GENERAL ANESTHESIA

Dr. Emilzon Taslim, Sp. An. M.Kes Medical Faculty University of Andalas M. Djamil Hospital

ANESTHESIA
GENERAL Intravenous Inhalation Intramuscular LOCAL
Topical

COMBINATION

Spinal + Infiltration propofol

Block peripheral nerve Spinal Epidural Caudal IVRA

General anesthesia
A reversible state of unconsciousness

produced by anesthetic agent, with loss of sensation of pain over the whole body. Reversible irregular CNS depression. General anesthetic drugs are administered by inhalation, intravenously, intramuscularly, orally, rectally.

The order of descending depression of the CNS

Cortical and psychic centers Basal ganglia and cerebellum Spinal cord Medullary centers

GENERAL ANESTHESIA

TRIAS ANESTHESIA Hypnotic Analgesic Relaxation

BALANCED ANESTHESIA

Balance anesthesia
Anesthesia component Hypnotic Analgesic Relaxation Drugs Pentothal, Propofol, Enflurane, Isoflurane, Sevoflurane Pethidine, Morphine, Fentanyl, Sufentanil, Remifentanil Succ choline, Atracurium, Cisatracurium, Pancuronium

Anesthetic drugs
Volatile anesthetic inhalation :

Halogen hydrocarbon (halothane) Halogen ether: enflurane, isoflurane, desflurane, sevoflurane Gas anesthetic inhalation : cyclopropane, N2O, ethylene. Intravenous : thiopental, propofol, ketamine, etomidate, diazepam, midazolam

Concept balanced anesthesia

Component VIMA anesthesia Hypnotic Analgesic Sevo, Iso, Enf, Hal, Desfluran TIVA Propofol, Pento, Ket, Mid

Fentanyl, alf, suf ,Mo, Fentanyl, alf, pethidine, remifentanilsuf ,Mo, pethidine, remifentanil Depol & non depol Depol & non depol

Relaxation

Indication general anesthesia

Infant and young children. Adult who prefer general anesthesia. Extensive surgical procedures Patient with mental disease Prolonged surgery Patient with a history of toxic or allergic

reaction to local anesthetic drugs Patient on anticoagulant treatment

General anesthesia
Induction inhalation, maintenance

anesthesia with inhalation anesthetic (VIMA) Induction intravenous , maintenance anesthesia with intravenous anesthetic (TIVA) Induction intravenous, maintenance anesthesia with inhalation anesthetic

General anesthesia technique

Spontaneous breathing Controlled ventilation Face mask Intubation LMA (Laryngeal Mask Airway) COPA (Cuffed Oro Pharyngeal Airway) LSA (Laryngeal Seal Airway)

Concentration of Anesthetic Agent

Inspired Gas

Alveolar Arterial Gas Blood

Brain

Brain

Venous Blood

Alveolar Inspired Gas Gas

Gambar : Perbedaan tekanan zat anestesi inhalasi pada saat induksi dan pemulihan.

Techniques of general inhalation anesthesia

Open-drop technique Insufflation Ayre T-piece system System with non-rebreathing valve Semiclosed Closed

Breathing circuit system

Open system Semi open system Semi closed system Closed system

Flow Rate Definition : Metabolic-flow : 250 ml/minute Minimal-flow ml/minute Low-flow ml/minute : 500 - 1000 : 250 500

Advantageous Low-flow anesthesia

Less of anesthesia gas consumption Less of pollution Heat loss decrease Cost effective

THE EQUIPMENT

Component anesthesia machine

Gas sources : Oxygen, N2O Reducing valve or pressure regulator Flow meter Vaporizer for halothane, enflurane,

isoflurane, desflurane or sevoflurane. CO2 absorption system (soda lime or bara lime)

 SEE THE MOVIE

Gases Vapors Diffusion Solubilities COMP. C.O. B.W. % %

L.Heart M.G. V.R.G. Brain Heart Splanc Kidney V.P.G. 20 55

FA

Circulation

75

R.Heart

38

Inspired Mixture Ventilation Blood Carriage Tissue Uptake

Figure : Schematic diagram of uptake and distribution of inhalation anesthetics. The inspired concentration. F1 or fraction inspired, of anesthetic is under direct control of the anesthetist. F1 is delivered to the alveoli by the minute volume of ventilation (M.V.V.). The alveolar concentration, FA or fraction in alveoli, regulates tension (partial pressure) of anesthetic agent in arterial blood. The four tissue groups or compartments (COMP), the vesel rich group (V.R.G.) tend toward equilibration with anesthetic tension in arterial blood but reach that equilibrium at rates determined by the volume of blood flow to each tissue. The brain is the site of action. C.O. = cardiac output and B.W. = body weight, both expressed in percent. SPLANC = splanchnic circulation.

