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General anesthesia

The document provides a comprehensive overview of general anesthesia, including its definitions, history, advantages, disadvantages, indications, and contraindications. It outlines the stages of general anesthesia, techniques, and the essential equipment needed for administration and monitoring. Additionally, it discusses the preoperative evaluation, patient conditions, and requirements for dentists involved in administering anesthetics.

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General anesthesia DR. DHARATI PATEL
Contents • DEFINITIONS • HISTORY OF ANESTHESIA • ADVANTAGES AND DISADVANTAGES • INDICATIONS AND CONTRA INDICATIONS • PREOPERATIVE EVALUATION • PREANAESTHETIC MEDICATION • STAGES OF GENERAL ANESTHESIA • CLASSIFICATION OF GENERAL ANESTHESIA • ARMAMENTARIUM
Will be covered in next part ….. • GENERAL ANAESTHETIC AGENTS • TECHNIQUES • RECOVERY/DISCHARGE • COMPLICATIONS OF GENERAL ANAESTHESIA • CONCLUSION
Definition • General anaesthesia is defined as controlled state of unconsciousness accompanied by a loss of protective reflexes, inducing the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command. • Also defined as an irregular, reversible depression of the higher centres of the central nervous system (CNS) that makes the patient unconscious and insensible to pain
History
• Ether - first described in 1540 by ‘Valerius Cordus’ • Used as anesthetic in 1842 by ‘Dr. W.E. Clark’ and ‘Dr.Crawford W. Long’ • First public demonstration of use of ether was in October 17, 1846 by ‘Dr. William T. G. Morton’ • ‘Morton’ - Successfully demonstrated properties of ether and named it as ‘Etherization’
William T.G. Morton’s Ether Inhaler
• 1847- ‘Simpson’ discovered use of Chloroform for Anesthesia • 1935 – First IV anesthetic Thiopentone was introduced • 1951- ‘C. W. Suckling’ of Manchester synthesized Halothane • 1956 – ‘Michael Johnstone’ used Halothane clinically J.Y.Simpson
General anesthesia represent …… Muscle relaxation Analgesia Unconscious ness
Advantages Success rate of 100% Patient cooperation is not essential for the success of general anesthesia Patient is unconscious Patient does not respond to pain Amnesia is present Onset of action of general anesthesia is usually quite rapid - <1 minute Titration is possible
• The only technique that will prove successful for certain patients  The un-cooperative child  Extremely fearful adult  Either physical or mental disabilities
Disadvantages • Patient is unconscious • Protective reflexes are depressed • Vital signs are depressed • Trained staff is required • An “anaesthesia team” is required • Special equipment is required • Need for recovery room • Intraoperative complications are more likely • Post-anesthetic complications • More extensive pre-op evaluation, including lab work
Indications Extreme anxiety and fear Adults or children who have mental or physical disabilities, senile patients, or disoriented patients Age—infants and children Short, traumatic procedures Prolonged, trauma
Indication in children • Patient unable to cooperate – mental or physical disability • When LA is ineffective – acute infection , anatomic variations, allergy • Extremely uncooperative , fearful, anxious, physically resistant, uncommunicative child • In whom there is no expectation that the behavior will improve • Patient who have sustained extensive orofacial or dental trauma and require surgical procedure • Patient requiring immediate comprehensive oral or dental needs • Use of GA may protect the developing psyche and reduce medical risks
Contraindications Lack of adequate training by the dentist Lack of adequately trained personnel Lack of adequate equipment Lack of adequate facilities ASA 4 and certain ASA 3 medically compromised patients
Requirements as a dentist • Dental residency of 1-4 year in a teaching hospital • A rotation in which dental resident actively involved in administrating GA • Current certification in basic cardiopulmonary resuscitation • Should be aware of hospital’s by laws, rules, regulations and meetings • Should endeavor to provide the highest quality care
Evaluation of the hospital… • Membership of other dentists on the hospital staff • Positive attitude of the hospital staff • Attitude of staff physicians toward dental treatment • Experience of anesthesiology staff • Availability of consulting physician • Hospitals regulations • Availability of operating room time • Availability of patient bed • Availability of dental equipment • Convenience of the location of hospital
Two general categories Young children who need extensive treatment and unmanageable as outpatient Children with mental or physical disabilities Admission justification
Pre - admission preparation • A dentist’s decision to treat a child under GA – approved by the child's parents • Dentist's responsibility – increased risk and expense • Must evaluate the child’s psychological state • An information page should be provided to parents • Necessity of having both or one parent prior to GA when the child awakens • For mentally or physical handicapped child – will require special control techniques and ensure they will be available • Child’s physician should prescribe special diet or pre-medicaments
• Dentist should make proper plan for hospitalization • Operating room must be scheduled • Arrangements must be made for an anesthesiologist • Physical examination – one day prior by physician • Should Assess general health (ASA Classification) • Ask for Drug history
ASA Classification ASA I Normal healthy patient ASA II Patient with mild systemic disease ASA III Patient with severe systemic disease that is limiting but not incapacitating ASA IV Patient with incapacitating disease which is constant threat to life ASA V Moribund patient not expected to live more than 24 hours ASA VI A declared brain dead patient whose organ are being removed for donor purposes
Admission letter to parents before two weeks
Medical history and Physical examination
Pediatric history Identification • Age • Sex • Racial-ethnic profile History of present illness Medical survey • Immunization • Previous hospitalization • Allergies • Dietary history • Current medications Developmental status Family history
Physical examination Vital signs • Pulse rate • Respiration rate • Blood pressure • Temperature Measurements • Weight • Height General appearance • Nutrition • Colour • Distress
Head Eyes – pupils and extraocular movements Ears Nose – patency and secretion Neck Lungs Cardiovascular system – heart sounds , rate , rhythm , murmurs Abdomen Genitalia Lymph nodes Skeleton nervous system
Vital signs
Heart rate and Respiratory rate
Blood pressure
Temperature °F 0-2 years 3-10 years 11-65 years > 65 years Oral - 95.9-99.5 97.6-99.6 96.5-98.5 Rectal 97.9-100.4 97.9-100.4 98.6-100.6 97.1-99.2 Axillary 94.5-99.1 96.6-98 95.3-98.4 96.0 – 97.4
Dental history and Intra-oral examination
Past dental history Behavior Past experience Treatment done Head and neck General Head Neck Face Lateral facial profile Intra oral examination Lips Tongue Floor of the mouth Buccal mucosa Hard and soft palate Teeth Caries Eruption sequence Occlusion Overjet Overbite Midline Oral habits
Pre – operative investigation
Patient undergoing surgery should be screened for…..  Biochemical  Hematological  Radiological abnormalities  ECG
Consent
Signature required • If the patient is adult  signature of patient  If the patient is incompetent – the guardian’s signature • Minor patient (under 18 )  If emancipated – patient’s signature  Signature of parent or guardian is required • In an emergency/life threatening situation - signatures as above are not available……  Signature of two physician  Signature of closest adult
Admission to the hospital
• Child is usually admitted on the day before treatment and have to stay till next morning • Parents should complete the necessary forms • Dentist should give the admission order which include  Order for NPO(nothing by mouth )  Order for specific drug and specific dosage  Preoperative sedation orders  Request for the child to be transferred to the operating room
Admission order
• Nursing staff should explain – standard hospital procedure to parents • Child will be visited by anesthesiologist • The decision regrading nothing by mouth - determined by anesthesiologist • Dentist should evaluate pre-operative laboratory data • Dentist should collect admitting note • And record preoperative note • 30 minute before dentist and staff should be in operating room area
Admitting note • Provides general information about the child and reason for admission • This form is given to child's physician • The physician have to enter preoperative physical examination and return it
Nothing by Mouth nil per os (NPO)
In general …
Operative room protocol • Must follow OSHA guidelines • Must wear – surgical suite • Eyeglasses, nose hood , face shield and mouth mask • Should follow standard scrubbing method • Avoid cross-contamination between patient in the hospital
Universal protocol checklist When patient enters the operating room the mandatory “ TIME OUT PROTOCOL” initiated by the nurse
Operating room
Pre- Anesthetic Medication • Relief of anxiety and apprehension preoperatively and facilitate smooth induction • Supplement analgesic action of anesthetics and potentiate them so that less anesthetic is needed • Decrease secretions and vagal stimulation caused by anesthetics • Produce antiemetic effect extending to the postoperative period • Decrease acidity and volume of gastric juice so that it is less damaging if aspirated
Stages of General Anesthesia • Guedel - 1920 • Observations on the following parameters  Character of respiration  Eyeball activity  Pupillary changes  Eyelid reflex  Swallowing and vomiting
I. Stage of Analgesia starts with the initial administration of a CNS-depressant drug and continues to the loss of consciousness 1. Respiration is normal 2. Eye movements are normal, with voluntary movement possible 3. Protective reflexes are intact 4. Amnesia (the lack of recall) may or may not be present 5. Diminished intellect, memory, integrative functions, perception of time and space
II. Stage of Delirium begins with loss of consciousness and progresses until entry into the stage of surgical anaesthesia (stage III) • Respirations are irregular early in stage II, but become more regular as stage II deepens • Eyeballs oscillate involuntarily, a movement termed Lateral nystagmus • Pupils react to light normally • Skeletal muscle tonus is increased, with muscular rigidity present in some patients early in stage II.
