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    GeneralAnesthetics and Stages of Anesthesia

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    Naghman Zuberi
    The document discusses general anesthetics and the stages of anesthesia. It describes how general anesthesia allows painless procedures by inducing unconsciousness, amnesia, analgesia, and muscle relaxation. It outlines the stages of general anesthesia, including induction, maintenance, and emergence. It also discusses goals of general anesthesia and desired effects, as well as factors that influence anesthetic depth.

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    GeneralAnesthetics and Stages of Anesthesia

    Uploaded by

    Naghman Zuberi
    303 views27 pages
    The document discusses general anesthetics and the stages of anesthesia. It describes how general anesthesia allows painless procedures by inducing unconsciousness, amnesia, analgesia, and muscle relaxation. It outlines the stages of general anesthesia, including induction, maintenance, and emergence. It also discusses goals of general anesthesia and desired effects, as well as factors that influence anesthetic depth.

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    General Anesthesia for Dental Students and Graduates

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    The document discusses general anesthetics and the stages of anesthesia. It describes how general anesthesia allows painless procedures by inducing unconsciousness, amnesia, analgesia, and muscle relaxation. It outlines the stages of general anesthesia, including induction, maintenance, and emergence. It also discusses goals of general anesthesia and desired effects, as well as factors that influence anesthetic depth.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    303 views27 pages

    GeneralAnesthetics and Stages of Anesthesia

    Uploaded by

    Naghman Zuberi
    The document discusses general anesthetics and the stages of anesthesia. It describes how general anesthesia allows painless procedures by inducing unconsciousness, amnesia, analgesia, and muscle relaxation. It outlines the stages of general anesthesia, including induction, maintenance, and emergence. It also discusses goals of general anesthesia and desired effects, as well as factors that influence anesthetic depth.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 27
    At a glance
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    The key takeaways are that anesthesia allows for painless surgical procedures by inducing unconsciousness, amnesia, analgesia and muscle relaxation. The main types of anesthesia are general, regional, local and conscious sedation.

    The goals of general anesthesia are hypnosis, amnesia, analgesia, immobility, inhibition of nociceptive reflexes and reduction of certain autonomic reflexes.

    The stages of general anesthesia are stage I (altered consciousness), stage II (excitation), stage III (surgical anesthesia with 4 planes of increasing depth), and stage IV (too deep anesthesia).

    General Anesthetics and Stages of Anesthesia

    By: Naghman Zuberi

    Naghman Zuberi

    Anesthesia

    Allow surgical, obstetrical and diagnostic procedures to be performed in a manner which is painless to the patient

    Allow control of factors such as physiologic


    functions and patient movement

    Naghman Zuberi

    Anesthetic techniques

    General anesthesia Regional anesthesia Local anesthesia Conscious Sedation (monitored anesthesia care)

    Naghman Zuberi

    What is Anesthesia

    No universally accepted definition Usually thought to consist of:


    Oblivion Amnesia Analgesia Lack of Movement Hemodynamic Stability

    Naghman Zuberi

    What is Anesthesia
    Sensory -Absence of intraoperative pain

    Cognitive: -Absence of intraoperative awareness -Absence of recall of intraoperative events Motor: -Absence of movement -Adequate muscular relaxation
    Autonomic: -Absence of hemodynamic response -Absence of tearing, flushing, sweating
    Naghman Zuberi 5

    Goals of General Anesthesia

    Hypnosis (unconsciousness) Amnesia Analgesia Immobility/decreased muscle tone

    (relaxation of skeletal muscle)

    Inhibition of nociceptive reflexes Reduction of certain autonomic reflexes

    (gag reflex, tachycardia, vasoconstriction)


    Naghman Zuberi 6

    Desired Effects Of General Anesthesia (Balanced Anesthesia)

    Rapid induction Sleep Analgesia Secretion control Muscle relaxation Rapid reversal

    Naghman Zuberi

    Stages Of General Anesthesia Phases of General Anesthesia


    Induction- initial entry to surgical anesthesia Maintenance- continuous monitoring and medication

