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ANESTHESIOLOGY:

GENERAL ANESTHESIA 1

GENERAL ANESTHESIA Maintenance of Patent Airway
reversible state of unconsciousness produced by 1. Chin/Jaw Thrust maneuver anterior displacement of
anesthetic agents mandible lift epiglottis and base of tongue from airway
Effects: 2. Pharyngeal airways augments elevation of epiglottis and
o loss of sensation of pain over the whole body base of tongue; airway bypasses tongue and displaces it
o Anterograde Amnesia anteriorly
o Muscle relaxation 3. Tracheal intubation insertion of tube through
Mechanism of Action mouth/nose to the trachea; supraglottic device
o Result of reversible changes in neurologic Advantages of ET Intubation:
function airway patency is assured
o Inhalational: inhibition of synapses in region of protection from aspiration and regurgitation
neuro-basal thalamus gastric distention is prevented
o Intravenous: drug-receptor interactions Disadvantage: not being adept to the technique

Indication for General Anesthesia Complications of General ET Anesthesia:
Infants and children 1. Trauma
Extensive surgical procedures 2. Endobronchial intubation
Patient with mental disease 3. Esophageal intubation
Prolonged surgery 4. ET tube obstruction
Surgery where local anesthesia is impractical 5. Laryngospasm
With history of toxic/allergic reactions to local anesthesia
Patients on anticoagulant treatment Complication of General Anesthesia (Intra-Op)
Adults who prefer general anesthesia 1. Respiratory complications
Hypoventilation
Order of Descending Depression Upper airway obstruction caused by falling back of
1. Cortical and psychic centers tongue, foreign bodies above glottis, endobronchial
2. Basal ganglia and cerebellum intubation, laryngeal spasm/hiccup
3. Spinal cord Lower airway obstruction aspiration, bronchospasm
4. Medullary centers 2. Cardiovascular complications
Hypotension
4 Components of General Anesthesia Hypertension
1. Sensory block loss of sensation or analgesia Arrhythmias
2. Motor block loss of muscle tone 3. Ocular complications corneal abrasions due to ill fitting mask
3. Block of the reflexes loss of reflexes 4. Malignant Hyperthermia rapid increase in body temperature of
4. Mental block loss of consciousness at least 2 degrees/hour; high mortality

Clinical Signs Prevention of Post-Op Complications
Breath holding, delirium, involuntary 1. Continuous monitoring of VS
Insufficient Depth movement, retching, increase mucus 2. Avoid excessive sedation
secretions 3. O2 inhalation
Stable CV response, adequate muscle 4. Turn from side to side
Sufficient Depth relaxation, amnesia, absence of troublesome 5. Deep breathing
reflexes 6. Steam inhalation liquefy secretions
No response or ability to resume normal
Excessive Depth ventilatory function at end of operation; BP INTRAVENOUS ANESTHESIA
and obtundation Depression of CNS
Blocking of pain stimuli at level of cerebral cortex
Types of General Anesthesia
1. By Inhalation through pulmonary blood alveolar BARBITURATES
interface MOA: enhances and mimic action of GABA by binding to
a. Mask Inhalation using fitted mask receptor
b. Nasal insufflation rubber anesthesia tubing Thiopental ultra-short acting; blocks central brain core
catheter inserted to nasopharynx (RAS) unconsciousness; rapid onset, short duration of
c. Endotracheal intubation tube in between action; lethal injection
glottic opening up to near carina Indications
d. Tracheal stoma o Induction of anesthesia
2. Intravenously o Sole anesthetic agent
3. Intramuscularly o Supplementation
4. Rectally o Conjunction with regional anesthesia
o Treatment of Status Epilepticus
o Cerebral protection with raised ICP


