GENERAL

ANESTHESIA
General anesthesia is an altered physiological state
characterized by reversible loss of consciousness,
analgesia, amnesia, and muscle relaxation.

The cardinal features of general anaesthesia are:

• Loss of all sensation, especially pain

• Sleep (unconsciousness) and amnesia

• Immobility and muscle relaxation

① GA cause an irregularly descending depression of the CNS
② The higher functions are lost first and progressively lower areas of the
brain are involved
③ In the spinal cord lower segments are affected earlier than the higher
segments.
④ The vital centres located in the medulla are paralysed last as the depth
of anaesthesia increases.
⑤
Stage I: Stage of Analgesia
• Starts from beginning of anaesthetic inhalation and lasts upto
loss of consciousness

• Pain is progressively abolished during this stage

Patient remains conscious, can hear and see, and feels a dream
like state

• Reflexes and respiration remain normal

• It is difficult to maintain – use is limited to short procedures

only
 Stage II: Stage of Delirium
• From loss of consciousness to beginning of automatic breathing
Eyelash reflex diasaapear

Apparent Excitement is seen – patient may shout, struggle and hold his
breath

• Potentially dangerous responses can occur during this stage including

vomiting, laryngospasm and uncontrolled movement.

•This stage is not found with modern anaesthesia – preanaesthetic

medication, rapid induction etc
Stage III: Stage of Surgical anaesthesia
• Extends from onset of spontaneus respiration to
respiratory paralysis.

• This has been divided into 4 planes:

- Plane 1: Roving eye balls. This plane ends when eyes

become fixed.

- Plane 2: Loss of corneal and laryngeal reflexes.

- Plane 3: Pupil starts dilating and light reflex is lost

 Stage IV: Medullary /
respiratory paralysis

• Cessation of breathing to failure of circulation – death

Pupils: widely dilated
• Muscles are totally flabby

• Pulse is imperceptible
• BP is very low.
 It is a complex procedure involving:

- Pre-anaesthetic assessment

- Airway management
- Administration of general anaesthetic drugs
-Cardio-respiratory monitoring
- Analgesia
- Fluid management
- Postoperative pain relief
Pre operative assessment of the patient

 History of previous anasthetics


 Family history of anasthetic problems

 Examination of airway, lungs and heart

 General history and physical for other potential medical
conditions( diabetes, heart disease, asthma etc )

 AIRWAY
MANAGEMENT
Routine airway management associated with general
anesthesia consists of:

• Airway assessment
• Preparation and equipment check
• Patient positioning
• Preoxygenation
• Bag and mask ventilation (BMV)
• Intubation (if indicated)
• Confi rmation of endotracheal tube placement
• Intraoperative management and
troubleshooting
• Extubation
AIRWAY ASSESSMENT
■ Airway assessment is the first step in successful airway management

■ Assessments include:
– Upper lip bite test: the lower teeth are brought in front of the upper teeth. The degree
to which this can be done estimates the range of motion of the temperomandibular
joints .
– Mallampati classification: a frequently performed test that examines the size of the
tongue in relation to the oral cavity. The greater the tongue obstructs the view of the
pharyngeal structures, the more difficult intubation may be.
 – Class I: the entire palatal arch, including the bilateral faucial pillars, are visible
down to heir bases.
– Class II: the upper part of the faucial pillars and most of the uvula are visible.
– Class III: only the soft and hard palates are visible.
– Class IV: only the hard palate is visible.
■ Thyromental distance: the distance between the mentum and the superior thyroid
notch. A distance greater than 3 fingerbreadths is desirable.
■ Neck circumference: a neck circumference of greater than 27 in is suggestive of
difficuties in visualization of the glottic opening.
Face Mask Technique

■ The use of a face mask can facilitate the delivery of oxygen or an anesthetic gas from a
breathing system to a patient by creating an airtight seal with the patient’s face.
■ Effective mask ventilation requires both a gas-tight mask fit and a patent airway.
■ If the mask is held with the left hand, the right hand can be used to generate positive-pressure
ventilation by squeezing the breathing bag. The mask is held against the face by downward
pressure on the mask body exerted by the left thumb and index finger.
■ The middle and ring finger grasp the mandible to facilitate extension of the atlanto-occipital
joint.
■ Finger pressure should be placed on the bony mandible and not on the soft tissues supporting the
base of the tongue, which may obstruct the airway.
■ Th e little finger is placed under the angle of the jaw and used to thrust the jaw anteriorly, the
most important maneuver to allow ventillation to the patient.
■ In difficult situations, two hands may be needed to provide adequate jaw thrust and to create a
mask seal.
POSITIONING

■ When manipulating the airway, correct patient positioning is required. Relative

alignment of the oral and pharyngeal axes is achieved by having the patient in the
“sniffing” position.
PREOXYGENATION
■ When possible, preoxygenation with face mask oxygen should precede all airway
management interventions.
■ Oxygen is delivered by mask for several minutes prior to anesthetic induction.
■ In this way, the functional residual capacity, the patient’s oxygen reserve, is purged of
nitrogen.
■ Considering the normal oxygen demand of 200–250 mL/min, the preoxygenated patient
may have a 5–8 min oxygen reserve,Increasing the duration of apnea without
desaturation improves safety, if ventilation following anesthetic induction is delayed.
 ENDOTRACHEAL INTUBATION
① The laryngoscope is held in the left hand.
② With the patient’s mouth opened, the blade is introduced
③ into the right side of the oropharynx
④ The tongue is swept to the left and
⑤ up into the floor of the pharynx by the blade’s
⑥ Flanges
⑦ the handle is raised up and away from the patient in a plane
perpendicular to the patient’s mandible to expose the vocal cords
⑧ The TT is taken with the right hand, and its tip is passed through the
abducted vocal cords.
⑨ Th e cuff is infl ated with the least amount of air necessary to create a
seal
PREANESTHETIC MEDICATIONS