• Muscle tonus decreases as stage II deepens. • The laryngeal and pharyngeal reflexes (swallowing and laryngeal closure) are still quite active early in stage II, but become progressively more obtunded as stage II progresses.
III. Stage of Surgical Anesthesia Entry into stage III is marked by several signs and divided into 4 planes : Plane 1 : • Respiratory regularity equally Thoracic and abdominal • Eyeballs oscillate slowly & pupils respond normally to light • Swallowing and vomiting reflexes disappear • Tears secreted • Tendency to breathe deeply and rapidly with skin incision decreases • Peripheral vasodilatation
Plane 2 : • Eyeballs cease to oscillate • Intercostal muscles weaken. • Respiration regular but tidal volume is decreased • Pupil size increases • Laryngeal reflexes diminishes • Tears secretion decreased • Respiratory response to skin incision disappears
Plane 3 : • Pupillary response to light is abolished • As plane deepens intercostal paralysis Plane 4 : • Complete intercostal & diaphragm paralysis • Pupils dilate and no muscle tonus
Stage IV : Medullary paralysis • Begins with onset of respiratory arrest and ends with cessation of effective circulation.
Types of General Anesthesia 1. In-office outpatient general anesthesia 1. IV anesthesia (Propofol or barbiturates) (less than 30 minutes) 2. Conventional operating theater type of general anesthesia(more than 30 minutes and less than 4 hours) 2. Inpatient general anesthesia
In-office outpatient general anesthesia
Intravenous Propofol or Barbiturates • IV Propofol or barbiturates are highly accepted and common - to induce and maintain unconsciousness in GA • Known as ultralight general anesthesia • May receive other drugs - nitrous oxide-oxygen (N2O-O2), benzodiazepine and opioids • The administration of O2 minimizes the risk of hypoxia. • Local anesthesia is important.
Conventional Operating Room Type of GA • A variation of outpatient general anesthesia is used in - procedure 30 minutes to 4 hours or longer • Same preparation and procedure as does the inpatient • Limited to the ASA 1, ASA 2, and selected ASA 3 patients • A dentist will be responsible for the dental care • In no circumstance should the same person administer the general anesthetic and perform the dental treatment • The duration of an outpatient general anesthetic not exceed - 4 hours
Inpatient General Anesthesia • This patient is admitted to the hospital before the planned procedure • Undergoes the procedure then remains in the hospital at least 1 day postoperatively • The dentist need not be trained in anesthesiology • The anesthesiologist is responsible for the administration of the anesthetic • In prolonged dental treatment - the dentist will request that the patient be intubated through the nose (nasoendotracheal) rather than through the mouth (oroendotracheal)
• The administration of general anesthesia for dental procedures is more difficult • Because the oral cavity is the treatment zone • Therefore the potential for airway complications is increased • Mortality rates for hospital inpatient anesthesia > outpatient procedures • ASA 1 and 2 patients are treated as outpatients • ASA 3 and 4 patients are usually hospitalized
Armamentarium
Anesthesia machine IV equipment Ancillary anesthesia equipment Pharyngeal throat pack Monitoring equipment Emergency equipment
Anesthesia Machine • Able to deliver oxygen (O2) and inhalation anesthetics to the patient. • The inhalation sedation (n2o o2) is a modification of the anesthesia machine • The anesthesia machine can deliver many gases: N2O, O2, sevoflurane, desflurane, and isoflurane. • Flowmeters and devices called vaporizers that contain the various volatile anesthetics and permit their concentrations to be controlled
• The anesthesia machine is capable of operating with O2 and N2O supplied from cylinders • Anesthesia machines have O2 monitors that sound an alarm - if the unit fails to provide a preset minimum percentage of O2 (i.E., 25%) • Ventilator - a device used to control or assist the ventilation of a patient during anesthesia - attached to the right side
• The modern anesthesia machine contains a number of important devices for monitoring patients  A blood pressure monitor  Electrocardiograph (ECG)  Pulse oximeter  Capnograph (end-tidal carbon dioxide [ETCO2] monitor)  Bispectral (BIS) electroencephalograph (EEG) monitor
Intravenous equipment • Winged needles (18 gauge ) • Indwelling catheters • Tubing and bags of IV solution (1000 ml) • Disposable syringes and needles • Adhesive tapes (paper, hypoallergenic)
Ancillary Anesthesia Equipment
Full-face masks - sizes and appropriate connectors Laryngoscope Endotracheal tubes and appropriate connectors Laryngeal mask airway (LMA) Oropharyngeal and nasopharyngeal airways Tonsillar suction tips Magill intubation forceps Child- and adult-size sphygmomanometers Stethoscopes
Face mask • Rubber or silicone masks • Cover both the mouth and nose of the patient • Face masks are - deliver O2, N2O-O2 and other inhalation anesthetics before, during and after the anesthetic procedure • Made from a clear plastic or rubber • Metal connectors - attach the face mask to the tubing of the anesthesia machine - variety of sizes and shapes
Laryngoscopes • Designed to assist in the visualization of the trachea during intubation • It consists of two parts  A handle and battery holder  Blade • The handle – made of metal and contains batteries (used to operate the light bulb found in the blade) • The blade - made of metal • The laryngoscope blade - designed to aid in visualization of the larynx • A small light bulb that illuminates the laryngeal area is attached to the blade
• There are two basic types of laryngoscope blades  The curved (Macintosh) - commonly used  The straight (Miller) blade • Available in a variety of sizes • The tip of the curved blade is inserted into the vallecular • Blades are designed to be held in the operator’s left hand • With the endotracheal tube held in the right hand
Technique The tip of the curved blade is inserted into the vallecular - between the base of the tongue and the epiglottis The handle of the laryngoscope is then lifted straight up and slightly forward - a movement that visualizes the vocal cords When a straight blade is used its tip is placed underneath the laryngeal surface of the epiglottis The larynx is exposed by an upward and forward lift of the blade
Endotracheal Tubes and Connectors • Endotracheal tubes and connectors are rubber tubes designed to be placed from the mouth (oroendotracheal) or nose (nasoendotracheal) into the patient’s trachea. • Reusable and disposable • Endotracheal tubes have an inflatable cuff located near their distal ends • Connectors for endotracheal tubes = used for full-face masks  Used to connect the endotracheal tube to the anesthesia machine
When a patient is intubated the endotracheal tube is inserted into the trachea so that the uninflated cuff disappears just beyond the level of the larynx. Air is then injected into a tube to inflate the cuff Enough air is injected into the cuff to seal the trachea
DEPTH OF ENDOTRACHEAL TUBE • Adult  Male = 23 cm  Female = 21cm • Children  Oral endotracheal tube = (Age / 2) + 12(cm)  Nasal endotracheal tube = (Age / 2) + 15(cm)
Size of endotracheal tube Internal diameter (ID) Male 8.0 mm Female 7.5 mm New born – 3 months 3.0 mm 3-9 months 3.5 mm 9-18 months 4.0 mm 2-6 yrs. (Age/3) +3.5 >6 yrs. (Age/4) + 4.5
Advantages of endotracheal intubation • Free unobstructed airway • Ventilation can be controlled or assisted • aspiration of blood, mucus, vomitus into lung is prevented • Measured amount of gases and vapors can be delivered • Safe and acceptable • Dead space can be managed
Disadvantages • Need of expertise • Injury to teeth, lips, larynx, epiglottis, pharynx or trachea • Cost
Complications of intubation
When Intubated • Obstruction from klinking , secretion or over-inflation of cuff • Accidental extubation or endobronchial intubation • Disconnection from breathing circuit • Pulmonary aspiration • Lip or nasal ulcer in case with prolong period of intubation • Sinusitis or otitis in case with prolong Naso-endotracheal intubation
During Intubation • Trauma to lip , tongue or teeth • Hypertension and tachycardia or arrhythmia • Pulmonary aspiration • Laryngospasm • Bronchospasm • Laryngeal edema • Spinal cord trauma in cervical spine injury • Esophageal intubation
Complications of extubation
During Extubation Laryngospasm Pulmonary aspiration Edema of upper airway After Extubation Sore throat Hoarseness Tracheal stenosis (Prolong intubation) Laryngeal granuloma
Oropharyngeal and Nasopharyngeal Airways • Oropharyngeal and nasopharyngeal airways - used to assist in maintaining a patent airway during and after the anesthetic procedure • Plastic, rubber or metallic devices • Designed to lie between the base of the tongue and the posterior pharyngeal wall • The nasopharyngeal airway - better tolerated by the conscious or sedated patient • Nasal airways should be lubricated
Oral airway Nasal airway Oral airway Nasal airway
Tonsillar Suction Tips • Excessive salivation , bleeding in the mouth or pharynx, or vomiting - can lead to airway obstruction, laryngospasm, or possible infection of the trachea or bronchi • Tonsillar suction tips are recommended ….. because they can be inserted blindly into the posterior pharynx of the patient with minimal risk of producing bleeding • The end of the tonsillar suction tip is rounded • Several tonsillar suction tips should be available
