PREPRATION OF PATIENT FOR

GENERAL ANASTHESIA

STAGES OF ANAESTHESIA
 CONTENTS

Definition
History
Pre-operative assessment
Pre-operative medication
Mechanism of action
Stages of anesthesia
Induction of G.A
Maintenance of G.A
Recovery of G.A
Complications
 DEFINITION:-

ANESTHESIA:-
Loss of all sensations, either due to neurological
disorder, or by administration of drugs or other
medical interventions.
18th Century Surgery
 History of Anesthesia

•Ether synthesized in 1540 by Cordus

October
•Ether used as anesthetic in 1842 by Dr. Crawford 17, 1846: First
W. Long
public demonstration of
use of ether in
anesthesia
•Horace wells discovered N2O IN 1845

•Ether publicized as anesthetic in 1846 by Dr. William

Morton

•Chloroform used as anesthetic in 1853 by Dr. John Snow

• Endotracheal tube discovered in 1878

• Local anesthesia with cocaine in 1885

• Thiopental first used in 1934

• Curare first used in 1942 - opened the “Age of

Anesthesia”
 Types ofAnesthesia

•Topical anesthesia
•Local anesthesia
•Regional anesthesia
•Minimal sedation
•Moderate sedation/analgesia
•Deep sedation/analgesia
•General anesthesia
 DEFINITION:-

GENERAL ANAESTHESIA (GRAY)

complete loss of consciousness (narcosis),
loss of pain (analgesia),
Muscle relaxation.

BALANCED GENERAL ANAESTHESIA:-

TRIAD OF ANAESTHESIA
 Principles of General Anesthesia

• Sustaining physiologic homeostasis during

surgical procedures

• Improving post-operative outcomes

 GENERAL ANAESTHESIA:-

INHALATION
• GAS • LIQUIDS
• Nitrous oxide • Ether
• Halothane
• Isoflurane
• Desflurane
• sevoflurane
 GENERAL ANAESTHESIA:-

INTRAVENOUS
• SLOWER ACTING
• INDUCING AGENT DRUGS
• Thiopentone sodium • Benzodiazepines:-
• propofol Diazepam
Lorazepam
Midazolam
• Dissociative anaesthesia:-
Ketamine
• Opoid analgesia:-
Fentanyl
 THE IDEAL ANESTHETIC
- cause loss of sensation .
- cause loss of noxious reflexes.
- induce muscular relaxation.
- induce smooth onset and recovery.
- induce amnesia.
- cause no systemic amnesia.
- cause no systemic toxicity.
- present no hazard to others.
 Mechanism of action:-
• L.A act by blocking axonal conduction whereas
G.A acts by depressing synaptic transmission.

• Inhalation anaesthetic agents – potentiate the

action of inhibitory transmitter GABA to open
chloride channels.

• Block the responsiveness to painful stimuli

• Immobility in anaesthetic state.

• Intravenous:- inhibits Ca++ selective cation
channels in neurons.
 Potency of GA
• Minimal alveolar concentration (MAC) is the lowest

concentration of the anaesthetic in pulmonary alveoli

needed to produce immobility in response to a painful
stimulus.
PHARMACOKINETICS OF INHALED ANESTHETICS
1. Amount that reaches the brain
(lipid solubility)

2. Solubility of gas into blood

The lower the blood:gas ratio, the more anesthetics
will arrive at the brain

3. Cardiac Output
Increased CO= greater Induction time
 EFFECT OF ANAESTHETICS

• Respiration
– Depressed respiration and response to CO2

• Kidney
– Depression of renal blood flow and urine output

• Muscle
– High enough concentrations will relax skeletal
muscle
 • Cardiovascular System
– Generalized reduction in arterial pressure and
peripheral vascular resistance. Isoflurane maintains
CO and coronary function better than other agents