Refers to use of drugs before anasthesia to make it safe and less unpleasant
■ relief of anxiety and to facilitate smooth induction
■ Amnesia for perioperative events
■ Supplement and potentiate anasthetic action
■ Decrease secretions and vagal stimulation
■ Antiemetic effect extending into the post operative period
■ Decrease acidity and volume of gastric secretions
 Sedative-antianxiety drugs
diazepam (5–10 mg oral) or lorazepam (2
mg oral or 0.05 mg/kg i.m. 1 hour before)


Opioids

 fentanyl is mostly injected i.v. just

before induction.
 Anticholinergics
Atropine
or hyoscine (0.6 mg or 10–20 µg/kg i.m./i.v.)
or glycopyrrolate (0.2–0.3 mg or 5–10 µg/kgi.m./i.v.) have been used,
primarily to reduce salivary and bronchial secretions
H2 blockers/proton pump inhibitors

Patients undergoing prolonged operations,

caesarian section and obese patients are at
increased risk of gastric regurgitation and
aspiration pneumonia.

Ranitidine (150 mg)/

famotidine (20 mg) or omeprazole (20 mg)/
pantoprazole (40 mg) given night before and
in the morning benefit by raising the pH ofgastric juice.
 Antiemetics

Metoclopramide 10–20 mg
i.m. preoperatively is effective in reducing
postoperative vomiting.

Ondansetron (4–8 mg i.v.) the selective 5-HT3

Inhalation
Anesthetics
Inhalational anaesthetics are gases or vapours that diffuse rapidly across
pulmonary alveoli
and tissue barriers.
 NITROUS OXIDE
① an NMDA receptor antagonist.
② Good analgesic
③ 70% N2O + 25–30% O2 + 0.2–2% another potent
anaesthetic is employed for most surgical
procedures
④ As the sole agent, N2O (50%) has been used with
O2 for dental and obstetric analgesia
⑤ Examples of conditions in which nitrous oxide
might be hazardous include venous or arterial air
embolism, pneumothorax, acute intestinal
obstruction with bowel distention, intracranial
air,pulmonary air cysts, intrwocular air bubbles, and
tympanic membrane grafting
Prolonged N2O anaesthesia has the potential
to depress bone marrow and cause peripheral neuropathy, probably
by depressing methionine synthase activity
 HALOTHANE

① Potent anesthetic, poor muscle relaxant, poor analgesic

② halothane is the preferred anaesthetic for asthmatics.

③ Dose-dependent reduction of arterial blood pressure

(controlled hypotension) is due to direct myocardial
depression

④ Halothane causes relatively greater depression

of respiration; breathing isshallow and rapid—PP of CO in
blood rises if respiration is not assisted.
a) It inhibits intestinal and uterine contractions.
b) Urine formation is decreased during halothane
anaesthesia—primarily due to low g.f.r. as a result of fall
in BP.
c) Hepatitis occurs in rare susceptible individuals (1 in
35000 to 1 in 10,000) especially after repeated use and in
those with familial predisposition.
d) malignant hyperthermia occurs rarely
 ISOFLURANE
① Similar to halothane
② It is a good maintenance anaesthetic, but not preferred for induction
because of ether-like odour

③ Magnitude of fall in BP is similar to that with halothane, but unlike

halothane, this is primarily due to vasodilatation, while cardiac
output is well maintained.
④ Hence, suitable anaesthetic for patients with latent or overt
myocardial insufficiency
⑤ Isoflurane dilates coronaries, Though not encountered clinically,
possibility of ‘coronary steal’ has been apprehended in coronary
artery disease patients on theoretical grounds.
 Desflurane
① has gained popularity as an anaesthetic for out patient surgery.
② Depth of anaesthesia changes rapidly with change in inhaled
concentration giving the anaesthetist better control.
③ Wakeup times are approximately 50% less than those observed
following isoflurane
 SEVOFLURANE

① Absence of pungency
② Acceptability is good even by pediatric patients.
③ suitable both for outpatient as well as inpatient
surgery
 INTRAVENOUS ANAESTHETICS
Rapid induction-
Propofol
• Unconsciousness after propofol injection occurs in 15–45 sec
and lasts 5–10 min
• cause CNS depression by enhancing GABAA receptor mediated
neuronal inhibition.
• Intermittent injection or continuous infusion of propofol is also
used for total i.v. anaesthesia when supplemented by fentanyl.
• will often cause pain during injection that can be decreased by
prior injection of lidocaine
decrease in arterial blood pressure due to a drop in
systemic vascular resistance (inhibition of sympathetic
• vasoconstrictor activity), preload, and cardiac contractility

• Propofol is a profound respiratory depressant that usually causes

apnea following an induction dose.

•
 KETAMINE

a. inhibit
ketamine increases arterial blood pressure, heart
rate, and cardiac output particularly
 after rapid bolus injections.

 it increases cerebral oxygen consumption, cerebral blood

flow, and intracranial pressure.
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