General Anesthesia

General Anesthesia

Controlled by a reversible irregular

paralysis of cells of the central nervous
system
ALL modalities of sensations are lost,
including consciousness
Depression must be REVERSIBLE, since
full recovery is very importnant
ARMAMENTARIUM
GAS MACHINES
 PURPOSE
General anaesthesia has many purposes
including:

Analgesia loss of response to pain,

Amnesia loss of memory,
Immobility loss of motor reflexes,
Unconsciousness loss of consciousness,
Skeletal muscle relaxation.
 Sequence of Depression in CNS
when G.A. is administered
1. Cerebrum
Cerebral cortex memory, judgement,
consciousness
2. Cerebellum
Basal Ganglia muscle coordination
3. Spinal Cord
Motor and sensory impulses
4. Medullary Centers
Medullary centers
 CEREBRUM
Most highly developed area of the CNS
First to be depressed
Produces loss of memory, impairment of
judgement, obtunding of the special senses,
unconsciousness
Patient will still react, however, to painful
stimuli with somewhat coordinated
muscular movements
 CEREBELLUM & BASAL
GANGLIA
Patient loses muscles coordination and mat
exhibit only purposeless movements in
response to painful stimuli.
 As the amount of anesthetic agent
increased, the irregular descending
depression will manifest itself as the
medullary centers of respiration and
circulation are bypassed and he spinal cord
are depressed.
 SPINAL CORD
Patient has now lost the ability to convey
motor & sensory impulses and thus cannot
respond to painful stimuli by any muscular
movements
 MEDULLARY CENTERS
Depressed until, if the depression is
allowed to continue, respiration and then
the circulation will cease.
THEORIES OF
GENERAL
ANESTHESIA
 ANOXIC THEORIES
Use ANOXIA as their basis no doubt
predicated on the intimate relationship
commonly exhibited between he effects of
anoxia an those of anesthetics
In effect, they stated the various anesthetic
agents inhibited the oxidative of the cells
on the CNS
 LIPID THEORY
States that there is a parallelism between
the oil-water distribution coefficient of an
anesthetic agent and its potency.
Evidence for this theory has been
strengthen with the fact that the lipid
solubility coefficient of anesthetic agents
compares favorably with their anesthetic
potency.
 Suggests that the anesthetic acts
nonspecifically on the lipid portions of the
neuronal membrane to cause a general
disturbance that causes the ion channels to
change structure thereby changing their
function

Interactions here cause a physical change

in the membrane
 SURFACE TENSION THEORY
It is based on the ability of the anesthetic
agents to lower surface tension, on which
their potency depends

This property enables the agents possesing

it to interfere with the permeability,
polarization and metabolic processes of the
cells
 ADSORPTION THEORY
Based on the concept of surface tension
It assumes that anesthetic agent thus
retarded the adsorption of other
substances.
The theory was substantiatedby the finding
of much lower concentrations of anesthetic
agent were needed to influence the activity
of enzymes in cellular structures with large
surface area than were needed in structure
free fluids
 CELLULAR PERMEABILITY
THEORY
Is an extension of the adsorption theory.
It states that reversible paralysis is produce
by a reversible decreased of cell lipid
membrane.
The decreased permeability for fat soluble
substance seems to be increased.
 COAGULATION THEORY
It is the earliest of all the theories of
anesthesia
Anesthesia results from the reversible
coagulation of proteins which is indeed
true for a limited number of agents.
 DEHYDRATION THEORY
Based on the assumption that anesthesia is
produced by dehydration of the cells in the
CNS.
It supposes that he brain loses some of its
water content under anesthesia
 MICROCRYSTAL THEORY
Based on the molecular properties of
anesthetic agent and aqueous molecular
structure of nervous tissue.
The theory involves the interaction of
molecules of the anesthetic agent and
water molecules of the brain, which is 78%
water rather than lipid molecules
 It suggests that consciousness is loss when
submicroscopic crystals are formed in the
aqueous part of the brain subtance.
ADMINISTRATION
OF GENERAL
ANESTHESIA
 To obtain general anesthesia