• Central Nervous System

– Increased cerebral blood flow and decreased
cerebral metabolism

• Hemodynamic effects: decrease in systemic arterial

blood pressure
• Hypothermia: body temperature < 36˚C

• Nausea and Vomiting

– Chemoreceptor trigger zone
 Pre anaesthetic procedure

• Instructions to parents
• Health assesment
AGE HEART RATE B.P RESP.RATE TIDAL
VOLUME
3 101+-15 100/67+- 24+-6 112
25/23
5 90+-10 94/55+-14/9 23+-5 270

12 70+-17 109/58+- 19+-5 480

16/9
ADULT 72+-5 122/75+- 12+-3 575
30/20
 Pre-operative assessment of physical
status & risk of anaesthesia.
Acc to American society of anesthesiologists
1.Pt has no organic,physiological,biochemical
or psychiatric disturbance.
2. Mild to moderate systemic disturbance.
E.g.= mild asthmatic.
3. Limitation of life style. E.g =severe diabetes,
cardiac failure.
4. Severe life threatening systemic disorders
e.g persistent angina.
5. Little chance of survival.
6.Brain dead
 PRE-OPERATIVE PREPARATION OF PATIENT
AIRWAY MANAGEMENT

Possible or definite difficulties with airway management

include the following:

• Small or receding jaw

• Prominent maxillary teeth
• Short neck
• Limited neck extension
• Poor dentition
• Tumors of the face, mouth, neck, or throat.
• Facial trauma
• Interdental fixation
 Lemon Rule
• L Look externally

• E Evaluate the 3-3-2 rule

• M Mallampati scale

• O Obstruction present?

• N Neck mobility
 Looking Externally

Atypical facial features or shape

• Edentulous mouth
• Morbid obesity
• Facial hair
• Protruding or “buck” teeth
• Protruding tongue
• Facial or neck trauma
 Evaluate the 3-3-2 Rule
• Three-finger mouth opening

• Three-finger mentun-to-hyoid

• Two-finger floor-of-mouth-to-thyroid cartilage

 MALLAMPATI SCORING

Class 1 Class 2 Class 3 Class 4

Visualization of
the soft palate, Visualization of Visualization of Soft palate is
fauces, uvula, the soft palate, the soft palate not visible at
anterior and fauces and and the base all.
posterior uvula. of the uvula.
pillars.
 Obstruction Present
• Presence of obstruction may make
laryngoscopy more difficult:
– Suspected laryngeal trauma
– Foreign body airway obstruction
– Edematous tissue (burns)
Neck Mobility

• Under no circumstances should the head or

neck of the trauma patient be manipulated
• Ability to flex, extend or otherwise
manipulate the head and neck of the
nontrauma patient may greatly increase the
likelihood of visualizing the vocal cords
• BALANCED GENERAL ANAESTHESIA:-
To achieve the 3 components of anaesthesia by providing ideal
conditions for surgery with no or minimum side effects.
1. Narcosis
2. Analgesia
3. Relaxation.
 NPO GUIDELINES
• To decrease Latham 1990
Gastric acid volume

• clear liquids for 2 hour prior to surgery

No breast milk for 4 hours prior to surgery

No solids or cow's milk for 6 hours prior to surgery.

SOCIETY FOR PEDIATRIC ANESTHESIA

 PRE- ANAESTHETIC MEDICATION:-

To reduce fear& anxiety,

To reduce saliva secretion,
To relieve pain,
For therapeutic effects
To produce amnesia.

Drugs used: given 1hr before anaesthesia.

Sedatives barbiturates,Benzodiazepines,phenothiazines.
Analgesics narcotics (morphine) & NSAIDS (ketoprofen)
Neuroleptic agents opoids
Anticholinergic agents atropine,hyoscine, glycopyrrolate
Oral antacids, H2 blockers.
• Children under 1 year
Atropine 0.02 mg/kg i.v at anaesthesia
i.m 30 mins before
• 1-3 years of age
Atropine 0.02 mg/kg i.v at anaesthesia
i.m 30 mins before
3 years and above
diazepam may be given 4mg/kg
 Anaesthetic Machine (Boyle’s equipment)

• Gas source- either piped gas or supplied in cylinders

• Flow meter

• Vaporisers

• Delivery System or circuit

 THE GAS SOURCE

• PIPED GAS
Piped gases are stored in a “bank”, remote from
the
operating room.Pin index system:

• The CYLINDERS contain gases under a very

high pressure.

