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General Considerations

General anesthesia (GA) is the state produced when a patient receives medications
for amnesia, analgesia, muscle paralysis, and sedation. An anesthetized patient can
be thought of as being in a controlled, reversible state of unconsciousness.
Anesthesia enables a patient to tolerate surgical procedures that would otherwise
inflict unbearable pain, potentiate extreme physiologic exacerbations, and result in
unpleasant memories.
The combination of anesthetic agents used for general anesthesia often leaves a
patient with the following clinical constellation: [1]
1. Unarousable even secondary to painful stimuli
2. Unable to remember what happened (amnesia)
3. Unable to maintain adequate airway protection and/or spontaneous ventilation
as a result of muscle paralysis
4. Cardiovascular changes secondary to stimulant/depressant effects of
anesthetic agents
General anesthesia
General anesthesia uses intravenous and inhaled agents to allow adequate surgical
access to the operative site. A point worth noting is that general anesthesia may not
always be the best choice; depending on a patient’s clinical
presentation, localor regional anesthesia may be more appropriate. [2, 3, 4]
Anesthesia providers are responsible for assessing all factors that influence a
patient's medical condition and selecting the optimal anesthetic technique
accordingly.
Advantages of general anesthesia include the following:

Reduces intraoperative patient awareness and recall [5]

Allows proper muscle relaxation for prolonged periods of time

Facilitates complete control of the airway, breathing, and circulation

Can be used in cases of sensitivity to local anesthetic agent

Can be administered without moving the patient from the supine position

Can be adapted easily to procedures of unpredictable duration or extent

Can be administered rapidly and is reversible
Disadvantages of general anesthesia include the following:
 Requires increased complexity of care and associated costs
 Requires some degree of preoperative patient preparation
 Can induce physiologic fluctuations that require active intervention
 Associated with less serious complications such as nausea or vomiting, sore
throat, headache, shivering, and delayed return to normal mental functioning
 Associated with malignant hyperthermia, a rare, inherited muscular condition
in which exposure to some (but not all) general anesthetic agents results in
acute and potentially lethal temperature rise, hypercarbia, metabolic acidosis,
and hyperkalemia
With modern advances in medications, monitoring technology, and safety
systems, as well as highly educated anesthesia providers, the risk caused
by anesthesia to a patient undergoing routine surgery is very small.
Mortality attributable to general anesthesia is said to occur at rates of less
than 1:100,000. Minor complications occur at predicable rates, even in
previously healthy patients. The frequency of anesthesia-related symptoms
during the first 24 hours following ambulatory surgery is as follows: [6]
 Vomiting - 10-20%
 Nausea - 10-40%
 Sore throat - 25%
 Incisional pain - 30%
Preparation for General Anesthesia
Safe and efficient anesthetic practices require certified personnel,
appropriate medications and equipment, and an optimized patient.
Minimum requirements for general anesthesia
Minimum infrastructure requirements for general anesthesia include a well-
lit space of adequate size; a source of pressurized oxygen (most commonly
piped in); an effective suction device; standard ASA (American Society of
Anesthesiologists) monitors, including heart rate, blood pressure, ECG,
pulse oximetry, capnography, temperature; and inspired and exhaled
concentrations of oxygen and applicable anesthetic agents. [7, 8, 9]
Beyond this, some equipment is needed to deliver the anesthetic agent.
This may be as simple as needles and syringes, if the drugs are to be
administered entirely intravenously. In most circumstances, this means the