Jena Dominguez
UST-FMS Batch 2019
ANESTHESIOLOGY: GENERAL ANESTHESIA 2

Contraindications
o Severe shock or hypovolemia 4. Ketamine
o Status asthmaticus profound analgesic, rapid
o Porphyria intravenous NMDA receptor antagonist
o Absence of IV access or GA equipment interrupt cerebral association pathways dissociative
anesthesia
NON-BARBITURATES intact laryngeal reflexes
1. Benzodiazepines BP, CR, IOP, ICP, CVP
MOA: potentiation of neural inhibition mediated by GABA-
aminobutyric acid 5. Balanced Anesthesia addition of nitrous oxide, oxygen and
Pharmacologic effect: muscle relaxants
o Anxiolytic
o Sedative ADJUNCTS TO ANESTHESIA
o Hypnotic OPOIDS
o Muscle relaxant Bind to morphine receptors
o Amnesic (Anterograde) Both analgesic and sedative properties
o Anticonvulsant Agonists: morphine, fentanyl, sufentanil, remifentanil,
Diazepam meperidine
Premedication; for seizures Agonist-Antagonists nalbuphine, butorphanol
Water insoluble pain during injections Antagonist Naloxone
No significant effects on CO, BP or cerebral blood flow Effects: analgesia, depression of sensorium and
Relieves muscle spasm respirations

Lorazepam Morphine
Premedication - Depressant effect analgesia, sedation, depress
Water insoluble respiration and cough reflex, decrease GI motility
5-10 times as potent as diazepam - Excitatory effect euphoria, miosis, N/V, bradycardia,
profound anterograde amnesia release of ADH
- Increases smooth muscle tone
Midazolam - HISTAMINE RELEASE bronchospasm, erythema
same action as diazepam
shorter duration of action Nalbuphine
rapid metabolism in liver - Sealing effect
water soluble to 2-3 times - > 60mg it reverses itself
useful drug for sedation in: outpatient anesthesia, minor
procedures and regional anesthesia, intensive care Meperidine
- action similar to morphine
2. Propofol - shorter duration of respiratory depression
increase inhibitory neurotransmission mediated by GABA - not as marked euphoria
highly lipid soluble rapid loss of consciousness - more pronounced N/V
has minimal accumulation even on repeated doses - mild quinidine like effect
has more cardio and respi depressant effect than - less histamine release
pentothal - less or no GIT actions

Severe pain on venous injection
Naloxone
Contraindicated with egg allergy
- pure opioids antagonist
For grand mal seizures
- competitive antagonist at opioid receptor sites
Effective in N/V
- rapid onset, short duration
Bolus dose: 2mg/kg in 4-5 mins
Advantages: NEUROMUSCULAR BLOCKING AGENTS
o Rapid clearance and few residual effects on muscle relaxants
awakening
blocking action of Ach at junction of nerve ending and
o ICP, IOP, arterial BP
motor end plate
o effective in treating N/V
facilitate intubation


3. Neuroleptanalgesia
1. Depolarizing muscle relaxant drugs
combination of potent analgesic and neuroleptic
- mimic affect of Ach depolarize postsynaptic membrane
tranquilizer (fentayl + droperidol)
at NM junction prolong or making persistent
produce state of mental detachment and indifference to depolarization
pain
MOA: competitive antagonism at dopaminergic receptors

Jena Dominguez
UST-FMS Batch 2019
ANESTHESIOLOGY: GENERAL ANESTHESIA 3

- Succinylcholine rapidly metabolized by
pseudocholinesterases; rapid onset of action; excellent
agent for intubation
2. Nondepolarizing muscle relaxant drugs
- Compete with Ach released at NM junction
- Block action of Ach prevent depolarization prevent
transmission of nerve impulses to muscle fibers
- Pancuronium, Rocuronium, vecuronium
- Short-acting 15-30 mins by mivacurium
- Intermediate-acting 30-40 mins by atracurium

3. Reversal agents for Neurouscular Blockade
- used during GA to reverse effects of muscle relaxants
- enables spontaneous breathing to recommence earlier
- Anticholinesterase reverse effect of nondepolarizing
muscle relaxant
- Sugammadex first selective relaxant binding agent
(SRBA); does not rely on inhibition of acetylcholinesterase


Jena Dominguez
UST-FMS Batch 2019