Nitrous oxide cylinder is of BLUE COLOUR

Oxygen cylinder is of BLACK COLOUR with
WHITE SHOULDER
 THE FLOWMETER
• The gases pass from the reducing valve, via
pressure tubing,to the flowmeter calibrated
for each gas.
• The flowmeters record the volume of gas
flowing to the patient per minute.
 THE VAPORISER
• From the flowmeters the gases pass in the
direction of the vaporisers.
• The vaporiser enables volatile agents to be
introduced into the gaseous mixture
Basic instrumental monitoring of anaesthesia
machine
• It is required for :-

oxygen failure warning

airway pressure
monitoring
ventilator failure alarms.
cardiac output.
coagulation parameters.
anaesthetic depth.
 Ancillary Anesthesia Equipment
Suction

Face masks

Oropharyngeal & nasopharyngeal airways

 Ancillary Anesthesia Equipment
• MAGILL FORCEPS
Used to guide tracheal tubes into the larynx, or
nasogastric tubes into the oesophagus under
direct vision.
 Endotracheal tubes
• Predicted Size Uncuffed Tube = (Age / 4) + 4
• Predicted Size Cuffed Tube = (Age / 4) + 3

Cuffed tubes are preferred as they prevent

aspiratation .
However they are indicated in children above 8
years of age.
Khine H, Corddry DH, Kettrick RG, et al. Comparison of cuffed
and uncuffed endotracheal tubes in young children during general
anesthesia. Anesthesiology 1997;86:627–31.
13cm Dia
11mm Laryngoscope & blades
The distance from
the upper incisor
teeth to the angle of
the jaw seems to be
an excellent clinical
landmark for
laryngoscope blade
length selection for
pediatric intubations.

Pediatr Emerg Care. 2006 Apr;22(4):226-9.

Pediatric laryngoscope blade size selection using facial landmarks.
Mellick LB, Edholm T, Corbett SW.
 STAGES OF ANAESTHESIA
• Guedel (1920) classified 4 stages of anaesthesia:-

I) STAGE OF ANALGESIA:-

 From beginning of anaesthetic inhalation to loss

of consciousness.
 Pain is abolished & pt experiences disorientation.
 minor procedures can be performed.
 STAGES OF ANAESTHESIA
II) STAGE OF DELIRIUM OR EXITEMENT:-

 From loss of consciousness to onset of surgical

anaesthesia.
 Pt becomes gradually unconscious but all
reflexes are intact.
 At times pt may become violent or
uncooperative. So
 Breath holding or jerky movements can occur.
 No procedure can be carried out.
III) STAGE OF SURGICAL ANAESTHESIA
• This stage is divided into 4 planes :-

1) Respiration becomes irregular, movts of extremities

stop.
Eyelid & conjuctival reflex lost.
laryngeal reflex present.
eyeball movts uncoordinated.
2) Eyes become fixed centrally.
pupils constricted.
laryngeal& corneal reflex lost
Muscle tone decreased.
Respiratory muscles functioning.
III) STAGE OF SURGICAL ANAESTHESIA

3)
Pupillary light reflex lost.
Muscle relaxation with onset of paralysis of
intercostal muscles.
Respiration is largely diaphragmatic.
4)
Respiration is more depressed & increase
diaphragmatic paralysis.
 IV) STAGE OF MEDULLARY PARALYSIS.

