General

Anesthetics By Abril Santos

Universidad Popular Autónoma del Estado de Puebla
International Intership Program
introduction
General anesthetics (GAs) are drugs
which:

• Reversible loss of all sensations and

consciousness.

• Loss of memory and awareness

with insensitivity to painful stimuli,
during a surgical procedure.
 General Anesthesia

Need for Need for analgesia

unconsciousness Need for muscle
‘Loss of sensory and relaxation
‘Amnesia-hypnosis’ autonomic reflexes’
• 1846 – Oliver Wendell Sr. “Anesthesia”
meaning:
Insensibility during surgery produced by
inhalation of ether.
• William T. G. Morton (dentist) was the first
to publicly demonstrate the use of ether
during surgery.
• 1860 – Albert Niemann  Cocaineas.
Types of Anesthesia
• General anesthesia
• Local and regional anesthesia
• Local Infiltration
• Topical block
• Surface anesthesia
• Nerve Block
• Spinal or subarachnoid anesthesia
• Peridural anesthesia
Balanced Anesthesia
Describes the multidrug approach to managing the patient needs.

Beneficial effects Adverse Qualities

 Intraoperative, an ideal anaesthetic drug:
1. Would induce anesthesia smoothly, rapidly
2. Permit rapid recovery as soon as administration ceased.

*So a ‘balanced anesthesia’ is achieved by a combination of I.V and inhaled anesthesia and Pre-anaesthetic medications
 General Anesthesia

Inhalational Intravenous

Gas Volatile liquids Slower acting Inducing agents

Nitrous oxide Dissociative Opiod analgesia Benzodiazepines

Zenon anesthesia
Thiopentone sod.
Ether
Methohexitone sod.
Halothane Diazepam
Ketamine Fentanyl Propofol
Enflurane Lorazepam Etomidate
Isoflurane Midazolam Droperidol
Desflurane
Sevoflurane
Methoxyflurane
 Stages of
anesthesia

Guedel (1920) described four stages with

ether anesthesia, dividing the III stage into 4
planes.
The order of depression in the CNS is:
1. Cortical centers
2. Basal ganglia
3. Spinal cord
4. Medulla
Surgical Period and GA protocol
Use pre-anesthetic medication
↓
Induce by I.V thiopental or suitable alternative
↓
Use muscle relaxant
↓
Intubate
↓
Use, usually a mixture of N2O and a halogenated hydrocarbon→maintain and
monitor.
↓

Withdraw the drugs → recover

Pre-operative Period
• Meet the patient personally.
• Choose the right technique by
the preferences, case and
patient.

Use the ASA and GOLDMAN scale

for anaesthetic risk.
ASA
score
Use to measure risk for anaesthetic
procedures.
Pre-
anaesthetic
Medications
Pre-anaesthetic Medications
Serve to
• Calm the patient, relieve pain
• Protect against undesirable effects of the subsequently administered anesthetics or the
surgical procedure.
• Facilitate smooth induction of anesthesia
• Lowered the dose of anaesthetic required
Preanesthetic Medicine:
• Benzodiazepines; midazolam or diazepam: Anxiolysis & Amnesia.
• Barbiturates; pentobarbital: sedation
• Diphenhydramine: prevention of allergic reactions: antihistamines
• H2 receptor blocker- ranitidine: reduce gastric acidity.
Intraoperative Period
• Induction: Onset of anesthetic to the surgical anesthesia (I.V thiopental
or inhalated halothane or sevoflurane)
• Maintenance: Volatile anesthetics = good minute-to-minute control
over the depth. (halothane, isoflurane or fentanyl, morphine,
pethidine + N.M blocking agents)
• Recovery: From discontinuation of anesthesia until
• Consciousness
• Protective physiologic reflexes
Regained.
Post-operative Period
• N.M blocking agents and Opioids  worn off or reversed by
antagonists.
• Regained consciousness and protective reflex restored
• Relief of pain: NSAIDs
• Postoperative vomiting: metoclopramide, prochlorperazine
 Properties of Intravenous Anesthetics.
Drug Induction and recovery Main unwanted effects Notes

Thiopental Fast onset (accumulation Cardiovascular and respiratory Used as induction agent declining. ↓
occurs, giving slow recovery) depression CBF and O2 consumption
hangover Injection pain

Etomidate Fast onset, fairly fast Excitatory effects during Less cvs and resp depression than with
recovery induction adrenocortical thiopental, injection site pain
suppression

Propofol Fast onset, very fast Cvs and resp depression Most common induction agent. Rapidly
recovery Pain at injection site. metabolized; possible to use as
continuous infusion. Injection pain.
Antiemetic

Ketamine Slow onset, after-effects Psychotomimetic effects Produces good analgesia and amnesia.
common during recovery following recovery, postop No injection site pain
nausea, vomiting， salivation

Midazolam Slower onset than other Minimal CV and resp effects. Little resp or cvs depression. No pain.
agents Good amnesia.
 Non-barbiturate induction drugs effects
on BP and HR

Drug Systemic BP Heart rate

Propofol ↓ ↓

Etomidate No change or slight ↓ No change

Ketamine ↑ ↑
Local Anesthetics
Order of sensory
function block
1. Pain
2. Cold
3. Warmth
4. Touch
5. Deep pressure
6. Motor

*Recovery in reverse order.

Vasoconstrictors decrease the rate of vascular absorption which allows
more anesthetic to reach the nerve membrane and improves the depth
of anesthesia.

Vasoconstrictor
 In Conclusion:
• Type of surgical procedure
• Duration of surgical procedure
• Type of anesthesia
• PATIENT
• Risk vs Benefit
• ALWAYS monitor
 References
• American Society of Anesthesiologists (2011). Guidelines for patient care in
anesthesiology. Available online: http://www.asahq.org/For-
Members/Standards-Guidelines-and-Statements.aspx.
• Dorian RS (2010). Anesthesia of the surgical patient. In FC Brunicardi et al., eds.,
Schwartz’s Principles of Surgery, 9th ed., pp. 1731–1752. New York: McGraw-Hill.
• Brown DL (2010). Spinal, epidural and caudal anesthesia. In RD Miller et al., eds.,
Miller's Anesthesia, 7th ed., pp. 1611–1638. Philadelphia: Churchill Livingstone.
• Handbook of Local Anesthesia 6th ed. Stanley F. Malamed, DDS iii Handbook of
Local Anesthesia, 6th Edition
Thank You!