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

Anesthesia

VIMA
Volatile

Induction and

Maintain

Anesthesia

Parts of general anesthesia

• Hypnosis- pharmacological sleep, reversable lack of consciousness

• Analgesia-pain management

• Areflexio-lack of reflexes

• Relaxation musculorum- muscle relaxation, pharmacological reversable neuromuscular

blockadeII.
 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

• 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 of the risk of anesthesia (American Society of Anesthesiologists scale)

• ASA 1: healthy patient.

• ASA 2: patient with stable, treated illness like arterial hypertension, diabetes melitus, asthma
bronchiale, obesity

• ASA 3: patient with systemic illness decreasing suffitiency like heart ilness, late infarct

• ASA 4: patient with serious illness influencing his state like renal insuficiency, unstable
hypertension, circulatory insuficiency

• ASA 5: patient in life treatening illness

• ASA 6: brain death- potential organ donor

Premedication Main reasons for premedication:

• Anxiolysis- lack of threat

• Sedation – calming down

• Amnesia – lack of memories of perioperative period

METHODS OF GENERAL ANESTHESIA

OPEN- old

SEMIOPEN – used mostly in pediatric anesthesia

SEMICLOSED- most common

CLOSED- modern anesthesia

Methods of general anesthesia

CIRCLE SYSTEM

*HIGH-FLOW FRESH GAS FLOW 3 l/min.

*LOW-FLOW FGF ok. 1l/min.

*MINIMAL-FLOW FGF ok. 0,5 l/min.

Stages of general anesthesia

• Introduction to anesthesia (induction)

• Maintaining of anesthesia (conduction)

• Recovery from anesthesia

 TYPES OF GENERAL ANESTHESIA
Intravenous Anesthetics

The Inhaled Anesthetics

Balanced Anesthesia

Intravenous Anesthetics

(1) barbiturates (eg, thiopental, methohexital)

(2) benzodiazepines (eg, midazolam, diazepam)

(3) propofol

(4) ketamine

(5) opioid analgesics (morphine, fentanyl, sufentanil, alfentanil, remifentanil)

(6) miscellaneous sedative-hypnotics (eg, etomidate, dexmedetomidine)

Anesthesia agents

An ideal anesthetic CHARACTERISTICS:

1. A smooth and rapid loss of consciousness

2. A prompt recovery after its administration is discontinued

3. A wide margin of safety and be devoid of adverse effects

AGENTS:

1. Inhalation anesthetics (volatile anesthetics) - gases : N2O, 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 ANESTHETICS agents

These compounds are volatile liquids that are aerosolized in specialized vaporizer delivery systems.

Division of inhalation agents

1. Gases: • N2O – 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
TCI

Target

Controlled

Infusion

Defining TCI When applied to anaesthesia What is 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 anesthesia by adjusting the
requested target concentration

• 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

Usual dose 2mg/kg induction then 1mg/kg every 20-30mins for anaesthesia

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

Very CVS stable steroid derivative

- Causes adrenal suppression

- Induction dose is 03 mg/kg

Midazolam

- 0.1-0.2 mg/kg, infusion 2 mcg/min/kg - cardio respiratory depression in compromised patient

ESPECIALLY if given with opioids

- not painful in peripheral iv (cf. diazepam)

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

Morphine

- 0.1-0.2 mg/kg, infusion 10-50 mcg/min/kg

- cardiorespiratory depression, nausea, vomiting, histamine release - duration ≈ 1 h

Fentanyl

- related chemically to pethidine - 0.1 mg fentanyl ≈ 10 mg morphine: dose 1-2 mcg/kg iv -

infusion 2-4 mcg/kg/h - duration of analgesia 20-30 min

- respiratory depression, nausea, vomiting

- can use for induction

- dose 10 mcg/kg (beware chest wall rigidity)

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

• T1/2 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)

Aminosteroids: Pankuronium (Pavulon) Pipekuronium (Arduan) Rapakuronium (Raplon) Rokuronium

(Esmeron) Wekuronium (Norcuron)

Benzylizochinolons: Miwakurium (Mivacron) Cisatrakurium (Nimbex) Atrakurium (Trakurium)

Division of nondepolarising relaxants due to time of action:

• Short acting < 3 min: still searching

• Midle time 60 min: pancuronium, pipecuronium Atracurium , cisatracurium, rocuronium,

vecuronium

Long acting > 60 min: pancuronium(dose 0.1 mg/kg), 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

Dose = 0.6 mg/kg (onset approx 1 min)

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: SpO2 (pulsoxymetry), EtCO2

• 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 - 4/10000 GA

• 2 - 16 % of surgical patients

• 80 % is caused by human mistake

Major causes of deaths

• Airway obstruction

• Difficult and unefficient intubation

• Insufficient ventillation

Other causes of mortality and morbidity

• Anoxia

• Haemodynamic instability
• Aspiration

• Toxity of drugs – mostly inhalation agents

• Anaphylaxia and drug interations

Balanced Anesthesia
Although general anesthesia can be produced using only intravenous or only inhaled anesthetic
drugs, modern anesthesia typically involves a combination of intravenous (eg, for induction of
anesthesia) and inhaled (eg, for maintenance of anesthesia) drugs.

