5 General Anesthesia

Dr/ Hany Kamal

 Definition:
 General anaesthesia is a medically induced coma with loss of protective reflexes,
resulting from the administration of one or more general anaesthetic agents.
 It is generally performed in:
▪ an operating theater to allow surgical procedures that would otherwise be
intolerably painful for the patient.
▪ or in an intensive care unit to facilitate mechanical ventilation in critically ill
patients.
 Components:
General anesthesia has many purposes and a variety of drugs may
be administered, with the aim of ensuring
1. Unconsciousness (loss of awareness). ‫انكيل‬
2. Amnesia (temporary loss of memory). ‫امين‬
3. Analgesia (loss of response to pain). ‫انانى‬
4. Paralysis (Skeletal muscle relaxation). ‫سكوته‬
5. Immobility (loss of motor reflexes). ‫راحه‬
 Preanesthetic evaluation:
 Prior to a planned procedure, the anesthesiologist reviews medical records and/or
interviews the patient to determine the best combination of drugs and dosages.
 The degree to which monitoring will be required to ensure a safe and effective
procedure.
 Key factors in this evaluation are the patient's age, body mass index, medical and
surgical history, current medications and fasting time.
 Assessment of the patient's airway.
 Premedication:
Prior to administration of a general anaesthetic, the anaesthetist may administer one or
more drugs that complement or improve the quality or safety of the anaesthetic.
1) clonidine, an alpha-2 adrenergic agonist:
▪ ↓ anaesthetic induction agents
▪ ↓ volatile agents conc. to maintain general anaesthesia
▪ ↓postoperative analgesics.
▪ ↓postoperative shivering
▪ ↓ postoperative nausea and vomiting.
However, oral clonidine can take up to 45 minutes to take full effect and drawbacks
include: hypotension and bradycardia.

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 2) Midazolam a benzodiazepine characterized by a rapid onset and short duration, is
effective in reducing preoperative anxiety.
3) Melatonin hypnotic, sedative ↓ anxiety, anticonvulsant properties and ↓ the
required induction dose of propofol " and sodium thiopental.
4) Beta adrenergic antagonists reduce the incidence of postoperative hypertension,
cardiac dysrhythmia, or myocardial infarction.
5) Anaesthesiologists may administer an antiemetic agent such as ondansetron,
droperidol, or dexamethasone to prevent postoperative nausea and vomiting
6) Subcutaneous heparin or enoxaparin to reduce the incidence of deep vein
thrombosis.
7) Other commonly used premedication agents include opioids such as fentanyl or
sufentanil.
 Stages of anesthesia:
1. Stage 1 induction, is the period between the administration of induction agents and
loss of consciousness.
2. Stage 2 (Excitement) is the period following loss of consciousness. The patient's
respiration and heart rate may become irregular. may be uncontrolled movements,
vomiting, suspension of breathing, and pupillary dilation.
Because the combination of spastic movements, vomiting, and irregular respiration
may compromise the patient's airway, rapidly acting drugs are used to minimize
time in this stage and reach Stage 3 as fast as possible.
3. Stage 3: Surgical anaesthesia, the skeletal muscles relax, vomiting stops,
respiratory depression occurs, and eye movements slow and then stop, Corneal and
laryngeal reflexes are lost, the pupils dilate and light reflex is lost; The patient is
unconscious and ready for surgery.
4. Stage 4 (Medullary depression) known as overdose, occurs when too much
anaesthetic medication is given relative to the amount of surgical stimulation and
the patient has severe brainstem or medullary depression, resulting in a cessation of
respiration and potential cardiovascular collapse. This stage is lethal without
cardiovascular and respiratory support.
 Induction:
 Anaesthetic agents may be administered by various routes, including:
▪ Inhalation
▪ Injection (intravenous, intramuscular, or subcutaneous)
▪ Oral
▪ Rectal.
 Once they enter the circulatory system, the agents are transported to their
biochemical sites of action in the central and autonomic nervous systems.

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  Most general anaesthetics are induced either intravenously or by inhalation.
Commonly used intravenous induction agents include propofol, sodium thiopental,
etomidate, methohexital, and ketamine.
 Inhalational anaesthesia may be chosen when intravenous access is difficult to
obtain (e.g., children). Sevoflurane is the most commonly used agent for
inhalational induction, because it is less irritating to the tracheobronchial tree than
other agents and has rapid onset.
 As an example sequence of induction drugs:
1) Pre-oxygenation to fill lungs with oxygen to permit a longer period.
2) Fentanyl.
3) Propofol.
4) Muscle relaxant to facilitate tracheal intubation and mechanical ventilation.
5) Switching from oxygen to a mixture of oxygen and inhalational anesthetic.
6) Laryngoscopy and intubation.
 Physiologic monitoring:
1. Continuous electrocardiography (ECG or EKG): Electrodes are placed on the
patient's skin to monitor heart rate and rhythm. This may also help the
anaesthesiologist to identify early signs of heart ischaemia. Typically lead II and V5
are monitored for arrhythmias and ischemia, respectively.
2. Continuous pulse oximetry (SpO2): A device is placed, usually on a finger, to allow
for early detection of a fall in a patient's haemoglobin saturation with oxygen
(hypoxaemia).
3. Blood pressure monitoring: There are two methods of measuring the patient's blood
pressure.
 The first, and most common, is noninvasive blood pressure (NIBP) monitoring.
This involves placing a blood pressure cuff around the patient's arm, forearm, or leg.
A machine takes blood pressure readings at regular, preset intervals throughout the
surgery.
 The second method is invasive blood pressure (IBP) monitoring. This method is
reserved for patients with significant heart or lung disease, the critically ill, and
those undergoing major procedures such as cardiac or transplant surgery, or when
large blood loss is expected. It involves placing a special type of plastic cannula in
an artery, usually in the wrist (radial artery) or groin (femoral artery).
4. Agent concentration measurement: Anesthetic machines typically have monitors
to measure the percentage of inhalational anesthetic agents used.
5. Oxygen measurement: Almost all circuits have an alarm in case oxygen delivery to
the patient is compromised. The alarm goes off if the fraction of inspired oxygen
drops below a set threshold.

