General anesthesia

Definition of anesthesia
It is a reversable blocking of pain feeling in
whole body or in a part of it using
pharmacology or other methods
Anesthesia- division
Local- regional anesthesia, patient is
conscious or sedated
General- anesthesia interact with whole
body, function of central nervous system is
depressed:
Intravenous
Inhalation (volatile)
Combined, balanced
TIVA
Total
Intra
Venous
Anaesthesia
VIMA
Volatile
Induction
and
Maintain
Anaesthesia
Parts of general anesthesia
Hypnosis- pharmacological sleep,
reversable lack of consciousness
Analgesia-pain management
Areflexio-lack of reflexes
Relaxatio musculorum- muscle relaxation,
pharmacological reversable neuromuscular
blockade
Parts of general anesthesia must be
in balance
Hypnosis
(anesthesia)
Analgesia
Lack of reflexes (muscle relaxation)
General anesthesia
features
Lack Lack of of reflexes reflexes
3
Lack Lack of of consciousness consciousness
1 1
Pain Pain management management
2 2
Neuromuscular Neuromuscular blockade blockade
4 4
Stages of general anesthesia
Stadium analgesiae (analgesia and
sedation stage)
Stadium excitationis (excitation stage)
Stadium anaesthesiae chirurgicae
(anesthesia for surgery)
Stadium paralysis respirationis
(intoxication, respiratory arrest)
I. Analgesia stage
Patient consciouss
Spontaneus respiration
Reflexes present
Possible small surgery procedures like
dressing change in burns
II. Excitation stage
Possible uncontrolled movements,
vomitings
Increase in respiratory rate
III. Anesthesia for surgery
It begins with lack of lid reflex
4 substages
Airway opening necessary
Possible surgery except for abdominal
opening if no relaxants are used
Possible endotracheal intubation
IV. intoxication, overdosing
Respiratory arrest
If anesthesia not discontinued possible
cardiac arrest
Estimation Estimation of of the the risk risk of of anesthesia anesthesia ( (American American
Society Society of of Anesthesiologists Anesthesiologists scale scale) )
ASA 1 ASA 1: : healthy healthy patient patient. .
ASA 2 ASA 2: : patient patient with with stable stable, , treated treated illness illness like like arterial arterial
hypertension hypertension, , diabetes diabetes melitus melitus, , asthma asthma bronchiale bronchiale, ,
obesity obesity
ASA 3 ASA 3: : patient patient with with systemic systemic illness illness decreasing decreasing
suffitiency suffitiency like like heart heart ilness ilness, , late late infarct infarct
ASA 4 ASA 4: : patient patient with with serious serious illness illness influencing influencing his his state state
like like renal renal insuficiency insuficiency, , unstable unstable hypertension hypertension, ,
circulatory circulatory insuficiency insuficiency
ASA 5 ASA 5: : patient patient in in life life treatening treatening illness illness
ASA 6 ASA 6: : brain brain death death- - potential potential organ donor organ donor
Premedication
Premedication
Main Main reasons reasons for for premedication premedication: :
Anxiolysis Anxiolysis- - lack lack of of threat threat
Sedation Sedation calming calming down down
Amnesia Amnesia lack lack of of memories memories of of
perioperative perioperative period period
Methodsof general anesthesia
OPEN
SEMIOPEN
SEMICLOSED
CLOSED
METHODSOF GENERAL ANESTHESI A
OPEN- old
SEMIOPEN used mostly in pediatric anesthesia
SEMICLOSED- most common
CLOSED- modern anesthesia
Methodsof general anesthesia
CI RCLE SYSTEM CI RCLE SYSTEM
*HIGH HIGH- -FLOW FLOW
FRESH GAS FLOW 3 l/min.
*LOW LOW- -FLOW FLOW
FGF ok. 1l/min.
*MINIMAL MINIMAL- -FLOW FLOW
FGF ok. 0,5 l/min.