Pa

Uptake and distribution

Respiration factor Circulation factor Anesthetic gas factor Tissue factor

Respiration factor
Inspiration concentration Ventilation effect

Circulation Factor
Solubility (partition coefficient) Cardiac output The difference of gas partial pressure

alveoli and vein

Partition coefficient of anesthetic

Anesthetic Ether Halothane Enflurane Isoflurane N2O Blood/gas Brain/blood Tissue/blood 12.1 2.3 1.8 1.4 0.47 1.1 2.6 2.6 3.7 1.1 0.9 2.5 1.7 4.0 1.2

Anesthetic gas factor

MAC (Minimal Alveolar concentration) MAC 50, MAC 95 MAC Ei 50, MAC Ei 95 MAC BAR 50, MAC BAR 95

MAC inhalation anesthetic

MAC =minimal alveolar concentration, in 1

atmosphere, 50% patient without movement in noxious stimuli MAC Ei = concentration of volatile agent permitting laryngoscopy and intubation without untoward movement. MAC BAR = concentration of volatile agent required to block adrenergic response to skin incision

MAC inhalation anesthetic, 40 years old.

Volatile anesthetic Halothane Enflurane Isoflurane Desflurane Sevoflurane N2O MAC 0,72 1.68 1.12 6.0 2.05 105.2

Factors influencing or not influencing MAC

MAC decreased MAC unchanged MAC increased
Increasing age CNS depressant: alcohol, barbiturate, lidocaine, benzodiazepine, narcotic Duration of anesthesia Gender Species Hypertension Hypocarbia Alcoholism chronic Hyperthermia > 42 Hypercarbia Anemia

Tissue factor
Tissue rich vessel : brain, heart, endocrine,

kidney. Intermediate : muscle, skin. Fat. Tissue poor vessel : ligament, tendon.

General anesthesia planning

Pre operative visit Premedication Anesthesia technique : General, Regional Intraoperative Postoperative

Anesthesia technique : General anesthesia

Airway controlled Induction Maintenance anesthesia Analgesia Muscle relaxation

Intraoperative
Monitoring Patient position Crystalloid and colloid Special technique

Postoperative
Post operative pain treatment Send patient to Ward or ICU

INTRAVENOUS ANESTHETIC

Intravenous anesthetic
Pentothal Propofol Etomidate Midazolam Diazepam

Ideal intravenous anesthetic

Water soluble Non irritation No anta analgesic effect Rapid and smooth Induction Cardiovascular stable in clinically dose

Thiopentone
Blood pressure decrease Heart rate increase or decrease Peripheral vasodilatation Heart contraction depressed Larynx spasm, bronchus spasm Respiratory depression until apnoea Dose 4-6 mg/kg BW

Relative contraindication thiopentone

Asthma bronchiale Severe liver disease Severe kidney disease Severe anemia Hypotension Shock

Ketamine

Dissociative anesthetic Delirium Hallucination Increase blood pressure : systolic 23% from base line Increase heart rate Arrhythmias Hypersecretion Dose 1-3 mg/kg I.v or 9-11 mg/kg I.m

Indication and Contraindication Ketamine

Indication : short surgery Contraindication : Hypertension systolic >

160 mmHg Arrhythmias Heart failure Pharynx and larynx surgery without intubation.

Propofol
New intravenous anesthetic Fast onset, short duration of action Accumulation minimal Fast recovery Rapid metabolism No complication at site of injection Dose 2-2.5 mg/kg BW

Pharmacology Propofol
No histamine release/reaction anaphylactoid

(chremophor El change with soya bean oil). Perivascular injection, tissue necrosis negative. Injection intra artery : tissue necrosis negative.