Tonsillar Suction Tips
Magill Intubation Forceps • Designed to assist in placing the endotracheal tube • It is most frequently used during nasoendotracheal • It is L shaped and has no catch • It is available in 2 sizes : adult and pediatrics
Pharyngeal throat pack • Pharyngopalatine area should be sealed off • With a strip of moist sterile gauze piece  Width – 3 inches  Length – 18-20 inches • Written documentation of throat pack placement is necessary • Reduce the escape of anesthetic agents and prevent any material entering the pharynx • Gauze should tightly pack around the tube – good seal
Sphygmomanometers and Stethoscopes • Must available during GA procedures • Used for the monitoring  Vital signs  Specifically blood pressure  Heart rate and rhythm  Heart sounds  Breathes sounds
Monitors ECG Pulse Oxymeter Pretracheal stethoscope Capnograph
Emergency Equipment
Emergency Drugs…. Vasopressor Corticosteroid Bronchodilator Muscle relaxant Appropriate drug antagonist(s) Antihistaminic Anticholinergic Antiarrhythmic Coronary artery vasodilator Antihypertensiv e Anticonvulsant O2 and 50% dextrose
Emergency Equipment • Backup lighting system • Backup suction device • O2 delivery system • Laryngoscope with complete selection of blades and spare batteries and bulb • Endotracheal tubes and appropriate connectors • Oral airways
• Tonsillar or pharyngeal type suction tip • Endotracheal tube forceps (Magill intubation forceps) • Sphygmomanometer and stethoscope • Electrocardioscope and defibrillator • Adequate equipment for the establishment of an IV infusion • Precordial or Pretracheal stethoscope • Pulse oximeter
Agents used for GA Inhalation Intravenous
Inhalation Gas Nitrous oxide Liquid Ether Halothane Enflurane Isoflurane Desflurane Sevoflurane
Intravenous Inducing agents Thiopentone sodium Methohexitone sodium Propofol Slower acting agents Diazepam Lorazepam Midazolam Dissociative anesthesia Ketamine Neuroleptic analgesia Fentanyl
Ether • Highly volatile – liquid • Vapor – irritating , inflammable and explosive • Potent anesthetic – good analgesia and muscle relaxation • Highly soluble in blood • Induction – prolonged and unpleasant • Atropine must – as premedication • Recovery – slow • Post anesthetic nausea , vomiting and retching
Halothane • Halogen substituted ethane • Volatile liquid – sweet odor , nonirritant and nonflammable • Solubility in blood – intermediate • Induction – quick and pleasant • Potent inhalational anesthetic • Dose: For induction 2-4%, Maintenance 0.5-1% • Not good analgesic nor muscles relaxant
• Cause direct depression of myocardial contractility • Cardiac output , blood pressure ,heart rate – decreased • Breathing – shallow and rapid • Pharyngeal and laryngeal reflexes are abolished early • Coughing – depressed and bronchi – dilated • Inhibits – intestinal and uterine contractions
• 20 % halothane enters to blood is metabolized in liver • The rest is exhaled out • Recovery – smooth and reasonably quick • Shivering , nausea , vomiting – may occur
Halothane side effects • Halothane hepatitis” -1/10,000 cases • Malignant hyperthermia - 1/60,000 with succinylcholine to 1/2,60,000 without succinylcholine • Clinical feature - rapid rise in body temperature, muscle rigidity, tachycardia, acidosis, hyperkalemia
Isoflurane • Fluoridated anesthetic • Similar to halothane • Less soluble in blood • Respiratory depression – prominent • Secretions – slightly increased • Post anesthetic nausea and vomiting – less • Slightly irritating • Does not provoke seizures
Desflurane • Less potent than isoflurane • Higher concentration has to be use • Irritates air passage • Pharmacological properties – same as isoflurane • Good alternative for isoflurane – prolonged operations
Sevoflurane • Properties – intermediate between isoflurane and desflurane • Induction – fast and rapid • Pleasant - acceptability good by pediatric patient • Suit for both – inpatient and outpatient • Expensive
Intravenous agents Loss of consciousness – 11 sec Used for induction – rapid onset Maintained by – inhalation agents
Thiopentone sodium • Ultrashort acting – Thiobarbiturate • Highly soluble in water yielding a very alkaline solution • Must be prepare freshly • Dose – I.V 3-5 mg/kg – 15-20 seconds • Has high lipid solubility – enters in to brain instantly • Consciousness regained in 8-12 minute • t1/2 of distribution – 3 minute
• Elimination t1/2 – 7-12 hr. • Poor analgesic • Weak muscle relaxant • BP falls immediately – due to vasodilation – but recovers rapidly • Employed as sole anesthetic – short operation –not painful • Adverse effect  laryngospasm while intubation  Shivering and delirium while recovery
Propofol • Oily liquid • 1% emulsion for I.V. induction • Unconsciousness occurs – 15-45 seconds • Distribution t1/2 – 2-4 minute • Elimination t1/2 – 100minute • Particularly suited for outpatient G.A • Fall in blood pressure – vasodilation • Bradycardia – frequent • Dose – 2.4 mg/kg/hr.
Ketamine • Induces dissociative anesthesia  Profound analgesia  Immobility  Amnesia  Light sleep  Dissociated from own body and surroundings • Primary site of action – in the cortex and subcortical areas • Respiration – not depressed • Airway reflexes – maintained • Muscle tone – increased
• Heart rate , cardiac output and blood pressure – are elevated • Recovery within – 10-15 minutes • Remains amnesic – 1-2 hr. • Injection is not painful • Children tolerate drug better • Elimination t1/2 – 3-4 hr. • Good for repeated use • May be dangerous for hypertensive and IHD • Good for hypovolemic patients
Indications • Has been employed for dental and other operation of head and neck • Asthmatic patient who do not want to lose consciousness for short operation • Combined with diazepam  Angiography  Trauma surgery  Cardiac catherization
Fentanyl • Short acting potent opioid analgesic • Given I.V. at the beginning of painful surgical procedures • Used as supplement anesthetics in balanced anesthesia • Dose – 2-4 µg/kg • After administration – patient remains drowsy but conscious • Pt may be encourage to breath and assistance may be provide • Nausea , vomiting and etching – during recovery
Techniques
In patient general anesthesia • Used in dentistry for the more severely medically compromised patient (ASA 3 or 4) 0r patients undergoing extensive treatment • Patient admitted a day before or early in the morning • Pre-operative evaluation – done a day before  Heamatocrit  Haemoglobin  CBC  Differential count  Urine analysis  Chest x-ray and ECG – in adults and medically compromised patients
• Give written pre-operative instructions • Anesthetist should visit the patient for Preanaesthetic visit  Evaluate patient for special risks (potential airway maintenance problems)  Review physical examination and results of lab test  Discuss anesthetic procedure – to allay apprehension  Review Preanaesthetic orders – fasting instruction – NBM before 8 hours  Administer pre-operative medication – anti-anxiety (diazepam) and anticholinergic (atropine) – IM 1 hour before or IV in the operating table
• On the operating table  Attach physiologic monitors – blood pressure cuff, a precordial stethoscope, ECG, pulse oximeter, capnograph  Establish IV infusion – indwelling catheter, not smaller than 18 gauge  Cases requiring blood transfusion – catheter of 16-gauge  Attach 1000 ml bag of normal saline or Ringer’s lactate to maintain infusion
Induction of anesthesia  Administer small dose of benzodiazepine to induce sedation  Apply topical anesthetic on nostrils – for analgesia and hemostasis during intubation  Place full face mask on the patient with flow of 5 to 7 L min of 100% O2  Administer Propofol until patient loses consciousness  ‘Bag’ the patient confirming the airway is patent  Administer depolarizing muscle relaxant – succinylcholine  Non-depolarizing muscle relaxant may be administered to prevent fasciculation.  Lubricate endotracheal tube and place into nostril -> advance into nasopharynx
 Use laryngoscope – visualize larynx and tip of tube  Using Magill’s intubation forceps – advance and insert the tube in larynx  Attach endotracheal tube to anesthesia machine and ventilate the patient  Administer drugs for maintenance of anesthesia – sevoflurane or IV meperidine  Adjust gas flow of machine – 3 L/min of N2O and 2 L/min of O2  Inflate cuff of endotracheal tube – auscultate chest to check proper intubation  Drape the patient & prepare for surgery
• Anesthetist administers additional doses during procedure • Administer LA for all dental procedure - for hemostasis and pain control • For additional muscle relaxation – administer neuromuscular blocking agent – vecuronium or atracurium
• At the termination of procedure,  Stop administration of inhalation anesthetics – administer 100% of O2 or combination of N2O-O2 followed by 100% of O2  In case of IV opioids, benzodiazepines and muscle relaxants – administer additional drugs to reverse their actions  Naloxane – to reverse opioid induce respiratory depression  Flumazenil – for residual benzodiazepine action  Anticholinesterase – to reverse muscle relaxation
 Patient will emerge from anesthesia  Suction the pharynx before extubation  When respiratory movements seem adequate, extubate the patient after deflating the cuff  Place the face mask and administer 100% O2
• Transfer the patient to recovery room • Administer O2 via nasal cannula • Monitor BP, pulse, respiration and ECG • Patient is discharged after he/she is stable.