However, volatile anesthetics (eg, sevoflurane) can also be used for induction of anesthesia, and
intravenous anesthetics (eg, propofol) can be infused for maintenance of anesthesia.

INHALATION ANASTHETICS MACHINE

1. Anesthesia Machine. - The entire piece of equipment that is used to deliver
precise amounts of inhaled anesthetic gas and/or a carrier gas (usually air, O2
or CO2, alone or in a mix). It consists of multiple parts (precision vaporizer,
carrier gas regulators, flow meters, delivery/breathing circuits and scavenge
systems and possibly a rebreathing reservoir (bag). a.
2. Rebreathing systems – for animals weighing over ~5kg b.
3. Non-rebreathing systems – for rodents and animals weighing under ~5kg.

DELIVERY SYSTEM :Compose of 2 major system

1. Anesthetic machine

2. Breathing system

Ideal Inhalation anesthetics: provide a quick induction

and emergence from anesthesia provide good analgesia, muscle
relaxation quick changes and easy maintenance of anesthesia no
side effects non-flammable , non explosion not expensive free
from pollution Unfortunately, the real world of medicine doesn’t
provide us with such an ideal agent

Inhalation anesthetic agents Anesthetic gas : ethylene , nitrous oxide ,

xenon Volatile agent ethers : Diethyl ether , Methoxypropane , Vinyl ether
halogenated ether: Desflurane , Enflurane , Isoflurane , Methoxyflurane ,
Sevoflurane haloalkanes : Chloroform , Halothane ,Trichloroethylene
A. BASIC COMPONENT OF ANESTHETIC MACHINE

Composed of - Medical gases

- Pressure gauges & Regulators

- flow meter

- flush values

- vaporizer

MEDICAL GASES

O2 or N2O o Oxygen use for :

- metabolic need

-carrier anesthetic gas

Nitrous oxide use for anesthetic gas

I. MEDICAL GASES

Sources may from pipeline system or cylinder Pipeline sources of N2O or O2 originate at bank
of large cylinder or oxygen may arise from a liquid oxygen

-Cylinder : E (700 L.) or H (7000 L.)

- tank color code label ; O2green , N2O blue, CO2 black

II. PRESSURE GAUGES & REGULATORS

Pressure gauges indicate the pressure (up to 2200 psi) on the cylinder or system

Regulators produce a safe operating pressure (≈ 45 psi)

III. FLOW METER

Flow meters are down steam from regulators

They measure the rate of gas flow to vaporizers

The scale shows rate of flow (in milliliters or liters per minute)

IV. FLUSH VALVES

Only use for oxygen It delivers a high flow (35-37 L/min.) of oxygen At fl ow rat e 50 L/ i
f i kl fill L/min of oxygen can quickly fill a breathing system Oxygen from flush valve is
directly through the breathing circuit (not pass the vaporizer)

V. VAPORIZERS

two type of vaporizers 1. Precision vaporizer (temperature, flow and back pressure
compensated) 2. Nonprecision or uncompensated vaporizer.

VI. Common gas outlet or fresh gas outlet

This is the exit port where anesthetic gas leave the anesthetic machine and enter to the breathing circuit
This is the point where all “ breathing circuit” attach to the “anesthetic machine”

• Vaporizer location is relation to the

breathing system , has 2 different location

1. Vaporizer outside the circle system (VOC) and must be a precision vaporizer

2. Vaporizer within the circle system (VIC) and must be a nonprecision vaporizer

Action of inhalation anesthetics

sedation,hypnosis ,amnesia ~ supra spinal mechanism immobilizing effect ~ spinal cord

mechanism

inhalation agent action

enhance inhibitory synap transmission by modulation of GABA receptor suppress excitatory

synap transmission by reducing release and action of glutamate

Uptake and distribution

Inspired concentration(Fi)

concentration effect

second gas effect

alveolar ventilation(VA)

Alveolar partial pressure of gas

solubility

cardiac output

gradient of tension in venous blood - alveolar(PV-PA)

Important characteristics of inhale anes.

which govern the anesthesia Solubility in the blood (blood : gas partition coefficient)

Solubility in the fat(oil : gas partition coefficient)

Metabolism and elimination of inhaled anesthetics

Mostly of inhaled agents eliminated via exhalation

The rates of liver metabolism in the human body are approximately 10 to 20 percent for
halothane, 2.5 percent for enflurane, about 0.2 percent for isoflurane, and zero percent for
nitrous oxide.

Functions

• Provide oxygen (O2) to the patient.

• Blend gas mixtures that can include (besides O2) an anesthetic vapor, nitrous oxide (N2O),
other medical gases, and air.

• Facilitate spontaneous, controlled, or assisted ventilation with these gas mixtures.

• Reduce, if not eliminate, anesthesia-related risks to the patient and clinical staff.

Anesthesia delivery

• The patient is anesthetized by inspiring a mixture of O2, the vapor of a volatile liquid
halogenated hydrocarbon anesthetic, and, if necessary, N2O and other gases.

