GENERAL ANAESTHESIA

Fundeni Clinical Institute

Anaesthesia and Critical Care Dept

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General Anaesthesia (GA)

 A variety of drugs are

given to the patient that
have different effects
with the overall aim of
ensuring
unconsciousness,
amnesia and analgesia.

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 Overview
 General anaesthesia is a complex procedure
involving :
 Pre-anaesthetic assessment
 Administration of general anaesthetic drugs
 Cardio-respiratory monitoring
 Analgesia
 Airway management
 Fluid management
 Postoperative pain relief

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Pre-anaesthetic evaluation

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Pre-anaesthetic evaluation

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Premedication

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Induction

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 Intravenous Induction Agents

 Commonly used IV induction agents include

Prpofol, Sodium Thiopental and Ketamine.
 They modulate GABAergic neuronal
transmission. (GABA is the most common
inhibitory neurotransmitter in humans).
 The duration of action of IV induction agents is
generally 5 to 10 minutes, after which time
spontaneous recovery of consciousness will
occur.
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 (1) Propofol
 Short-acting agent used for the
induction, maintenance of GA
and sedation in adult patients
and pediatric patients older than
3 years of age.
 It is highly protein bound in vivo
and is metabolised by
conjugation in the liver.
 Side-effects is pain on injection
hypotension and transient apnea
following induction

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 (2) Sodium thiopental
 Rapid-onset ultra-short acting
barbiturate, rapidly reaches the brain
and causes unconsciousness within
30–45 seconds.
 The short duration of action is due to
its redistribution away from central
circulation towards muscle and fat
 The dose for induction is 3 to 7 mg/kg.
 Causes hypotension, apnea and
airway obstruction
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 (3) Ketamine
 Ketamine is a general dissociative
anaesthetic.
 Ketamine is classified as an NMDA
Receptor Antagonist.
 The effect of Ketamine on the
respiratory and circulatory systems is
different . When used at anaesthetic
doses, it will usually stimulate rather
than depress the circulatory system.

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 inhalational induction agents

 The most commonly-used agent

is sevoflurane because it causes
less irritation than other inhaled
gases.
 Rapidly eliminated and allows
rapid awakening.

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 Maintenance

 In order to prolong anaesthesia for the required

duration (usually the duration of surgery), patient
has to breathe a carefully controlled mixture of
oxygen, nitrous oxide, and a volatile anaesthetic
agent. This is transferred to the patient's brain
via the lungs and the bloodstream, and the
patient remains unconscious.

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 Maintenance
 Inhaled agents are supplemented by intravenous
anaesthetics, such as opioids (usually fentanyl or
morphine).
 At the end of surgery the volatile anaesthetic is
discontinued.
 Recovery of consciousness occurs when the
concentration of anaesthetic in the brain drops
below a certain level (usually within 1 to 30
minutes depending upon the duration of surgery).

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 Maintenance
 Total Intra-Venous Anaesthesia (TIVA): this
involves using a computer controlled syringe
driver (pump) to infuse Propofol throughout the
duration of surgery, removing the need for a
volatile anaesthetic.
 Advantages: faster recovery from anaesthesia,
reduced incidence of post-operative nausea and
vomiting, and absence of a trigger for malignant
hyperthermia.

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 Neuromuscular-blocking drugs

 Block neuromuscular transmission at the

neuromuscular junction.
 Used as an adjunct to anesthesia to induce
paralysis.
 Mechanical ventilation should be available to
maintain adequate respiration.

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Types of NMB

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 Airway management

 To maintain an open airway and

enable mechanical ventilation, an
endotracheal tube or laryngeal
mask airways are often used.

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 Monitoring
 ECG
 Pulse oximetry (SpO2)
 Blood Pressure Monitoring (NIBP or IBP)
 Agent concentration measurement
 Low oxygen alarm
 Carbon dioxide measurement (capnography)
 Temperature measurement
 Circuit disconnect alarm

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Postoperative Analgesia

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 Mortality rates
 Overall, about five deaths per million.
 Most commonly related to surgical factors or pre-
existing medical conditions ( haemorrhage, sepsis).
 Common causes of death directly related to
anaesthesia include:
1- aspiration of stomach contents
2- suffocation (due to inadequate airway management)
3- allergic reactions to anaesthesia
4- human error
5- equipment failure

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Mortality rates – ASA
Classification

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 LOCAL ANAESTHESIA
AND
REGIONAL ANAESTHESIA
 Types of Anaesthesia

 Local anaesthesia – the administration of an

anaesthetic agent to one part of the body by
local infiltration or topical application. It is
usually administered by the surgeon.
Used for minor proceduresif the patient’s
cooperation and the condition warrants
its use.

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 Types of Anaesthesia cont…

 Regional Anaesthesia – is broadly defined as a

reversible loss of sensation in a specific area or
region of the body when a local anaesthetic is
injected to purposefully block or anaesthetize
nerve fibres in and around the operative site.
Commonly R.A techniques include:
Spinals (subarachnoid block), epidurals
(extradural space) , caudals, and major
peripheral nerve blocks.

