GENERAL ANESTHESIA

2.3.1 Definition
Anesthesia means a state with no pain. General anesthesia is a condition
characterized by loss of perception of all sensations due to drug induction. In this case, in
addition to the loss of pain, consciousness is also lost. General anesthetics consist of a
heterogeneous group of chemical compounds which reversibly depress the CNS with
nearly the same spectrum and can be controlled. General anesthetic drugs can be
administered by inhalation and intravenously. General anesthetic drugs given by
inhalation (volatile gases and liquids), the most important of which are N2O, halothane,
enflurane, methoxyflurane, and isoflurane. General anesthetic drugs used intravenously,
namely thiobarbiturates, narcotic-analgesics, other alkaloid compounds and similar
molecules, and some special drugs such as ketamine.
To determine the prognosis, the ASA (American Society of Anesthesiologists)
makes a classification based on the pre-anesthesia patient's physical status which divides
the patient into 5 groups or categories as follows:
 ASA 1, namely the patient is in good health who requires surgery.
 ASA 2, namely patients with mild to moderate systemic abnormalities either due to
surgical disease or other diseases. For example, patients with ureteral stones with
hypertension being controlled, or patients with acute appendicitis with leukocytosis
and fever.
 ASA 3, namely patients with severe systemic disorders or diseases caused by
various causes. For example, patients with perforated appendicitis with septicemia,
or patients with obstructive ileus with myocardial ischemia.
 ASA 4, namely patients with severe systemic disorders that directly threaten their
lives.
 ASA 5, namely patients with severe systemic disorders who are no longer able to be
helped, whether operated on or not within 24 hours the patient will die. Examples
are elderly patients with cranial base hemorrhage and hemorrhagic shock due to
hepatic rupture. The ASA classification is also used in emergency surgery by
including an emergency sign (E = emergency), for example ASA 1 E.
2.3.2 Anesthesia Stages
Table 3. Anesthesia Stages
Stage Name Information
1 Analgesia Begins with a conscious state and ends with loss
of consciousness. It's hard to talk; sense of smell
and pain are lost. Dreams and auditory and visual
hallucinations may occur. This stage is also known
as the induction stage
2 Excitation or delirium Loss of consciousness occurs due to compression
of the cerebral cortex. Mental confusion,
excitation, or delirium may occur. Short induction
time.
3 Surgical Surgical procedures are usually performed at this
stage
4 Medullary paralysis Toxic stage of anesthesia. Breathing is lost and
circular collapse occurs. Ventilation assistance is
required

2.3.3 Properties of an Ideal General Anesthesia

The ideal properties of general anesthesia are: (1) work quickly, good induction
and selection, (2) quickly achieve deep anesthesia, (3) wide safety margin; (4) not toxic.
Deep anaesthesia requires drugs that directly reach high levels in the CNS (intravenous
drugs) or high partial pressures in the CNS (inhalation drugs). The speed of induction and
recovery depends on the level and rate of change of anesthetic drug levels in the CNS.

