GENERAL

ANESTHESI
A
Nicyela Jillien Harlendea (406182061)
Pembimbing: dr. Budi Wahono, Sp. An
WHAT IS
ANESTHESIA?

Anesthesia is a reversible condition

induced by anesthetic drugs that
cause a reduction or complete loss
of response to pain or another
sensation such as consciousness and
muscle movements during surgery
or other invasive procedures that
can be painful.

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ASA PS
CLASSIFICATIO
N

3
GENERAL
ANESTHESIA

General anesthetics (GAs) are drugs which causes reversible

loss of all sensation and consciousness.

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CARDINAL
FEATURES

Loss of all modalities of sensations

Sleep and Amnesia

Immobility or Muscle relaxation

Abolition of reflexes – somatic and

autonomic
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TRIAD OF
ANESTHESIA
HIPNOTIC
Pentothal, Propofol,
Enflurane, Isoflurane,
Sevoflurane

MUSCLE
ANALGESIA RELAXATION
Pethidine, Morphine, Succinylcholine, Atracurium,
Fentanyl, Sufentanil Rocuronium, Pancuronium
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 INDICATIO CONTRAINDICA
NS TIONS

• Long periods • Severe heart disease

• Unable to be adequately • Uncontrolled hypertension
anesthetized with local or • Uncontrolled diabetes
regional anesthesia mellitus
• Operations that are likely to • Acute infection
result in significant blood • Sepsis
loss or in which breathing
will be affected
• Uncooperative patients
• Patient preference

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EQUIPMENT

General anesthesia requires an anesthetic machine which contains a gas

supply, reducing valves, vaporizers, flow meters and breathing circuits.

Accessories are also required including a face mask, laryngoscope,

endotracheal tubes, stylets and oral/nasal airways.

Endotracheal tube size is based on the measurement of the inner

diameter of the tube. Size 6.0 ETT and size 8.0 ETT are standard
starting size for the adult female and male respectively.

Additional intubation equipment should be available for patients with

difficult airways including Eschmann catheter, C-mac or flexible fiber-
optic scope.
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LEMON

LOOK EXTERNALLY
Facial trauma, Large Incisors, Beard or Moustache, Large tongue
L
EVALUATE THE 3-3-2 RULE
E Inter-incisor distance : 3
Hyoid-mental distance : 3
Hyoid-tyroid distance : 2

MALLAMPATI SCORE ≥
3
M
NECK MOBILITY
Limited neck
mobility N
O
OBSTRUCTION
Presence of any condition like epiglotitis, peritonsillar abscess, Trauma
STAGES OF
ANESTHESIA

1
0
PHASE OF
ANESTHESIA
PHASE OF
ANESTHESIA

INDUCTION MAINTENANCE RECOVERY

Intravenous agent
injection like
propofol
Medications such as Anesthetic vapor decrease
desflurane, sevoflurane in until turned off
Additional injection
progress with facial mask
of opioid analgesic
Injection of opioid
like fentanyl and
Airway management, analgesic like morphine and
muscle relaxant like
temperature and blood others like atropine to keep
nimbex
pressure intermittent check patients comfortable
Secure patients
airway
PREANESTHETIC
MEDICATION

Ensures comfort to the patient & to minimize adverse effects of

anesthesia
Relief of anxiety & apprehension preoperatively & facilitate smooth
induction

Potentiate action of anaesthetics, so less dose is needed

Antiemetic effect extending to post- operative period

Decrease secretions & vagal stimulation caused by anaesthetics

Decrease acidity & volume of gastric juice to prevent reflux &

aspiration pneumonia
PREANESTHETIC
MEDICATION

Anti-anxiety drugs Sedatives-hypnotics Opioid analgesics

• Provide relief from • Causes negligible • Provide sedation,
apprehension & respiratory pre-& post-operative
anxiety depression & analgesia, reduction
• Post-operative suitable for children in anaesthetic dose
amnesia • Promethazine (25mg • Morphine (8-12mg
• Diazepam (5-10mg i.m.) has sedative, i.m.) or Pethidine
oral), Lorazepam antiemetic & (50- 100mg i.m.)
(2mg i.m.) anticholinergic used one hour before
action surgery
• Fentanyl (50-100μg
i.m. or i.v.) preferred
nowadays (just
before induction of
anaesthesia)
PREANESTHETIC
MEDICATION

