Basic Concept of General Anesthesia

1
Review
Anesthesia
It indicates that medicine or other
methods is used to make patient lose sense
completely or partly, and finally to make
them feel no pain during operation.

2
Review
General anesthesia
I t is an anesthetic method that narcotic
acts on central nervous system and restrains
its function.

3
Review
Local anesthesia
I t is an anesthetic method that
narcotic only acts on peripheral
nervous system and retrains some or
one nerve’s functional password to
make one part of the body losing sense
of pain.

4
Review
Airway examination
Mallampati classification
1. Class 1: able to visualize the soft palate, fauces,
uvula, anterior and posterior tonsillar pillars.
2. Class 2: able to visualize the soft palate, fauces,
and uvula. The anterior and posterior tonsillar
pillars are hidden by the tongue.
3. Class 3: only the soft palate and base of uvula
are visible.
4. Class 4: only the soft palate can be seen (no
uvula seen).

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Review
Assessment of physical status
Ⅰ A normal healthy patient
Ⅱ A patient with mild systemic disease
Ⅲ A patient with severe systemic disease
Ⅳ A patient with severe systemic disease that is a
constant threat to life
Ⅴ A moribund patient who is not expected to
survive without the operation
Ⅵ A declared brain-dead patient whose organs are
being removed for donor purposes
For emergent operations, add the letter ‘E’ after the
classification

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Basic Concept of General Anesthesia

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Definition of General Anesthesia

General anesthesia is an altered physiologic

state characterized by reversible loss of
consciousness, analgesia of the entire body,
amnesia and some degree of muscle
relaxation.

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Anesthesia – denotes a lose of sensibility
Surgical Anesthesia – is a controlled degree of CNS

depression with the following component

• Analgesia – lack of pain

• Amnesia – lack of memory
• Inhibition from reflexes such as bradycardia and
laryngospasm
• Skeletal muscle relaxation
• (altered state consciousness) state of unconsciousness.

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Depth of Surgical Anesthesia –
can be divided into a series
of four sequential stages:

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Depth of Surgical Anesthesia

Stage I: Analgesia
Loss of pain sensation results from
interference. With sensory transmission
in the spinothalamic tract. The patient
is conscious and conversational. A
reduced awareness of pain occurs as
stage II is approached.

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Depth of Surgical Anesthesia

Stage II: Excitement

The patient experience delirium and violent
combative behaviour. There is a
rise and irregularity in blood pressure. The
respiratory rate may be increase

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Depth of Surgical Anesthesia

Stage III: Surgical anesthesia

Regular respiration and relaxation of the
skeletal muscle occur in this stage.
Eye reflexes decreases progressively,
until the eye movements cease and
the pupil is fixed. Surgery may proceed
during this stage.

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Depth of Surgical Anesthesia

Stage IV: Medullary paralysis

Severe depression of the resp. center
& vasomotor center. Death can
rapidly ensure.

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KINETICS OF ANESTHESIA
2. Induction
2. Maintenance
3. Recovery

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Two Kinds of General Anesthetics

D.Inhalational
E.Intravenous

16
Induction and Recovery from Anesthesia

Induction – is the period of time from onset

of administration of the anesthetic to the
development of effective surgical anesthesia
in the patient. It depends on how fast the anesthetic
reaches the brain.

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Recovery – is the time form discontinuation
of adm. of anesthetic until consciousness is
regained .It depends on how fast the
anesthetic is removed from the brain.

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Maintenance of Anesthesia – maintenance is the
time during which the patient is surgically
anesthetized, anesthesia is usually maintained
by the administration of gases or volatile
anesthetics since these agents offer good minute to
minute control over the depth
of anesthesia.

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Inhalational Gen Anesthetics
1. N2O (Nitrous oxide) – laughing gas
2. Halothane
3. Enflurane
4. Isoflurane
5. Methyoxyflurane
6. Diethyl ether
Newer Inhalational General Anesthetics
1. Desflurane 2. Seroflurane

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Mechanism of Action of Inhalational General
Anesthetics

These agents decrease the firing rate of nerve cells

by decreasing the rise of the action potential.
They inhibit the rapid increase in membrane
premeability to sodium ion.