Ambulatory GA • Drugs used are short acting to permit a more rapid and complete recovery at the end of procedure • Inhalational anesthetics used • Written preoperative instruction of NBM of atleast 6-8 hours • Basic lab test done and results obtained • Complete physical examination done • IM pre-medication not preferred.
Procedure • Patient placed on operating table • Place all monitoring devices on the patient • Obtain IV line with 18 gauge indwelling catheter – using NS or ringer’s lactate • Induce anesthesia with IV Propofol, Iv midazolam and fentanyl or with inhalational sevoflurane • Muscle relaxants used rarely • If intubation is desired, low dose of succinylcholine administered • Once GA is induced, airway maintained with combination of N2O-O2 and appropriate inhalation anesthetic
• Place gauze or curtain in posterior part of pharynx • Administration of LA desirable • At the termination of procedure, 100% O2 is administered • Patient taken to recovery room – 1 hour of recovery period is recommended • Patient discharged after adequate recovery • Possibility of hospitalization may be explained in case of inadequate require.
Intravenous GA • Short procedures – requiring less than 30 minutes – short acting drugs such as Propofol, midazolam or fentanyl used • Establish IV line using 21 gauge catheter and 500-ml of suitable infusate • Small dose of Propofol, methohexital or thiopental is administered IV • Bite block placed in-between patient’s teeth • IV anesthetic titrated slowly until loss of consciousness • Airway must be maintained • Continued administration of Propofol is necessary to maintain level of GA
• Infusion pumps are used to regulate administration of short acting drugs • LMAs are used frequently to maintain a patent and clean airway • In case of open airway, a lubricated nasopharyngeal airway in inserted into nares to assist in managing airway. • Throughout the procedure, the patient receives ether 100% O2 or combination of N2O- O2 • Administration small IV doses of benzodiazepines smooth out the anaesthetic
• Administration of Propofol alone or with remifentanil via infusion pumps help maintain a constant level of CNS depression • Throat pack placement necessary • LA administration recommended • Return of consciousness is quite rapid, permits immediate removal of LMA • Patient have stable vital signs, patent airways and are responsive to verbal commands in 5-15 minutes • Patient discharged when stable
Reversal of anesthesia • The only component - effect of the non depolarizing muscle relaxant. • The timing of the last dose of the muscle relaxant is important and if it is too near to the conclusion of surgery, adequate time must be allowed before reversal is attempted. • Non depolarizing muscle relaxant is reversed by anti choline esterase drugs  E.G. Neostigmine sulphate (0.05- 0.07 mg/ kg). • Atropine sulphate (anticholinergic) is given along with this to prevent the muscarinic effects of neostigmine like bradycardia, profuse salivation and bronchospasm.
Dental Consideration
Completion of the procedure
• Notify anesthetist before 10 min of completion. • Notify recovery room personnel • Debride oral cavity after completion. • Remove throat pack – prevent aspiration. • The dentist should remain in the operating room during the extubation process to assist the anesthesiologist if necessary • When the child is transported to the recovery room the dentist should accompany the anesthesiologist and provide assistance during the transportation.
Discharge from recovery
• Responsibility for the discharge process is shared between the dentist, the anesthetist and the recovery nursing staff. • Patients and parents should receive verbal and written post-operative instructions • Advice should be given of any symptoms that might be experienced in the first 24 hours following discharge. • Analgesics including paracetamol should be recommended for use in the 24 to 48 hours following discharge. • Specific instructions regarding mouth care after surgery should be given. • The nature of any sutures placed should be described and an appointment made for post-operative assessment
• Conscious level should be consistent with the child’s preoperative state • Cardiovascular and respiratory parameters should be stable • Scoring systems exist to aid in the assessment of recovery • Pain, nausea, vomiting and surgical bleeding should be minimal • Mobility should be at a preoperative level • A responsible adult must be present to accompany the child home • Suitable transport home should have been arranged
• Contact telephone numbers should be provided for both emergency and continuing care • Verbal and written instructions about the child’s recovery at home should be given to the parent / carer, with confirmation of the level of understanding • Follow‐up arrangements should be made where appropriate • Support and guidance on the administration of medication at home should be provided as necessary • A letter to the General Dental Practitioner should be posted or given to the parent / carer, depending on the policy of the unit • Suitable home environment, with regard to supervision of the child as well as access to further healthcare services, if required
Complication of GA
• Postoperative nausea and vomiting • Respiratory • Cardiovascular • Anaphylaxis • Delayed recovery from anesthesia • Malignant hyperthermia
Conclusion • Preanaesthetic evaluation – vital for success! • Vigilant monitoring – prevent untoward complications • Whichever method of induction or intubation is planned problems may be encountered which will alter strategy. • A good and sound knowledge about C.P.R and Emergency Medicine is not only invaluable but essential • A multidisciplinary team approach of a surgeon and anesthetist must utilize well tried and tested protocols to minimize the complications
References • Avery D R, McDonald R E.Dentistry for the child and Adolescent. Mosby, 9th Edition 2012 , 253-76 • Malamed SF: Rectal sedation. In Malamed SF: Sedation: a guide to patient management, ed 4, St Louis, 2002, Mosby • Alan R. Aitkenhead, Graham Smith. Textbook of anesthesia , edition 6 , Churchill Livingstone/Elsevier, 2007 • Pallasch TJ: Pharmacology for dental students and practitioners, Philadelphia, 1980, Lea & Febiger. • Trieger NT: Pain control, ed 2, St Louis, 1994, Mosby • American Dental Association, Council on Dental Education: Guidelines for the use of sedation and general anesthesia by dentists, as adopted by the Oct 2007 ADA House of Delegates, Chicago, 2007
Thank you

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General anesthesia

  • 1.
  • 2.
    Contents • DEFINITIONS • HISTORYOF ANESTHESIA • ADVANTAGES AND DISADVANTAGES • INDICATIONS AND CONTRA INDICATIONS • PREOPERATIVE EVALUATION • PREANAESTHETIC MEDICATION • STAGES OF GENERAL ANESTHESIA • CLASSIFICATION OF GENERAL ANESTHESIA • ARMAMENTARIUM
  • 3.
    Will be coveredin next part ….. • GENERAL ANAESTHETIC AGENTS • TECHNIQUES • RECOVERY/DISCHARGE • COMPLICATIONS OF GENERAL ANAESTHESIA • CONCLUSION
  • 4.
    Definition • General anaesthesiais defined as controlled state of unconsciousness accompanied by a loss of protective reflexes, inducing the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command. • Also defined as an irregular, reversible depression of the higher centres of the central nervous system (CNS) that makes the patient unconscious and insensible to pain
  • 5.
  • 6.
    • Ether -first described in 1540 by ‘Valerius Cordus’ • Used as anesthetic in 1842 by ‘Dr. W.E. Clark’ and ‘Dr.Crawford W. Long’ • First public demonstration of use of ether was in October 17, 1846 by ‘Dr. William T. G. Morton’ • ‘Morton’ - Successfully demonstrated properties of ether and named it as ‘Etherization’
  • 7.
  • 8.
    • 1847- ‘Simpson’discovered use of Chloroform for Anesthesia • 1935 – First IV anesthetic Thiopentone was introduced • 1951- ‘C. W. Suckling’ of Manchester synthesized Halothane • 1956 – ‘Michael Johnstone’ used Halothane clinically J.Y.Simpson
  • 9.
    General anesthesia represent…… Muscle relaxation Analgesia Unconscious ness
  • 10.
    Advantages Success rate of100% Patient cooperation is not essential for the success of general anesthesia Patient is unconscious Patient does not respond to pain Amnesia is present Onset of action of general anesthesia is usually quite rapid - <1 minute Titration is possible
  • 11.
    • The onlytechnique that will prove successful for certain patients  The un-cooperative child  Extremely fearful adult  Either physical or mental disabilities
  • 12.
    Disadvantages • Patient isunconscious • Protective reflexes are depressed • Vital signs are depressed • Trained staff is required • An “anaesthesia team” is required • Special equipment is required • Need for recovery room • Intraoperative complications are more likely • Post-anesthetic complications • More extensive pre-op evaluation, including lab work
  • 13.