2.3.4 Stages of Action General Anesthesia

1. Pre-anesthetic assessment and preparation
Inadequate pre-surgical preparation is a risk factor for accidents in anesthesia. Before
the patient is operated on, the patient should be visited first so that when the patient is
operated on, the patient is in good health. The purpose of the visit is to reduce surgical
morbidity, reduce operating costs, and improve the quality of health services.
2. Pre-surgical assessment
1) Anamnesis
A history of whether the patient has received anesthesia before is very important
to find out if there are things that need special attention, such as allergies, nausea,
vomiting, muscle pain, itching, or shortness of breath after surgery so that the next
anesthesia can be planned properly. Some researchers recommend that drugs that have
caused problems in the past should not be reused, for example halothane should not be
reused within 3 months or succinylcholine which causes prolonged apnea also should
not be repeated. Smoking habits should be stopped 1-2 days before.
2) Physical examination
Examination of the teeth, opening the mouth, or a relatively large tongue is very
important to know whether it will complicate laryngoscopy intubation. A short, stiff
neck will also complicate laryngoscopy intubation. Routine systemic examination of
the general state of course should not be missed such as inspection, palpation,
percussion and auscultation of all the patient's organ systems.
3) Laboratory examination
Laboratory tests are carried out for appropriate indications according to suspected
disease. Examinations performed included blood tests (Hb, leukocytes, bleeding time,
and clotting period) and urinalysis. At the age of patients over 50 years there is a
recommendation for an EKG and chest photo.
4) Fitness for anesthesia
The classification commonly used to assess a person's physical fitness is
originating fromThe American Society of Anesthesiologists (ASA). This physical
classification is not a tool for estimating anesthetic risk because side effects of
anesthesia cannot be separated from side effects of surgery.
 Class I: Organic, physiological, psychiatric, biochemical healthy patients.
 Class II: Patients with mild or moderate systemic disease.
 Class III: Patients with severe systemic disease limiting routine activities.
 Class IV: The patient with severe systemic disease is unable to carry out routine
activities and the disease poses an imminent threat to life.
  Class V: Patients with severe systemic disease who can no longer be helped,
whether they are operated on or not, will die within 24 hours.In cito or emergency
surgery, the letter E is usually written.
5) Oral input
Laryngeal reflexes are decreased during anesthesia. Regurgitation of gastric
contents and debris in the airways is a major risk in patients undergoing anesthesia. To
minimize this risk, all patients scheduled for elective surgery under anesthesia should
abstain from oral intake (fasting) for a specified period prior to induction of
anesthesia. In adult patients generally fasting 6-8 hours, small children 4-6 hours, and
in infants 3-4 hours. Lean food is allowed 5 hours before induction of anaesthesia.
Drink water, sweet tea for up to 3 hours, and for medicinal purposes drink water in
limited quantities, 1 hour before induction of anesthesia.
3. Premedication
Before the patient is given anesthetic drugs, the next step is
donepremedicationnamely the administration of drugs before the induction of
anesthesia is given with the aim of facilitating induction, maintenance, and awakening
from anesthesia including:
1) Create a sense of comfort for the patient
a) Eliminating worry through pre-anesthesia visits, understanding the problems
encountered, ensuring the success of the operation.
b) Provide calm (sedative).
c) Create amnesia.
d) Reducing pain (non-narcotic or narcotic analgesics).
e) Prevent nausea and vomiting.
2) Facilitate or expedite induction. Administration of sedative or narcotic hypnotics.
3) Reducing the amount of anesthetic drugs. Administration of sedative or narcotic
hypnotics.
4) Suppresses unwanted reflexes (vomiting or drooling)
5) Reduces secretion of salivary glands and stomach
Administration of the drug subcutaneously will not be effective within 1 hour,
intramuscularly must be waited at least 40 minutes. In very emergency cases with
 uncertain timing of surgery drugs can be given intravenously. Medication will be most
effective before induction. If surgery has not started within 1 hour, intramuscular
premedication is recommended, subcutaneous administration is not recommended. All
premedication drugs given intravenously can cause slight hypotension except atropine
and hyoscine. This can be reduced by administering slowly and diluted.
Commonly used drugs:
1) Narcotic analgesic
a) Pethidine (amp 2cc = 100 mg), dose 1-2 mg/kgBB
b) Morphine (amp 2cc = 10 mg), dose 0.1 mg/kgBB
c) Fentanyl (fl 10cc = 500 mg), dose 1-3μgr/kgBB
2) Hypnotic
a) Ketamine (fl 10cc = 100 mg), dose 1-2 mg/kgBW
b) Pentotal (amp 1cc = 1000 mg), dose 4-6 mg/kgBB
3) sedative
a) Diazepam/valium/stesolid (amp 2cc = 10mg), dose 0.1 mg/kgBB
b) Midazolam/dormicum (amp 5cc/3cc = 15 mg), dose 0.1mg/kgBB
c) Propofol/recofol/diprivan (amp 20cc = 200 mg), dose 2.5 mg/kgBB
d) Dehydrobenzperidone/DBP (amp 2cc = 5 mg), dose 0.1 mg/kgBB
4) Anticholinergic
a) Atropine sulfate (anticholinergic) (amp 1cc = 0.25 mg), dose 0.001 mg/kgBB
5) Neuroleptic
a) Droperidol, a dose of 0.1 mg/kgBB