    Maintain depth of anesthesia, ventilation, fluid balance, hemodynamic control, hoemostasis

    Emergence- resumption of normal CNS function

    Extubation, resumption of normal respiration

    Naghman Zuberi

    Stages Of General Anesthesia Phases of General Anesthesia


    Stage I: Disorientation, altered consciousness Stage II: Excitatory stage, delirium, uncontrolled movement, irregular breathing. Goal is to move through this stage as rapidly as possible. Stage III: Surgical anesthesia; return of regular respiration. Plane 1: light anesthesia, reflexes, swallowing reflexes. Plane 2: Loss of blink reflex, regular respiration (diaphragmatic and chest). Surgical procedures can be performed at this stage. Plane 3: Deep anesthesia. Shallow breathing, assisted ventilation needed. Level of anesthesia for painful surgeries (e.g.; abdominal exploratory procedures).

    Plane 4: Diaphragmatic respiration only, assisted ventilation is required. Cardiovascular impairment.


    Stage IV: Too deep; essentially an overdose and represents anesthetic crisis. This is the stage between respiratory arrest and death due to circulatory Naghman Zuberi collapse.

    Routes of Induction

    Intravenous
    Safe, pleasant and rapid

    Mask
    Common for children under 10 Most inhalational agents are pungent, evoke coughing and gagging

    Avoids the need to start an intravenous catheter before induction of anesthesia


    Patients may receive oral sedation for separation from parents/caregivers

    Intramuscular
    Used in uncooperative patients
    Naghman Zuberi 10

    Anesthetic Techniques

    Inhalation anesthesia

    Anesthetics in gaseous state are taken up by inhalation

    Total intravenous anesthesia Inhalation plus intravenous (Balanced Anesthesia)

    Most common

    Naghman Zuberi

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    Anesthetic drugs have rapid onset and offset

    Minute to minute control is the holy grail of general anesthesia

    Allows rapid adjustment of the depth of anesthesia


    Ability to awaken the patient promptly at the end of the surgical procedure Requires inhalation anesthetics and short-acting intravenous drugs

    Naghman Zuberi

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    Anesthetic Depth

    During the maintenance phase, anesthetic doses are adjusted based upon signs of the depth of anesthesia Most important parameter for monitoring is blood pressure There is no proven monitor of consciousness

    Naghman Zuberi

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    Selection of anesthetic technique

    Safest for the patient Appropriate duration

    i.v. induction agents for short procedures

    Facilitates surgical procedure Most acceptable to the patient

    General vs. regional techniques

    Associated costs

    Naghman Zuberi

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    MAC Minimal Alveolar Concentration


    "The alveolar concentration of an inhaled anesthetic that prevents movement
    in 50% of patients in response to a standardized stimulus (eg, surgical incision)."

    A measure of relative potency and standard for experimental studies. MAC values remain constant regardless of stimuli, weight, sex, and even
    across species

    Steep DRC: 50% respond at 1 MAC but 99% at 1.3 MAC


    MAC values for different agents are approximately additive. (0.7 MAC N2O +
    0.6 MAC halothane = 1.3 MAC total)

    "MAC awake," (when 50% of patients open their eyes on request) is


    approximately 0.3.

    Light anesthesia is 0.8 to 1.2 MAC, often supplemented with adjuvant i.v.
    Naghman Zuberi

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    drugs

    Factors Affecting MAC

    Circadian rhythm Body temperature Age Other drugs

    Prior use Recent use

    Naghman Zuberi

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    How do Inhalational Anesthetics Work?