This stage is possible only by overdose of an

anaesthetic drugs.
Respiration is gasping & finally arrested.
Pupils are widely dilated.
B.P is low & pulse is feeble.
Skin is cold & ashen grey.
 Drugs for General Anesthesia
IV induction agents
Narcotics
Neuroleptic / dissociative agents
Muscle relaxants
Inhalation anesthetics
 THERE ARE 3 PHASES DURING ANAESTHESIA
DELIVERY:-

• INDUCTION

• MAINTENANCE

• RECOVERY
 IV Induction Agents

Used to achieve Stage III rapidly

IV agents preferred to inhalation agents

Methohexital, Thiopental, Propofol

 Narcotics
Used for maintenance of general anesthesia

"Balanced Technique"

Morphine, Fentanyl, Alfentanil, Sufentanil

 Dissociative Agents
Ketamine
Dissociates patient from environment
Minimal depression of protective reflexes
Hallucinations are common on emergence
 Muscle Relaxants
Neuromuscular blockade

Administer after Stage III obtained

Defasciculating dose /paralyzing dose

Succinylcholine, Atracrurium, Pancuronium

 MAINTAINANCE OF G.A.
Once anaesthesia is induced & endotracheal intubation is done
it has to be maintained till the end of surgical procedure.

Hypnosis& amnesia are maintained by inhalation agent or

intravenous agent.

If muscle relaxant is not required as in minor operations

maintain proper ventilation using nitrous oxide , oxygen &
inhalation agent or intravenous agent.

If muscle relaxant is required in major procedures, then a non

depolarizing muscle relaxant is administered & respiration is
controlled.
 MONITORING DURING ANAESTHESIA
• It is a regular & careful assessment of patient’s vital signs
like :-
color of the skin & blood( oxygenation)
pulse character & rate.
Blood pressure
respiratory movement & movement of anaesthetic bag.
temperature of the skin
Circulatory status
urine flow or output (0.5 ml/ kg/ min)
muscle tone
pupils
Clotting time
Degree of filling of jugular veins.
 RECOVERY FROM ANAESTHESIA
Recovery is the period from the cessation of
anaesthesia until the patient is awake & regained
protective reflexes.

• Agent
• Reverse relaxation
• Cough reflex
• Extubate when awake

So lateral position ( slight head down tilt)

 RECOVERY FROM ANAESTHESIA

Normally early recovery of a patient occurs in

post- anaesthesia care unit (PACU) where there
are facilities for close monitoring of the patient
• As this is the vulnerable period for
hypoxia
airway obstruction,
aspiration
laryngospasm
pharyngitis.
 Post-Operative Recovery

Patient must be evaluate prior to discharge.

START ON CLEAR LIQUIDS 4 HOURS

AFTER THE PROCEDURE.
COMPLICATIONS OF GENERAL ANAESTHESIA

DURING ANAESTHESIA:-
Respiratory depression
Salivation, respiratory secretion.
Cardiac arrhythmias.
Fall in B.P.
Aspiration of gastric contents.
Laryngospasm & asphyxia.
Delirium, convulsions.
Hyperpyrexia or hypothermia.
• Insertion or removal of airways may cause respiratory
problems such as coughing; gagging; or muscle spasms in the
voice box, or larynx (laryngospasm), or in the bronchial tubes
in the lungs (bronchospasm).

• Insertion of airways also may cause (hypertension)

and(tachycardia).

• Other complications may include damage to teeth and lips,

swelling in the larynx, sore throat, and hoarseness caused by
injury or irritation of the larynx.

• Death or serious illness or injury due solely to anesthesia is

rare
AFTER ANAESTHESIA

Nausea & vomiting.

 Persisting sedation.
 Pneumonia, lung abscess,
pneumothorax.
 Nerve palsies, seizures.
 Hypertension or
hypotension.
 Respiratory obstruction,
hypoxia.
 shivering, restlessness
 REFERENCES
• T Cecil Gray “General Anaesthesia” publisher:
Butterworth-Heinman 4th edition.
• Petersons “principles of oral and maxillofacial surgery”
publisher Decker 2nd edition.
• T.Shobha “Textbook of Pedodontics” paras publishers 2nd
edition
• S.G Damle “Textbook of Pediatric Dentistry” Arya
publishing house 3rd edition
• Khine H, Corddry DH, Kettrick RG, et al. Comparison of
cuffedand uncuffed endotracheal tubes in young children
during generalanesthesia. Anesthesiology 1997;86:627–31