availability of a properly serviced and maintained anesthetic gas delivery
machine.
An array of routine and emergency drugs, including Dantrolene sodium (the
specific treatment for malignant hyperthermia), airway management
equipment, a cardiac defibrillator, and a recovery room staffed by properly
trained individuals completes the picture.
Preparing the patient
The patient should be adequately prepared. The most efficient method is
for the patient to be reviewed by the person responsible for giving the
anesthetic well in advance of the surgery date.
Preoperative evaluation allows for proper laboratory monitoring, attention to
any new or ongoing medical conditions, discussion of any previous
personal or familial adverse reactions to general anesthetics, assessment
of functional cardiac and pulmonary states, and development of an
effective and safe anesthetic plan. It also serves to relieve anxiety of the
unknown surgical environment for patients and their families. Overall, this
process allows for optimization of the patient in the perioperative setting. [10]
Physical examination associated with preoperative evaluations allow
anesthesia providers to focus specifically on expected airway conditions,
including mouth opening, loose or problematic dentition, limitations in neck
range of motion, neck anatomy, and Mallampati presentations (see below).
By combining all factors, an appropriate plan for intubation can be outlined
and extra steps, if necessary, can be taken to prepare for fiberoptic
bronchoscopy, video laryngoscopy, or various other difficult airway
interventions.
Airway management
Possible or definite difficulties with airway management include the
following:
 Small or receding jaw
 Prominent maxillary teeth
 Short neck
 Limited neck extension
 Poor dentition
 Tumors of the face, mouth, neck, or throat
 Facial trauma
 Interdental fixation
 Hard cervical collar
 Halo traction
Various scoring systems have been created using orofacial measurements
to predict difficult intubation. The most widely used is the Mallampati score,
which identifies patients in whom the pharynx is not well visualized through
the open mouth.
The Mallampati assessment is ideally performed when the patient is seated
with the mouth open and the tongue protruding without phonating. In many
patients intubated for emergent indications, this type of assessment is not
possible. A crude assessment can be performed with the patient in the
supine position to gain an appreciation of the size of the mouth opening
and the likelihood that the tongue and oropharynx may be factors in
successful intubation (see image below).
Mallampati classification.
High Mallampati scores have been shown to be predictive of difficult
intubations. [11]However, no one scoring system is near 100% sensitive or
100% specific. As a result, practitioners rely on several criteria and their
experience to assess the airway.
In addition to intubation during surgery, some patients may require
unanticipated early postoperative intubation. A large-scale study of 109,636
adult patients undergoing nonemergent, noncardiac surgery identified risk
factors for postoperative intubation. Independent predictors include patient
comorbidities such as chronic obstructive pulmonary disease, insulin-
dependent diabetes, active congestive heart failure, and hypertension.
Severity of surgery is also an identified risk factor. Half of unanticipated
tracheal intubations occurred within the first 3 days after surgery and were
independently associated with a 9-fold increase in mortality.[12]
When suspicion of an adverse event is high but a similar anesthetic
technique must be used again, obtaining records and previous anesthetic
records from previous operations or from other institutions may be
necessary.
Other requirements
The need for coming to the operating room with an empty stomach is well
known to health professionals and the lay public. The reason for this is to
reduce the risk of pulmonary aspiration during general anesthesia when a
patient loses his or her ability to voluntarily protect the airway.