Drugs reducing acid

Anticholinergics Antiemetics
secretion
• Reduces salivary & • Metoclopramide (10mg • Ranitidine (150-300mg
bronchial secretions, i.m.) used as antiemetic oral) or Famotidine (20-
vagal bradycardia, & as prokinetic gastric 40mg oral) given night
hypotension emptying agent prior to before & in morning
• Atropine (0.5mg i.m.) or emergency surgery along with
Hyoscine (0.5mg i.m.) • Domperidone (10mg Metoclopramide reduces
or Glycopyrrolate (0.1- oral) more preferred risk of gastric
0.3mg i.m.) one hour (does not produce regurgitation &
before surgery (not used extrapyramidal side aspiration pneumonia
nowadays) effects) • Proton pump inhibitors
• Ondansetron (4-8mg like Omeprazole (20mg)
i.v.), a 5HT3 receptor with Domperidone
antagonist, found (10mg) is preferred
effective in preventing nowadays
post-anaesthetic nausea
& vomiting
INDUCTION

Gas Nitrous Oxide

Halothane
Inhalation
Desflurane
Anesthesia
General

Volatile liquids
Sevoflurane
Propofol
Isoflurane
Ketamine
Injection
Etomidate
Thiopentone
sod
 Intravenous Inhalation
• Indications: • Indications:
• Usual or default method of starting general • Difficult IV access
anesthesia • Potential airway obstruction e.g. epiglottitis
• Risk of aspiration (see rapid sequence) • Thoracic diseases which preclude use of
• Standard method involves drug IPPV
combination: • Mediastinal mass, foreign body in airway,
• Sedative in large dose (propofol) usually broncho-pleural fistula
with narcotic and/or anxiolytic • Patients unable to cooperate with awake
(midazolam) airway endoscopy
• Muscle relaxant if doing intubation • Contraindications:
• Mask 100% O2 during process (before, • Aspiration risk (unless overruled by airway
during, after) concerns)
• Drug doses are initially based on weight • Active bleeding in airway (risk of cough,
and age of patient. Extra doses as directed laryngospasm)
by response of patient
• Contraindications:
• Lack of proper equipment for resuscitation
(IPPV, oxygen, airway devices, suction)
• Uncertainty about ability to ventilate or
Thiopent
Ketamine
al Sodium
Injection, 0.5g and 1g ampoules

Injection, 10ml vial

Contraindications: inability to
maintain airway, hypersensitivity to
barbiturates, cardiovascular disease,
dyspnea, obstructive respiratory
disease, porphyria

Induction, by IV as a 2.5% (25

mg/ml) solution over 10-15 seconds, Uses
Adult 100-150mg, followed by a
further 100-150mg if necessary
according to response after
60seconds, Child 2-7 mg/kg repeated
if necessary
 PROPOFOL
- Dosis 2 – 3 mg/kgBB
- Dosis rumatan : 4 – 12 mg/kgBB/j
- Dapat diencerkan dengan D5%
- Tidak dianjurkan u/ manula & ibu hamil
- Sering menimbulkan rasa nyeri pd INDU
penyuntikan KSI

INTR
AVEN
INDUKSI A
Tindakan untuk membuat pasien dari
sadar menjadi tidak sadar sehingga
memungkinkan dimulainya
pembedahan

KETAMIN
• Dosis 1 - 2 mg/kgBB
• Jarang diberikan saat induksi anestesi 
menimbulkan takikardi, hipertensi
hipersaliva, nyeri kepala
pasca anestesi  mual muntah, pandangan
kabur
• Untuk < hipersaliva  Midazolam / Diazepam
0.1 mg/kgBB
 HALOTAN
• Digunakan sebagai induksi anestesi kombinasi
dengan O2 > 4 L/m atau N2O+O2 (3:1 ; 4L/m)
dengan didahului Halotan 0.5vol% sampai
konsentrasi yang dibutuhkan
• Efek yg tidak diharapkan pasien sering batuk

