General Anesthesia

Dr. Pritish Patnaik

House Surgeon
Sept. 2010 DSCDS

D E F I N I T I O N :General Anesthetics (GAs) are drugs which produce reversible loss of all sensation and consciousness
(Essentials of Medical Pharmacology, 5th edition, K.D. TRIPATHI)

Analgesia Hypnosis Muscle relaxation

TRIAD OF GENERAL ANESTHESIA

H I S T O R Y : Cordus discovered ether - 1540  Priestley discovered Nitrous Oxide - 1776  Horace Wells, dentist, used Nitrous Oxide - 1844  Long used Ether as an anesthetic - 1842  Morton demonstrated the use of ether as a GA in Massachusetts General Hospital, Boston, USA - 1846

HISTORY WAS MADE

16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 th October 1846 16th OCTOBER 1846 16th OCTOBER 1846 16 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846 16th OCTOBER 1846

M O A: Unitary hypothesis

???

 Agent Specific theory  Fluidization & lateral phase separation theories  Critical volume hypothesis  Meyer-Overton rule  Ligand gated ion-channels major target of Gas (GABA)  NMDA receptor inhibition

 The principal locus of causation of Unconsciousness appears to be in the thalamus or RAS; Amnesia may result from action in hippocampus; while spinal cord is the likely seat of immobilization on surgical stimulation

M A C:Minimal alveolar concentration is the lowest concentration of the anesthetic in pulmonary alveoli needed to produce immobility in response to painful stimulus of surgical incision
(Essentials of Medical Pharmacology, 5th edition, K.D. TRIPATHI)

STAGES OF ANESTHESIA :DEATH

Respiratory Paralysis Surgical Anesthesia

Delirium Analgesia

PROPERTIES OF GAS :For the Patient

(no nausea, non-irritating, smooth induction-recovery)

For the Surgeon

(m. relaxatn, immobility, analgesia, non-inflammable & non-explosive)

For the Anesthetist

(margin of safety, potency , depth adjustment, no rxn with tubes)

CLASSIFICATION OF GAS :Inhalational

Gas
(nitrous oxide)

Intravenous
Inducing agents
(thiopental sod., propofol)

Liquids
(ether, halothane, isoflurane, desflurane)

Slower acting Drugs

(BZDs, ketamine, fentanyl)

Inhalational
GAs

N i t r o u s o x i d e :-

(Laughing Gas)

 Colorless, odorless, non-inflammable, non-irritating  M A C - 1 0 5 % : even 100% cant produce anesthesia  Good analgesic; even 20% produces adequate analgesia  Poor muscle relaxant  Induction & recovery- rapid  Usually N2O 70% + 25-30% O2 + 0.2%-2% other potent anesthetic used for most surgical procedures  Second Gas effect and Diffusion hypoxia seen

E t h e r : Colorless, pungent odor, volatile, irritating, inflammable  Potent anesthetic, good analgesic, marked muscle relaxation  Induction long & unpleasant with salivation and respiratory secretions (+++) so ,

Rx

Atropine

 Recovery slow with post-anesthetic nausea & vomiting

H a l o t h a n e : Fluorinated volatile anesthetic similar to CHCl3  Colorless, sweet-fruity odor, non-irritant, non-inflammable, supplied in amber colored bottles  Potent anesthetic, fair analgesic & MR  Speedy induction & recovery

Asthmatics

 Depresses myocardial contractility; sensitizes heart to Adr, severe vasodilation  Respiratory depression , malignant hyperthermia, hepatitis in susceptibles

E n f l u r a n e : Mild sweet odor, non-irritating, non-inflammable  Similar to halothane with better muscle relaxation

Epileptics

 After isoflurane, use of enflurane has declined & currently not used in India

I s o f l u r a n e : Isomer of enflurane but 1 times more potent  More volatile , physically stable & non-inflammable  Rapid induction & recovery  1.5-3% induces anesthesia in 7-10 mins; 1-2% used for maintenance  Near ideal anesthetic

 Epileptics  Pts. with myocardial ischemia

D e s f l u r a n e : Fluorinated congener of isoflurane; less potent  Anesthetic agent for Out-pt. surgery  Rapid induction & recovery  Irritates air passage (pungent odor), laryngospasm  Other systemic effects similar to isoflurane

S e v o f l u r a n e : Latest polyfluorinated anesthetic agent, intermediate to isodesflurane  Administration pleasant

 Pediatric pts.

Intravenous
GAs

T h i o p e n t a l N (Pentothal) a : Ultra-short acting thiobarbiturate; very alkaline  Induction quick & pleasant  Commonest inducing agent, poor analgesic, weak MR  Injected i.v. (3-5 mg/kg) as a 2.5% soln., produces unconsciousness in 15-20 secs, which is regained by in 8-12 mins (t = 3 mins)  Laryngospasm , intubation difficult while anesthesia is light.