Published guidelines recommend that solid food (including gum or
candy) should be avoided for 6 hours prior to the induction of
anesthesia. [13]

Clear fluids (ie, water, Pedialyte, or Gatorade ONLY; no other liquids)
should be avoided for 2-4 hours prior to the induction of anesthesia. [13]
Patients should continue to take regularly scheduled medications up to and
including the morning of surgery. Exceptions may include the following:
 Anticoagulants to avoid increased surgical bleeding
 Oral hypoglycemics (For example, metformin is an oral hypoglycemic
agent that is associated with the development of metabolic acidosis
under general anesthesia.)
 Monoamine oxidase inhibitors
 Beta blocker therapy (However, beta blocker therapy should be
continued perioperatively for high-risk patients undergoing major
noncardiac surgery. [14] )
Recent catastrophes under anesthesia have focused attention on the
interaction between nonprescribed medications and anesthetic drugs,
including interactions with vitamins, herbal preparations, traditional
remedies, and food supplements. Good information on the exact content of
these supplement preparations is often hard to obtain. [15]
The Process of Anesthesia
Premedication
Premedication is the first stage of a general anesthetic.
This stage, which is usually conducted in the surgical ward or in a
preoperative holding area, originated in the early days of anesthesia, when
morphine and scopolamine were routinely administered to make the
inhalation of highly pungent ether and chloroform vapors more tolerable.
The goal of premedication is to have the patient arrive in the operating
room in a calm, relaxed frame of mind. Most patients do not want to have
any recollection of entering the operating room.
The most commonly used premedication is midazolam, a short-acting
benzodiazepine. For example, midazolam syrup is often given to children to
facilitate calm separation from their parents prior to anesthesia. In
anticipation of surgical pain, nonsteroidal anti-inflammatory drugs or
acetaminophen can be administered preemptively. When a history of
gastroesophageal reflux exists, H2 blockers and antacids may be
administered.
Drying agents (eg, atropine, scopolamine) are now only administered
routinely in anticipation of a fiberoptic endotracheal intubation.
Induction
The patient is now ready for induction of general anesthesia, a critical part
of the anesthesia process.
In many ways, induction of general anesthesia is analogous to an airplane
taking off. It is the transformation of a waking patient into an anesthetized
one. The role of the anesthesia provider is analogous to the role of the
pilot, checking all the systems before taking off. The mnemonic DAMMIS
can be used to remember what to check ( D rugs, A irway
equipment, M achine, M onitors, I V, S uction).
This stage can be achieved by intravenous injection of induction agents
(drugs that work rapidly, such as propofol), by the slower inhalation of
anesthetic vapors delivered into a face mask, or by a combination of both.
For the most part, contemporary practice dictates that adult patients and
most children aged at least 10 years be induced with intravenous drugs,
this being a rapid and minimally unpleasant experience for the patient.
However, sevoflurane, a well-tolerated anesthetic vapor, allows for elective
inhalation induction of anesthesia in adults.
In addition to the induction drug, most patients receive an injection of an
opioid analgesic, such as fentanyl (a synthetic opioid many times more
potent than morphine). Many synthetic and naturally occurring opioids with
different properties are available. Induction agents and opioids work
synergistically to induce anesthesia. In addition, anticipation of events that
are about to occur, such as endotracheal intubation and incision of the skin,
generally raises the blood pressure and heart rate of the patient. Opioid
analgesia helps control this undesirable response.
The next step of the induction process is securing the airway. This may be
a simple matter of manually holding the patient's jaw such that his or her
natural breathing is unimpeded by the tongue, or it may demand the
insertion of a prosthetic airway device such as a laryngeal mask airway or
endotracheal tube. [16, 17] Various factors are considered when making this
decision. The major decision is whether the patient requires placement of
an endotracheal tube. Potential indications for endotracheal intubation
under general anesthesia may include the following:
 Potential for airway contamination (full stomach, gastroesophageal
[GE] reflux, gastrointestinal [GI] or pharyngeal bleeding)
 Surgical need for muscle relaxation
 Predictable difficulty with endotracheal intubation or airway access
(eg, lateral or prone patient position)
 Surgery of the mouth or face
 Prolonged surgical procedure
Not all surgery requires muscle relaxation.
If surgery is taking place in the abdomen or thorax, an intermediate or long-
acting muscle relaxant drug is administered in addition to the induction
agent and opioid. This paralyzes muscles indiscriminately, including the
muscles of breathing. Therefore, the patient's lungs must be ventilated
under pressure, necessitating an endotracheal tube.
Persons who, for anatomic reasons, are likely to be difficult to intubate are
usually intubated electively at the beginning of the procedure, using a
fiberoptic bronchoscope or other advanced airway tool. This prevents a
situation in which attempts are made to manage the airway with a lesser