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Intravenous General Anesthetics
: are often use for the rapid
induction of anesthesia

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A.Barbiturates – Ultra-short Acting:
1. Thiopental
2. Thiamylal
3. Methohexital
Acts less than one (1) minute, B.P
due to myocardial depression.
Depresses the resp center in a dose
dependent manner may cause
laryngospasm – not an analgesic.

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B. Ketamine (Ketalar) – Dissociative
anesthesia – a short – acting non
barbiturate – induces a dissociative state in
which the patient appears to be
awake consist of Amnesia. Analgesia and
often catatonia (rigidity). There is
disorientation, hallucinations and changes
in perception.

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Combination Anesthetics – lighter
stage of anesthesia is produce using
2 or more drugs.

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A.Balanced Anesthesia : Full loss of
consciousness and pain – induced
reflexes with muscle relaxation using:

a. Ultra – short acting barbiturate

b. Opioid analgesic (Meperidine, Morphine,
Fentanyl or Sufentamil)
c. Muscle relaxation
d. Nitrous Oxide + Oxygen

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B. Neuroleptanesthesia – is induced by the
combined actions of a narcotic analgesic
(Fentanyl) and a neuroleptic agent
(Droperidol), together with N2O &
Oxygen. Consciousness is not lost, there is
tranquility and reduce motor activity.
Useful in pnt wherein cooperation is
needed (diagnostic
procedures) but may cause resp. depression.

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Pre-Anesthetic Medications :

- Administered prior to anesthesia to

reduce pain, relieve anxiety decrease excess
salivation and to combat nausea.

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A. Anxiolytic drugs – provides
sedation, relieve anxiety-
Benzodiazepam - diazepam, Lorazepam
and Midazolam
B. Narcotic Analgesic - reduces pain –
Morphine Fentanyl
C.Neuroleptics - promethazine,
trimeprazine or chlorpromazine; use to
sedate and for its anti-emetic
properties.
D.Anticholinergic - Atropine and
Scopolamine decreases bronchial and
salivary secretions, and promote
bronchodilatation. 29
Properties Anesthetics
(Learn by yourself)

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Rapid-sequence Intravenous Induction
s e d a t i v e s , h y p n o t i c s o r
I n t r a v e n o u s a n e s t h e t i c s a g e n t s

u n c o n s c i o u s n e s s

m a s k v e n tila tio n fo r 5 m in
c lo s e - fittin g fa c e m a s k
1 0 0 % o x y g e n d e liv e r y

m u s c le r e la x a n ts

t r a c h e a l in tu b a tio n

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Rapid-sequence Intravenous Induction
-- Disadvantage and Complications

Regurgitation and Vomitting

Cardiovascular depression
Respiratory depression
Histamine release
Pain on injection
Hiccup and muscle movements

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Inhalational Induction-- Indications

young children
myasthenia gravies
upper airway obstruction, e.g. Epiglottises
lower airway obstruction with foreign body
bronchopleural fistula or empyema
no accessible veins

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Inhalational Induction -- Methods

Initially, nitrous oxide 70% in oxygen is

used and anesthesia is deepened by gradual
introduction of increments of a volatile
agent,
e.g. Halothane 1-3%, Enflurane 1.5-2.5%,
Isoflurane 1-2% .

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Inhalational Induction-- characteristics

Spontaneous ventilation is to be maintained.

The face mask is applied firmly as consciousness
is lost and the airway is supported manually.
 Insertion of an oropharyngeal airway , a
laryngeal mask airway or a tracheal tube may be
considered when anesthesia has been established.