ENFLURAN

INDUKSI Efek depresi nafas lbh kuat & lbh iritatif

dibanding halotan
INHALASI
Kelarutan zat inhalasi dalam darah
ISOFLURAN
adalah faktor utama yang penting
dalam menentukan kecepatan Jarang dilakukan krn pasien srg batuk dan
induksi dan pemulihan. waktu induksi menjadi lama

SEVOFLURAN
• Efek kardiovaskular cukup stabil
• Tidak ada keluhan batuk saat
induksi berlangsung
• Jarang menyebabkan aritmia
 PERSIAPAN INDUKSI ANESTESI
Scope
Stetoskop untuk mendengarkan suara paru dan jantung. Laringo-Scope, pilih bilah atau daun (blade) S
yang sesuai dengan usia pasien. Lampu harus cukup terang.

Tube
Pipa trakea pilih sesuai usia. Usia < 5 tahun tanpa balon (cuffed) dan > 5 tahun dg balon (cuffed). T

Airway
Pipa mulut faring (Guedel, orotracheal airway) atau pipa hidung-faring (naso-tracheal airway). Pipa
ini untuk menahan lidah saat pasien tidak sadar untuk menjaga supaya lidah tidak menyumbat jalan A
napas.

Tape
Plester untuk fiksasi pipa supaya tidak terdorong atau tercabut. T

Introducer
Mandrin atau stilet dari kawat dibungkus plastic (kabel) yang mudah dibengkokan untuk pemandu I
supaya pipa trakea mudah dimasukkan.

Connector
Penyambung antara pipa dan peralatan anestesia C

Suction
penyedot lender, ludah danlain-lainnya. S
 MAINTENANCE
Dpt dikerjakan dg metode Intravena dan Inhalasi

RUMATAN INTRAVENA
• Fentanyl (opioid dosis tinggi):10-50 mcg/kgBB 
menyebabkan pasien tidur dg analgesia cukup
• Propofol : 4-12 mg/kgBB/jam

RUMATAN INHALASI
• Menggunakan campuran N2O & O2 3:1 ditambah
• Halotan 0,5-2 Vol% ATAU
• Isofluran 2-4 Vol% ATAU
• Sevofluran 2-4 Vol%
(bergantung apakah pasien bernapas spontan,
dibantu atau dikendalikan)
 RELAXANT
Manfaat dibidang anestesi :

Memudahkan dan mengurangi cedera dari tindakan laringoskopi dan intubasi trakea

Membuat relaksasi otot lurik selama tindakan pembedahan

Menghilangkan spasme laring dan refleks jalan napas atas selama anestesi

Memudahkan pernapasan kendali selama anestesi

 RELAXANT

 Suksinil-kolin (diasetil-kolin) dan dekametonium

 Bekerja spt asetil kolin tp tidak dirusak oleh kolinesterase shg
menyebabkan depolarisasi (kontraksi otot) dan berakhir menjadi
relaksasi otot lurik

PELUMPUH OTOT DEPOLARISASI PELUMPUH OTOT NON-DEPOLARISASI

(NONKOMPETITIF, LEPTOKURARE) (NONKOMPETITIF, LEPTOKURARE)
 Nondepol Long acting (durasi kerja 30-120 menit)
d-tubokurarin (tubarin), pankuronium, metakurin, pipekuronium,
doksakurium, alkurium (alloferin)
 Nondepol Intermediate acting (15-30 menit )
gallamin (flaxedil), atrakurium (notrixum), vekuronium
(norcuron), rokuronium (esmeron), cistacuronium
 Nondepol Short-acting (10-15 menit)
mivakurium (mivacron), ropacuronium

Antidot : Neostigmin (prostigmin)

 EMERGENCY
SUKSINIL KOLIN
EPHEDRINE
• Spasme atau kejang laring
• Hipotensi (TD sistol < 90mmHg)  • Dosis 0,5 mg/kgBB
berikan 2cc
ADRENALIN

SULFAS ATROPIN • Diberikan apabila tjd cardiac arrest

• Dosis : 0,25- 0,3 mg/KgBB
Diberikan sebagai antibradikardi (<60)
 berikan 2cc
DEXAMETHASON
AMINOFILIN • Apabila tjd reaksi anafilaksis
Diberikan bila tjd bronkokonstriksi  • Dosis : 1mg/KgBB
5mg/KgBB
MONITORING

01 Qualified anesthesia personnel shall be present in the room

throughout the conduct of all general anesthetics, regional
anesthetics and monitored anesthesia care.