Effect Propofol to CNS

Hypnotic effect 1,8 time pentothal Airway depression > pentothal Anti emetic effect No anti convulsant effect

Comparative properties of intravenous anesthetics

Thiopen Ketamin Propof Aqueous solution Available in solution Pain on injection Venous thrombosis + + + + + Diazep Midaz + + + + + -

Comparative properties of intravenous anesthetics

Thiopen Ketamin Propof Rapidly acting + Smooth induction ++ Respiratory depression + Cardiovascula r depression ++ + + + + ++ Diazep Midaz + +/+ +/+/-

Comparative properties of intravenous anesthetics

Thiopen Ketamin Propof Rapid recovery Smooth recovery Suitable for infusion Interaction with relaxant + +/+ + +/Diazep Midaz -

Resume: Effect anesthetic non volatile to organ system

Drug Thiopentone Diazepam Midazolam Meperidine Morphine Fentanyl Ketamine Propofol HR 0/ 0 MAP * * Vent Bdil 0 0 * * 0 0

Resume: Effect anesthetic non volatile to CNS

Drug Thiopentone Diazepam Midazolam Meperidine Morphine Fentanyl Ketamine Propofol CBF CMRO2 ICP

INHALATION ANESTHETIC

Choice of anesthetic inhalation

Cardio pulmonal effect Product degradation with soda lime What metabolites ? How much metabolism?

Ideal anesthetic inhalation

Pleasant odor and non irritation Low solubility No organ toxic Side effect cardiovascular and respiration minimal CNS effect reversible without stimulant activity Effective in high O2 concentration Boiling pressure and boiling point can delivered by

vaporizer standard

New Trend in General Anesthesia

VIMA Fast-Track Anesthesia Low-flow Anesthesia Low-cost Anesthesia
Single-breath induction (Rapid induction)

Physicochemical properties
Halothane Odor + Irritating to Resp system Solubility 2,35 MAC 0,76 Metabolism 17-20% Metabolites F, Cl, Br, TFA BCDFE, CDE, CTE, DBE Enfl + 1,91 1,68 2,4% F, CDA Isofl + 1,4 1915 <0,2% F, TFA Desfl + 0,42 6,0 0,02% F, TFA + 0,63 2,05 <5% F, HFIP

Sevo

Interaction with Sodalime

Anesthetic Halothane Enflurane Isoflurane Desflurane Sevoflurane degradation Product BCDFE CO CO CO Compound A Compound B organ Toxicity clinical Relevancy Nephrotoxic Nephrotoxic Non identified to data Non identified to date

WHY VIMA???
intravenous induction, ex: Propofol : rapid

and smooth induction, but need vein access first, hypotension, apnoe. Pediatric anesthesia commonly by VIMA. More advantages than intravenous induction, maintenance inhalation.

Cardiovascular effect of Volatile inhalational anesthetics

Variable
Blood pressure Vascular resistance Cardiac output Cardiac contraction CVP Heart rate Sensitization of the heart to epinephrine
0 = No change (<10%) = increase

Halothane Enflurane Isoflurane

0 0
= Variable change

0 0 0 0?
= 20-40% decrease

= 10-20% decrease

Clinical pharmacology of Inhalational anesthetics : Respiratory

N2O Halo Enflur Isoflu Sevoflu

Tidal volume Resp rate PaCO2 resting

Clinical pharmacology of Inhalational anesthetics : CNS

N2O Halo Enflur Isoflu Sevoflu

CBF ICP CMRO2 Seizure

Clinical pharmacology of Inhalational anesthetics

N2O Halo Enflur Isoflu Sevoflu

HBF Nondep blockade Metabolism

0.004 15-20 2.5

0.2 2-3

N2O
1.5 time heavier than air Must be give with O2 100% Weak anesthetic Analgesic N2O 20% equal with 15 mg

morphine Dont use in closed system At the end of anesthesia, to prevent diffusion hypoxia O2 100%

Advantages N2O
Rapid induction and recovery No sensitized myocardium with

catecholamine No irritation respiratory tract Odor pleasant Strong analgesic

Disadvantages N2O
Weak anesthetic No muscle relaxation effect Need high concentration oxygen Possibility aplasia bone marrow

Halothane
A clear, colorless, potent volatile liquid. Metabolism 17-20%

Advantages Halothane
Rapid, smooth induction and recovery. Pleasant Non irritating, no secretion Bronchodilator Nonemetic Non flammable and non explosive

Disadvantages Halothane
Myocardial depressant An arrhythmia producing drug Sensitizes the myocardial conduction

system to the action of catecholamines A potent uterine relaxant Possible toxic to the liver Shivering during recovery period.