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Inhalational Induction
--Disadvantage and Complications

Slow induction of anesthesia

Airway obstruction , bronchospasm
Laryngeal spasm , hiccups
Environmental pollution

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Induction with spontaneous ventilation
-- Indications

Airway obstruction
Anticipant difficult intubation

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Induction With Spontaneous Ventilation
-- Characteristics

Maintaining spontaneous ventilation

throughout the procedure

Sufficient surface anesthesia

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Other induction methods

Intramuscular injection of ketamine

Take midazolam orally
Administration of fentanyl via mucosa

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Maintenance of general anesthesia

Sedation
Analgesia
muscle relaxation

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Maintenance of general anesthesia

Inhalational agents
Intravenous anesthetics
Opioids
Muscle relaxants

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Recovery

Antagonizing residual neuromuscular blockade

Extubation
Airway supporting
Recovery position is benefit to avoid airway
obstruction

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43
Prevention and treatment of
serious complications during
general anesthesia

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Introduction

Complications of anesthesia involve

three aspects ：
A. Patient's condition
B. Diathesis of anesthetist
C. Influence and fault of anesthetics 、

anesthetic apparatus and

correlated
instrument

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Serious Complications
during General Anesthesia
Respiratory tract obstruction
Respiratory depression
Hypotension and Hypertension
Myocardial ischemia
Hyperthermia and Hypothermia
Awareness and Delay of Awake
Cough 、 Singultus 、 Postoperative vomiting 、
Postoperative pulmonary infection
Malignant hyperthermia

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Respiratory Obstruction
 Glossocoma ：
A ． Etiology ：
B ． Liability factor ：
◆Justo major of corpus linguae
◆ Short and stout
◆ Short neck
◆ Lymphadenosis of throat posterior wall
◆ Hypertrophy of tonsils

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Respiratory Obstruction

C ． Clinical features ：
D ． Management ：
◆ Side lying 、
◆ Head hypsokinesis 、
◆ Lift submaxilla 、
◆ Oropharyngeal parichnos
◆ Nasopharyngeal parichnos

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49
Respiratory Obstruction

Airway obstruction by secretion 、

purulent sputum 、 blood and
foreign object
A ． Etiology ：
◆ Inhalation of stimulant anesthetic ，
◆ Bronchiectasis 、 pulmonary
abscess 、
pulmonary tuberculous cavity

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Respiratory Obstruction

◆ Operation of cavum nasopharyngeum 、

oral cavity 、 Harelip
◆ Desquamation of tooth or artifcial teeth
B ． Management ：
◆ Sufficient belladonna premedication
◆ Intubation
◆ Suck respiratory tract
◆ Pull out dentium vacillatia or artifcal
teeth

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Respiratory Obstruction

Regurgitation and Aspiration

A ． Etiology ： Anticholinergic agent
Morphine
General anaesthetics
Muscle relaxant
B ． Clinical features ：
◆ Bronchospasm
◆ Tachypnea and dyspnea
◆ Moist rales
◆ Sever hypoxia

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Respiratory Obstruction
C ． Management ：
◆ Fasting ：
Adult ： 8h before anesthesia
Children ： milk and solid diet liquid
<6m 4h 2h
6~36 m 6h 3h
> 36 m 8h 3h

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Respiratory Obstruction
◆ Preoperative administration of an H2-
receptor antagonist （ cimetidine or
ranitidine ） to decrease further
secretion of additional acid.
◆ Application of gastric decompression
by a wide-bore nasogastric tube;
Preparing for suction
◆ Full stomach/high level ileus ： awake
intubation
◆ Rapid - sequence induction and
intubation without positive - pressure
ventilation before intubation.
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Respiratory Obstruction
◆ Application of cricoid compression to
control regurgitation of gastric
contents
◆ Extubation when the patient is fully
awake
◆ Aspiration ：
Head down position ， suck vomitus
Bronchial antispasmodic and antibiotics
Respiration support
Lavage of trachea using 0.9%NaCl

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Respiratory Obstruction
Malposition of catheter 、 Obstruction
of lumina 、 Anaeshetic machine failure
A. Etiology ： Catheter twist
Block by sputum
Corrugated tube twist
Malfunction of respiration
valve
B. Management ： Examine position of
catheter
Respiratory sound
Breathing circuit
Respiration valve
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Respiratory Obstruction
Trachea Compression
A. Etiology ： tumor of neck or mediastinum
hematoma 、 edema calidum
B. Management ：
Inflame affection of pharyngo-oral cavity 、
Larynx tumor 、 Allergia laryngeal edema
A. Etiology ： peritonsillar abscess 、
Larynx
tumor 、 pharynx posterior wall

abscess
B. Management ： 57
Respiratory Obstruction

Laryngospasm and Bronchospasm

Laryngospasm ：
A. Etiology ： pharyngeal vagus nerve
excitability↑
B. Evoked reasons ：