    Indications Extreme anxiety andfear Adults or children who have mental or physical disabilities, senile patients, or disoriented patients Age—infants and children Short, traumatic procedures Prolonged, trauma
  • 14.
    Indication in children •Patient unable to cooperate – mental or physical disability • When LA is ineffective – acute infection , anatomic variations, allergy • Extremely uncooperative , fearful, anxious, physically resistant, uncommunicative child • In whom there is no expectation that the behavior will improve • Patient who have sustained extensive orofacial or dental trauma and require surgical procedure • Patient requiring immediate comprehensive oral or dental needs • Use of GA may protect the developing psyche and reduce medical risks
  • 15.
    Contraindications Lack of adequatetraining by the dentist Lack of adequately trained personnel Lack of adequate equipment Lack of adequate facilities ASA 4 and certain ASA 3 medically compromised patients
  • 16.
    Requirements as adentist • Dental residency of 1-4 year in a teaching hospital • A rotation in which dental resident actively involved in administrating GA • Current certification in basic cardiopulmonary resuscitation • Should be aware of hospital’s by laws, rules, regulations and meetings • Should endeavor to provide the highest quality care
  • 17.
    Evaluation of thehospital… • Membership of other dentists on the hospital staff • Positive attitude of the hospital staff • Attitude of staff physicians toward dental treatment • Experience of anesthesiology staff • Availability of consulting physician • Hospitals regulations • Availability of operating room time • Availability of patient bed • Availability of dental equipment • Convenience of the location of hospital
  • 18.
    Two general categories Youngchildren who need extensive treatment and unmanageable as outpatient Children with mental or physical disabilities Admission justification
  • 19.
    Pre - admissionpreparation • A dentist’s decision to treat a child under GA – approved by the child's parents • Dentist's responsibility – increased risk and expense • Must evaluate the child’s psychological state • An information page should be provided to parents • Necessity of having both or one parent prior to GA when the child awakens • For mentally or physical handicapped child – will require special control techniques and ensure they will be available • Child’s physician should prescribe special diet or pre-medicaments
  • 20.
    • Dentist shouldmake proper plan for hospitalization • Operating room must be scheduled • Arrangements must be made for an anesthesiologist • Physical examination – one day prior by physician • Should Assess general health (ASA Classification) • Ask for Drug history
  • 21.
    ASA Classification ASA INormal healthy patient ASA II Patient with mild systemic disease ASA III Patient with severe systemic disease that is limiting but not incapacitating ASA IV Patient with incapacitating disease which is constant threat to life ASA V Moribund patient not expected to live more than 24 hours ASA VI A declared brain dead patient whose organ are being removed for donor purposes
  • 22.
  • 23.
  • 24.
    Pediatric history Identification • Age •Sex • Racial-ethnic profile History of present illness Medical survey • Immunization • Previous hospitalization • Allergies • Dietary history • Current medications Developmental status Family history
  • 25.
    Physical examination Vital signs •Pulse rate • Respiration rate • Blood pressure • Temperature Measurements • Weight • Height General appearance • Nutrition • Colour • Distress
  • 26.
    Head Eyes – pupilsand extraocular movements Ears Nose – patency and secretion Neck Lungs Cardiovascular system – heart sounds , rate , rhythm , murmurs Abdomen Genitalia Lymph nodes Skeleton nervous system
  • 27.
  • 28.
    Heart rate andRespiratory rate
  • 29.
  • 30.
    Temperature °F 0-2 years3-10 years 11-65 years > 65 years Oral - 95.9-99.5 97.6-99.6 96.5-98.5 Rectal 97.9-100.4 97.9-100.4 98.6-100.6 97.1-99.2 Axillary 94.5-99.1 96.6-98 95.3-98.4 96.0 – 97.4
  • 31.
  • 32.
    Past dental history Behavior Past experience Treatment done Headand neck General Head Neck Face Lateral facial profile Intra oral examination Lips Tongue Floor of the mouth Buccal mucosa Hard and soft palate Teeth Caries Eruption sequence Occlusion Overjet Overbite Midline Oral habits
  • 33.
  • 34.
    Patient undergoing surgeryshould be screened for…..  Biochemical  Hematological  Radiological abnormalities  ECG
  • 35.
  • 38.
    Signature required • Ifthe patient is adult  signature of patient  If the patient is incompetent – the guardian’s signature • Minor patient (under 18 )  If emancipated – patient’s signature  Signature of parent or guardian is required • In an emergency/life threatening situation - signatures as above are not available……  Signature of two physician  Signature of closest adult
  • 39.
  • 40.
    • Child isusually admitted on the day before treatment and have to stay till next morning • Parents should complete the necessary forms • Dentist should give the admission order which include  Order for NPO(nothing by mouth )  Order for specific drug and specific dosage  Preoperative sedation orders  Request for the child to be transferred to the operating room
  • 41.
  • 42.
    • Nursing staffshould explain – standard hospital procedure to parents • Child will be visited by anesthesiologist • The decision regrading nothing by mouth - determined by anesthesiologist • Dentist should evaluate pre-operative laboratory data • Dentist should collect admitting note • And record preoperative note • 30 minute before dentist and staff should be in operating room area
  • 43.
    Admitting note • Providesgeneral information about the child and reason for admission • This form is given to child's physician • The physician have to enter preoperative physical examination and return it
  • 45.
  • 48.
  • 49.
    Operative room protocol •Must follow OSHA guidelines • Must wear – surgical suite • Eyeglasses, nose hood , face shield and mouth mask • Should follow standard scrubbing method • Avoid cross-contamination between patient in the hospital
  • 50.
    Universal protocol checklist When patiententers the operating room the mandatory “ TIME OUT PROTOCOL” initiated by the nurse
  • 53.
  • 54.
    Pre- Anesthetic Medication •Relief of anxiety and apprehension preoperatively and facilitate smooth induction • Supplement analgesic action of anesthetics and potentiate them so that less anesthetic is needed • Decrease secretions and vagal stimulation caused by anesthetics • Produce antiemetic effect extending to the postoperative period • Decrease acidity and volume of gastric juice so that it is less damaging if aspirated
  • 56.
    Stages of GeneralAnesthesia • Guedel - 1920 • Observations on the following parameters  Character of respiration  Eyeball activity  Pupillary changes  Eyelid reflex  Swallowing and vomiting
  • 57.
    I. Stage ofAnalgesia starts with the initial administration of a CNS-depressant drug and continues to the loss of consciousness 1. Respiration is normal 2. Eye movements are normal, with voluntary movement possible 3. Protective reflexes are intact 4. Amnesia (the lack of recall) may or may not be present 5. Diminished intellect, memory, integrative functions, perception of time and space
  • 58.
    II. Stage ofDelirium begins with loss of consciousness and progresses until entry into the stage of surgical anaesthesia (stage III) • Respirations are irregular early in stage II, but become more regular as stage II deepens • Eyeballs oscillate involuntarily, a movement termed Lateral nystagmus • Pupils react to light normally • Skeletal muscle tonus is increased, with muscular rigidity present in some patients early in stage II.
  • 59.
    • Muscle tonusdecreases as stage II deepens. • The laryngeal and pharyngeal reflexes (swallowing and laryngeal closure) are still quite active early in stage II, but become progressively more obtunded as stage II progresses.
  • 60.
    III. Stage ofSurgical Anesthesia Entry into stage III is marked by several signs and divided into 4 planes : Plane 1 : • Respiratory regularity equally Thoracic and abdominal • Eyeballs oscillate slowly & pupils respond normally to light • Swallowing and vomiting reflexes disappear • Tears secreted • Tendency to breathe deeply and rapidly with skin incision decreases • Peripheral vasodilatation
  • 61.
    Plane 2 : •Eyeballs cease to oscillate • Intercostal muscles weaken. • Respiration regular but tidal volume is decreased • Pupil size increases • Laryngeal reflexes diminishes • Tears secretion decreased • Respiratory response to skin incision disappears
  • 62.
    Plane 3 : •Pupillary response to light is abolished • As plane deepens intercostal paralysis Plane 4 : • Complete intercostal & diaphragm paralysis • Pupils dilate and no muscle tonus
  • 63.
    Stage IV :Medullary paralysis • Begins with onset of respiratory arrest and ends with cessation of effective circulation.
  • 65.
    Types of GeneralAnesthesia 1. In-office outpatient general anesthesia 1. IV anesthesia (Propofol or barbiturates) (less than 30 minutes) 2. Conventional operating theater type of general anesthesia(more than 30 minutes and less than 4 hours) 2. Inpatient general anesthesia
  • 66.
  • 67.
    Intravenous Propofol orBarbiturates • IV Propofol or barbiturates are highly accepted and common - to induce and maintain unconsciousness in GA • Known as ultralight general anesthesia • May receive other drugs - nitrous oxide-oxygen (N2O-O2), benzodiazepine and opioids • The administration of O2 minimizes the risk of hypoxia. • Local anesthesia is important.