Rx ,

Premedicate with atropine Post-thiopental, inj. SCh

P r o p o f o l :-(Propovan)
 Used as 1% emulsion i.v., 2mg/kg bolus for induction  Unconsciousness occurs in 15-45 secs and lasts ~10 mins  Intermittent inj. in the dose of 9mg/kg/hr with fentanyl is used for total i.v. sedation  Produces dose-dependant respiratory depression  Also used in su-anesthetic doses for sedating intubated pts. in ICU

S l o w e r a c t i n g B Z D s : Sometimes used for induction, maintenance & supplementing GA  Slow onset & recovery  Large doses injected i.v. produce sedation, amnesia, and then unconsciousness in 5-10 mins  Poor analgesic. Add N2O  Weak MR. Add Neuromuscular blockers for adequate relaxation of surgical grade  Rx for endoscopies, angiographies, catheterization, # setting

Diazepam
(Valium)

0.2-0.5 mg/kg by slow undiluted inj in a running i.v drip

Lorazepam
(Calmese)

3 times more potent than Diazepam, slower acting, less irritating 0.04mg/kg i.v

Midazolam
(Hypnovel)

More potent than Diazepam or Lorazepam 0.02-0.1 mg/kg i.v

K e t a m i n e(ketamax) :-

(D i s s o c i a t i v e

Anesthesia)

 This GA is NMDA antagonist  Induces dissociative anesthesia due to its action on cerebral cortex, particularly the limbic system  Dose-0.5 mg/kg i.m or 1-2 mg/kg i.v  Analgesia for 40mins & anesthesia for 15 mins  May cause delirium, hallucinations & unpleasant dreams during induction & recovery.

Rx

administration of DIAZEPAM abolishes these disturbances

N a r c o l e p t

i c s*

Narcoleptics* are a group of drugs which induce a state of apathy & mental detatchment in which the pt. is mildly sedated and uncaring about his surrounding. Most favored combination:Droperidol (neurolept) Fentanyl (analgesic)

*N o t

used

generally

D r o p e r i d o l : Short acting potent neurolept (2-3hrs)  Effects calming anti-emesis adrenolytic action extra-pyramidal disturbances  Rx Droperidol (2.5mg) + Fentanyl Citrate (50mcg in 1ml) (Thalamonal, Innovar)

F e n t a n y l :(Trofentyl)

 Short-acting (30-50 mins) potent opioid analgesic  After i.v fentanyl, pt. remains drowsy but can be commanded  Tone of chest mm. increases so

Rx

MR

 Nausea, vomiting & itching occurs during recovery .

Rx Naloxone (0.4-0.8 mg i.v)

SKELETAL MUSCLE RELAXANTS

Skeletal Muscle Relaxants are drugs that act peripherally at Neuromuscular junction /muscle fiber itself or centrally in the cerebrospinal axis to reduce muscle tone and/or cause paralysis
(Essentials of Medical Pharmacology, 5th edition, K.D. TRIPATHI)

NEUROMUSCULAR

JUNCTION

P e r i p h e r a l l y A c t i n g M R :Neuromuscular blockers
Depolarizing (non-competitive)
(SCh, Decamethonium)

Directly acting
(Dantrolene Na)

Nondepolarizing (competitive)
(Curares)

S u c c i n y l c h o l i n e :(Scoline)

 Used clinically  Resembles 2 molecules of ACh joined together  A partial agonist of Ach, depolarizes by action on membrane channel  Onset- 1-1.5 mins, Duration-6-8 mins  SCOLINEAPNEA : Presence of hereditary, abnormal pseudo-cholinesterase or its deficiency. Apnea needing respiratory support longer than 15mins abnormal.

Rx

Fresh blood transfusion

+ Artificial respn

PRE-ANESTHETIC MEDICATION :Pre-anesthetic medication is the term applied to the use of drugs prior to the administration of an anesthetic agent, with the important objective of making anesthesia safer and more agreeable to the patient
(Pharmacology and Pharmacotherapeutics, 20th edition, R.S. Satoskar, S.D.Bhandarkar, Nirmala N. Rege)

O p i o i d s :Morphine (10mg) or pethidine (50-100mg) i.m.  Allay anxiety & apprehension  Produce pre & post-op analgesia  Reduce the dose of anesthesia, supplements poor analgesics & weak anesthetics  Disadv interferes with papillary signs of GA depresses respn sometimes hypotension ppts. asthma

S e d a t i v e T r a n q u i l l i z e r s :-

BZDs like Diazepam (5-10mg) or Lorazepam (2mg i.v) or Midazolam (1 mg i.v) produce tranquility & smoothen induction. They are also good amnesic.