device, only for the anesthesia provider to discover that oxygenation and
ventilation are inadequate. At that point during a surgical procedure, swift
intubation of the patient can be very difficult, if not impossible.
Maintenance phase
At this point, the drugs used to initiate the anesthetic are beginning to wear
off, and the patient must be kept anesthetized with a maintenance agent.
For the most part, this refers to the delivery of anesthetic gases (more
properly termed vapors) into the patient's lungs. These may be inhaled as
the patient breathes spontaneously or delivered under pressure by each
mechanical breath of a ventilator.
The maintenance phase is usually the most stable part of the anesthesia.
However, understanding that anesthesia is a continuum of different depths
is important. A level of anesthesia that is satisfactory for surgery to the skin
of an extremity, for example, would be inadequate for manipulation of the
bowel.
Appropriate levels of anesthesia must be chosen both for the planned
procedure and for its various stages. In complex plastic surgery, for
example, a considerable period of time may elapse between the completion
of the induction of anesthetic and the incision of the skin. During the period
of skin preparation, urinary catheter insertion, and marking incision lines
with a pen, the patient is not receiving any noxious stimulus. This requires
a very light level of anesthesia, which must be converted rapidly to a
deeper level just before the incision is made. When the anesthesia provider
and surgeon are not accustomed to working together, good communication
(eg, warning of the start of new stimuli, such as moving the head of an
intubated patient or commencing surgery) facilitates preemptive deepening
of the anesthetic. This maximizes patient safety and, ultimately, saves
everyone's time.
As the procedure progresses, the level of anesthesia is altered to provide
the minimum amount of anesthesia that is necessary to ensure adequate
anesthetic depth. Traditionally, this has been a matter of clinical judgment,
but new processed EEG machines give the anesthesia provider a simplified
output in real time, corresponding to anesthetic depth. These devices have
yet to become universally accepted as vital equipment.
If muscle relaxants have not been used, inadequate anesthesia is easy to
spot. The patient moves, coughs, or obstructs his airway if the anesthetic is
too light for the stimulus being given.
If muscle relaxants have been used, then clearly the patient is unable to
demonstrate any of these phenomena. In these patients, the anesthesia
provider must rely on careful observation of autonomic phenomena such as
hypertension, tachycardia, sweating, and capillary dilation to decide
whether the patient requires a deeper anesthetic.
This requires experience and judgment. The specialty of anesthesiology is
working to develop reliable methods to avoid cases of awareness under
anesthesia.
Excessive anesthetic depth, on the other hand, is associated with
decreased heart rate and blood pressure, and, if carried to extremes, can
jeopardize perfusion of vital organs or be fatal. Short of these serious
misadventures, excessive depth results in slower awakening and more
adverse effects.
As the surgical procedure draws to a close, the patient's emergence from
anesthesia is planned. Experience and close communication with the
surgeon enable the anesthesia provider to predict the time at which the
application of dressings and casts will be complete.
In advance of that time, anesthetic vapors have been decreased or even
switched off entirely to allow time for them to be excreted by the lungs.
Excess muscle relaxation is reversed using specific drugs and an adequate
long-acting opioid analgesic to keep the patient comfortable in the recovery
room.
If a ventilator has been used, the patient is restored to breathing by himself,
and, as anesthetic drugs dissipate, the patient emerges to consciousness.
Emergence is not synonymous with removal of the endotracheal tube or
other artificial airway device. This is only performed when the patient has
regained sufficient control of his or her airway reflexes.
Anesthesia Drugs in Common Use
Numerous choices exist for every aspect of anesthetic care; the way in
which they are sequenced depends partially on the personal preference of
the person administering them.
Induction agents
For 50 years, the most commonly used induction agents were rapidly
acting, water-soluble barbiturates such as thiopental, methohexital, and
thiamylal. These drugs are not commonly in use today.
Propofol, a nonbarbiturate intravenous anesthetic, has displaced
barbiturates in many anesthesia practices.
 The use of propofol is associated with less postoperative nausea and
vomiting and a more rapid, clear-headed recovery.
 In addition to being an excellent induction agent, propofol can be
administered by slow intravenous infusion instead of vapor to maintain
the anesthesia.
 Among its disadvantages are the facts that it often causes pain on
injection and that it is prepared in a lipid emulsion, which, if not
handled using meticulous aseptic precautions, can be a medium for
rapid bacterial growth.
Anesthesia can also be induced by inhalation of a vapor. This is how all
anesthetics were once given and is a common and useful technique in
uncooperative children. It is reemerging as a choice in adults. Sevoflurane
is most commonly used for this purpose.
Traditional opioid analgesics