4. Anesthesia induction
Is an action to make the patient from conscious to unconscious so as to allow the
start of anesthesia and surgery. Induction can be done intravenously, inhalation,
intramuscularly, or rectally. After the patient sleeps due to induction of anesthesia, it is
immediately followed by maintenance of anesthesia until the surgical procedure is
complete.
For the preparation of induction of anesthesia is necessary'STATIC':
 S:scopes -Stethoscope to listen to lung and heart sounds. Laryngoscope select blades
or blades (blades) according to the age of the patient. The lamp must be bright
enough.
Q:Tubes-Tracheal tube choose according to age. Age < 5 years without balloon
(cuffed) and > 5 years with balloons (cuffed).
A:airways-pharyngeal tube (guedel,oro-tracheal airway) or nasal-pharyngeal tube
(naso-tracheal airway). This pipe is to hold the tongue when the patient is
unconscious to keep the tongue from blocking the airway.
Q:Tape-Plaster for pipe fixation so that it is not pushed or pulled out.
I:Introducer-Mandrin or stylet of wire wrapped in plastic (cable) that easily bends for
guides to allow easy insertion of the tracheal tube.
C:Connectors-Connection between the pipe and anesthesia equipment.
S:Suction-suction mucus, saliva, and others.

Types of induction of general anesthesia are:

a. Intravenous induction
 Most done. Intravenous indications are done carefully, slowly, gently, and under control.
The bolus induction drug is injected at a rate of between 30-60 seconds. During induction
of anesthesia, the patient's breathing, pulse, and blood pressure should be monitored and
oxygen should always be administered. Performed on cooperative patients.
 Intravenous induction drugs:
 Tiophental (pentothal, tiophenton)
preparationampoules of 500 mg or 1000 mg. Before use it is dissolved in sterile
distilled water to a concentration of 2.5% (1 ml = 25 mg). Only used for intravenous
at a dose of 3-7 mg/kg injected slowly spent in 30-60 seconds. Depending on the dose
and rate of injection, tiophental will cause the patient to be in a state of sedation,
hypnosis, anesthesia or respiratory depression. Tiophental reduces cerebral blood
flow, liquor pressure, intracranial pressure, and is thought to protect the brain from
O2 deficiency. Low doses are anti-analgesic.
Contra indication:
1) Children under 4 years
 2) Shock, anemia, uremia and debilitated patients
3) Respiratory disorders: asthma, shortness of breath, mouth and respiratory tract
infections
4) Heart disease
5) Liver disease
6) Patients who are too fat so it is difficult to find a good vein.
b. Intramuscular induction
Until now, only ketamine (ketalar) can be administered intramuscularly at a dose of 5-7
mg/kg and after 3-5 minutes the patient is asleep.
c. Inhalation Induction
 N2O(laughing gas, laughing gas, nitrous oxide, nitrous oxide)
It is a gas, colorless, has a sweet odor, is non-irritating, non-flammable, and
weighs 1.5 times the weight of air. Administration must be accompanied by at least 25%
O2. It is a weak anesthetic and strong analgesic, so it is often used to reduce pain before
childbirth. Inhalation anesthetics are rarely used alone, often in combination with one of
the other anesthetic fluids such as halothane.

 Halothane (fluothane)
Also as an induction for laryngoscope intubation, provided that the anesthesia is
deep enough, stable, and before the action is given an analgesic spray of 4% or 10%
lidocaine around the pharynx-larynx. Halothane induction requires an O2 boost gas or a
mixture of N2O and O2. Induction begins with O2 flow > 4 ltr/min or a mixture of
N2O:O2 = 3:1. Flow > 4 ltr/min. If the patient coughs, the concentration of halothane is
lowered, then when it is calm, it is increased again until the concentration is needed.
Overdosage can cause respiratory depression, decreased sympathetic tone, hypotension,
bradycardia, peripheral vasodilation, vasomotor depression, myocardial depression, and
inhibition of baroreceptor reflexes. It is a weak analgesic but a strong anesthetic.
Halothane inhibits the release of insulin thereby increasing blood sugar levels.
 Enflurane
 The respiratory depressant effect is stronger than that of halothane and enflurane
is more irritating than halothane. Circulatory depression is more potent than halothane
but causes arrhythmias less frequently. The relaxing effect on striated muscles is better
than that of halothane.
 Isoflurane (foran, aeran)
Elevates cerebral blood flow and intracranial pressure. Increased cerebral blood
flow and intracranial pressure can be reduced by hyperventilation anesthetic techniques
so that isoflurane is widely used for brain surgery. The effect on cardiac depression and
cardiac output is minimal, so it is popular for anesthetic technique of hypotension and is
widely used in patients with coronary disorders.
 Desflurane (suprane)
Very volatile. Low potency (MAC 6.0%) is sympathomimetic causing
tachycardia and hypertension. Respiratory depressant effects such as isoflurane and etran.
Stimulate the upper airway so that it is not used for induction of anesthesia.
 Sevoflurane (ultane)
Induction with sevoflurane is preferred because the patient rarely coughs even
when given directly at high concentrations up to 8 vol%. Induction and recovery from
anesthesia are quicker than isoflurane. It has a non-stinging odor and does not stimulate
the airways, so it is popular for inhalation anesthetic induction in addition to halothane.
d. Rectal Induction
Anesthesia is absorbed through the rectal mucosa into the blood and then reaches the
brain. Used for diagnostic procedures (cardiac catheterization, photo x-rays, examination of
the eyes, ears, oesophagoscopi, irradiation, etc.), especially in infants and young children.
Also used as induction of narcotics by inhalation in infants and children.