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 Types of Anaesthesia Care

 Monitored anaesthesia care (MAC) is scheduled when an

anaesthesia provider’s presence is necessary.
- The infiltration of the surgical site with a local anaesthesia
and supplements the local anaesthesia with IV drugs that
provide sedation and systemic analgesia. Additional
medication may be used to optimize the patient’s
physiologic status.
- Can be used for some procedures for critically ill patients
who may poorly tolerate a general anaesthetic without
extensive invasive monitoring and pharmacologic support.
- Often used for healthy patients undergoing relatively
minor surgical procedures.

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 Types of Anaesthesia Care cont….

 Conscious sedation/analgesia is administered

for specific short-term surgical, diagnostic, and
therapeutic procedures within the hospital and
ambulatory centre.

It allows patients to tolerate unpleasant

procedures while maintaining adequate cardio-
respiratory function and the ability to respond
purposefully to verbal command and/or tactile
stimulation
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 Conduction Anaesthesia

 Conduction anesthesia is a comprehensive term which

encompasses a great variety of local and regional
anesthetic techniques.
 Conduction anesthesia allows patients to undergo many
surgical procedures without significant pain or distress. In
many situations, such as cesarean section, conduction
anesthesia is safer and therefore superior to general
anesthesia. In other situations, either conduction or
general anesthesia are suitable. Anaesthetists sometimes
combine both techniques.

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 Conduction Anaesthesia cont…

 Conduction anesthesia is also used for relief

of non-surgical pain, also to enable diagnosis
of the cause of some chronic pain conditions.

 The most common form of conduction

anaesthesia is probably local anaesthesia to
enable dental procedures.

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 Clinical techniques
include:
 Surface anesthesia - application of local anesthetic
spray, solution or cream to the skin or a mucous
membrane. The effect is short lasting and is limited to
the area of contact.
 Infiltration anesthesia - injection of local anesthetic
into the tissue to be anesthetized. Surface and
infiltration anesthesia are collectively topical
anesthesia.
 Field block - subcutaneous injection of a local
anesthetic in an area bordering on the field to be
anesthetized.
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Local Anaesthesia

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Local Anesthesia

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 Clinical techniques include:
cont…
 Peripheral nerve blocks - injection of local
anesthetic in the vicinity of a peripheral nerve to
anesthetize that nerve's area of innervation.
 Plexus anesthesia - injection of local anesthetic
in the vicinity of a nerve plexus, often inside a
tissue compartment that limits the diffusion of the
drug away from the intended site of action. The
anesthetic effect extends to the innervation areas
of several or all nerves stemming from the
plexus.
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Peripheral nerve blocks

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 Clinical techniques include:
cont…
 Epidural anesthesia - a local anesthetic is injected into
the epidural space where it acts primarily on the spinal
nerve roots. Depending on the site of injection and the
volume injected, the anesthetized area varies from
limited areas of the abdomen or chest to large regions
of the body.
 Spinal anesthesia - a local anesthetic is injected into
the cerebrospinal fluid, usually at the lumbar spine (in
the lower back), where it acts on spinal nerve roots
and part of the spinal cord. The resulting anesthesia
usually extends from the legs to the abdomen or chest.
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Lumbar Vertebrae

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Spinal Block - Position

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Spinal and Epidural
Anaesthesia

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Spinal and Epidural
Anaesthesia

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 Clinical techniques include:
cont…
 Intravenous regional anesthesia (Bier's block) - blood
circulation of a limb is interrupted using a tourniquet (a
device similar to a blood pressure cuff), then a large
volume of local anesthetic is injected into a peripheral
vein. The drug fills the limb's venous system and
diffuses into tissues where peripheral nerves and
nerve endings are anesthetized. The anesthetic effect
is limited to the area that is excluded from blood
circulation and resolves quickly once circulation is
restored.
 Local anesthesia of body cavities (e.g. intrapleural
anesthesia, intraarticular anesthesia).

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Intravenous Regional
Anaesthesia

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 Caudal Block

 Anatomy of the Caudal Caudal analgesia is produced by

Space injection of local anaesthetic into the
caudal canal. This produces block of
the sacral and lumbar nerve roots. It is
useful as a supplement to general
anaesthesia and for provision of
postoperative analgesia. This
technique is popular in paediatric
patients. Catheter insertion may be
performed for continuous caudal
block.

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Caudal

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 Local Anaesthetics
 Local anaesthetic agents can be defined as drugs which are
used clinically to produce reversible loss of sensation in a
circumscribed area of the body.
 Drugs include Beta-adrenoceptor antagonists, opioid
analgesics, anticonvulsants and antihistamines.
 Local anaesthetics can be divided into two groups on the
basis of their chemical structure:
- amides: Lignocaine, prilocaine and bupivacaine
- esters: Amethocaine, benzocaine, cocaine
e.g., amethocaine lozenges for the oropharynx, cocaine for
nasal surgery.
Most blocks take 5 – 20 minutes to work.
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 The potential side effects and/or
complications

 The most common side effects of a block is a

temporary weakness or paralysis of the affected
area.

 The complications may arise when the L.A is

injected in the wrong place, e.g., 10-20mls of
L.A is injected into a vein by mistake, it may
cause convulsions and even cardiac arrest.

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 Why choose a L.A or R.A?

 L.A avoids some of the risks and unpleasantness,

such as nausea and vomiting, which sometimes
occurs with G.A.
 L.A often lasts longer than the surgery, providing pain
relief for several hours after operation.
 L.A may reduce blood loss.
 Some patients feel more “in control” when they are
awake during surgery.

THE END
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