabolite non active
No cardiovascular effect
No histamine release
Counteract with anticholinesterase

Mechanism
neuromuscular blockade

Competitive block : non-depol, avoid AcCh

access to receptor.
Depolarization block : depol, depolarization
as AcCh but permanent
Deficiency block: influence syntesis and
release AcCh: Procaine, toxin botulinus, Ca
decrease, Mg increase.
Morgan GE, Mikhail MS. Clinical Anesth, 1996

Terminology in muscle relaxant

ED 50 : dose what can paralyzed 50%

muscle strength
ED 90 : dose what can paralyzed 90%
muscle strength.
Onset : interval between start of
injection until maximal effect

Table 9 - 1. Depolarizing and nondepolarizing

muscle relaxants.

Depolarizing
Short-acting
Succinylcholine
Decamethonium

Nondepolarizing
Long-acting
Tubocurarine
Metocurine
Doxacurium
Pancuronium
Pipecuronium
Gallamine
Intermediate-acting
Atracurium
Vecuronium
Rocuronium
Short-acting
Mivacurium

Nondepolarizing drug
Do not produce muscular fasciculation
Effect are decreased by anticholinesterase

agent, depolarizing agent, lowered body

temperature, epinephrine, acetylcholine
Effect are increased by non-depolarizing
drugs, volatile anesthetic .

Depolarizing drugs
Produce muscular fasciculation .
Effect are increased by anticholinesterase

agent, Acetylcholine, hypothermia

Effect decrease with non-depolarizing
relaxant drugs, anesthetic inhalation
Dose Succ choline : 1 mg/kg BW

Table 9 - 5. Conditions causing susceptibility to

succiniylcholine-induced hyperkalemia.

Burn injury
Massive trauma
Severe intra-abdominal infection
Spinal cord injury
Encephalitis
Stroke
Guillain-Barre syndrome
Severe Parkinsons disease
Tetanus
Prolonged total body immobilization
Ruptured cerebral aneurysm
Polyneuropathy
Closed head injury
Near drowning
Hemorrhagic shock with metabolic acidosis
Myopathies ( eg, Duchenness dystrophy )

Table 9 - 6. A summary of the pharmacology of nondepolarizing

muscle relaxant
Relaxant

Metabolism

Primary
Excretion

Onset

Duration

Histamine
Release

Vagal
Blockade

Relative
Potency1

Relative
Cost2

Tubocurarine

Insignificant

Renal

++

+++

+++

Low

Metocurine

Insignificant

Renal

++

+++

++

Moderate

Atracurium

+++

Insignificant

++

++

High

Mivacurium

+++

Insignificant

++

2.5

Moderate

Doxacurium

Insignificant

Renal

+++

12

High

Pancuronium

Renal

++

+++

++

Low

Pipecuronium

Renal

++

+++

High

Vecuronium

Biliary

++

++

High

Rocuronium

Insignificant

Biliary

+++

++

High

For example, pancuronium and vecuronium are five times more potent than tubocurarine or atracurium
Based on average wholesale price per 10 mL; does not necessarily reflect duration and potency
Onset
: + = slow;
++ = moderately rapid; +++ = rapid
Duration : + = short; ++ = intermediate;
+++ = long
Histamine release : 0 = no effect; + = slight effect; ++ = moderate effect; +++ marked effect
Vagal blockade : 0 = no effect; + = slight effect;
++ = moderate effect
2

Relaxation
Drug

ED95
(mg/kg)

Atracurium 0.21
Pancuronium 0.067
Vecuronium 0.043

Recommended Infusion rate

intubating dose for steady state
(mg/kg)
blockade
(mg/kg/h)
0.3-0.6
0.005-0.008
0.08-0.1

0.25
0.032
0.078

INDUCTION AND
MAINTENANCE OF
ANESTHESIA

Choice of anesthesia technique

depend on:
Patient condition
Skill anesthetist
Skill surgeon
Hospital socioeconomi

Problem during induction of

anesthesia
Main problem : airway
Sign of partial obstruction : snoring,

crowing, gargling, wheezing, chest

retraction, cyanosis
Sign of total obstruction : air flow from
nose/mouth negative, supraclavicular
retraction, intercostal retraction, cyanosis

Other problem during induction

Respiratory depression
Cough
Larynx spasm
Mucus and saliva
vomiting

Airway controlled
Without equipment : Triple mannuver Safar
With equipment:

OPA (Oro Pharyngeal Airway)

NPA (Naso Pharyngeal Airway)
LMA ( Laryngeal Mask Airway)
ETT (Endo Tracheal Tube)

Indication Intubation
Head and neck surgery
Difficult airway
Thoracotomy
Laparotomy
Lateral position
Prone position
Controlled ventilation

Technique laryngoscopy
Head position
Insertion laryngoscope blade
Visualization epiglottis
Lift epiglottis
View larynx and surrounding structure

Advantages Endotracheal
intubation
Ensures a patent airway

Normal anatomic dead space (75 ml) is

decreased to 25 ml.
Ventilation can be assisted or controlled
Possibility of aspiration diminished
drastically
Suctioning of the lung is facilitated

Disadvantages endotracheal
intubation
Increases resistance to respiration
Trauma to the lips, teeth, nose, throat,

larynx.