2.3.5 Anesthesia Complications and Anesthesia Hazards

Anesthesia complications can end in death or unexpectedly even though the
anesthesia procedure has been carried out properly. In general, the complications of
anesthesia that are often encountered include:
1. Physical Damage
 Physical damage that can occur as a complication of anesthesia include: blood
vessels, intubation, and superficial nerves.
2. Blood vessel
Technical errors in venipuncture can cause bruising, drug exavation which can
cause overlying skin ulceration, local infection, thrombophlebitis and damage to
adjacent structures, especially arteries and nerves. Several drugs including
Benzodiazepines and Propanidide cause thrombophlebitis. Prolonged venous
cannulation is more likely to cause thrombophlebitis and infection.
3. Intubation
Damage often occurs to the lips and gums as a result of tracheal intubation by an
inexperienced person. Tooth decay will be more serious if accompanied by the
possibility of inhalation of fragments followed by a lung abscess. If left undetected,
nasotracheal intubation can cause unpleasant epistaxis and sometimes a tube can form a
passage under the nasal mucosa; nasal intubation often fractures the concha. Damage to
the tonsillar and larynx structures (especially the vocal cords) is fortunately common,
but the rough handling of the posterior oral structures contributes to postoperative sore
throat.
4. Superficial Nerve
Continuous direct pressure will damage the nerves, such as the lateral popliteal as
it surrounds the head of the fibulae, which causes "foot drop”, facial when it crosses the
mandible, which paralyzes the facial muscles, ulnar when it crosses the medial
epicondyle, which causes paralysis and loss of sensation in the hand and the radial
nerve as it circles the humerus posteriorly, which causes “wrist drop”. The brachial
plexus can be damaged by stretching it over the humeral head if the arm is abducted or
externally rotated too far.
5. Respiratory
Respiratory complications that may arise include undetected hypoxaemia,
atelectasis, bronchitis, bronchopneumonia, lobar pneumonia, hypostatic pulmonary
congestion, pneumonia, and superinfection.
Respiratory failure is primarily a postoperative phenomenon, usually due to a
combination of events. Muscle weakness after recovery from inadequate relaxants,
 central depression with opioids and anesthetics, inhibition of cough and inadequate
alveolar ventilation secondary to wound pain combine to causeRestrictive respiratory
failure with CO2 retention and later CO2 narcosis, especially if PO2 is maintained with
oxygen administration.
6. Cardiovascular
Cardiovascular complications that can occur include hypotension, hypertension,
cardiac arrhythmias, and heart failure. Hypotension is defined as systolic blood
pressure less than 70 mmHg or a decrease of more than 25% from the previous value.
Hypotension can be caused by hypovolemia caused by bleeding, anesthetic drug
overdose, cardiovascular disease such as myocardial infarction, arrhythmia,
hypertension, and drug-induced hypersensitivity reactions, muscle relaxants, and
transfusion reactions.
7. Heart
The cause of postoperative hepatitis can be caused by halothane. The incidence of
active Hepatitis A virus in the general population is probably much more prevalent,
estimated to be around 100–400 per million at any one time. Repeated Halothan
anaesthesia at 6 week intervals should probably be avoided.
8. Body temperature
As a result of peripheral venodilation that is still elicited by anesthesia, it causes a
decrease in core body temperature. During prolonged surgery, especially with exposed
vesera, severe hypothermia may occur, resulting in delayed return of consciousness,
breathing and inadequate peripheral perfusion. Respiratory problems will be
complicated, if the need for oxygen increases as a result of shivering during the
postoperative period.