General (GA) World Anesthesia Day - 16 October 1846
Anesthesia Ether by William Morton
Local (LA) : LOC -
Parts of GA
1. Loss of consciousness ( LOC + )
2. Analgesia ( pain - )
Balanced Anesthesia
3. Amnesia ( No memory )
By Lundy
4. No reflex
5. Muscle relax
3 steps of GA 100% O2
IV : Adults
1. Induction Used for both Induction and
Inhalational : Paediatric
Maintenance
2. Maintenance : Inhalational > IV TIVA - Total IV Anesthesia
3. Reversal : consciousness restored
Propofol
Dr Manmohan Singh is a PM
Day Care Sx
Desflurane
Midazolam Gas
Sevoflurane IV
Isoflurane
Alfentanil
Propofol TIVA
Mivacurium
MAC - minimum alveolar concentration is minimum concentration of an inhalational gas
that produce LOC in 50% patients
MAC Potency
BGS - blood gas solubility A gas given to the lung will first go to blood, from
blood it goes to brain. If a gas is highly soluble in
the blood then it will stay in blood. If high blood
solubility less gas reach brain ( slower induction ).
BGS Speed of induction
Minimum MAC Maximum MAC
HISD - His Dick Maximum Potency Minimum Potency
Halothane
Isoflurane HISD
Sevoflurane
Desflurane
Slowest Fastest
Least MAC
Methoxyflurane Most potent, Maximum Fluoride ion F , Nephrotoxic
Not used
Enflurane Epilepsy
Sevoflurane Desflurane Most used
Sweet smell Disgusting smell
Children Used in Neurosurgery
N2O
MAC = 104
Maximum MAC = Least Potent N O ( Nitrous oxide )
2
Fail to cause Anesthesia, despite good But it help in faster action of
Analgesia and Muscle relaxant other inhalational agents
N O + Sevoflurane faster induction
2
1st gas 2nd gas Second Gas Effect
Second Gas Effect
Occurs when another inhalational anesthetic is used with N 2 O.
Rapid uptake of N 2 O produces a vacuum in alveoli, Second Gas also undergoes rapid
uptake along with N O.
2
Diffusion Hypoxia / Fink / Third Gas Effect
Results from the dilution of alveolar oxygen concentration by the large amount of N 2 O
leaving the pulmonary capillary into alveoli during recovery.
Treatment is 100 % oxygen.
ENTONOX
50 % O 2 Expands air containing cavities
50 % N 2 O C/I - Pneumoperitoneum
Intestinal obstruction
Cochlear Sx
Laser Sx ( Fire risk )
Xenon
MAC = 70
Not potent
Carrier gas ( Xe, N 2 O )
Fastest acting : Minimum BGS
Safe, Best agent, But Less Used
X = Expensive
Xenon & Ketamine
- Act by NMDA blockade NMDA is receptor for Glutamate
Glutamate excite the Brain
If you block the NMDA, brain is shutdown
And all other agents act by GABA,
GABA inhibit CNS
Fastest acting Xe > DSIH
Most potent Methoxyflurane > HISD
TIVA , Day Care Propofol
Important
Malignant Hyperthermia
Autosomal Dominant mutation of Calcium channel RYR1
Ryanodine receptor (RYR1) gene encodes the key channel
which mediates calcium release in skeletal muscle during
excitation-contraction
Pharmacogenetics is the study of how people respond differently to drug therapy based
upon their genetic makeup or genes
Malignant hyperthermia is a type of severe reaction that occurs in response to particular
medications used during general anesthesia, among those who are genetically susceptible
Agents : Skeletal muscle relaxant ( Succinylcholine )
Lignocaine
All inhalational anesthetic ( except N 2 O, Xenon )
2+
Mutation in RYR1 gene, altered Ca release channel protein
In the presence of triggering agents. Mutated channel
opens more easily and stays open longer
2+
High intracellular levels of Ca, sustained muscle
2+
contraction ( Rigidity ), high Ca also stimulate breakdown
of glycogen ( Glycolysis ) and aerobic metabolism
Results in excessive production of heat
Excessive muscle contraction
O 2 used up
Hypoxia, Hypercapnia
Cell injury & death Metabolic acidosis
pH < 7.35
+
K & Myoglobin
Arrhythmia Kidney failure
nd
MCC : Death 2 MCC : Death
Treatment : Stop agent
Dantrolene (DOC) Dantrolene depresses excitation-contraction
coupling in skeletal muscle by binding to the
ryanodine receptor 1, and decreasing
intracellular calcium concentration
IV Agents
Thiopentone
Rapidly acting barbiturate
Induction agent
Arm-brain circulation time : 11 seconds
DOC : Neuroprotection It suppresses brain activity (CMR -
Cerebral Metabolic Rate) less O used
2
and that protects the neurons
C/I - Shock
Asthma
Porphyria
Propofol
Isopropyl alcohol
Milky white colour
TIVA , Day Care
C/I - Shock
S/E - Pain at site of injection
Ketamine
NMDA receptor antagonist
Dissociative anesthesia
Sympathetic All pressure BP, IOP, ICP, also cause bronchodilation
Used in : Shock, Asthma
S/E - Postoperative Hallucinations
C/I - Hypertension
Anesthesia used in -
Shock, Asthma : Ketamine
Cardiac disease : Opioids ( Remifentanil ) C/I in resp. - cause Respiratory depression
Rest : Propofol
ASA physical status classification
system is a system for assessing the
fitness of patients before surgery
I -N
II - Mild
III - Severe
IV - Incapacitating disease
V - Can’t survive more than 24 hours
VI - Emergency
prevent from functioning in a normal way.
"he was incapacitated by a heart attack"
Mallampati score (or Mallampati classification) is used to predict the ease of intubation
Easy Intubation Difficult Intubation
Laryngeal Mask
Supraglottic airway device
Weak seal = risk of Aspiration
Not a Definitive Airway
Sellick maneuver
used in preventing
aspiration
Sellick's maneuver works by closing
off the opening of the esophagus by
compressing the Cricoid Cartilage
Sniffing Position
Flexion of the neck and extension of
the head, is considered to be suitable
for the performance of intubation
Chin Lift
Head Tilt
Parts of Endotracheal Tube
Secure Airway
Prevent Aspiration
Machine Boyle Apparatus
60-120 L/min
Anesthetic agent
Soda lime is a mixture of NaOH & Ca(OH)2, used in closed breathing
environments, such as general anaesthesia, to remove carbon dioxide from
breathing gases to prevent CO2 retention and carbon dioxide poisoning
Pin Index and Colour
5 6 7
Air 1,5 1,6 CO 2 > 7% ENTONOX
O2 2,5 2,6 CO 2 < 7%
N2O 3,5 3,6 Cyclopropane
Halothane : Red
Sevoflurane : Yellow
Isoflurane : Purple
Desflurane : Blue
Enflurane : Oranges
Monitoring in GA
ECG
BP
Pulse Oximetry
Capnography
Temperature