◆hypoxemia 、 hypercapnia 、 secretion 、

intubation oropharynx
parichnos 、
laryngoscope
◆light anesthesia
C. Clinical features 58
Respiratory Obstruction

E. Prevention ： avoid light anesthesia 、

hypoxia
、 carbon dioxide
accumulation
Bronchospasm ：
A. Etiology ：
◆ Tracheal
intubation 、 aspiration 、 suck
sputum
◆ Operation stimulate
◆ Thiopental Sodium 、 Morphine 59
Respiratory depression
Central Respiratory depression
A ． Etiology ： anesthetics 、

hyperventilation
narcotic analgesics 、
inflate lung unduly
B ． Management ：
◆ Anesthetics → reduce depth of 　　
　　 　　　 　　 　　　 　　 　　
　　 　 anesthesia
◆ Narcotic analgesics → Naloxone
◆ Hyperventilation 、 inflate lung
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Respiratory depression

Peripheral Respiratory depression

A. Etiology ： muscle relaxant
hypopotassemia
general anaesthesia +
　　　 　　　 　 epidural block
B. Management ：
◆ Muscle relaxant → Neostigmine 　
　　　 　　　 　　 　　　 　 Bromide
◆ Hypopotassemia → supply potassium
　　　
in time
◆ Spinal nerve block → wait the block 61
Respiratory depression

Respiration Management
A. Effective ventilation
B. Select of ventilation mode ：
◆ Assistor respiration
◆ Controlled respiration

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Hypotention and Hypertension

Hypotension(P380)
A ． Hypotension ： > 20% or ↓80mmHg
B ． Etiology ：
◆ anesthesia aspects
◆ operation aspects
◆ patient aspects

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Hypotention and Hypertension
C ． Prevention ：
◆ Insufficient body fluid →
sufficiently supply
◆ Severe anemia
◆ Severe mitral valve stenosis
◆ Myocardial ischemia → maintain
blood pressure

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Hypotention and Hypertension
◆ Myocardial infarction
◆ Congestive heart failure
◆ Ⅲ°BBB 、 sick sinus syndrome
→ pacemaker
◆ Hypopotassemia
◆ Atrial fibrilation → 80~120 bpm
◆ Using long-term corticosteroid

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Hypotention and Hypertension
D ． Management ：
◆ Reduce depth of anesthesia
◆ Transfusion ， Ephedrine
◆ Severe coronary heart disease
→ support cardiac pump function
◆ Drag internal organs
→stop operative procedure
◆ Adrenal insufficiency
→large dose of dexamethasone
◆ Cardiac arrest→cardiac resuscitation

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Hypotention and Hypertension
Hypertension
A ． Hypertension ：
B ． Etiology ：
◆ Anesthesia aspects
◆ Operation aspects
◆ Patient aspects

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Hypotention and Hypertension

C. Prevention ：
◆ Sufficient premedication
◆ hyperthyroidism
◆ Intubation → enhance anesthesia
surface anaesthesia
α or β-receptor blocker
◆ Avoid hypoxia and carbon dioxide
accumulation

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Hypotention and Hypertension

◆ Craniocerebral operations→droperidol
◆ Operation stress → compound with
epidural block
D ． Management ：
◆ Increase depth of anesthesia
◆ α or β-Receptor blocker 、
vascular smooth muscle relaxant
◆ ↑Ventilatory capacity 、↑ FiO2

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Myocardiac Ischemia
Correlative physiological knowledge
A. Oxygen consumption of myocardium ：
◆ HR
◆ myocardial contractility
◆ intraventricular pressure
B. Coronary Perfusion Pressure = AOP – IMP
AOP- aortic pressure
IMP- intramyocardial pressure

