INTRODUCTION TO
GENERAL
ANAESTHESIA
THE CLASSICAL TRIAD OF
ANAESTHESIA
Hypnosis
Analgesia
(anaesthesia)
Muscle relaxation
THE REVISED TRIAD
Hypnosis
Analgesia
(anaesthesia)
Lack of reflexes
(i.e. haemodynamic stability)
General Anaesthesia: Components
• Hypnosis- pharmacologically-induced
sleep, reversable lack of consciousness
• Analgesia-pain management
• Lack of reflexes, i.e. haemodynamic
stability
• Muscle relaxation, pharmacological,
reversable neuromuscular blockade
GENERAL ANESTHESIA:
STEP BY STEP
• PREANESTHETIC ASSESSMENT
• INDUCTION
• MAINTENANCE
• EMERGENCE
• POSTANESTHETIC CARE &
SURVEILLANCE
OVERALL RISK
OVERALL RISK
•Overall medical condition
• Surgery
• Anaesthesia
RISK OF ANAESTHESIA
CEPOD (Confidential Enquiry into Perioperative
Deaths)- 1987
Mortality cause in the 30 days after surgery- one milion
surgeries
Current anaesthetic-related mortality
(in otherwise healthy patients): 1:250 000
(Lienhart A, et al. Survey of anesthesiarelated mortality in France. Anesthesiology 2006;105: 1087–1097
RISK OF ANAESTHESIA
Minimize the risk related to comorbidities :
Minimize intraoperative stress
Anaesthetic risk:
Airway management
Intravenous access (central line)
Drugs used
Intraoperative monitoring
Anaesthetist’s experience
Estimation of the perioperative outcome
(American Society of Anesthesiologists physical
status classification system)
• ASA 1: healthy patient.
• ASA 2: patient with mild, stable systemic disease, e.g. arterial
hypertension, diabetes melitus, asthma bronchiale, obesity
• ASA 3: patient with systemic disease leading to functional
limitation: controlled congestive heart failure (CHF), stable angina,
old heart attack, poorly controlled hypertension, morbid obesity, chronic
renal failure; bronchospastic disease with intermittent symptoms
• ASA 4: patient in life treatening illness: unstable angina,
symptomatic COPD, symptomatic CHF, hepatorenal failure
• ASA 5: moribound patient who is not expected to survive
without surgery
• ASA 6: brain death- potential organ donor
L-E-M-O-N
(difficult airway anticipation)
• LOOK
• EVALUATE 3:3:2
• MALLAMPATI SCORE
• OBSTRUCTION
• NECK
3:3:2 Rule
3 fingers between the
teeth
3 fingers from the
chin to the hyoid
2 fingers from the
mandible to thyroid
cartilage
MALLAMPATI SCORE
Fasting (NPO)
The 2-4-6 rule
• Liquids- up to 2 hours
• Solids (including milk)- up to 6 hours
• Breast feeding- up to 4 hours
Anesthetic premedication
Anaesthetic premedication
• Reduces anxiety and agitation, gives amnesia
• Usually benzodiazepines
• Midazolam 7,5-15 mg p.o.
• The night before the surgery and 30-45 min
before
INDUCTION:
PREOXYGENATION
SAFE APNEA TIME
ON ROOM AIR
1 MINUTE IN HEALTHY ADULTS
A MATTER OF SECONDS IN THE OBESE
AFTER PREOXYGENATION
UP TO 8 MINUTES IN HEALTHY ADULTS
UP TO 2,5 MINUTES IN THE OBESE
APNEIC OXYGENATION TO
PROLONG SAFE APNEA TIME
by Matt Pratt, Florida Gulf University
INDUCTION
MAINTENANCE
Total Volatile
Intra Induction
Venous Maintenance
Anaesthesia Anaesthesia
Division of inhalation agents
1. Gases:
• N2O – old, weak, used as adjuvant
• Xenon – limited use only
2. Vapours (fluids):
• Halothane
• Enflurane
• Isoflurane
• Sevoflurane
• Desflurane
Characteristics of an ideal
volatile anaesthetic
• No disturbing smell
• Enabling fast onset and emergence
• Low solubility in blood- fast transport to the brain
• Stable when stored, not reacting with other
chemicals
• Non-flammable
• Low methabolism in body, fast elimination, no
tissue accumulation
• No depressing effect on circulatory and respiratory
systems
MAC
The best estimate of anaesthetic potency
Minimum Alveolar Concentration of an
agent that produces immobility in 50% of
subjects exposed to noxious stimulus -
usually skin incision.
blocked adrenergic response – MAC-BAR
for verbal response – MAC-awake
for intubation MAC-intubation
MAC reduction
• N2 O
• Other anesthetics (opioids, ketamine,
benzodiazepines)
• Age
• Hyponatremia, hypothermia, hypocapnia,
hypoxemia, acidosis
Nitrous oxide, laughing gas
• Old (1875, Horace Wells)
• Weak as an anaesthetic, has
analgesic properties
• Used as adjuvant
• Will be removed form medical
use- ozone layer, emetogenic,
vit. B deficiency
Halothane
• First non-flamable volatile fluid
anesthetic
• High MAC (long onset)
• Depression of circulatory system
• Associated with liver inflammation
• Limited use in paediatric
anaesthesia, otherwise considered
obsolete
Isoflurane
• Disturbing smell
• May decrease heart
contractility
• Potentiates
neuromuscular
blockade??
