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Lecture Title : General Anesthesia

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Title: Lecture Title : General Anesthesia


1
Lecture Title General Anesthesia
  • Lecturer name
  • Lecture Date

2
Lecture Objectives.. Students at the end of the
lecture will be able to
  • Define general Anaesthesia
  • Learn about several agents used on induction of
    general anaesthesia including intravenous agents,
    inhalation agents, neuromuscular blocking agents
    and reversal agents.
  • Understand basic advantages and disadvantages of
    these agents.
  • Complications commonly encountered during general
    anaesthesia

3
General anesthetics have been performed since
1846 when Morton demonstrated the first
anesthetic (using ether) in Boston, USA. Local
anesthetics arrived later, the first being
scientifically described in1884.
4
General anesthesia is described as a reversible
state of unconsciousness with inability to
respond to a standardized surgical stimulus. In
modern anesthetic practice this involves the
triad of unconsciousness, analgesia, muscle
relaxation.
5
Anesthetic plan
  • A good anesthetic begins with a good plan.
  • There is no rigid format for planning anesthesia.
  • Each plan is adapted to each case.
  • The fundamental goal of anesthetic management is
  • to provide safety,
  • comfort and convenience, first for the patient
    and second for those caring for the patient.

6
Anesthetic plan
  • After a good plan, a good preparation is required
    for a good anesthetic.
  •  Before every anesthetic, every anesthesiologist
    should go through a checklist of necessary items
    including,
  • anesthesia machine,
  • ventilator,
  • oxygen and nitrous supply check,
  • suction device,
  • monitors and anesthesia cart.  

7
Anesthetic plan
  • Before bringing the patient to the operating
    room,
  • the proper verification of patient's identity,
  • the planned procedure and
  • the site of the procedure should be carried out
    by the anesthesiologist.
  • All the preparations should be completed before
    the patient enters the room including the
    placement of a working peripheral intravenous
    line.

8
Anesthetic plan
  • The primary goals of general anesthesia are
  • to maintain the health and safety of the patient
    while providing amnesia, hypnosis (lack of
    awareness), analgesia, and optimal surgical
    conditions (e.g., immobility).
  • Preoperative planning involves
  • the integration of pre-,
  • intra-, and
  • postoperative care.
  • Flexibility is an essential
  • multiple approaches to
  • induction,
  • maintenance, and
  • emergence should be considered.

9
Anesthetic plan
  • Preoperative planning involves the integration
    of
  • pre-,
  • intra-, and
  • postoperative care.
  • Flexibility is an essential
  • Multiple approaches to
  • induction,
  • maintenance, and
  • emergence should be considered.

10
Anesthetic plan
  • The plan should include the following
  • A premedication.
  • Need standard ASA monitors. However, if the
    patient may experience large hemodynamic
    fluctuations, invasive monitoring should be
    considered (e.g., central venous pressure for
    volume monitoring, arterial line for potential
    hemodynamic instability).
  • A review of anesthetic options general
    anesthesia, regional anesthesia, and combinations
    thereof should be reviewed and options
    appropriate for the patient listed in the final
    assessment.
  • Plan for postoperative pain control.

11
NPO status
  • NPO, Nil Per Os, means nothing by mouth
  • Solid food 8 hrs before induction
  • Liquid 4 hrs before induction
  • Clear water 2 hrs before induction
  • Pediatrics stop breast milk feeding 4 hrs
  • before induction

12
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13
Premedication
  • Guidelines for prophylaxis for pulmonary
    aspiration
  • Histamine (H2) antagonists
  • Cimetidine (Tagamet), ranitidine (Zantac),
    significantly reduce the volume and the acidity
    of gastric secretions.
  • Metoclopramide (Reglan) enhances gastric emptying
  • Midazolam (Versed) provides excellent amnesia and
    sedation.
  • Lorazepam (Ativan) may also be used but can cause
    more prolonged amnesia and postoperative
    sedation. It should not be given intramuscularly.
  • Opioids are not usually given as premedication
    unless the patient has significant pain

14
THE MONITORS
  • Standard ASA monitoring -
  • Oxygenation (oxygen analyzer, pulse oximetry)
  • Ventilation (capnography, minute ventilation),
    respiratory rate (under regional anesthesia)
  • Circulation (electrocardiogram ECG, arterial
    blood pressure, perfusion assessment),
  • Temperature.

15
General Anesthesia
  • Monitor
  • Preoxygenation
  • Induction ( including RSI cricoid pressure)
  • Muscle relaxants
  • Mask ventilation
  • Intubation ETT position comfirmation
  • Maintenance
  • Emergence

16
Airway exam Mallampati classification
Class I uvula, faucial pillars, soft palate
visible Class II faucial pillars, soft pillars
visible Class III soft and hard palate
visible Class IV hard palate visible
17
Sniffing position
18
Mask and airway tools
19
Mask ventilation and intubation
20
Oral and nasal airway
21
Intubation
22
Intubation
23
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24
Laryngeal view
25
Laryngeal view scoring system
26
Difficult airway
27
Fiberoptic scope intubation
28
Trachea view Carina view
29
Glidescope
30
Fast track LMA
31
LMA
32
Induction agents
  • Opioids fentanyl
  • Propofol, Thiopental and Etomidate
  • Muscle relaxants
  • Depolarizing
  • Nondepolarizing