  • 68.
    Conventional Operating RoomType of GA • A variation of outpatient general anesthesia is used in - procedure 30 minutes to 4 hours or longer • Same preparation and procedure as does the inpatient • Limited to the ASA 1, ASA 2, and selected ASA 3 patients • A dentist will be responsible for the dental care • In no circumstance should the same person administer the general anesthetic and perform the dental treatment • The duration of an outpatient general anesthetic not exceed - 4 hours
  • 69.
    Inpatient General Anesthesia •This patient is admitted to the hospital before the planned procedure • Undergoes the procedure then remains in the hospital at least 1 day postoperatively • The dentist need not be trained in anesthesiology • The anesthesiologist is responsible for the administration of the anesthetic • In prolonged dental treatment - the dentist will request that the patient be intubated through the nose (nasoendotracheal) rather than through the mouth (oroendotracheal)
  • 70.
    • The administrationof general anesthesia for dental procedures is more difficult • Because the oral cavity is the treatment zone • Therefore the potential for airway complications is increased • Mortality rates for hospital inpatient anesthesia > outpatient procedures • ASA 1 and 2 patients are treated as outpatients • ASA 3 and 4 patients are usually hospitalized
  • 71.
  • 72.
  • 73.
    Anesthesia Machine • Ableto deliver oxygen (O2) and inhalation anesthetics to the patient. • The inhalation sedation (n2o o2) is a modification of the anesthesia machine • The anesthesia machine can deliver many gases: N2O, O2, sevoflurane, desflurane, and isoflurane. • Flowmeters and devices called vaporizers that contain the various volatile anesthetics and permit their concentrations to be controlled
  • 74.
    • The anesthesiamachine is capable of operating with O2 and N2O supplied from cylinders • Anesthesia machines have O2 monitors that sound an alarm - if the unit fails to provide a preset minimum percentage of O2 (i.E., 25%) • Ventilator - a device used to control or assist the ventilation of a patient during anesthesia - attached to the right side
  • 76.
    • The modernanesthesia machine contains a number of important devices for monitoring patients  A blood pressure monitor  Electrocardiograph (ECG)  Pulse oximeter  Capnograph (end-tidal carbon dioxide [ETCO2] monitor)  Bispectral (BIS) electroencephalograph (EEG) monitor
  • 77.
    Intravenous equipment • Wingedneedles (18 gauge ) • Indwelling catheters • Tubing and bags of IV solution (1000 ml) • Disposable syringes and needles • Adhesive tapes (paper, hypoallergenic)
  • 78.
  • 79.
    Full-face masks -sizes and appropriate connectors Laryngoscope Endotracheal tubes and appropriate connectors Laryngeal mask airway (LMA) Oropharyngeal and nasopharyngeal airways Tonsillar suction tips Magill intubation forceps Child- and adult-size sphygmomanometers Stethoscopes
  • 80.
    Face mask • Rubberor silicone masks • Cover both the mouth and nose of the patient • Face masks are - deliver O2, N2O-O2 and other inhalation anesthetics before, during and after the anesthetic procedure • Made from a clear plastic or rubber • Metal connectors - attach the face mask to the tubing of the anesthesia machine - variety of sizes and shapes
  • 82.
    Laryngoscopes • Designed toassist in the visualization of the trachea during intubation • It consists of two parts  A handle and battery holder  Blade • The handle – made of metal and contains batteries (used to operate the light bulb found in the blade) • The blade - made of metal • The laryngoscope blade - designed to aid in visualization of the larynx • A small light bulb that illuminates the laryngeal area is attached to the blade
  • 84.
    • There aretwo basic types of laryngoscope blades  The curved (Macintosh) - commonly used  The straight (Miller) blade • Available in a variety of sizes • The tip of the curved blade is inserted into the vallecular • Blades are designed to be held in the operator’s left hand • With the endotracheal tube held in the right hand
  • 86.
    Technique The tip ofthe curved blade is inserted into the vallecular - between the base of the tongue and the epiglottis The handle of the laryngoscope is then lifted straight up and slightly forward - a movement that visualizes the vocal cords When a straight blade is used its tip is placed underneath the laryngeal surface of the epiglottis The larynx is exposed by an upward and forward lift of the blade
  • 87.
    Endotracheal Tubes andConnectors • Endotracheal tubes and connectors are rubber tubes designed to be placed from the mouth (oroendotracheal) or nose (nasoendotracheal) into the patient’s trachea. • Reusable and disposable • Endotracheal tubes have an inflatable cuff located near their distal ends • Connectors for endotracheal tubes = used for full-face masks  Used to connect the endotracheal tube to the anesthesia machine
  • 89.
    When a patientis intubated the endotracheal tube is inserted into the trachea so that the uninflated cuff disappears just beyond the level of the larynx. Air is then injected into a tube to inflate the cuff Enough air is injected into the cuff to seal the trachea
  • 91.
    DEPTH OF ENDOTRACHEALTUBE • Adult  Male = 23 cm  Female = 21cm • Children  Oral endotracheal tube = (Age / 2) + 12(cm)  Nasal endotracheal tube = (Age / 2) + 15(cm)
  • 92.
    Size of endotrachealtube Internal diameter (ID) Male 8.0 mm Female 7.5 mm New born – 3 months 3.0 mm 3-9 months 3.5 mm 9-18 months 4.0 mm 2-6 yrs. (Age/3) +3.5 >6 yrs. (Age/4) + 4.5
  • 95.
    Advantages of endotracheal intubation •Free unobstructed airway • Ventilation can be controlled or assisted • aspiration of blood, mucus, vomitus into lung is prevented • Measured amount of gases and vapors can be delivered • Safe and acceptable • Dead space can be managed
  • 96.
    Disadvantages • Need ofexpertise • Injury to teeth, lips, larynx, epiglottis, pharynx or trachea • Cost
  • 97.
  • 98.
    When Intubated • Obstructionfrom klinking , secretion or over-inflation of cuff • Accidental extubation or endobronchial intubation • Disconnection from breathing circuit • Pulmonary aspiration • Lip or nasal ulcer in case with prolong period of intubation • Sinusitis or otitis in case with prolong Naso-endotracheal intubation
  • 99.
    During Intubation • Traumato lip , tongue or teeth • Hypertension and tachycardia or arrhythmia • Pulmonary aspiration • Laryngospasm • Bronchospasm • Laryngeal edema • Spinal cord trauma in cervical spine injury • Esophageal intubation
  • 100.
  • 101.
    During Extubation Laryngospasm Pulmonary aspiration Edema ofupper airway After Extubation Sore throat Hoarseness Tracheal stenosis (Prolong intubation) Laryngeal granuloma
  • 102.
    Oropharyngeal and NasopharyngealAirways • Oropharyngeal and nasopharyngeal airways - used to assist in maintaining a patent airway during and after the anesthetic procedure • Plastic, rubber or metallic devices • Designed to lie between the base of the tongue and the posterior pharyngeal wall • The nasopharyngeal airway - better tolerated by the conscious or sedated patient • Nasal airways should be lubricated
  • 104.
    Oral airway Nasalairway Oral airway Nasal airway
  • 105.
    Tonsillar Suction Tips •Excessive salivation , bleeding in the mouth or pharynx, or vomiting - can lead to airway obstruction, laryngospasm, or possible infection of the trachea or bronchi • Tonsillar suction tips are recommended ….. because they can be inserted blindly into the posterior pharynx of the patient with minimal risk of producing bleeding • The end of the tonsillar suction tip is rounded • Several tonsillar suction tips should be available
  • 106.
  • 107.
    Magill Intubation Forceps •Designed to assist in placing the endotracheal tube • It is most frequently used during nasoendotracheal • It is L shaped and has no catch • It is available in 2 sizes : adult and pediatrics
  • 109.
    Pharyngeal throat pack •Pharyngopalatine area should be sealed off • With a strip of moist sterile gauze piece  Width – 3 inches  Length – 18-20 inches • Written documentation of throat pack placement is necessary • Reduce the escape of anesthetic agents and prevent any material entering the pharynx • Gauze should tightly pack around the tube – good seal
  • 110.
    Sphygmomanometers and Stethoscopes •Must available during GA procedures • Used for the monitoring  Vital signs  Specifically blood pressure  Heart rate and rhythm  Heart sounds  Breathes sounds
  • 111.
  • 112.
  • 113.
    Emergency Drugs…. Vasopressor CorticosteroidBronchodilator Muscle relaxant Appropriate drug antagonist(s) Antihistaminic Anticholinergic Antiarrhythmic Coronary artery vasodilator Antihypertensiv e Anticonvulsant O2 and 50% dextrose
  • 114.
    Emergency Equipment • Backuplighting system • Backup suction device • O2 delivery system • Laryngoscope with complete selection of blades and spare batteries and bulb • Endotracheal tubes and appropriate connectors • Oral airways
  • 115.