Morphine, meperidine, and hydromorphone are widely used in anesthesia
as well as in emergency departments, surgical wards, and obstetric suites.
In addition, anesthesia providers have at their disposal a range of synthetic
opioids, which, in general, cause less fluctuation in blood pressure and are
shorter acting. These include fentanyl, sufentanil, and remifentanil.
Muscle relaxants
Succinylcholine, a rapid-onset, short-acting depolarizing muscle relaxant,
has traditionally been the drug of choice when rapid muscle relaxation is
needed.
 For decades, anesthesia providers have used it extensively despite
numerous predictable and unpredictable adverse effects associated
with its use.
 The search for a drug that replicates its onset and offset speed
without its adverse effects is the holy grail of muscle relaxant
research.
Other relaxants have durations of action ranging from 15 minutes to more
than 1 hour.
Older drugs in this class, such as pancuronium or curare, were often
associated with changes in heart rate or blood pressure. Newer muscle
relaxants are devoid of these adverse properties.
Muscle relaxants generally are excreted by the kidney, but some
preparations are broken down by plasma enzymes and can be used safely
in patients with partial or complete renal failure.
Anesthetic vapors
These are highly potent chlorofluorocarbons, which are delivered with
precision from vaporizers and directly into the patient's inhaled gas stream.
They may be mixed with nitrous oxide, a much weaker but nonetheless
useful anesthetic gas.
The prototype of modern anesthetic vapors is halothane. It is no longer
used in routine clinical practice. In the 1980s, it was displaced by isoflurane
and enflurane, agents that were cleared from the lungs faster and thus
were associated with more rapid anesthetic emergences.
In the late 1990s, desflurane and sevoflurane came into use. These inhaled
anesthetics are much more maneuverable than their predecessors and are
associated with a more rapid emergence.
Intense commercial interest is present in anesthesia drug research, and the
continuous introduction of new and better drug products for many years to
come seems inevitable.
Positioning
When inducing general anesthesia, patients can no longer protect their airway,
provide effective respiratory effort, or protect themselves from injury. For these
reason, ideal positioning for general anesthesia is extremely important and can help
prevent potential injuries and devastating consequences.
Positioning for induction of general anesthesia
When inducing general anesthesia, the patient is no longer able to protect their
airway or provide an effective respiratory effort. The goal of care is to provide
adequate ventilation and oxygenation during general anesthesia. Patients are
evaluated in the preoperative period for the signs of difficult mask ventilation and/or
intubation. Positioning is especially important in morbidly obese patients. The body
habitus of these patients can make them difficult to ventilate and intubate.
Ideal masking and intubating position is called the "sniffing" position. This is obtained
by lifting the patients chin upward (when supine) so as to look, from a profile view,
that the patient is sniffing the air. Doing this in addition with lifting the mandible
forward (to remove the tongue from the oropharynx) facilitates easiest mask
ventilation.
In obese patients, it is often difficult to mask ventilate and intubate owing to their
body habitus. When mask ventilating, even with perfect technique, there is often
excess tissue on the chest wall, which will make it difficult to properly ventilate at low
pressures, so as not to inflate the stomach with air during attempted ventilation.
Often, obese patients are ramped at a 30° angle to help improve the mask ventilation
and intubation.
When attempting intubation, the goal of positioning is to align the tragus of the ear
with the level of the sternum. This improves intubating conditions and creates direct
visualization of the vocal cords when performing direct laryngoscopy.
Positioning during general anesthesia
When a patient is under general anesthesia, he or she has lost all protective
reflexes, so providers must be very careful to position the patient. The primary
concerns of positioning are ocular injuries, peripheral nerve injuries, musculoskeletal
injuries, and skin injuries.
Initially after induction of anesthesia, eyelids should be gently taped down in a closed
position. This helps prevent corneal injury by accidental scratching of the cornea.
Another ocular injury that can be made less likely during surgical positioning is to
prevent ocular venous congestion, which can cause perioperative vision loss. This is
often seen in prone patient who develops increased ocular pressure either through
mechanical force on the eye or increased venous congestion.
Another concern during general anesthesia is peripheral nerve injuries. The most
common peripheral nerve injuries are ulnar nerve, common peroneal nerve, and
brachial plexus injuries. These can be prevented with appropriate positioning,
padding, and vigilance during general anesthesia. The arms should be at less than
90° in relation to the body. Gel/foam padding should be used for superficial nerves
(eg, ulnar nerve in the ulnar groove-lateral epicondyle of elbow). Prevent positioning
up against hard objects (eg, metal, plastic). Prevent hyperextension/flexion of the
spine or neck. Exercise vigilance by checking positioning every 15 minutes during
general anesthesia.