Anesthetic agent must be

introduced in the body

Will eventually be absorbed

into the blood stream

Reach the susceptable areas

of the central nervous system
Agent reaches a certain concentration
in these areas

Exerts its depressant effect on the

cells

Increases concentration = depression

becomes more pronounced

Unconsciousness and other

manifestations of GA developed
 What must be maintained for a
satisfactory result of GA?
Sufficient concentration of the anesthetic
agent.
Enough oxygen to supply the patients
metabolic needs
An efficient elimination of Carbon Dioxide
 ROUTES OF
ADMINISTRATI
ON
 Inhalation Route
Anesthetic agent is given as GAS, VAPOR,
or LIQUID
vaporized through a mask so that it is
eventually taken into the lungs then
transmitted into the blood stream
 Inhalation Route
Transmission is dependent on a gradient or
pressures between the concentration of
anesthetic in the lungs and that in the
blood stream
 5 Different Methods of
Inhalation Route
1. OPEN DROP
A suitable mask or gauze stucture is needed for
penetration and vaporization of volatile
anesthetic agent
No other cloth or confining covering is used
2. SEMI-OPEN DROP
Same as the open drop method except that a
confining wrapper or covering is used to
uncrease the concentration of anesthetic
vapor more readily within the area.
Confining wraper or covering also prevents
the entrance of atmospheric air and the exit
of carbon dioxide
3. INSUFFALATION
Done by vaporizing a volatile anesthetic agent
by air or oxygen under pressure.
Resultant mixture is brought by a catheter
into the upper respiratory passeges
4. SEMI-CLOSED
Done by using an anesthetic apparatus where
in controlled amounts of anesthetic agent and
oxygen are delivered by meanes of gauges,
vaporizers, breathing tube and masks.
Exhalation are blown into the atmosphere,
which maintains equilibrium of gasses,
reduces mechanical dead space and affords an
efficient elimination of carbon dioxide.
5. CLOSED
Done in the same manner as that of the semi-
closed to a closed system
Difference with semi closed is that the
exhalations are confined to a closed system
Anesthetic machine and the external part of
the respiratory system are in one continuous
circuit where exhalations or inhalations are
routed through a chemical compound (soda
lime)
 May be accomplished by using:
CIRCLE FILTER - gasses pass
over the canister with soda
only during inhalation
To-and-fro System gasses
pass over the soda lime during
both exhalation and inhalation
 ROUTES OF
ADMINISTRATION (cont.)
Quizon, Lhajean May
 INTRAVENOUS ROUTE
Most direct route for
inducing
unconsciousness
Anesthetic agent:
carried directly into
the venous circulation
2 techniques:
a. INTERMITTENT TECHNIQUE
An intravenous agent is injected
slowly into the bloodstream until
desired plane of anesthesia is
reached
Patient watched carefully as the
signs of anesthesia are observed
Additional intravenous agent is
administered when necessary to
maintain the proper level of
anesthesia
b. CONTINUOUS DRIP
TECHNIQUE
Employs the anesthetic agent in
a much weaker concentration
and allows it to drip constantly
into the venous circulation
Rate of the drip is increased or
decreased as desired to
maintain the proper plane of
anesthesia
 Inhalation and Intravenous
Most frequent routes used to secure
anesthesia for dental and oral surgery
Afford the anesthesia a fairly accurate
control of the degree of depression of the
central nervous system
RECTAL ROUTE
Anesthesia is administered
rectally in a single dose
and is absorbed onto the
bloodstream to elicit it
effects
Anesthetist does not have
minute to minute control
over the depth of
anesthesia
Often used when basal
narcosis is needed and is
supplemented by
inhalational anesthesia
 INTRAMUSCULAR ROUTE
Anesthetic drug or agent is
injected into the muscle tissues
and then absorbed into the
bloodstream to produce the
desired effect
Provides the anesthetist little
control of the drug one it is
administered
Used primarily for
premedication
90 positioned
INTRAORAL ROUTE
Patient is instructed to
swallow a previously
calculated dose
Provides the anesthetist
little control of the drug
one it is administered
Used primarily for
premedication purposes
Method of choice of most
dentists for
premedication for the
reason of convenience of
the administration
 Mode of Action
First type of body tissue
to be depressed = brain
Brain: more readily
susceptible to the
depressant action of
anesthetic agents
: receive a
proportionately higher
percentage of circulating
blood volume
General anesthetic
agents:
Depress brain tissues in
advance of other body
tissues
Selectively depress
specific cells of brain so
that the ital functions are
lost in a predetermined
manner
Dissolved in the
circulating blood and
transported by this
means to the circulatory
system
 What happens when in When concentration in
bloodstream tissues=
the circulatory system? direction of diffusion is
During each circuit of the reversed
blood a certain proportion Result:
of the dissolved agent is: Exertion of a depressant
Carried to the brain action
Carried to the other tissue Reversal of the temporary
paralysis
Being excreted Return of the ell to the
Remained in the circulating normal
blood to reinitiate the Why would the
previous action concentration in the
This action continues with bloodstream fall?
the direction of diffusion: Detoxification
Higher concentration in the Elimination
bloodstream lower Reduced administration
concentration in the tissues
 Control of the anesthetic in the
bloodstream depends on :
Rate of uptake of the anesthetic agent
Excretion from the circulating blood
Excretion via: lungs kidneys and liver
 GENERAL ANESTHESIA IN
DENTAL PROCEDURES
Patients level of fear is usually a more important
factor than the nature of the procedure
High levels of preoperative anxiety lengthy and
complex procedures and need for a pain free
operative period ay be indications for general in
anesthesia in healthy adults and young children
At least 3 professionals are required:
Operating dentist
A professional responsible for observing and
monitoring the patient
Assistant of the operating dentist
 INDICATIONS FOR GENERAL
ANESTHESIA
1. Children who are too young to cooperate
2. Lancing abscesses
3. Adults who are abnormally fearful of needle
4. Extraction of teeth in the early stage of
suppurative infection
5. Multiple uncomplicated extractions
6. In its analgesic stage for preparation of
sensitive teeth for fillings
7. Treatment of peridental disease
 CONTRAINDICATIONS FOR
GENERAL ANESTHESIA
1. Presence of persistent thymus glands in children(status lypmhaticus)
2. Exopthalmic goiter diabetes or other disturbance of endocrine function
3. Abnormally high blood pressure
4. Uncompensated valvular lesions of the heart myocarditis pronounced
cardiac arrhythmia
5. Inflammations of the respiratory system including pulmonary tuberculosis
6. Grave primary or secondary anemia
7. Patients addicted to the excessive use of alcohol tobacco coal tar
derivatives and narcotic drugs
8. Advanced pregnancy
9. Obesity
10. Children with greatly enlarged tonsils
11. Operations requiring prolonged anesthesia
12. Senility
Yasi anaesthetic agent
STAGES OF ANESTHESIA