    • Tonsillar orpharyngeal type suction tip • Endotracheal tube forceps (Magill intubation forceps) • Sphygmomanometer and stethoscope • Electrocardioscope and defibrillator • Adequate equipment for the establishment of an IV infusion • Precordial or Pretracheal stethoscope • Pulse oximeter
  • 116.
    Agents used forGA Inhalation Intravenous
  • 117.
  • 118.
  • 119.
    Ether • Highly volatile– liquid • Vapor – irritating , inflammable and explosive • Potent anesthetic – good analgesia and muscle relaxation • Highly soluble in blood • Induction – prolonged and unpleasant • Atropine must – as premedication • Recovery – slow • Post anesthetic nausea , vomiting and retching
  • 120.
    Halothane • Halogen substitutedethane • Volatile liquid – sweet odor , nonirritant and nonflammable • Solubility in blood – intermediate • Induction – quick and pleasant • Potent inhalational anesthetic • Dose: For induction 2-4%, Maintenance 0.5-1% • Not good analgesic nor muscles relaxant
  • 121.
    • Cause directdepression of myocardial contractility • Cardiac output , blood pressure ,heart rate – decreased • Breathing – shallow and rapid • Pharyngeal and laryngeal reflexes are abolished early • Coughing – depressed and bronchi – dilated • Inhibits – intestinal and uterine contractions
  • 122.
    • 20 %halothane enters to blood is metabolized in liver • The rest is exhaled out • Recovery – smooth and reasonably quick • Shivering , nausea , vomiting – may occur
  • 123.
    Halothane side effects •Halothane hepatitis” -1/10,000 cases • Malignant hyperthermia - 1/60,000 with succinylcholine to 1/2,60,000 without succinylcholine • Clinical feature - rapid rise in body temperature, muscle rigidity, tachycardia, acidosis, hyperkalemia
  • 124.
    Isoflurane • Fluoridated anesthetic •Similar to halothane • Less soluble in blood • Respiratory depression – prominent • Secretions – slightly increased • Post anesthetic nausea and vomiting – less • Slightly irritating • Does not provoke seizures
  • 125.
    Desflurane • Less potentthan isoflurane • Higher concentration has to be use • Irritates air passage • Pharmacological properties – same as isoflurane • Good alternative for isoflurane – prolonged operations
  • 126.
    Sevoflurane • Properties –intermediate between isoflurane and desflurane • Induction – fast and rapid • Pleasant - acceptability good by pediatric patient • Suit for both – inpatient and outpatient • Expensive
  • 127.
    Intravenous agents Loss ofconsciousness – 11 sec Used for induction – rapid onset Maintained by – inhalation agents
  • 128.
    Thiopentone sodium • Ultrashortacting – Thiobarbiturate • Highly soluble in water yielding a very alkaline solution • Must be prepare freshly • Dose – I.V 3-5 mg/kg – 15-20 seconds • Has high lipid solubility – enters in to brain instantly • Consciousness regained in 8-12 minute • t1/2 of distribution – 3 minute
  • 129.
    • Elimination t1/2– 7-12 hr. • Poor analgesic • Weak muscle relaxant • BP falls immediately – due to vasodilation – but recovers rapidly • Employed as sole anesthetic – short operation –not painful • Adverse effect  laryngospasm while intubation  Shivering and delirium while recovery
  • 130.
    Propofol • Oily liquid •1% emulsion for I.V. induction • Unconsciousness occurs – 15-45 seconds • Distribution t1/2 – 2-4 minute • Elimination t1/2 – 100minute • Particularly suited for outpatient G.A • Fall in blood pressure – vasodilation • Bradycardia – frequent • Dose – 2.4 mg/kg/hr.
  • 131.
    Ketamine • Induces dissociativeanesthesia  Profound analgesia  Immobility  Amnesia  Light sleep  Dissociated from own body and surroundings • Primary site of action – in the cortex and subcortical areas • Respiration – not depressed • Airway reflexes – maintained • Muscle tone – increased
  • 132.
    • Heart rate, cardiac output and blood pressure – are elevated • Recovery within – 10-15 minutes • Remains amnesic – 1-2 hr. • Injection is not painful • Children tolerate drug better • Elimination t1/2 – 3-4 hr. • Good for repeated use • May be dangerous for hypertensive and IHD • Good for hypovolemic patients
  • 133.
    Indications • Has beenemployed for dental and other operation of head and neck • Asthmatic patient who do not want to lose consciousness for short operation • Combined with diazepam  Angiography  Trauma surgery  Cardiac catherization
  • 134.
    Fentanyl • Short actingpotent opioid analgesic • Given I.V. at the beginning of painful surgical procedures • Used as supplement anesthetics in balanced anesthesia • Dose – 2-4 µg/kg • After administration – patient remains drowsy but conscious • Pt may be encourage to breath and assistance may be provide • Nausea , vomiting and etching – during recovery
  • 135.
  • 136.
    In patient generalanesthesia • Used in dentistry for the more severely medically compromised patient (ASA 3 or 4) 0r patients undergoing extensive treatment • Patient admitted a day before or early in the morning • Pre-operative evaluation – done a day before  Heamatocrit  Haemoglobin  CBC  Differential count  Urine analysis  Chest x-ray and ECG – in adults and medically compromised patients
  • 137.
    • Give writtenpre-operative instructions • Anesthetist should visit the patient for Preanaesthetic visit  Evaluate patient for special risks (potential airway maintenance problems)  Review physical examination and results of lab test  Discuss anesthetic procedure – to allay apprehension  Review Preanaesthetic orders – fasting instruction – NBM before 8 hours  Administer pre-operative medication – anti-anxiety (diazepam) and anticholinergic (atropine) – IM 1 hour before or IV in the operating table
  • 138.
    • On theoperating table  Attach physiologic monitors – blood pressure cuff, a precordial stethoscope, ECG, pulse oximeter, capnograph  Establish IV infusion – indwelling catheter, not smaller than 18 gauge  Cases requiring blood transfusion – catheter of 16-gauge  Attach 1000 ml bag of normal saline or Ringer’s lactate to maintain infusion
  • 139.
    Induction of anesthesia Administer small dose of benzodiazepine to induce sedation  Apply topical anesthetic on nostrils – for analgesia and hemostasis during intubation  Place full face mask on the patient with flow of 5 to 7 L min of 100% O2  Administer Propofol until patient loses consciousness  ‘Bag’ the patient confirming the airway is patent  Administer depolarizing muscle relaxant – succinylcholine  Non-depolarizing muscle relaxant may be administered to prevent fasciculation.  Lubricate endotracheal tube and place into nostril -> advance into nasopharynx
  • 140.
     Use laryngoscope– visualize larynx and tip of tube  Using Magill’s intubation forceps – advance and insert the tube in larynx  Attach endotracheal tube to anesthesia machine and ventilate the patient  Administer drugs for maintenance of anesthesia – sevoflurane or IV meperidine  Adjust gas flow of machine – 3 L/min of N2O and 2 L/min of O2  Inflate cuff of endotracheal tube – auscultate chest to check proper intubation  Drape the patient & prepare for surgery
  • 141.
    • Anesthetist administersadditional doses during procedure • Administer LA for all dental procedure - for hemostasis and pain control • For additional muscle relaxation – administer neuromuscular blocking agent – vecuronium or atracurium
  • 142.
    • At thetermination of procedure,  Stop administration of inhalation anesthetics – administer 100% of O2 or combination of N2O-O2 followed by 100% of O2  In case of IV opioids, benzodiazepines and muscle relaxants – administer additional drugs to reverse their actions  Naloxane – to reverse opioid induce respiratory depression  Flumazenil – for residual benzodiazepine action  Anticholinesterase – to reverse muscle relaxation
  • 143.
     Patient willemerge from anesthesia  Suction the pharynx before extubation  When respiratory movements seem adequate, extubate the patient after deflating the cuff  Place the face mask and administer 100% O2
  • 144.
    • Transfer thepatient to recovery room • Administer O2 via nasal cannula • Monitor BP, pulse, respiration and ECG • Patient is discharged after he/she is stable.
  • 145.
    Ambulatory GA • Drugsused are short acting to permit a more rapid and complete recovery at the end of procedure • Inhalational anesthetics used • Written preoperative instruction of NBM of atleast 6-8 hours • Basic lab test done and results obtained • Complete physical examination done • IM pre-medication not preferred.
  • 146.
    Procedure • Patient placedon operating table • Place all monitoring devices on the patient • Obtain IV line with 18 gauge indwelling catheter – using NS or ringer’s lactate • Induce anesthesia with IV Propofol, Iv midazolam and fentanyl or with inhalational sevoflurane • Muscle relaxants used rarely • If intubation is desired, low dose of succinylcholine administered • Once GA is induced, airway maintained with combination of N2O-O2 and appropriate inhalation anesthetic
  • 147.