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Myocardiac Ischemia

Diagnostic method ： ECG

A. Cardiac conduction abnormality
B. Arrhythmia
C. Q wave ， R wave progressive step down
D. S-T↓> l mm or ↑> 2 mm
E. T wave is low 、 bidirection or inversion

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Myocardiac Ischemia
Etiology
A. Tension 、 fear 、 pain
B. Hypotension or hypertension
C. Myocardial contractility suppression and
vessel distension by anesthetic
D. Hypoxia
E. Tachyrhythmia or Arrhythmia

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Myocardiac Ischemia
Management
A. Maintain the balance of Oxygen supply-
　　 demand
B. Delay selective operation
C. Monitor ： ECG 、 MAP 、 CVP 、 CO 、
SVR 、 Urine volume
D. β-receptor blocker or calcium channel
　　 blocker
E. Analgesia using morphine
F. General anaesthesia + epidural block

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Hyperthermia and hypothermia
Heat Production and Elimination
A ． Heat Production ：
B ． Heat Elimination ：
◆ Radiation ： > 60%
◆ Conduction ： 3%
◆ Convection ： 12%
◆ Evaporation ： 25%

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Hyperthermia and hypothermia
Normal Thermoregulation ：
A. Thermoregulatory control system ：
◆ Cold-response thresholds ：
36.5℃,vasoconstriction
◆ Warm-response thresholds ： 37℃,sweat
B. Thermoregulation during General
Anesthesia ：
◆ warm-response thresholds ：↑ 1℃ to 38℃
◆ cold-response thresholds ：↓ 2℃ to 34.5℃

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Hyperthermia and hypothermia
Hypothermia ： core temperature < 36℃
A ． Evoked reasons ：
◆Cold operating rooms
◆Indoor vent(high theatre flow rates)
◆ Administration of cold intravenous
fluids
◆ Evaporation from surgical incisions
◆ General anesthetic

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Hyperthermia and hypothermia

B ． Influence of hypothermia ：
◆ Drug metabolism is markedly ↓ ↓
duration of action of anesthetics ↑
◆ Coagulation is impaired
◆ Blood vicidity↑
◆ Oxygen dissociation curve shift to
left
◆ Shivering → oxygen capacity↑↑
C ． Prevention ： measures depend on
the cause

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Hyperthermia and hypothermia
Hyperthermia ：
A ． Evoked reasons ：
◆ Room temperature > 28℃
◆Sepsis
◆Excessive catecholamine secretion
◆ large dosage of atropine
◆ Response to transfusions
◆ Malignant hyperthermia

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Hyperthermia and hypothermia
B ． Influence of Hyperthermia
◆ Basal metabolic rate↑
◆ Metabolic acidosis 、 hyperkalemia
hyperglycosemia
◆ > 40℃→convulsion
C ． Prevention

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Awareness and Delay of Awake
Awareness
A. Etiology
Low concentrations of volatile agents
B. Anesthetic technique
◆ N2O-O2- Muscle relaxant
◆ Fentanyl - Diazepam
◆ Thiopental or
Thiopental - Ketamine

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Awareness

◆ N2O- Fentanyl
◆ Etomidate - Fentanyl
◆ Procaine combined anesthesia
C. Management ：
◆ Avoid light anaesthesia
◆ Monitor brain stem auditory evoked
potential （ BSAEP ）

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Delay of Awake

Delay of Awake ： > 30min

A. Etiology ：
◆ Influence of Anaesthetic ：
Premedication
Inhalation Anaesthetic
Narcotic Analgesic
Muscle Relaxant

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Delay of Awake
◆ Respiratory depression ：
Narcotic Analgesic and Muscle Relaxant
Hypocapnia
Hypercarbia
Kaliopenia
Overdose of Transfusion
Complications of operation
Severe metabolic acidosis

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Delay of Awake

◆ Severe Complications ：
massive bleeding
serious cardiac arrhythmias
acute myocardial infarction
rupture of intracranial aneurysm
cerebral hemorrhage
cerebral embolism
◆ Long time of hypotension and hypothermia
◆ Cerebral vessels affection before operation