Enflurane
A clear, colorless, stable volatile liquid with

a pleasant ether-like odor. A potent inhalation anesthetic CNS excitation Use of epinephrine : saver than halothane.

Advantages Enflurane
Pleasant Rapid induction and recovery Non-irritating : no secretion Bronchodilator Good muscle relaxation Nonemetic Non flammable and non explosive Compatible with epinephrine

Disadvantages Enflurane
Myocardial depressant Shivering on emergence CSF production increase CNS excitation, in high dose and

hypocarbia.

Isoflurane
A stabe, volatile liquid A isomer enflurane Inhalation anesthetic choice for

neurosurgical patient, kidney, liver.

Advantages Isoflurane
Rapid induction of anesthesia and swift

recovery Nonirritating : no secretion Blood pressure remain stable Indicated in poor-risk patient

Disadvantages Isoflurane
Less than halothane and enflurane

Sevoflurane
Inhalation

anesthetic with low solubility (0,63), low MAC (2,05), pleasant odor, no airway irritation, rapid uptake and elimination , cardio vascular stable. Rapid induction, with technique single breath induction, induction time 23 seconds.

Sevoflurane
Drugs of choice for Neuro anesthesia :

WCA 2000 Montreal, Canada. Drugs of choice for Pediatric Anesthesia : ESA Barcelona, 1998. ASPA, Singapore, 2000., ESA Sweden 2001. In Sectio Caesarea equal with Isoflurane and spinal anesthesia Reduce sphlannic blood flow, hepatic blood flow lesser than other anesthetic inhalation.

NARCOTIC ANALGESIC

Narcotic analgesic ideal : o o o o o o o Wide margin of safety Fast onset of action Short duration of action Easier analgesia controlled Strong analgesic no histamine release Non active metabolite

Opiate in Anesthesia 1. 2. 3. 4. 5. 6. 7. Premedication Induction Anesthesia Narcotic anesthesia A part of balanced anesthesia Adjuvant in regional anesthesia Neurolept anesthesia Post operative pain relief

Drugs

Protein binding

Lipid solubilit

Morphine Pethidine Fentanyl Sufentanil Alfentanil

++ +++ +++ ++++ ++++

+ ++ ++++ ++++ +++

Note : + = very low; ++ = low; +++ = high ++++ = very high

Narcotic effect :

y Bradycardia : central vagotonic effect & SA & AV node depression y Respiratory depression : respiratory rate, rhythm, Response CO2, Minute Volume, Tidal Volume y Muscle stiffness y Nausea vomiting cause by stimulation CTZ, GIT mobility, decrease gastric mobility, increased

Clinical Doses of Narcotics

Drug Morphine Meperidine Fentanyl Sufentanil Alfentanil i.v dose 0.05-0.3 mg/kg 0.5-1 mg/kg 1-5 ug/kg 10-40 ug/kg 30-80 ug/kg Onset (min) 5-10 5-10 2 <1 <1 Approximate duration 3-5 h 2-3 h 45 min 2 h < 30 min < 60 min

MUSCLE RELAXANT

Muscle relaxant
Very useful in general anesthesia. laryngoscopy and intubation more easier

and avoid injury Muscle relaxation very useful during surgery and controlled ventilation

Ideal muscle relaxant

Non depolarization Rapid onset, short duration of action Rapid recovery, high potency non cumulative, metabolite non active No cardiovascular effect No histamine release Counteract with anticholinesterase

Mechanism neuromuscular blockade

Competitive block : non-depol, avoid AcCh

access to receptor. Depolarization block : depol, depolarization as AcCh but permanent Deficiency block: influence syntesis and release AcCh: Procaine, toxin botulinus, Ca decrease, Mg increase.
Morgan GE, Mikhail MS. Clinical Anesth, 1996

Terminology in muscle relaxant

ED 50 : dose what can paralyzed 50%

muscle strength ED 90 : dose what can paralyzed 90% muscle strength. Onset : interval between start of injection until maximal effect

Table 9 - 1. Depolarizing and nondepolarizing muscle relaxants.