    • Place gauzeor curtain in posterior part of pharynx • Administration of LA desirable • At the termination of procedure, 100% O2 is administered • Patient taken to recovery room – 1 hour of recovery period is recommended • Patient discharged after adequate recovery • Possibility of hospitalization may be explained in case of inadequate require.
  • 148.
    Intravenous GA • Shortprocedures – requiring less than 30 minutes – short acting drugs such as Propofol, midazolam or fentanyl used • Establish IV line using 21 gauge catheter and 500-ml of suitable infusate • Small dose of Propofol, methohexital or thiopental is administered IV • Bite block placed in-between patient’s teeth • IV anesthetic titrated slowly until loss of consciousness • Airway must be maintained • Continued administration of Propofol is necessary to maintain level of GA
  • 149.
    • Infusion pumpsare used to regulate administration of short acting drugs • LMAs are used frequently to maintain a patent and clean airway • In case of open airway, a lubricated nasopharyngeal airway in inserted into nares to assist in managing airway. • Throughout the procedure, the patient receives ether 100% O2 or combination of N2O- O2 • Administration small IV doses of benzodiazepines smooth out the anaesthetic
  • 150.
    • Administration ofPropofol alone or with remifentanil via infusion pumps help maintain a constant level of CNS depression • Throat pack placement necessary • LA administration recommended • Return of consciousness is quite rapid, permits immediate removal of LMA • Patient have stable vital signs, patent airways and are responsive to verbal commands in 5-15 minutes • Patient discharged when stable
  • 151.
    Reversal of anesthesia •The only component - effect of the non depolarizing muscle relaxant. • The timing of the last dose of the muscle relaxant is important and if it is too near to the conclusion of surgery, adequate time must be allowed before reversal is attempted. • Non depolarizing muscle relaxant is reversed by anti choline esterase drugs  E.G. Neostigmine sulphate (0.05- 0.07 mg/ kg). • Atropine sulphate (anticholinergic) is given along with this to prevent the muscarinic effects of neostigmine like bradycardia, profuse salivation and bronchospasm.
  • 152.
  • 154.
  • 155.
    • Notify anesthetistbefore 10 min of completion. • Notify recovery room personnel • Debride oral cavity after completion. • Remove throat pack – prevent aspiration. • The dentist should remain in the operating room during the extubation process to assist the anesthesiologist if necessary • When the child is transported to the recovery room the dentist should accompany the anesthesiologist and provide assistance during the transportation.
  • 156.
  • 157.
    • Responsibility forthe discharge process is shared between the dentist, the anesthetist and the recovery nursing staff. • Patients and parents should receive verbal and written post-operative instructions • Advice should be given of any symptoms that might be experienced in the first 24 hours following discharge. • Analgesics including paracetamol should be recommended for use in the 24 to 48 hours following discharge. • Specific instructions regarding mouth care after surgery should be given. • The nature of any sutures placed should be described and an appointment made for post-operative assessment
  • 158.
    • Conscious levelshould be consistent with the child’s preoperative state • Cardiovascular and respiratory parameters should be stable • Scoring systems exist to aid in the assessment of recovery • Pain, nausea, vomiting and surgical bleeding should be minimal • Mobility should be at a preoperative level • A responsible adult must be present to accompany the child home • Suitable transport home should have been arranged
  • 159.
    • Contact telephonenumbers should be provided for both emergency and continuing care • Verbal and written instructions about the child’s recovery at home should be given to the parent / carer, with confirmation of the level of understanding • Follow‐up arrangements should be made where appropriate • Support and guidance on the administration of medication at home should be provided as necessary • A letter to the General Dental Practitioner should be posted or given to the parent / carer, depending on the policy of the unit • Suitable home environment, with regard to supervision of the child as well as access to further healthcare services, if required
  • 160.
  • 161.
    • Postoperative nauseaand vomiting • Respiratory • Cardiovascular • Anaphylaxis • Delayed recovery from anesthesia • Malignant hyperthermia
  • 162.
    Conclusion • Preanaesthetic evaluation– vital for success! • Vigilant monitoring – prevent untoward complications • Whichever method of induction or intubation is planned problems may be encountered which will alter strategy. • A good and sound knowledge about C.P.R and Emergency Medicine is not only invaluable but essential • A multidisciplinary team approach of a surgeon and anesthetist must utilize well tried and tested protocols to minimize the complications
  • 163.
    References • Avery DR, McDonald R E.Dentistry for the child and Adolescent. Mosby, 9th Edition 2012 , 253-76 • Malamed SF: Rectal sedation. In Malamed SF: Sedation: a guide to patient management, ed 4, St Louis, 2002, Mosby • Alan R. Aitkenhead, Graham Smith. Textbook of anesthesia , edition 6 , Churchill Livingstone/Elsevier, 2007 • Pallasch TJ: Pharmacology for dental students and practitioners, Philadelphia, 1980, Lea & Febiger. • Trieger NT: Pain control, ed 2, St Louis, 1994, Mosby • American Dental Association, Council on Dental Education: Guidelines for the use of sedation and general anesthesia by dentists, as adopted by the Oct 2007 ADA House of Delegates, Chicago, 2007
  • 164.

Editor's Notes

  • #9 At the same time with the use of ether for anaesthesia . Chloroform also gained popularity. Queen victoria was given chloroform at the birth of her seventh son prince leopold. Chloroform became considerably popular in the later part of nineteenth century and word Anaesthesia became synonymous with the word chloroform.but due to various adverse effects its use is not in vogue in recent times. The modern era of flourinated anaesthesia agent dates back to early 1950’’s
  • #10 Controlled state of unconsciousness analgesia and amnesia and loss of muscle tone which allows safe surgical procedure
  • #12 Downs syndrome , cerebral palsy and autism
  • #13 Obstruction of airway
  • #16 poliomyelitis in whom the chest muscles have been involved , history of myasthenia gravis , decreased cardiac and/or pulmonary reserve Obese patient malignant hyperthermia (hyperpyrexia)
  • #17 Gain experience in recording and evaluating the medical history , receives instruction in physical examination technique , learn to inititate medical consultation develpoe proficiency in opeating room protocol
  • #18 Musselman and roy in 1974 …Dentist should seek practical information about the hospital
  • #19 Initial examination Parental consultation – describe risk , expense Consultation
  • #20 Before one or two week – hospitalization need , timings , location of the hospital , physician’s apoointment , cancelleation
  • #39 If married – signature of patient and spouse are required Guardian – a person who has the legal right and responsivity of taking care oor herself f someone who can not take care of him self
  • #50 Occupational safety and health
  • #57 Guedel based his observations on the following parameters
  • #68 It is used primarily in oral and maxillofacial surgery for relatively short patient recovery from propofol anesthesia is rapid and more complete than that seen with methohexital or other barbiturates. and local anesthetics that assist in maintenance of a smooth level of general anesthesia. The benzodiazepine and N2O-O2 act to prolong the duration of the anesthesia and to potentiate the effect of the IV propofol or barbiturate, permitting a smaller dose to be used.
  • #69 ASA 4 patients requiring general anesthesia for their dental care will be hospitalized before the procedure and remain hospitalized after the procedure.
  • #71 Ecomomical , phycological effects , Decreased nosocomial infection Parentral preferences
  • #81 that allows the patient’s mouth and nose to be seen so that foreign material (e.g., vomitus, blood) may be observed and removed.
  • #90 thereby preventing foreign material, such as blood, saliva, or vomitus, from entering the trachea and bronchi
  • #93 Endotracheal tubes are manufactured in a variety of diameters Because the diameter of the laryngeal opening and the trachea varies from patient to patient.
  • #103 The purpose of both of these devices is to displace the tongue from the pharynx and thereby permit the patient to exchange air either around or through the airway.
  • #111 Appropriate-size sphygmomanometers must be available if accurate blood pressure values are desired.
  • #114 The emergency drugs required by the board of dental examiners in the state of California [176] for dentists using general anesthesia are listed here
  • #120 Unpleasant with struggling , breath holding , salivation and marked respiratory secretion Not use in developed country bcz of unpleasant an inflammable properties Still used in developing country bcz cheap and safe in experienced hand
  • #121 Delivered by special vaporizer Competitive neuromuscular blockers
  • #123 Most popular – non irritant , non inflammable , pleasant and rapid action
  • #129 Extravasation of solution or inadvertent intra-arterial injection produce – pain , necrosis and gangrene
  • #131 Elimination much shorter because of rapid metabolism
  • #156 that the child can begin to be aroused and preparations can be made for extubation. notified that the child will soon be arriving so that they can begin preparations.
  • #158 It is wise to arrange such a follow up to ensure that healing is progressing normally and that any absorbable (dissolving) sutures have been lost spontaneously.
  • #159 (this adult must be able to give the child his / her undivided attention during the journey home) The discharge process should create an environment in which parents / carers understand their roles and responsibilities for continuing care and therefore feel confident to take their child home.