Kamran
 The Guedel's classification by Arthur
Ernest Guedel described four stages of
anaesthesia in 1937. Despite newer
anaesthetic agents and delivery techniques,
which have led to more rapid onset and
recovery from anaesthesia, with greater
safety margins, the principles remain.
 Stage 1
Stage 1 anaesthesia, also known as the "induction", is the period
between the initial administration of the induction agents and loss of
consciousness. During this stage, the patient progresses from
analgesia without amnesia to analgesia with amnesia. Patients can
carry on a conversation at this time.
 Stage 2
Stage 2 anaesthesia, also known as the "excitement stage", is the
period following loss of consciousness and marked by excited and
delirious activity. During this stage, respirations and heart rate may
become irregular. In addition, there may be uncontrolled
movements, vomiting, breath holding, and pupillary dilation. Since
the combination of spastic movements, vomiting, and irregular
respirations may lead to airway compromise, rapidly acting drugs are
used to minimize time in this stage and reach stage 3 as fast as
possible.
 Stage 3
Stage 3, "surgical anaesthesia". During
this stage, the skeletal muscles relax,
vomiting stops, and respiratory depression
occurs . Eye movements slow, then stop,
the patient is unconscious and ready for
surgery.
It has been divided into 4 planes:
eyes initially rolling, then becoming fixed
loss of corneal and laryngeal reflexes
pupils dilate and loss of light reflex
intercostal paralysis, shallow abdominal
respiration
 Stage 4
Stage 4 anaesthesia, also known as "overdose", is the stage where too
much medication has been given relative to the amount of surgical
stimulation and the patient has severe brain stem or medullary
depression. This results in a cessation of respiration and potential
cardiovascular collapse. This stage is lethal without cardiovascular
and respiratory support.
 Phases of General Anesthesia:
1. Preanesthesia
2. Induction
3. Maintenance
 Preanesthesia:
The stage from full consciousness to a state of sedation or
tranquilization with varying degrees of muscle relaxation and
immobilization.
 Reasons for preanesthesia:
Induce sedation
Calm patient
Reduce general anesthetic drug requirements
Provide analgesia and muscle relaxation
Decrease airway secretion, salivation, gastric fluid volume
and acidity
Suppress vomiting or regurgitation
Obtund autonomic reflexes
Promote smooth and rapid induction and recovery phases
 Preanesthesia Drugs:
Anticholinergics e.g. Atropine,
glycopyrrolate
Tranquilizers e.g. Acepromazine
Sedatives e.g. Diazepam
 Induction:
The stage following the preanesthetic stage
characterized by a loss of consciousness and
complete muscular relaxation and immobilization.
Typically a very short phase (5-10 minutes)
Often associated with an excitement phase prior to
achievement of general anesthesia
Both injectable and inhalant drugs are available
 Induction drugs
Barbituates e.g. Thiopental, thiamylal,
methohexital
Alkylphenol e.g. Propofol
Inhalant gases e.g. Isoflurane, halothane
 Maintenance:
A plane of general anesthesia that is achieved prior to
surgical intervention.
Associated with the greatest physiological impact
(hypothermia, hypotension, depression of
cardiopulmonary parameters).
 Maintenance Drugs:

Examples:
Inhalant gases (isoflurane, halothane)
Barbituates (pentobarbital)
Neuroleptanalgesics (fentanyl-fluanisone, Hypnorm
Tribromoethanol (Avertin)
Drug combinations (e.g.ketamine, xylazine and
acepromazine)
 NOUGHANCHI
SABET,MAHDIEH
Signs of anesthesia
DDB
 Respiratory signs
Preparatory stage:
Rate &volume: usually normal or depressed
Character: normal
Rhythm: not significant

Chemanesia stage:
Rhythm : irregular or uncertain
Depend on patients preoperative emotional & physical state as well as
preanesthetic medication
 Surgical stage:
Rhythm: regular rhythmic onset of respiration
Inhalation_ volume: greater than normal
Rate: slightly increased caused by the shortening
of the pause that follows expiratory phase
Intravenous_ volume and rate :
slightly decreased and depressed
with a prolongation of the pause that follows expiration
 Optic (eye) signs
Subdivided into:
a) Lid reflex
b) Eyeball movements
c) Tearing
d) Pupillary reactions
a. Lid reflex :
Earliest to be eliminated
Absent by the time patient enters coordinated plane of 2nd
stage (except Vinethene)

b . Eyeball movement :
Inhalation : more active than when intravenous agents are
administered
Chemanesia stage : in both coordinated and uncoordinated
planes , the eyeballs oscillate because of an imbalance in
the tone of the ocular muscles
 c. Tearing :

Surgical stage:
Lighter plane : eyeball is moist
tearing is sometimes evident (particularly in
second stage)
Depressed plane : eyeball loses its luster
(more so with administration of agents than
with
intravenous agents.)
d.Pupilary reactions:
Maybe the extreme interest during the various stages of
anesthesia.
Pupils ability to dilate and contract is altered by various
drugs and conditions.
Iris:
Circular fibers or sphincter papillae : parasympathetic
_ contraction
Radiating fibers or dilator papillae : sympathetic _ dilation
 Preparation stage : normal unless premedication is given .
Morphine _ constricts
Atropine _ dilates
Chemanesia stage : pupil reacts to sympathetic stimulation and also
to the excitation of the antagonistic cortical centers of the
parasympathetic fibers.
Surgical stage : greately constricted particularly when morphine has
been used for medication.
Miosis is also characteristic of the more potent inhalation agents
(probabely due to the paralysis of the antagonistic cortical centers of
theparasympathetic fibers.As a result ,the fibers accompanying the
oculomotor nerve are no longer inhibited and have a decided
predominance over the dilation fibers of the cervical sympathetic
system.)
Moderate or depressed plane: pupil begins to dilate.
 Muscular signs :