Stages of general anesthesia
Introduction to anesthesia (induction)
Maintaining of anesthesia (conduction)
Recovery from anesthesia
Anesthesia agents
1. Inhalation anesthetics (volatile anesthetics)
- gases : N
2
O, xenon
- Fluids (vaporisers)
2. Intravenous anesthetics
- Barbiturans : thiopental
- Others : propofol, etomidat
3. Pain killers
- Opioids: fentanyl, sufentanil, alfentanil, remifentanil, morphine
- Non Steroid Anti Inflamatory Drugs: ketonal, paracetamol
4. Relaxants
- Depolarising : succinilcholine
- Non depolarising : atracurium, cisatracurium, vecuronium, rocuronium
5. adiuvants
-benzodiazepins: midasolam, diazepam
Volatile
vs
intravenous anesthesia
Mechanism of action of
inhaled anesthetics
Reaction depends on concentration. This depends
on alveolar (first compartment), blood and brain
(central compartment) concentration , (third
compartment- other tissue like muscles, fat-
accumulation effect):
Minute ventilation
Lung blood perfusion
Solubility in tissues
MAC-minimal alveolar
concentration
Concentration in which 50% of anesthetised
patients do not react on skin incision
Corelation with solubility in fat tissue
The lower MAC is the higher strenght of
action is
Inhalation agents
Division of inhalation agents
1. Gases:
N
2
O old, weak, used as adiuvant
Xenon lately introduced
2. Vapors (fluids):
Halothan
Enfluran
Isofluran
Sevofluran
Desfluran
Features of ideal volatile
anesthetic
Not disturbing smell
Fast acting, titrable
Low solubility in blood- fast transport to brain
Stable when stored, not reacting with other
chemicals
Non- flamable, non- explosive
Low methabolism in body, fast elimination, no
accumulative effect
No depressing effect on circulatory and respiratory
systems
Nitrous oxide, laughing gas
Old
Weak
Used as adiuvant
Will be removed form medical use up to
2010- destroyes ozone lawyer
Halothan
Used for many years with good effect
First non-flamable volatile fluid anesthetic
MAC high
Depression of circulatory system
May destroy liver
Now-a-days used only in pediatric
anesthesia
Isofluran
Disturbing smell
May interact with heart contractivity
Increases relaxation of muscles
Sevofluran
Not disturbing smell- may be used for VIMA
Low solubility in blood- fast acting
Does not disturbs airway
May depress circulatory system
Methabolised to Compound A- may be renal toxic
(but not confirmed in humans)
May be used in one-day surgery
Modern, and more and more widely used volatile
anesthetic
Desfluran
Very disturbing smell- can not be used for
VIMA
Is not methabolised
Very fast acting
May be used for one-day surgery
Expensive, difficult to store (boiling temp.
about 20 C)
Modern and widelly used
Intravenous anesthesia
Target
Controlled
Infusion
TCI
TCI is an infusion system which allows the
anaesthetist to select the target blood
concentration required for a particular
effect
and then to control depth of anaesthesia
by adjusting the requested target
concentration
Defining TCI
When applied to anaesthesia
What is TCI?
Instead of setting ml/h or a dose rate (mg/kg/h),
the pump can be programmed to target a
required blood concentration.
Effect site concentration targeting is now
included for certain pharmacokinetic models.
The pump will automatically calculate how
much is needed as induction and maintenance to
maintain that concentration.
Intravenous anesthetics
Thiopental
Old, one of the first used intravenous
anesthetics
Depressing effect on circulatory system
May be used in patients with ASA 1
Ketamine
Only intravenous anesthetic which has good analgesia
effect
Does not depress circulatory nor respiratory function
Used in children, and in emergency and diseaster medicine
Gives night mare dreams in adult patients
Etomidat
Has no depressing effect on circulatory
system- may be used in patients with
circulatory insufficiency
May give musle contractions
Depressing effect on epirenals function
Can not be given in repeated bolus nor
continuous infusion
Propofol
Very good anesthetic for induction and
maintaince of anesthesia with no
accumulation effect
Titrable
May be used in short procedures titrated
do not effect circulatory and respiratory
system in important manner
Good for sedation, brain protecting effect
May be used in TCI
Pain killers
Opioids
fentanyl, alfentanil, sufentanil, remifentanil
May be used for induction and maintain of
anesthesia in repeated bolus or continuous
infusion technique
Sedative effect
In high doses may be used alone for so called
opioid anesthesia- formerly used in
cardioanesthesia- very stable circulatory effect
Compications of use
Respiratory depression !!!!
Muscle rigidity in high doses
Post-Operative Nausea and Vomitings
Accumulation effect after prolonged
administration (except for remifentanil)
Remifentanil modern opioid
analgesic
T
1/2
3-5 min !!
Methabolised by non-specific tissue
esterases- methabolism is not altered by
renal or liver function
No accumulation effect after prolonged
infusion !!
NSAID
Used as adiuvants in short, not very painful
procedures
Used for preemptive analgesia
reduction of consumption of opioids by
blocking COX
Benzodiazepines
Benzodiazepiny
Used in anesthesia:
Diazepam
Midazolam
Used as adiuvants for premedication
Muscle relaxants
Division of relaxants depending
on mechanism of action
1.nondepolarising- combine with receptor for Ach
like antagonists- they are fake mediators do not
cause muscle contractation but block access to
receptors for Ach
2.depolarising- they combine with receptors for Ach
and cause contractation of muscle but they stay
connected with receptor blocking access to it for
Ach. They act like agonists.