Complication Intubation
Teeth rupture
Mouth bleeding
Endobronchial intubation
Oesophageal intubation
Sore throat
Hypertension
Arrhythmias

Induction technique
Mask induction / inhalation
Intravenous
Intra muscular
Per rectal

Mask Induction with Sevoflurane

Gradual

Induction
Single Breath Induction
Triple Breath Induction (Multiple Breath
Induction)
Fast technique with Single Breath Induction,
without cough, breath holding, spasm
larynx.

Gradual Induction
Classic

method for Mask Induction.

To decrease respiratory tract irritation and non
pungent odor no need for Sevoflurane.
Combined with N2O or Oxygen 100%.
Concentration Sevo increase 0.5-1,5 vol% every
2-3 breath until anesthesia adequate.
Commonly reach in 60-90 seconds with Sevo
7%.

Single-Breath Induction
Priming

circuit with N2O 60% + Sevo 8% 30

seconds.
Ask patient for maximal expiration (until residual
volume) face mask .
Ask patient inspiration maximal (vital capacity),
keep 20 seconds, then normal breathing.
After eyelash reflex negative, Sevo turn to 2%.

Triple Breath Induction

A variation

from Single Breath Induction

Ask patient 3 times deep breath.
Difference with Single Breath, no breath
holding.
Commonly patient sleep, in 2-3 breathing.

How to maintain anesthesia ?

Maintenance anesthesia depend on deep of

anesthesia to reach adequate anesthesia.

Commonly with SEVO 1-1,5 vol% depend
on type of surgery, spontaneous breathing
or controlled.
To reduce vol% (MAC) : add N2O or
Fentanyl.

Sign of deep anesthesia

PRST Score (balanced anesthesia)
Guedel sign (ether anesthesia)
PRST Score (score 2-4: adequate

anesthesia)
P = Systolic arterial pressure (mmHg)
R = rate (heart rate)
S = sweat/ lacrimation
T = tear

Index

PRST Scoring indexes for

Balanced anesthesia

Systolic arterial pressure

(mmHg)
Heart rate (beats/min)

Sweat

Tears or Lacrimation

Condition

Score

Less than control + 15

Less than control + 30
More than control +30
Less than control + 15
Less than control + 30
More than control +30
Nil
Skin moist to touch
Visible beads of sweat
No excess tears when eyelids open
Excess teas visible when eyelids open
Tears overflow from closed eyelid

0
1
2
0
1
2
0
1
2
0
1
2

Extubation
After adequate ventilation
In deep anesthesia or after patient awake
Clear airway
Oxygen 100% after and before extubation

Factor which influence total

anesthetic inhalation :
1.
2.
3.
4.

Constanta
Fresh gas flow
Volume % (MAC)
Length of surgery

Total anesthetic inhalation =

constanta x fresh gas flow (ml)
x vol % x time (minute)

If length of surgery 2 h,
total Sevoflurane :

Induction
first 30 second
Fresh gas
x 1/183
flow (ml)
6000
x 1/183
3 minute for intubation :
6000
x 1/183
3 minute start for low-flow :
3000
x 1/183
second 3 minute:
1000
x 1/183
Operation 2 hours :
1000
x 1/183
Total Sevoflurane 11,6 ml

x Vol %
x 8%

x time
(minute)
x 0,5 = 1,3

x 2%

x 3

= 1,9

x 3%

x 3

= 1,4

x 1%

x 3

= 0,5

x 1%

x 120 = 6,5

TIVA CONTINU
Propofol 6-10 mg/kg/h + Vecuronium 0.1 mg/kg/h +
Fentanyl 2 ug/kg
Pentotal 1-3 mg/kg/h + Vecuronium 0.1 mg/kg/h +
Fentanyl 2 ug/kg
Ketamine 2 mg/kg/h + Vecuronium 0.1 mg/kg/h +
Diazepame 0.25 mg/kg
Midazolam 50 ug/kg/h + Ketamine 2 mg/kg/h +
Atracurium 0,25 mg/kg/h

POSTOPERATIVE
See: Lecture of RR and ICU

Thank you
for your kind attention
Tatang Bisri
Bandung, 2001