Degree of skeletal muscle not required or desired

manifestation:
degree of relaxation of skeletal muscle
absence or presence of certain reflexes
(pharyngeal reflex,laryngeal reflex,swallowing
reflex,and the vomiting reflex.)
 NEUROLEPTANALGESIA
In 1949 Laborit challenged the idea that general
anesthesia can protect an organism from surgical pain by
depression of cortical and subcortical centers alone. He
introduced a concept based on selective blocking of the
cerebral cortex and other cellular , autonomic, and
endocrine mechanisms activated as a response to stress.
Drug combinations consisting of chlorpromazine ,
promethazine and meperidine were used to produce this
state.
Marked circulatory depression often resulted from this
induced homeostatic imbalance, which may explain why
yhe technique never become popular.
 Recently compounds have been made available that depress
subcortical and central autonomic activity with a minimum of toxic
effects. These butyrophenone derivatives are potent psychosedatives
and are also alpha_adrenergic blocking agents. When they are
combined with a potent narcotic, a state, not unlike that of laborit , of
neuroleptanalgesia may be produced in which the patient lies at rest
and is completely passive.With the possible exception of respiratory
depression , vital signs are remarkably stable.
The search for improved means of selectively blocking afferent
systems involved in surgical led to increased stress led to increased
emphasis on analgesia.Fentanyl , a meperidine derivative, has been
found to produce analgesia (it is reported to be 150 times as potent as
morphine) without certain of the central nervous system that are
blocked by orthodox anesthesia.
The most popular drug combination used to produce neurolept
analgesia today consist of a fixed mixture of 2.5 mg. droperidol (
inapsine) and 0.05 mg. fentanyl (sublimaze ) per ml.
 Introduction is carried out by administering 1 to 2 ml. per
20 pounds of body weight intravenously. During
maintenance phase additional fentanyl is administered
whenever signs if surgical stress occur.
Nitrous oxide and oxygen mixture is administered after
completion if the intravenous injection , or the surgery
maybe performed under regional analgesia if practical .
Anesthesia is terminated by discontinuing the nitrous
oxide and oxygen and allowing the patent to breathe
room air ,which results in immediate awakening of the
patient.
 Advantages of
neuroleptanalgesia:
1. Simple , safe,nonexplosive,economical
2. Low toxicity of agent used
3. Profound analgesia produced without
cardiovascular and cortical depression
4. Total amnesia for the induction,maintenance,
and early recovery phases
5. Nausea and vomiting rarely seen
 Disadvantages of
neuroleptanalgesia:
1. Profound respiratory depression possible after
completion of intravenous injection
2. Poor skeletal muscle relaxation
3. Possible lead-pipe chest wall rigidity , which
may be easily overcome by administrating
neumuscular blocking agents and then
providing artificial ventilation
4. Not suitable for outpatients because of the long
action of droperidol (6 hours and more)
 Dissociative anesthetics:
a unique anesthesia characterized by analgesia and
amnesia with minimal effect on respiratory function. The
patient does not appear to be anesthetized and can
swallow and open eyes but does not process information.
This form of anesthesia may be used to provide analgesia
during brief, superficial operative procedures or
diagnostic processes. Ketamine hydrochloride is a
phencyclidine derivative used to induce dissociative
anesthesia. Ketamine is used for trauma patients with
very unstable, low blood pressure or for elderly patients.
Emergence may be accompanied by delirium, excitement,
disorientation, and confusion.
 Advantages of dissociative anesthesia:

1. Pleasant induction possible by the intravenous

or intra muscular route.
2. With margin of safety
3. May be used asan induction technique prior to
the administration of inhalation agents
4. Produces good analgesia
5. Pharyngeal and larengeal reflexes active,
the patient maintaining own airway in a
patent state
 Disadvantages of dissociative anesthesia:

1. Heightened muscular tone andactive oral and

pharyngeal reflexes
2. Recovery time longer ,which discourages use in
ambulatory patients
3. Irrational behaviour occasionally seen during
recovery
4. Actives pharyngeal reflexes, possible
laryngospasm
5. Vivid dreams during emergence
COMMON SIDE EFFECTS

Regalado, Liel Marie

 Common side effects
Nausea and vomiting after surgery (also called postoperative nausea and vomiting)
How common is it?
Post-operative nausea and vomiting (PONV for short) is one of the most common side-
effects that occurs in the first 24 hours after your surgery. It affects 20-30% of patients.
However, nearly half of all patients who do not have PONV in the hospital, experience
nausea and/or vomiting in the first few days after discharge.
Who is at risk?
For adults, there are many factors that increase the risk of having PONV. Firstly - being
female, not smoking (the only benefit from smoking, but definitely not worth it!) and having
a history of motion sickness or PONV after a previous surgery.
Then some anesthetic drugs and painkillers - most commonly those gases that keep you
asleep, the morphine-like painkillers (called opioids in medical terms) and laughing gas
(called nitrous oxide in medical terms). The morphine-like painkiller used for pain relief
after surgery (commonly used by the acute pain service) do a good job in relieving pain, but
are a common reason for nausea on the first and second day after surgery.
Lastly, some surgeries are known to carry a high risk for PONV. These include surgery on the
ear or intestines and laparoscopic surgery (key-hole surgery) for operations on the female
organs.
 Sore throat
How common?
Sore throat and hoarseness in the first hours to days after anesthesia occurs in up to 40% of
patients (13).
Who is at risk?
The following increase your risk:. Being female; younger than 50 years old and having a
general anesthetic lasting more than 3 hours.
Can it be prevented and/or treated?
Having a regional anesthetic (link bold word to regional anesthesia) will completely prevent
this problem. However, if you need a general anesthetic, your anesthetist may chose a
smaller size for the device used to help you breath during surgery. Some drugs have also
been proven to be beneficial, such as a freezing medication or an anti-inflammatory
medication. In addition, the use of some over the counter substances such as Tantum or
Strepsils can help alleviate acute sore throat pain.
 Teeth damage
How common is it?
Teeth damage is a rare but very unfortunate complication of general
anesthesia, roughly occurring in 1:2000-cases. The most frequently
injured teeth are the upper front ones (the upper incisors) (25;26).
Who is at risk?
Patients mostly at risk for dental injury are those with poor dental
health and where the anesthetist have had difficulty to get the
breathing tube down (called a difficult intubation).
Can it be prevented?
Although the anesthetists are always very careful, prevention of
dental damage is not always possible. Several devices have been used
such as mouth-guards and bite-blocks but provide no guarantee.
Moreover, these devices may make it more difficult to place to place
the breathing tube.
 Shivering/Chills
How common is it?
Shivering after an anesthetic is an occurs in the early recovery
phase after anesthesia in approximately 25-50% of patients.
Who is at risk?
Cooling down is the most common cause. Other causes
including include pain, fever and stress after surgery. It seems
to be more common in males and after longer surgeries, but it
is quite rare in elderly patients.
Can it be prevented and/or treated?
While we try to reduce the drop in body temperature, is itit is
impossible to completely prevent it. There are also a few drugs
that can be used either to prevent and/or to treat post-
operative shivering.
 Goals of General Anesthesia
Hypnosis (unconsciousness)
Amnesia
Analgesia
Immobility/decreased muscle tone
(relaxation of skeletal muscle)
Inhibition of nociceptive reflexes
Reduction of certain autonomic reflexes
(gag reflex, tachycardia, vasoconstriction)
 Desired Effects Of General
Anesthesia
(Balanced Anesthesia)
Rapid induction
Sleep
Analgesia
Secretion control
Muscle relaxation
Rapid reversal