84
Delay of Awake

B. Management ：
◆ Aspect of Anaesthetic technique
◆ corresponding management
◆ dehydration ： encephaledema
intracranial hypertension
◆ hypothermia - warm
◆ long-term hypotension
◆ primary cerebral disease

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Postoperative vomiting
A. Etiology ：
◆ role of anaesthetics
inhalation anesthetic ： ether >
methoxyflurane
>enflurane > isoflurane > N2O > sevoflurane
intravenous anesthetic
◆ category of operation
◆ conditions of patients

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Postoperative vomiting

B. Harmful effects of vomiting ：

◆ pain 、 wound dehiscence ：
◆ vomit aspiration or asphyxiation
◆ Water-Electrolyte unbalance and
Acid-Base unbalance
C. Management

87
Postoperative pulmonary infection

Etiology ：
A. Aerosolizer pollution
B. Intubation 、 incision of trachea 、
endotracheal anesthesia
C. Aspiration
D. Surgery
E. Abuse medication

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Postoperative pulmonary infection

Clinical manifestation
A. Sings and symptoms
B. Examination of bacteriology
◆ Smear of sputum and bacterial culture
◆ Hemoculture
C. Chest X-ray

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Postoperative pulmonary infection

Diagnostic criteria
A. Fever 、 rales ， X-ray
B. Pathogenic bacteria
C. Hemoculture ： positive
D. Secretion of lower respiratory tract
E. Secretion of respiratory
tract 、 serum 、
and other body fluid

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Postoperative pulmonary infection
Treatment ：
A. antibiotics
B. immunotherapy

91
Malignant Hyperthermia

Malignant hyperthermia （ MH ） :
an eerie and erratic metabolic mayhem, is
a clinical syndrome that in its classic form
occurs during anesthesia with a potent
volatile agent such as halothane and the
depolarizing muscle relaxant
succinylcholine, producing rapidly
increasing temperature （ by as much as 1
℃/5 min ） and extreme acidosis.
incidence was 1:1.6~10×104 ， mortality
rate was 73%
92
Malignant Hyperthermia

Evoked reasons ：
halothane 、 ethoxyflurane
enflurane 、 scoline 、
chloropromazine
lidocaine 、 bupivacaine
Clinical Syndromes ：
A. Temperature increases : exceed 43℃
B. Whole-body rigidity occurs

93
Malignant Hyperthermia

C. Myocardial function is severely altered

D. Increased serum levels of CK
myoglobinuria
E. Contractile response
F. PaCO2 may exceed 100 mm Hg,
and pHa may be less than 7.00

94
Malignant Hyperthermia

Lab
❏ hyper CO2, hypoxia (early)
❏ metabolic acidosis
❏ respiratory acidosis
❏ hyperkalemia
❏ myoglobinemia/myoglobinuria
❏ increased creatine kinase (CK)

95
Malignant Hyperthermia
Complications
❏ death/coma
❏ disseminated intravascular
coagulation (DIC)
❏ muscle necrosis/weakness
❏ myoglobinuric renal failure
❏ electrolyte abnormalities (i.e.
iatrogenic hypokalemia)

96
Malignant Hyperthermia
Prevention
❏ suspect possible MH in patients
presenting with a family history of
problems/death with anesthetic
❏ dantrolene prophylaxis no longer routine
❏ avoid all triggers
❏ central body temp and ET CO2
monitoring
❏ use regional anesthesia if possible
❏ use equipment “clean” of trigger agents

97
Malignant Hyperthermia

Treatment:
A. Discontinue all anesthetic agents and
hyperventilate with 100% oxygen.
B. Control fever by iced fluids, surface
cooling, cooling of body cavities with
sterile iced fluids, and a heat exchanger
with a pump oxygenator
C. Administer bicarbonate （ 2 to 4
mEq/kg ）

98
Malignant Hyperthermia

D. Repeat administration of dantrolene ：

2mg/kg ， 5~l0 min repeat
E. Treatment of hyperkalemia :10u insulin
F. Monitor urinary output : mannitol 0.5g/kg
frusemide lmg/kg
G. Corticosteroids
H. ICU: monitor and treat for 48h

99
THANK YOU

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