33
Induction
  • IV induction
  • Inhalation induction

34
General Anesthesia
  • Reversible loss of consciousness
  • Analgesia
  • Amnesia
  • Some degree of muscle relaxation

35
Intraoperative management
  • Maintenance
  • Inhalation agents N2O, Sevo, Deso, Iso
  • Total IV agents Propofol
  • Opioids Fentanyl, Morphine
  • Muscle relaxants
  • Balance anesthesia

36
Intraoperative management
  • Monitoring
  • Position supine, lateral, prone, sitting, Litho
  • Fluid management
  • - Crystalloid vs colloid
  • - NPO fluid replacement 1st 10kg weight-
  • 4ml/kg/hr, 2nd 10kg weight-2ml/kg/hr and
  • 1ml/kg/hr thereafter
  • - Intraoperative fluid replacement minor
  • procedures 1-3ml/kg/hr, major procedures
    4-
  • 6ml/kg/hr, major abdominal procedures
    7-10/kg/ml

37
Intraoperative management Emergence
  • Turn off the agent (inhalation or IV agents)
  • Reverse the muscle relaxants
  • Return to spontaneous ventilation with adequate
    ventilation and oxygenation
  • Suction upper airway
  • Wait for pts to wake up and follow command
  • Hemodynamically stable

38
Postoperative management
  • Post-anesthesia care unit (PACU)
  • - Oxygen supplement
  • - Pain control
  • - Nausea and vomiting
  • - Hypertension and hypotension
  • - Agitation
  • Surgical intensive care unit (SICU)
  • - Mechanical ventilation
  • - Hemodynamic monitoring

39
General Anesthesia Complications and Management
  • Respiratory complication
  • - Aspiration airway obstruction and
    pneumonia
  • - Bronchospasm
  • - Atelectasis
  • - Hypoventilation
  • Cardiovascular complication
  • - Hypertension and hypotension
  • - Arrhythmia
  • - Myocardial ischemia and infarction
  • - Cardiac arrest

40
General Anesthesia Complication and Management
  • Neurological complication
  • - Slow wake-up
  • - Stroke
  • Malignant hyperthermia

41
Case Report Arterial oxygen desaturation
following PCNL
  • ????????? ???

42
The Patient
  • Patient 73 y/o Female
  • BW 68 kg, BH 145 cm (BMI 32)
  • Chief complaint
  • Right flank pain (stabbing, frequent attacks)
  • General malaise and fatigue

43
The Patient
  • Past history Hypertension under regular
    control
  • Senile dementia (mild)
  • Preoperative diagnosis Right renal stone (3.2
    cm)
  • Operation planned Right PCNL (percutaneous
    nephrolithotomy)

44
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45
Pre-anesthetic Assessment
  • EKG Normal sinus rhythm
  • CXR Borderline cardiomegaly tortuous aorta
  • Lab data Hb 10.5 / Hct 33.2
  • BUN 24 / Creatinine 1.1
  • GOT 14
  • PT, aPTT WNL

46
Preop
47
Anesthetic Technique
  • General anesthesia with endotracheal intubation
  • Standard monitoring apparatus for ETGA
  • Induction Fentanyl ug/kg
  • propofol 2mg/kg
  • Succinylcholine 80 mg
  • Atracurium 25 mg
  • Endotracheal tube (ID 7.0-mm) _at_ 19cm
  • Maintenance Isoflurane 23 in O2 0.5 L/min
  • Position prone
  • Blood loss 300 mL ? PRBC 2U

48
Intra-operative Events
  • Stable hemodynamics
  • Abnormal findings 30 minutes after surgery
    started
  • Increased airway pressure 3540 mmHg
  • SpO2 dropped to 9095
  • Bilateral breathing sounds were still audible
    then
  • Management Solu-cortef 100 mg IV stat
  • Aminophylline 250 mg IV
    drip
  • Bricanyl 5 mg inhalation

49
Intra-operative Events
pH 7.2
PaO2 90.5
PaCO2 66.8
HCO3- 26.0
BE -2.4
Na 143.0
K 4.0
Ca2 1.1
Hb/Hct 11.4/36.1
  • ABG data

50
Post-operative Course
  • The patients condition was kept up until the
    end of surgery
  • SpO2 9092 after the patient was placed in the
    supine position
  • again with diminished breathing sound over
    right lower lung
  • The patient was transferred to SICU for further
    care ()
  • Chest X-ray was followed in SICU

51
Immed. Postop
52
Preop
Immed. Postop
53
Postoperative Course
  • Pigtail drainage in SICU
  • Pleural effusion bloody
  • RBC numerous
  • WBC 7800 (Seg 94)
  • Gram stain (-)
  • Impression Right hydrothorax and hemothorax

54
s/p pigtail
55
s/p pigtail
Immed. Postop
56
Postoperative Course
  • Extubation and transfer to ordinary ward
  • Pigtail removed

57
Reference book and the relevant page numbers..
58
Thank You ?
  • Dr.
  • Date
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