Basic components of general anesthesia
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Transcript Basic components of general anesthesia
General anesthesia
Outline of lecture
Components and phases of general anesthesia
Indications for GA
Induction of GA
Standard
Rapid sequence induction
Inhalation
Monitors employed
Basic components of
general anesthesia
Definition of Anesthesia: state of being unaware
and unresponsive to painful stimuli
Several aspects are involved
a) lack of conscious awareness = unconsciousness
b) lack of perception of pain = analgesia
c) lack of movement
= muscle relaxation
d) modification of autonomic responses (HR,BP) to
painful stimuli.
Components of general anesthesia 2
Definition of Anesthesia: state of being unaware
and unresponsive to painful stimuli
a) lack of conscious awareness = unconsciousness
Regional anesthesia (spinal, epidural, plexus block) is
perhaps more correctly termed regional analgesia.
Analgesia is an altered sensation of painful stimuli.
The stimulus is felt as movement, pressure.
Patient is usually partly aware of surroundings
pregnant woman having C. Section under spinal analgesia
Components of general anesthesia 3
Two aspects of conscious awareness: being awake and
the formation of a memory of being awake.
Goal of providing a level of sedation adequate to prevent
patient being awake.
Amount of required sedation depends on intensity of
stimulation.
If also give analgesia, one can prevent a patient being
awake and in pain.
If give relaxants and no analgesia, a patient can be awake
and paralyzed and in pain.
Awareness during GA
Sedation with midazolam also causes amnesia (failure
to form a memory of event even when awake)
Volatile anesthesia at a depth greater than 0.7 MAC is
thought to prevent awareness.
Titration of level of anesthesia to a BIS level less than
60 is claimed to prevent awareness.
Components of general anesthesia 4
Definition of Anesthesia: state of being unaware
and unresponsive to painful stimuli
b) lack of perception of pain = analgesia
c) lack of movement in response to painful stimuli
This will occur at MAC level of anesthesia or sub MAC
levels and use of muscle relaxants
d) modification of autonomic responses (HR,BP) to
painful stimuli. This usually requires a dose of more
than 1.0 MAC and is easier to achieve with specific
drugs (beta blockers, potent narcotics)
Components of general anesthesia 5
Practically impossible to create state of general
anesthesia with a single drug
A combination of various drugs of specific types is
commonly used.
Result of the combination satisfies all the desired
categories and often has a synergistic effect.
A sedative + narcotic is more potent than bigger dose of
either alone
Components of general anesthesia 6
Volatile agent e.g. sevoflurane has large amount of
sedation, some muscle relaxation, but no analgesia.
(Nitrous oxide has above features and analgesia)
Propofol has sedation, some relaxation, some amnesia
and no analgesia.
Fentanyl has mild sedation, no relaxation, no amnesia
and large amount of analgesia
Muscle relaxants have no sedation, amnesia or
analgesia
5 phases of general anesthesia
(Preparation)
Induction
Maintenance
Emergence
Recovery
Preparation for GA
Patient assessment
NPO status
Airway
Functional reserve of major organ systems
CVS, respiratory, renal, hepatic
Medications used regularly
Allergies and previous experience with GA
Type of planned procedure
Urgency
Position of patient during surgery
Area of body involved
Phases of general anesthesia
Induction phase: transition from awake state to full
affect of anesthesia on CNS, CVS, respiratory and
muscle system
Changes in CNS function are always accompanied by
those of other systems
Magnitude of changes in various systems reflect
physiological state of patient
age, stress level, physiological reserve, fluid balance,
drug therapy
Induction of anesthesia
Drug effect on CNS is primarily depression of usual
response
There may be contrary effects related to loss of
inhibitory actions of CNS (excitement)
Examples: movements of limbs, hiccough, cough
Induction of anesthesia
Addition of supports is required to ensure adequate
function of respiratory and CVS systems
Airway control with oral airway, LMA, or ETT
Ventilatory support
Protection of the airway
Blood pressure support with medication or IV fluids
Further adjustment of anesthesia levels based on
Patient response
Stage of surgery
Trends of monitored variables
Maintenance of anesthesia
Further adjustment of anesthesia levels based on
Patient response
Stage of surgery
Trends of monitored variables
Maintenance phase usually a stable period unless
Changing level of surgical stress
Impaired state of patient fitness
Anesthesia gases form the major component with
some IV narcotics or relaxants as background
Emergence from anesthesia
Slower version of induction phase in a reverse order
CNS wakes up in stages or by regions
Brainstem or lower functions first (breathing, cough,
shivering)
Cerebral cortex later (purposeful movements, response
to commands)
Removal of supports at appropriate time intervals
Excitement aspects are common: limb movement,
restlessness, coughing.
Potential for vomiting, laryngospasm, upper airway
obstruction
Indications for general anesthesia
Defined by surgical procedure
Requires profound muscle relaxation
Incision location above umbilicus
Inability to provide comfort with local/regional anesthesia
Duration of surgery more than 3 hours
Defined by patient
Airway protection
Respiratory failure
Unstable clinical state
Inability to cooperate/ understand regional
Complications of general anesthesia
Respiratory failure
Atelectasis
Aspiration
Hypotension
Injury to peripheral nerves, cornea
Injury to respiratory tract
Intravenous induction
Indications:
Usual or default method of starting general anesthesia
Risk of aspiration (see rapid sequence)
Standard method involves drug combination:
Sedative in large dose (propofol) usually with narcotic
and/or anxiolytic (midazolam)
Muscle relaxant if doing intubation
Mask 100% O2 during process (before, during, after)
Drug doses are initially based on weight and age of
patient. Extra doses as directed by response of patient
Intravenous induction
Contraindications:
Lack of proper equipment for resuscitation (IPPV,
oxygen, airway devices, suction)
Uncertainty about ability to ventilate or intubate patient
if they become apneic
Patient with partial airway obstruction (avoid apnea)
Intravenous induction
Precautions:
Patient with limited or uncertain CVS reserve
(hypovolemia, CHF, valvular stenosis, sepsis)
Patients with poorly controlled CVS disease (high BP,
angina, disturbed heart rhythm)
Patients with risk of aspiration
Patients with respiratory failure
Intravenous induction
Standard form vs slow form
Standard form indicates use of standard doses given
on basis of body weight.
