GENERAL ANESTHESIA

Tatang Bisri, dr., SpAnK

Department of Anesthesiology & ICU
Medical Faculty University of
Padjadjaran/Hasan Sadikin Hospital
 ANESTHESIA
GENERAL LOCAL COMBINATION
•Intravenous •Topical
Spinal +
•Infiltration propofol
•Inhalation
•Block
•Intramuscular 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 physic centers

 Basal ganglia and cerebellum
 Spinal cord
 Medullary centers
GENERAL ANESTHESIA


TRIAS ANESTHESIA
Hypnotic
Analgesic
Relaxation

BALANCED ANESTHESIA
Balance anesthesia
Anesthesia Drugs
component
Hypnotic Pentothal, Propofol, Enflurane,
Isoflurane, Sevoflurane
Analgesic Pethidine, Morphine, Fentanyl,
Sufentanil, Remifentanil
Relaxation Succ choline, Atracurium,
Cisatracurium, Pancuronium
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
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 TIVA
anesthesia
Hypnotic Sevo, Iso, Enf, Hal, Propofol, Pento,
Desfluran Ket, Mid
Analgesic Fentanyl, alf, suf Fentanyl, alf,
,Mo, pethidine, suf ,Mo,
remifentanil pethidine,
remifentanil
Relaxation Depol & non depol Depol & non
depol
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 technique
 Spontaneous breathing
 Controlled ventilation

 Face mask
 Intubation
 LMA (Laryngeal Mask Airway)
 COPA (Cuffed Oro Pharyngeal Airway)
 LSA (Laryngeal Seal Airway)
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 : 250 - 500 ml/minute
Low-flow : 500 - 1000 ml/minute
Medium-flow : 1-2 liter/minute
High-flow : 2-4 liter/minute
Advantageous Low-flow
anesthesia
 Less of anesthesia gas consumption
 Less of pollution
 Heat loss decrease
 Cost effective
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 Blood/gas Brain/blood Tissue/blood

Ether 12.1 1.1 0.9

Halothane 2.3 2.6 2.5
Enflurane 1.8 2.6 1.7
Isoflurane 1.4 3.7 4.0
N2O 0.47 1.1 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 MAC

Halothane 0,72
Enflurane 1.68
Isoflurane 1.12
Desflurane 6.0
Sevoflurane 2.05
N2O 105.2
 Factors influencing or not
influencing MAC
MAC decreased MAC MAC increased
unchanged
Increasing age Duration of Alcoholism
CNS depressant: anesthesia chronic
alcohol, Gender Hyperthermia > 42
barbiturate, Species Hypercarbia
lidocaine, Hypertension Anemia
benzodiazepine, Hypocarbia
narcotic
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 Diazep Midaz

Aqueous + + - - +
solution
Available in - + + + +
solution
Pain on - - + + -
injection
Venous
thrombosis - - - + -
 Comparative properties of
intravenous anesthetics
Thiopen Ketamin Propof Diazep Midaz

Rapidly + - + - -
acting
Smooth ++ + + + +
induction
Respiratory + - + - +/-
depression
Cardiovascul
ar depression ++ - ++ +/- +/-
 Comparative properties of
intravenous anesthetics
Thiopen Ketamin Propof Diazep Midaz

Rapid - - + - -
recovery
Smooth + - + - -
recovery
Suitable for - +/- +/- - -
infusion
Interaction
with relaxant - - - - -
 Resume: Effect anesthetic non
volatile to organ system
Drug HR MAP Vent B’dil

Thiopentone    
Diazepam 0/   0
Midazolam    0
Meperidine  *  *
Morphine  *  *
Fentanyl    0
Ketamine     
Propofol 0   0
 Resume: Effect anesthetic non
volatile to CNS
Drug CBF CMRO2 ICP