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 6. A circuit disconnect alarm or low pressure alarm:
Indicates failure of the circuit to achieve a given pressure during mechanical
ventilation.
7. Capnography measures the amount of carbon dioxide exhaled by the patient in
percent or mmHg, allowing the anaesthesiologist to assess the adequacy of
ventilation.
8. Temperature measurement to discern hypothermia or fever, and to allow early
detection of malignant hyperthermia.
9. Electroencephalography, may be used to verify the depth of anaesthesia. This
reduces the likelihood of anaesthesia awareness and of overdose.
 Airway management:
 Anaesthetized patients lose protective airway reflexes (such as coughing), airway
patency, and sometimes a regular breathing pattern due to the effects of
anaesthetics, opioids, or muscle relaxants.
 To maintain an open airway and regulate breathing, some form of breathing tube
(e.g endotracheal tube, laryngeal mask airways) is inserted after the patient is
unconscious.
 Eye management:
 General anaesthesia reduces the tonic contraction of the orbicularis oculi muscle,
causing lagophthalmos, or incomplete eye closure, in 59% of patients.
 Tear production is reduced, resulting in corneal epithelial drying.
 The protection afforded by Bell's phenomenon (in which the eyeball turns upward
during sleep, protecting the cornea) is also lost.
 Careful management is required to reduce the likelihood of eye injuries during
general anaesthesia.
 Neuromuscular blockade:
 Paralysis, or temporary muscle relaxation with a neuromuscular blocker, is an
integral part of modern anaesthesia. The first drug used for this purpose was curare,
introduced in the 1940s, which has now been superseded by drugs with fewer side
effects and, generally, shorter duration of action.
 Muscle relaxation allows surgery within major body cavities, such as the abdomen
and thorax, without the need for very deep anaesthesia and also facilitates
endotracheal intubation.
 Acetylcholine, the natural neurotransmitter at the neuromuscular junction, causes
muscles to contract when it is released from nerve endings. Muscle relaxants work
by preventing acetylcholine from attaching to its receptor.
 Paralysis of the muscles of respiration—the diaphragm and intercostal muscles of
the chest—requires that some form of artificial respiration be implemented.

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  The effects of muscle relaxants are commonly reversed at the end of surgery by
anticholinesterase drugs, which are administered in combination with muscarinic
anticholinergic drugs to minimize side effects.
 Maintenance:
 The duration of action of intravenous induction agents is generally 5 to 10 minutes,
after which spontaneous recovery of consciousness will occur.
 In order to prolong unconsciousness for the required duration (usually the duration
of surgery), anaesthesia must be maintained.
 This is achieved by:
▪ allowing the patient to breathe a carefully controlled mixture of oxygen and a
volatile anaesthetic agent
▪ or by administering medication (usually propofol) through an intravenous
catheter. (Infusion)
 At the end of surgery, administration of anaesthetic agents is discontinued.
Recovery of consciousness occurs when the concentration of anaesthetic in the brain
drops below a certain level (usually within 1 to 30 minutes, depending on the
duration of surgery).
 Other medications are occasionally used to treat side effects or prevent
complications:
▪ Antihypertensives to treat high blood pressure.
▪ Ephedrine or phenylephrine to treat low blood pressure.
▪ Salbutamol to treat asthma, laryngospasm or bronchospasm
▪ Epinephrine to treat allergic reactions.
▪ Glucocorticoids or antibiotics are sometimes given to prevent inflammation and
infection, respectively.
 Postoperative care:
 Our aim is pain-free awakening from anaesthesia. Although not a direct result of
general anaesthesia, postoperative pain is managed in the anaesthesia recovery unit
with regional analgesia or oral, transdermal, or parenteral medication.
 Patients may be given opioids, as well as other medications like non steroidal anti-
inflammatory drugs.
 Sometimes, opioid medication is administered by the patient themselves using a
system called a patient controlled analgesic. The patient presses a button to activate
a syringe device and receive a preset dose or "bolus" of the drug, usually a strong
opioid such as morphine, fentanyl, or oxycodone (e.g., one milligram of morphine).
The PCA device then "locks out" for a preset period to allow the drug to take effect.
 In the recovery unit, many vital signs are monitored, including oxygen saturation
heart rhythm and respiration, blood pressure and core body temperature.
Thank You
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