Sevoflurane
• Acceptable smell- may be used for
VIMA
• Low solubility in blood- fast acting
•
• Does not irritate the airway
• May depress circulatory system
• Metabolised to Compound A-
possible kidney toxicity (but not
confirmed in humans)
• May be used in day-case surgery
• Mainstay of contemporary
volatile/balanced anaesthesia
Desflurane
• Very disturbing smell- cannot be
used for VIMA
• Metabolised to a negligible
extent
• Low solubility- fast onset
• Number one agent for day-case
surgery
• Requires electrical vaporizers to
be heated up to 39 oC
Intravenous anesthesia - drugs
• Sedatives
• Hypnotics
• Analgesics
• Muscle relaxants
Benzodiazepines - Sedatives
• Chlordiazepoxide (Librium) – 1955
• Diazepam (Valium) - 1959.
• Diazepam in anesthesia - 1966
• Lorazepam - 1971
• Midazolam – 1976
Benzodiazepines
• Act through GABA receptor
• Amnesia, sedation
• Remarkably safe (respiratory failure)
• Moderate respiratory depression, mild decrease
in blood pressure
Classification – rapid acting hypnotics
Barbiturates- Thiopentone
• Hypnotic, acts through GABA receptor
• Rapid onset and offset
• Accumulates with continous delivery
• Provides cerebral protection by decreasing brain
metabolism
• Moderate dose-dependent respiratory depression and
decrease in blood pressure
Thiopentone: dosing for induction
• Adults - 2.5-4.5 mg/kg
• Children 5-6 mg/kg
• Infants - 7-8 mg/kg
Ketamine – phencyclidine derivative
• Acts through NMDA receptor
• Dissociative state of hypnosis and analgesia
• Stimulates sympathetic nervous system– increase in
HR and BP
• Bronchial smooth muscle relaxant
• Increases saliva production
• Adverse psychological effects – hallucinations in
adults
Propofol- mainstay of intravenous
induction and maintenance
Propofol pharmacodynamics
Propofol
• The most commonly used hypnotic
• Rapid onset and offset
• Moderate dose-dependent respiratory depression
• Decrease in cardiac output and systemic vascular
resistance
• Antiemetic effect
Etomidate
• Hypnotic, rapid onset and offset
• Minimal effect on cardiovascular system
• Prolonged infusion results in inhibition of
adrenocortical synthesis
• Increased mortality in ICU patients
• Associated with thrombophlebitis and increased
PONV
OPIOID ANALGESICS
• Most potent analgesics (µ, d, k receptors)
• Decrease central respiratory drive
• Suppress stimulatory effect of CO2 on ventilation
• Decrease BP
• Decrase gastrointestinal motility
• Decrease MAC of volatile anaesthetics
• Increase muscle tone and muscle rigidity
• Urinary retention
• Reduce thermoregulatory treshold
• Cause nausea and vomitting
Opioids – initial doses
• Fentanyl – 1- 3 - 5 µg/kg
• Alfentanil - 10 - 15 µg/kg
• Remifentanil 0,1 - 1 µg/kg
• Sufentanil - 0,2 µg/kg
NEW OPIOIDS
• Alfentanil • Remifentanil
10-30 µg/kg iv (Ultiva) 0,25-1,0 µg/kg
• Fast and short (15 • Eliminated through
min) action cholinesterase
• May cause muscle • Does not acccumulate
stiffness
The most popular muscle relaxants
Myoneural junction
Myoneural junction
Presynaptic
ZAKOŃCZENIE membrane-
NERWOWEneuron
AChE ACh Dystroglikan-a
AChR Agryna
Rapsyna
NO
Cytoplazma DRC
NOS
Postsynaptic
Jądro membrane- muscle Kanał Na
komórkowe
NO
Boonyapisit K: AM J Med 1999; 106: 97-113
Division of relaxants depending
on mechanism of action
1.nondepolarising- true receptor antagonists, bind to
the receptor for Ach (nicotinic) but do not cause
muscle contraction and block access for the
agonist (ACh)
2.depolarising- exhibit agonisitc activity, combine
with ACh receptor and cause transient muscular
contraction but stay bound to the receptor
blocking access for the agonist (Ach).