Thiopentone   

Diazepam   
Midazolam   
Meperidine   
Morphine   
Fentanyl   
Ketamine   
Propofol   
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 Enfl Isofl Desfl Sevo
Odor + - - - +
Irritating to
Resp system - + + + -
Solubility 2,35 1,91 1,4 0,42 0,63
MAC 0,76 1,68 1915 6,0 2,05
Metabolism 17-20% 2,4% <0,2% 0,02% <5%
Metabolites F, Cl, F, F, F, F,
Br, TFA CDA TFA TFA HFIP
BCDFE,
CDE, CTE,
DBE
 Interaction with Sodalime
Anesthetic degradation organ Toxicity clinical
Product Relevancy
Halothane BCDFE Nephrotoxic Non identified
to data
Enflurane CO - -
Isoflurane CO - -
Desflurane CO - -
Sevoflurane Compound A Nephrotoxic Non identified
Compound B 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 Halothane Enflurane Isoflurane

Blood pressure   
Vascular resistance 0  
Cardiac output   0
Cardiac contraction   0
CVP   0
Heart rate 0  

Sensitization of the  0?
heart to epinephrine
0 = No change (<10%)  = Variable = 10-20% = 20-40%
 = increase change decrease 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   2-3
2.5 0.2
N2O
 1.5 time heavier than air
 Must be give with O2 100%
 Weak anesthetic
 Analgesic N2O 20% equal with 15 mg
morphine
 Don’t 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 :

 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. Premedication
2. Induction Anesthesia
3. Narcotic anesthesia
4. A part of balanced anesthesia
5. Adjuvant in regional anesthesia
6. Neurolept anesthesia
7. Post operative pain relief
Drugs Protein binding Lipid solubility

Morphine ++ +
Pethidine +++ ++
Fentanyl +++ ++++
Sufentanil ++++ ++++
Alfentanil ++++ +++

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

++++ = very high

Morgan GE. Clinical Anesthesiology, 1996.

Narcotic effect :

 Bradycardia : central vagotonic effect & SA &

AV node depression
 Respiratory depression : respiratory rate,
rhythm, Response CO2, Minute Volume,
Tidal Volume
 Muscle stiffness
 Nausea vomiting cause by stimulation CTZ,
GIT mobility, decrease gastric mobility,
increased gastric volume
 Clinical Doses of Narcotics
Drug i.v dose Onset Approximate
(min) duration
Morphine 0.05-0.3 mg/kg 5-10 3-5 h
Meperidine 0.5-1 mg/kg 5-10 2-3 h
Fentanyl 1-5 ug/kg 2 45 min – 2 h
Sufentanil 10-40 ug/kg <1 < 30 min
Alfentanil 30-80 ug/kg <1 < 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 Nondepolarizing

Short-acting Long-acting
Succinylcholine Tubocurarine
Decamethonium 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 Parkinson’s disease
• Tetanus
• Prolonged total body immobilization
• Ruptured cerebral aneurysm
• Polyneuropathy
• Closed head injury
• Near drowning
• Hemorrhagic shock with metabolic acidosis
• Myopathies ( eg, Duchennes’s dystrophy )
 Table 9 - 6. A summary of the pharmacology of nondepolarizing
muscle relaxant
Relaxant Metabolism Primary Onset Duration Histamine Vagal Relative Relative
Excretion Release Blockade Potency1 Cost2

Tubocurarine Insignificant Renal ++ +++ +++ 0 1 Low

Metocurine Insignificant Renal ++ +++ ++ 0 2 Moderate
Atracurium +++ Insignificant ++ ++ + 0 1 High
Mivacurium +++ Insignificant ++ + + 0 2.5 Moderate
Doxacurium Insignificant Renal + +++ 0 0 12 High
Pancuronium + Renal ++ +++ 0 ++ 5 Low
Pipecuronium + Renal ++ +++ 0 0 6 High
Vecuronium + Biliary ++ ++ 0 0 5 High
Rocuronium Insignificant Biliary +++ ++ 0 + 1 High

1
For example, pancuronium and vecuronium are five times more potent than tubocurarine or atracurium
2
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 Recommended Infusion rate
(mg/kg) intubating dose for steady state
(mg/kg) blockade
(mg/kg/h)

Atracurium 0.21 0.3-0.6 0.25

Pancuronium 0.067 0.005-0.008 0.032
Vecuronium 0.043 0.08-0.1 0.078
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)
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)