    Membrane Stabilization Theory:
    Site of action in lipid phase of cell membranes (membrane stabilizing effect) or

    Hydrophobic regions of membrane-bound proteins


    May induce transition from gel to liquid crystalline state of phospholipids Supported by NMR and electron-spin resonance studies Anesthesia can be reduced by high pressure

    Naghman Zuberi

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    Receptors Possibly Mediating CNS Effects Of Inhaled Anesthetics

    Potentiation of inhibitory receptors


    Inhibition of excitatory receptors


    GABAA Glycine Potassium channels

    NMDA (glutamate) AMPA (glutamate) Nicotinic acetylcholine Sodium channels

    Inferred from demonstration of effect on receptor at clinically relevant concentrations and lack of effect in absence of receptor
    Naghman Zuberi 18

    Inhaled Anesthetics

    Gases
    Nitrous oxide Present in the gaseous state at room temperature and pressure Supplied as compressed gas

    Naghman Zuberi

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    Inhaled Anesthetics

    Volatile anesthetics

    Present as liquids at room temperature and pressure Vaporized into gases for administration

    Naghman Zuberi

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    Inhaled Anesthetics

    Volatile anesthetics

    Present as liquids at room temperature and pressure BUT NOT ALWAYS! Vaporized into gases for administration

    Naghman Zuberi

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    Concentration of Inhaled Anesthetics Determines Dose


    Partial pressure (mmHg)

    Applies to gas phase or to dissolved gases


    Percentage of total gas volume contributed by anesthetic Percentage of total gas molecules contributed by anesthetic Partial pressure/atmospheric pressure

    Volumes %

    Naghman Zuberi

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    Solubility of Inhaled Anesthetics Determines Dose and Time-course

    Ratio of concentration in one phase to that in a second phase at equilibrium Important solubility coefficients for inhaled anesthetics

    Lower blood-gas partition coefficient leads to faster induction and emergence

    Higher oil-gas partition coefficient leads to increased potency


    Naghman Zuberi 23

    Inhaled Anesthetics - Historical


    Ether Slow onset, recovery, explosive
    Chloroform Slow onset, very toxic Cyclopropane Fast onset, but very explosive

    Halothane (Fluothane) first halogenated ether (non-flammable)


    50% metabolism by P450, induction of hepatic microsomal enzymes; TFA, chloride, bromide released Myocardial depressant (SA node), sensitization of myocardium to catecholamines Hepatotoxic Methoxyflurane (Penthrane) - 50 to 70% metabolized Diffuses into fatty tissue Releases fluoride, oxalic acid Renotoxic
    Naghman Zuberi 24

    Inhaled Anesthetics Currently


    Enflurane (Ethrane) Rapid, smooth induction and maintenance
    2-10% metabolized in liver Introduced as replacement for halothane, canabilized to make

    way for isoflurane


    Isoflurane (Forane) smooth and rapid induction and emergence Very little metabolism (0.2%) Control of Cerebral blood flow and Intracranial pressure Potentiates muscle relaxants, Uterine relaxation CO maintained, arrhythmias uncommon, epinephrine can be used

    with isoflurane; Preferential vasodilation of small coronary vessels


    can lead to coronary steal No reports of hepatotoxicity or renotoxicity
    Naghman Zuberi 25

    Most widely employed

    Inhaled Anesthetics Currently


    Nitrous Oxide is still widely used
    Potent analgesic (NMDA antagonist) MAC ~ 120%

    Used ad adjunct to supplement other inhalationals


    Xenon Also a potent analgesia (NMDA antagonist) MAC is around 80% Just an atom what about mechanism of action?

    Naghman Zuberi

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    Malignant Hyperthermia
    Malignant hyperthermia (MH) is a pharmacogenetic hypermetabolic state of skeletal muscle induced in susceptible individuals by inhalational anesthetics and/or succinylcholine (and maybe by stress or exercise).

    Genetic susceptibility-Ca+ channel defect (CACNA1S) or RYR1 (ryanodine receptor) Excess calcium ion leads to excessive ATP breakdown/depletion, lactate production, increased CO2 production, increased VO2, and, eventually, to myonecrosis and rhabdomyolysis, arrhythmias, renal failure May be fatal if not treated with dantrolene increases reuptake of Ca++ in Sarcoplasmic Reticulum Signs: tachycardia + tachypnea + ETCO2 increasing + metabolic acidosis; also hyperthermia, muscle rigidity, sweating, arrhythmia Detection:

    Caffeine-halothane contracture testing (CHCT) of biopsied muscle; Naghman Zuberi Genetic testing for 19 known mutations associated with MH

    27

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