Slow form indicates careful titration of strong sedative
drugs (propofol) or narcotics. Possible substitution
with or addition of other medications (ketamine)
Goal is the use of minimal but sufficient doses of
anesthesia to reduce intensity of CVS and respiratory
effects and allow time for compensation
Rapid
Sequence
Induction
Rapid sequence induction
Indications:
Patient at risk for regurgitation and aspiration who
require GA
History of recent vomiting or recent meal
Pregnancy
Increased intra-abdominal pressure
Abdominal distension
Poorly controlled GE reflux
Decreased level of consciousness
Rapid sequence induction
Contraindications:
Potential difficult intubation
Potential airway obstruction
Laryngeal injury
Cervical spine injury
Poorly controlled BP
Rapid sequence induction
Precautions:
Potential for loss of airway control
Potential for severe BP change (high or low)
Potential for cardiac dysrhythmias, including arrest, in
predisposed patient.
Potential for marked increase in ICP
Rapid sequence induction
Method:
Preoxygenation is critical; best method unclear.
Suction and airway alternatives available
Use adjuvant drugs to control BP, HR response:
midazolam, narcotics, lidocaine, ketamine, etc
Explain and rehearse use of cricoid pressure with the
patient. Optimize position of upper airway.
Dose of potent sedative (propofol) as per body weight
or titrate depending on reserve of CVS
Rapid sequence induction
After patient is asleep, apply cricoid pressure and give
relaxant in large dose.
Two choices:
no active ventilation, proceed with laryngoscopy as
relaxant has peak effect
Gentle IPPV (Paw 10-15 cm H2O) with 100% O2 until
relaxant has peak effect.
Place ETT, and inflate cuff and confirm correct
position of ETT before removing cricoid pressure
Inhalation induction
Inhalation induction
Indications:
Difficult IV access
Potential airway obstruction e.g. epiglottitis
Thoracic diseases which preclude use of IPPV
Mediastinal mass, foreign body in airway, broncho-pleural
fistula
Patients unable to cooperate with awake airway
endoscopy
Inhalation induction 2
Contraindications:
Aspiration risk (unless overruled by airway concerns)
Active bleeding in airway (risk of cough, laryngospasm)
Note profound changes in BP are unusual with this as
compared to rapid sequence with IV drugs
No controlled studies in this area of “right way to do
induction in this type of patient”
Inhalation induction 3
Precautions:
Lack of patient cooperation or comprehension
Preexisting respiratory failure
Patients may become restless before falling deeply
asleep. This is a temporary phenomenon “excitement
phase”. Use gentle assisted ventilation and wait.
After several minutes of anesthesia, expect improved
conditions for starting an IV, if not already done.
Inhalation induction 4
Describe steps briefly to patient. Emphasis on deep
breaths with maximal breath holding interval.
Best agents are sevoflurane, enflurane, halothane.
Desflurane and isoflurane are irritating to airway.
Avoid narcotics; give sedation with midazolam.
Coach patient with calm, reassuring voice
Choices of technique:
Several deep breaths from a primed circuit
Slow incremental doses with normal ventilation
Inhalation induction 5
Single / several deep breath technique:
Prime circuit with anesthesia agent from vapourizer at
maximum setting, FGF at 8L/min, pop off valve open
and patient end of circuit occluded.
Have patient exhale maximally, then apply face mask
to patient and inhale maximally from primed circuit.
Expect prompt onset of sleep (60 seconds) followed by
transient apnea, then pattern of rapid shallow
respirations.
Inhalation induction 6
Slow incremental doses with normal ventilation
Prime circuit with N2O 70%, FGF at 8L/min, pop off
valve open and patient end of circuit occluded.
When patient is comfortable with situation, begin
volatile agent increasing vapourizer setting by 0.5%
every 3 or 4 breaths. Reassure patient with calm voice
encouraging a regular smooth breathing pattern.
Use of a deep breathing pattern here may lead to
premature onset of apnea with prolonged phase.
Expect several minutes to fall asleep. Assist ventilation
Inhalation induction 7
Time to safe airway insertion: Use eye signs and
elapsed time, not ET concentration as guide.
Consider response to oral airway as trial
With single deep breath technique, authors suggest
possible insertion of LMA after at least 2 minutes, ETT
at least 5 minutes following onset of sleep.
Laryngospasm, coughing, inadequate view of larynx is
possible. Do not rush.
Place patient on 50-100% O2 shortly before attempted
insertion of LMA / ETT
Monitors
used
during
Induction
of
Anesthesia
Monitors during induction
of anesthesia
Pulse oximetry and end tidal CO2 are critical
Eyes and ears of the anesthesia person
Experienced assistant is very important
Stethescope, BP, EKG
Prepare with plan B