Depolarizing Short-acting Succinylcholine Decamethonium

Nondepolarizing Long-acting Tubocurarine Metocurine Doxacurium Pancuronium Pipecuronium Gallamine Intermediate-acting Atracurium Vecuronium Rocuronium Short-acting Mivacurium

Nondepolarizing drug
Do not produce muscular fasciculation Effect are decreased by anticholinesterase

agent, depolarizing agent, lowered body temperature, epinephrine, acetylcholine Effect are increased by non-depolarizing drugs, volatile anesthetic .

Depolarizing drugs
Produce muscular fasciculation . Effect are increased by anticholinesterase

agent, Acetylcholine, hypothermia Effect decrease with non-depolarizing relaxant drugs, anesthetic inhalation Dose Succ choline : 1 mg/kg BW

Table 9 - 5. Conditions causing susceptibility to succiniylcholine-induced hyperkalemia.

Burn injury Massive trauma Severe intra-abdominal infection Spinal cord injury Encephalitis Stroke Guillain-Barre syndrome Severe Parkinsons disease Tetanus Prolonged total body immobilization Ruptured cerebral aneurysm Polyneuropathy Closed head injury Near drowning Hemorrhagic shock with metabolic acidosis Myopathies ( eg, Duchenness dystrophy )

Table 9 - 6. A summary of the pharmacology of nondepolarizing muscle relaxant

Relaxant Tubocurarine Metocurine Atracurium Mivacurium Doxacurium Pancuronium Pipecuronium Vecuronium Rocuronium
1 2

Metabolism Insignificant Insignificant +++ +++ Insignificant + + + Insignificant

Primary Excretion Renal Renal Insignificant Insignificant Renal Renal Renal Biliary Biliary

Onset ++ ++ ++ ++ + ++ ++ ++ +++

Duration +++ +++ ++ + +++ +++ +++ ++ ++

Histamine Release +++ ++ + + 0 0 0 0 0

Vagal Blockade 0 0 0 0 0 ++ 0 0 +

Relative Potency1 1 2 1 2.5 12 5 6 5 1

Relative Cost2 Low Moderate High Moderate High Low High High High

For example, pancuronium and vecuronium are five times more potent than tubocurarine or atracurium Based on average wholesale price per 10 mL; does not necessarily reflect duration and potency Onset : + = slow; ++ = moderately rapid; +++ = rapid Duration : + = short; ++ = intermediate; +++ = long Histamine release : 0 = no effect; + = slight effect; ++ = moderate effect; +++ marked effect Vagal blockade : 0 = no effect; + = slight effect; ++ = moderate effect

Relaxation
Drug ED95 (mg/kg) Recommended Infusion rate for intubating dose steady state (mg/kg) blockade (mg/kg/h) 0.3-0.6 0.005-0.008 0.08-0.1 0.25 0.032 0.078

Atracurium 0.21 Pancuronium 0.067 Vecuronium 0.043

INDUCTION AND MAINTENANCE OF ANESTHESIA

Choice of anesthesia technique depend on:

Patient condition Skill anesthetist Skill surgeon Hospital socioeconomi

Problem during induction of anesthesia

Main problem : airway Sign of partial obstruction : snoring,

crowing, gargling, wheezing, chest retraction, cyanosis Sign of total obstruction : air flow from nose/mouth negative, supraclavicular retraction, intercostal retraction, cyanosis

Other problem during induction

Respiratory depression Cough Larynx spasm Mucus and saliva vomiting

Airway controlled
Without equipment : Triple mannuver Safar With equipment:

OPA (Oro Pharyngeal Airway) NPA (Naso Pharyngeal Airway) LMA ( Laryngeal Mask Airway) ETT (Endo Tracheal Tube)

Indication Intubation
Head and neck surgery Difficult airway Thoracotomy Laparotomy Lateral position Prone position Controlled ventilation

Technique laryngoscopy
Head position Insertion laryngoscope blade Visualization epiglottis Lift epiglottis View larynx and surrounding structure

Advantages Endotracheal intubation

Ensures a patent airway Normal anatomic dead space (75 ml) is

decreased to 25 ml. Ventilation can be assisted or controlled Possibility of aspiration diminished drastically Suctioning of the lung is facilitated

Disadvantages endotracheal intubation

Increases resistance to respiration Trauma to the lips, teeth, nose, throat,

larynx.