Action of relaxants
Succinylcholine
§ Rapid onset (30sec), rapid offset (3-5 min)
§ Sinus bradycardia
§ Increased intragastric, intracranial, intraocular pressure
§ Masseter spasm
§ Fascicullations and muscle pain
§ Histamine release
§ Hyperkalemia
§ Malignant hyperthermia
Succinylcholine- indications
• Short (2-5 min) muscle relaxation
• Full stomach and rapid tracheal intubation
(RSI)– drug of choice along with rocuronium
• Indicated in case of anticipated difficult
airways
Succinylcholine or other drugs
(nomuscle relaxation ) for intubation
??
• Combined propofol and fentanyl may provide
good intubation conditions
• Decrease reflexes from upper respiratory tract, but
don’t prevent movements and cough.
Nondepolarizing agents
(aminosteroids)
Pancuronium (Pavulon ®; 0.1 mg/kg IV)
slowest onset and longest duration of action up to 60 to 90 min.
Vecuronium (Norcuron ®; 0.15 mg/kg IV)
onset of action (120 to 180 seconds)
duration of action = 30 to 45 minutes.
Rocuronium (Esmeron ®; 1.0 to 1.2 mg/kg IV)
fastest onset of action (60 to 90 seconds)
duration of action = 30 to 45 minutes.
Non-depolarizing agents –
beznzylisoquinolinium compounds
• Atrakurium (Tracrium®) - onset 150-180 sec,
duration 25-30 min, releases histamine,
• Cis-atrakurium (Nimbex®) - onset 180-210 sec,
duration 25-30 min, cis-isomer of atracurium
• Mivacurium (Mivacron®) - very short acting,
onset 90-120 sec, duration 7-10 min, releases
histamine
ONSET
Sugammadex neostigmine
(4 mg/kg IV) 70 μg/kg IV)
edrophonium
(1 mg/kg IV)
more rapidly
more effectively reversed residual neuromuscular blockade
3 Compartment Model
Second Third
compartment
Central compartment
compartment
(highly (Poorly
perfused (Blood or perfused
tissues i.e tissues. i.e Fat)
muscles, liver, Plasma)
heart
The patient is me and anyone can use this picture. Jan Henning Austnes
k= Proportions of drug exchanged between compartments per unit of time
ke0 Effect site (brain)
k1e
k10
Second Central compartment Third
compartment (Plasma) compartment
(highly perfused k12 k13 (Poorly perfused
tissues) tissues)
k31
k21
k= Proportions of drug exchanged between compartments per unit of time
ke0 Effect site (brain)
k1e
k10
Second Central compartment Third
compartment (Plasma) compartment
(highly perfused k12 k13 (Poorly perfused
tissues) tissues)
k31
k21
5
Cpt
4
Time
k= Proportions of drug exchanged between compartments per unit of time
ke0 Effect site (brain)
k1e
k10
Second Central compartment Third
compartment (Plasma) compartment
(highly perfused k12 k13 (Poorly perfused
tissues) tissues)
k31
k21
5
Cpt
4
Time
Single bolus administration
With kind permission from Prof. Michel Struys, University Hospital of Gent, Belgium
30
propofol concentration (µg/ml)
25
20
plasma conc.
15
10
0
0 200 400 600 800 1000 1200 1400 1600 1800 2000
time (s)
Repeated bolus administration
With kind permission from Prof. Michel Struys, University Hospital of Gent, Belgium
16
propofol concentration (µg/ml)
14
12 plasma conc.
10
0
0 200 400 600 800 1000 1200 1400 1600 1800 2000
time(s)
Continuous infusion
i.e. a syringe pump set at 90 ml/h
5
propofol conc.(µg/ml)
2 plasma conc.
0
0 1000 2000 3000 4000 5000 6000
time(s)
TCI
Target
Controlled
Infusion
Defining TCI
• TCI is an infusion system which allows the
anaesthetist to select the target blood
concentration required for a particular
effect and to control the depth of anaesthesia
by adjusting the requested target
concentration
What is TCI?
• Instead of setting ml/h or a dose rate (mg/kg/h),
the infusion device can be programmed to target
a required blood concentration.
• Effect site concentration targeting is now
included for certain pharmacokinetic models.
• The device will automatically calculate how
much is needed for induction and maintenance
to maintain that concentration.
Monitoring during general
anesthesia
Patient monitoring during general anaesthesia
Accelerometry
Train of four stimulation in different
types of n-m blockade
Depolarising block
Nondepolarising block
Monitoring the depth of anaesthesia
BIS
BIS
EEG, BIS
(bispectral index)
AEP – auditory evoced potentials