Nondepolarising agents
-d-tubocurine oldest deliverate of curarine
-alcuronium
-pancuronium cheap and still used
-pipercuronium
-vercuronium
-atracurium
-cisatracurium
-mivacurium
-rocuronium
Division of nondepolarising
relaxants due to
Chemical structure:
Miwakurium (Mivacron)
Cisatrakurium (Nimbex)
Atrakurium (Trakurium)
Pankuronium (Pavulon)
Pipekuronium (Arduan)
Rapakuronium (Raplon)
Rokuronium (Esmeron)
Wekuronium (Norcuron)
Benzylizochinolons: Aminosteroids:
Division of nondepolarising
relaxants due to
time of action:
Short acting < 3 min: still searching
Midle time <60 min: mivacurium,
atracurium, cisatracurium, rocuronium,
vecuronium
Long acting > 60 min: pancuronium,
pipecuronium
Atracurium
Elimination non-enzymatic, independent of
renal and liver function, Hoffman
elimination- hydrolisis
Releases histamine
Acts about 30 min
Cisatracurium
One of stereoisomers of atracurium,
Do not release histamine
Acts about 60 min
Mivacurium
Releases histamine
Acts about 15-20 min used for short
procedures
Methabolised by plasma esterases
Rocuronium
Fast acting- time to 100% supresion 60 sec.
Do not release histamine
Acts about 60 min
Is methabolised in liver- disfunction of liver
may alter elimination
Reverse of neuromuscular blockade
Neostigmine, piridostigmine- blockers of
acetylocholinesterase
Must be given toghether with atropine to
avoid bradycardia caused by activation of
perisympatic system
Depolarising agents
Only one: chlorsuccinilocholine
- It is methabolised by pseudocholinesterase
- Causes many complications, has many
contraindications
- Indications:
Rapid sequence induction: full stomach, suspected difficult
intubation because it acts very fast < 30 seconds and short < 3
min
Monitoring during general
anesthesia
Obligatory
Clinical observation
Circulatory system function: ECG, blood
pressure - Non-Invasive-Blood Pressure
Respiratory function: SpO
2
(pulsoxymetry),
EtCO
2
Neuromuscular function- ie accelerometry
TOF Guard
Additional- advanced
Invasive Blood Pressure
Haemodynamic monitoring ie Doppler
transesophageal probe
EEG monitoring for deepness of anesthesia
ie BIS (Bispectral Index), AEP - Auditory
Evoced Potentials, Entropy
Complications of general
anesthesia
Respiratory: residual relaxants/opioids
action
Circulatory
Neurological: residual anesthetics/opioids
action
Post-Operative Nausea and Vomitings
Mortality connected with anesthesia

0,05
0,05
-
-
4/10000 GA
4/10000 GA

2
2
-
-
16 %
16 %
of
of
surgical
surgical
patients
patients

80 %
80 %
is
is
caused
caused
by
by
human
human
mistake
mistake
Major causes of deaths
Airway Airway obstruction obstruction
Difficult Difficult and and unefficient unefficient intubation intubation
Insufficient Insufficient ventillation ventillation
Other causes of mortality and morbidity
Anoxia Anoxia
Haemodynamic Haemodynamic instability instability
Aspiration Aspiration
Toxity Toxity of of drugs drugs mostly mostly inhalation inhalation
agents agents
Anaphylaxia Anaphylaxia and and drug drug interations interations
Airway management and
artificial ventillation
AIRWAY MANAGEMENT
AIRWAY MANAGEMENT
RespiratoryDistressvs. RespiratoryFailure RespiratoryDistressvs. RespiratoryFailure
Distress Distress
- -Increased work of breathing Increased work of breathing
- -Relative Relative hypoxia/ hypoxia/hypercapnea hypercapnea
- -Compensating Compensating
Failure Failure
- -Increased work of breathing Increased work of breathing
- -Profound Profound hypoxia/ hypoxia/hypercapnea hypercapnea
- -Decompensating Decompensating
Its a constant reassessment process
Contraindications for face mask
and bag ventillation
Hernia hiatus aesophagus
gastric reflux
injury of face or neck
brochial-esophagaeal connection
injury of trachea cartiladges
full stomach patient, vomitings
I ndicationsfor ET
(endotracheal intubation)
Airway obstruction
Cardio Pulmonary Resuscitation
Artificial ventilation
Anesthesia
Brain injury, facial injury, facial burn,
airway burn
Complicationsof ET
Injuries:
- theeth injury, mouth injury
- laryngs rupture
- aspiration
- bleeding
oesophagus intubation
one bronchus intubation
Reactions: vomitings, coughing, apnea,
laryngospasm, bradycardia, hypertension
Alternative airway management
Laryngeal mask- for short, not major
operations ecxept for head and neck surgery
for elective surgery- patient must be
prepared for anesthesia