• Because normal breathing is routinely depressed by anesthetic agents and by muscle relaxants
administered in conjunction with them, respiratory assistance — either with an automatic
ventilator or by manual compression of the reservoir bag — is usually necessary to deliver the
breathing gas to the patient.

Principles of operation

• An anesthesia system comprises four basic subsystems:

– a gas supply and control circuit;

– a breathing and ventilation circuit;

– a scavenging system;

– a set of system function and breathing circuit monitors (e.g., inspired O2

concentration, breathing circuit integrity).
 MAJOR COMPONENTS

• Gas Supply

• Pressure Regulators

• Flowmeters

• Vaporizers

• Safety Devices

• Breathing System

B. BREATHING CIRCUIT OR SYSTEM Function of breathing system :

1. Deliver anesthetic gases and oxygen

2. Remove CO2 from exhaled gases

3. Support ventilation

Basic component of rebreathing system ;

1. Y piece : - use for connected with endotracheal tube connector and breathing tube

2. Breathing tube : plastic or rubber

3. One – way (unidirectional) paired values

4. Fresh gas inlet

5. Pop-off value

6. Reservoir bag

7. Manometer

8. CO2 absorber

INHALATION ANESTHETICS MACHINE:

Reservoir bag or rebreathing bag

- At least 6 times of tidal volume

CO 2 absorbent canister - Exhaled gas passing through a canister containing soda lime

- Exhaled CO2 is eliminated.

Carbon dioxide absorbent canister - Two products are commonly used in circle systems as chemical
carbon dioxide absorbent : Soda lime and Baralyme
- In both, Calcium hydroxide is primary component of granules

- Fresh absorbent is white (or pink) in colour

- After expose to carbon dioxide will change the color to pink or violet depend on pH indicator in the
granules.

Operation of rebreathing circuit Divided 2 type :

1. Closed circuit

2. Semi – close circuit

Operation of rebreathing circuit 1.

Closed circuit - There is no “waste of oxygen” from circuit

- Oxygen supply Oxygen supply oxygen consumption = oxygen consumption = 4 – 8 ml /Kg / min

- Must be monitor oxygenation of blood

- Not be use Nitrous oxide because induced hypoxia

Operation of rebreathing circuit 2. Semi – closed - Advantage of rebreathing system

Oxygen supply > oxygen consumption - Excess gases Economical
are eliminated through pop Expired oxygen and anesthetic vapor are recirculated
– off valve continually and reused Fresh gas flow and anesthetic agent
- Oxygen flow rate : 1. Low flow = 10 -20 ml/Kg/min utilization are minimized Humidifying inspired gas
2. Medium flow = 20 – 40 ml/Kg/min 3. High flow = Preserving heat and moisture of the patient
greater than 60 ml/Kg/min

Non – rebreathing circuit: Non – rebreathing circuit •Reason for NOT using a
Recommended for ; - Small dogs & cats rebreathing circuit in a small patient : - Increase
- Neonates resistance to breathing from : - Inspiratory and
- Small birds expiratory valve - CO 2 absorption canister - Large
- Pocket pets mechanical dead space : - Breathing tubes.
- Small exotic animals

Non – rebreathing circuit Oxygen flow rate : Non – rebreathing circuit Advantages
- High gas flow to prevent rebreath of exhaled gases - Less resistance to breathing - Less mechanical dead
- Flow rate = 3 times of minute volume or 200 – 250 space
ml/Kg/min - They are simply devices and light weight
- Inadequate flow rate allow CO2 to be rebreathed and - Easier to clean and maintain
creates respiratory acidosis - More portable than rebreathing circuit
Non – rebreathing circuit Disadvantages Scavenging system Purpose • Eliminate excess
- Delivery a high flow of dry cool gas anesthetic gases from the OR room or working area
- causes heat and humidify loss • Scavenging connected to pop – off valve
- easy to hypothermia in small patient Divided 2 System
- Higher waste - Increase cost - Active
- Passive

Scavenging system Active system Scavenging system Passive system

- High pressure vacuum - Gases sent to outside building 1. Elimination through the outside wall
-Use for the Hospital or OR that place at central of the 2. Use of Activated charcoal - have to changed for every
building 8 hours of using

WORKING ADVANTAGES OF INHALATION ANESTHETIC

Safety

 Stable ( not metabolized in the body)

 Excreted via the same route (lung)

Easier to adjust the depth of anesthesia

 Rapid recovery ( fast excrete) Easy to assist ventilation

DISADVANTAGES OF INHALATION ANESTHESIA

The anesthetic machine is expensive

 Require more equipments

 May be “stormy” recovery

 Flammable and explosive

References

file:///C:/Users/Awais/Desktop/New%20folder/anesthetic_machine_for_mtu

file:///C:/Users/Awais/Desktop/New%20folder/Inhalation-Anesthesia-Machine.
file:///C:/Users/Awais/Desktop/New%20folder/New%20folder/anestgeneral.

file:///C:/Users/Awais/Desktop/New%20folder/New%20folder/Anaesthetic
%20Drugs.pdf