Complication Intubation
Teeth rupture Mouth bleeding Endobronchial intubation Oesophageal intubation Sore throat Hypertension Arrhythmias

Induction technique
Mask induction / inhalation Intravenous Intra muscular Per rectal

Mask Induction with Sevoflurane

Gradual

Induction Single Breath Induction Triple Breath Induction (Multiple Breath Induction) Fast technique with Single Breath Induction, without cough, breath holding, spasm larynx.

Gradual Induction
Classic

method for Mask Induction. To decrease respiratory tract irritation and non pungent odor no need for Sevoflurane. Combined with N2O or Oxygen 100%. Concentration Sevo increase 0.5-1,5 vol% every 2-3 breath until anesthesia adequate. Commonly reach in 60-90 seconds with Sevo 7%.

Single-Breath Induction
Priming

circuit with N2O 60% + Sevo 8% 30

seconds. Ask patient for maximal expiration (until residual volume) face mask . Ask patient inspiration maximal (vital capacity), keep 20 seconds, then normal breathing. After eyelash reflex negative, Sevo turn to 2%.

Triple Breath Induction

A

variation from Single Breath Induction Ask patient 3 times deep breath. Difference with Single Breath, no breath holding. Commonly patient sleep, in 2-3 breathing.

How to maintain anesthesia ?

Maintenance anesthesia depend on deep of

anesthesia to reach adequate anesthesia. Commonly with SEVO 1-1,5 vol% depend on type of surgery, spontaneous breathing or controlled. To reduce vol% (MAC) : add N2O or Fentanyl.

Sign of deep anesthesia

PRST Score (balanced anesthesia) Guedel sign (ether anesthesia) PRST Score (score 2-4: adequate

anesthesia) P = Systolic arterial pressure (mmHg) R = rate (heart rate) S = sweat/ lacrimation T = tear

PRST Scoring indexes for Balanced anesthesia

Index Systolic arterial pressure (mmHg) Heart rate (beats/min) Condition Less than control + 15 Less than control + 30 More than control +30 Less than control + 15 Less than control + 30 More than control +30 Nil Skin moist to touch Visible beads of sweat No excess tears when eyelids open Excess teas visible when eyelids open Tears overflow from closed eyelid Score 0 1 2 0 1 2 0 1 2 0 1 2

Sweat

Tears or Lacrimation

Extubation
After adequate ventilation In deep anesthesia or after patient awake Clear airway Oxygen 100% after and before extubation

Factor which influence total anesthetic inhalation : 1. 2. 3. 4. Constanta Fresh gas flow Volume % (MAC) Length of surgery

Total anesthetic inhalation = constanta x fresh gas flow (ml) x vol % x time (minute)

If length of surgery 2 h, total Sevoflurane :

Induction first 30 second Fresh gas x 1/183 flow (ml) 6000 x 1/183 3 minute for intubation : 6000 x 1/183 3 minute start for low-flow : 3000 x 1/183 second 3 minute: 1000 x 1/183 Operation 2 hours : 1000 x 1/183 Total Sevoflurane 11,6 ml x Vol % x 8% x 2% x 3% x 1% x 1% x time (minute) x 0,5 = 1,3 x 3 x 3 x 3 = 1,9 = 1,4 = 0,5

x 120 = 6,5

TIVA CONTINU
Propofol 6-10 mg/kg/h + Vecuronium 0.1 mg/kg/h + Fentanyl 2 ug/kg Pentotal 1-3 mg/kg/h + Vecuronium 0.1 mg/kg/h + Fentanyl 2 ug/kg Ketamine 2 mg/kg/h + Vecuronium 0.1 mg/kg/h + Diazepame 0.25 mg/kg Midazolam 50 ug/kg/h + Ketamine 2 mg/kg/h + Atracurium 0,25 mg/kg/h

POSTOPERATIVE
See: Lecture of RR and ICU

Thank you for your kind attention

Tatang Bisri Bandung, 2001