A n t i C h o l i n e r g i c s :-

Atropine or Hyoscine (0.6mg i.m/i.v) used to reduce salivary or bronchial secretions to facilitate intubation & prevent aspiration. They also reduce vagal bradycardia and hypotension Glycopyrrolate (0.1-0.3 mg i.m), a longer acting quaternary atropine substitute, is a potent antisecretory & antibradycardiac drug with minimal central effects

H2 b l o c k e r s :-

Ranitidine (150-300mg) or Famotidine (20 mg) given raises gastric pH & its volume. PPIs may be preferred

A n t i e m e t i c s :Metoclopromide (10-20mg i.m) reduces post-op nausea by enhancing gastric emptying & increasing LES tone Domperidone (10 mg po) or Ondansetron (4-8 mg i.v) also very effective Promethazine (50mg i.m) is an antihistaminic with sedative, antiemetic & anticholinergic properties

PRE-ANESTHETIC EVALUATION
Pre-anesthetic evaluation is the process of clinical assessment that precedes the delivery of anesthesia care for surgery

It consists of medical history, physical evaluation, lab. Investigations, consultation and finally informed consent
(Internet : Practice Advisory for Pre-anesthesia Evaluation)

 Airway examination & Pulmonary evaluation, CXR  Cardiovascular evaluation, ECG  Hematological investigation  Serum Chemistries  Urine testing At a minimum, a directed Preanaesthetic` physical examination should include an assessment of the airway, lungs, and heart; Other tests may not be ordered routinely unless warranted by a Clinical situation

A S A C l a s s i f i c a t i o n o f P t s. :I. II. III. IV. A normal healthy patient A patient with mild systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive without the operation A declared brain-dead patient whose organs are being removed for donor purposes

V.

VI.

ENDOTRACHEAL INTUBATION
Endotracheal intubation refers to the passage of a tube through the nose or mouth into the trachea for maintenance of airway during anesthesia , or for ventilatory support or for maintenance of an imperiled airway
(Stedmans Medical dictionary, 28th edition)

ANATOMY OF AIRWAY

A r m a m e n t a r i u m :-

A r m a m e n t a r i u m :-

A r m a m e n t a r i u m :-

A r m a m e n t a r i u m :-

Macintosh blades

Miller blades

A r m a m e n t a r i u m :-

A r m a m e n t a r i u m :-

inflated cuff

A r m a m e n t a r i u m :-

A r m a m e n t a r i u m :-

Face masks

Magill forceps

A i r w a y A s s e s s m e n t :-

Interincisor gap > 3 cms

Thyromental distance > 6 cms

A i r w a y A s s e s s m e n t :-

Flexion and extension of neck

A i r w a y A s s e s s m e n t :-

TMJ Movement

A i r w a y A s s e s s m e n t :Soft palate Uvula

Mallampati classification: Class 3,4 -> may be difficult intubation

A i r w a y A s s e s s m e n t :-

Laryngoscopic views

Grade 3,4 - risk for difficult intubation

Orotracheal
Intubation

Sniffing

P o s i t i o n :-

Depth of

E T T I n s e r t i o n :-

Midtrachea or below vocal cord ~ 2 cms

Adult Male = 23 cms , Female = 21 cms Children Oral endotracheal tube = (Age/2) + 12 Nasal endotracheal tube = (Age/2) + 15 (cm) (cm)

I n t u b a t e d P a t i e n t :-

Nasotracheal
Intubation

A d v a n t a g e s :Comfortable for prolong intubation in postoperative period Suitable for oral surgery : tonsillectomy , mandible surgery For blind nasal intubation

D i s a d v a n t a g e s : Trauma to nasal mucosa

 Risk for sinusitis in prolong intubation  Risk for bacteremia  Smaller diameter than oral route - difficult for suction

C o n t r a i n d i c a t i o n s :Nasal cavity obstruction

C o m p l i c a t i o n s o f E T I n t u b a t i o n :-

 Trauma-lip, teeth, mucosa  Laryngospasm & bronchospasm  Spinal cord injury in case of previous cervical spinal injury  Obstruction from overinflation of cuff or secretions  Aspiration  Edema of upper airway

D i f f i c u l t E T I n t u b a t i o n : Infection in Airway  Tumor in airway  Enlarge thyroid secretions  Maxillofacial, Cervical, Laryngeal trauma  Burns at the area  TMJ dysfunction

SURGICAL ACCESS TO AIRWAY