02 During all anesthetics, the patient’s oxygenation, ventilation,

circulation and temperature shall be continually evaluated.
MONITORING
Oxygenation
Inspired oxygen,
Hemoglobin saturation
with a pulse oximeter
and observation of skin
color

Temperature Ventilation
Thermometry, if Capnography, Tracheal intubation
must be verified clinically and by
changes are detection of exhaled CO2.
anticipated, intended, Mechanical ventilation must be
monitored with an audible
or suspected disconnect monitor

Circulation
ECG monitoring and blood
pressure measurement at least
every 5 minutes, continous
monitoring of peripheral
circulation by palpation,
auscultation, plethysmography, or
arterial pressure
STANDARDS FOR
POST ANESTHETIC
CARE
01
ALL PATIENTS WHO HAVE
RECEIVED GENERAL ANESTHESIA,
REGIONAL ANESTHESIA OR
MONITORED ANESTHESIA CARE
SHALL RECEIVE APPROPRIATE
02
POSTANESTHESIA MANAGEMENT.
A PATIENT TRANSPORTED TO THE
PACU SHALL BE ACCOMPANIED BY
A MEMBER OF THE ANESTHESIA
CARE TEAM WHO IS
KNOWLEDGEABLE ABOUT THE
PATIENT’S CONDITION.  THE
PATIENT SHALL BE CONTINUALLY
EVALUATED AND TREATED
DURING TRANSPORT WITH
MONITORING AND SUPPORT
APPROPRIATE TO THE PATIENT’S
CONDITION.
03
UPON ARRIVAL IN THE PACU, THE
PATIENT SHALL BE RE-EVALUATED
AND A VERBAL REPORT PROVIDED
TO THE RESPONSIBLE PACU NURSE
BY THE MEMBER OF THE
ANESTHESIA CARE TEAM WHO
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ACCOMPANIES THE PATIENT.
THE PATIENT’S CONDITION SHALL
BE EVALUATED CONTINUALLY IN
THE PACU.
05
A PHYSICIAN IS RESPONSIBLE FOR
THE DISCHARGE OF THE PATIENT
FROM THE POSTANESTHESIA CARE
UNIT.
2
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POST ANESTHETIC
CARE

Mental Status
Temperature
Nausea
Vomiting
Respiratory
Cardiovascular
Pain
Neuromuscular
Hydration
Urine
Drainage and
bleeding
2
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ALDRETE
SCORE
Parameters Description of the patient Score
Activity level Moves all extremities voluntarily/on command 2
Moves 2 extremities 1
Cannot move extremities 0
Respiration Breathes deeply and coughs freely 2
Is dyspneic, with shallow, limited breathing 1
Is apneic 0
Circulation (Blood Pressure) Is 20 mmHg > preanesthetic level 2
Is 20 to 50 mmHg > preanesthetic level 1
Is 50 mmHg > preanesthetic level 0
Consciousness Is fully awake 2
Is arousable on calling 1
Is not responding 0 ≥9 Discharge
Oxygen saturation as Has level >90% when breathing room air 2 5-8 Observation
determined by pulse Requires supplemental oxygen to maintain level >90% 1 <5 ICU
oximetry
Has level <90% with oxygen supplementation 0
STEWARD
SCORE
Parameters Description of the patient Scor
e
Consciousness Awake 2
Respond to stimuli 1
Doesn’t respond to stimuli 0
Airway Actively crying or coughs on command 2
Maintains airway patency 1
Requires assistance to maintain airway patency 0
Movement Moves limbs purposefully 2
Moves limbs randomly 1
Not moving 0
≥5 Discharge