Anesthesia drugs are also known as “anesthetics” used to induce anesthesia to avoid pain and discomfort during and after surgery. Benzodiazepines, Diazepam, Lorazepam, Midazolam, Etomidate, Ketamine, Propofol.

1. GENERAL
ANESTHESIA

2. DEFINITION OF
ANESTHESIA
• It is a reversable blocking of pain feeling in
whole body or in a part of it using
pharmacology or other methods

3. ANESTHESIA-
DIVISION
• Local- regional anesthesia, patient is
conscious or sedated
• General- anesthesia interact with whole
body, function of central nervous system is
depressed:
– Intravenous
– Inhalation (volatile)
– Combined, balanced

4. TIVA
Total
Intra
Venous
Anaesthesia

5. VIMA
Volatile
Induction
and
Maintain
Anaesthesia

6. PARTS OF GENERAL
ANESTHESIA
• Hypnosis- pharmacological sleep,
reversable lack of consciousness
• Analgesia-pain management
• Areflexio-lack of reflexes
• Relaxatio musculorum- muscle relaxation,
pharmacological reversable neuromuscular
blockade

7. PARTS OF GENERAL
ANESTHESIA MUST BE
IN BALANCE
Hypnosis
(anesthesia) Analgesia
Lack of reflexes (muscle relaxation)

8. STAGES OF GENERAL
ANESTHESIA
• Stadium analgesiae (analgesia and
sedation stage)
• Stadium excitationis (excitation stage)
• Stadium anaesthesiae chirurgicae
(anesthesia for surgery)
• Stadium paralysis respirationis
(intoxication, respiratory arrest)

9. I. ANALGESIA
STAGE
• Patient consciouss
• Spontaneus respiration
• Reflexes present
• Possible small surgery procedures
like dressing change in burns

10. II. EXCITATION
STAGE
• Possible uncontrolled
movements, vomitings
• Increase in respiratory rate

11. III. ANESTHESIA FOR
SURGERY
• It begins with lack of lid reflex
• 4 substages
• Airway opening necessary
• Possible surgery except for abdominal
opening if no relaxants are used
• Possible endotracheal intubation

12. IV. INTOXICATION,
OVERDOSING
• Respiratory arrest
• If anesthesia not discontinued possible
cardiac arrest

13. ESTIMATION OF THE RISK OF ANESTHESIA
(AMERICAN
SOCIETY OF ANESTHESIOLOGISTS SCALE)
• ASA 1: healthy patient.
• ASA 2: patient with stable, treated illness like arterial
hypertension, diabetes melitus, asthma bronchiale,
obesity
• ASA 3: patient with systemic illness decreasing
suffitiency like heart ilness, late infarct
• ASA 4: patient with serious illness influencing his state
like renal insuficiency, unstable hypertension,
circulatory insuficiency
• ASA 5: patient in life treatening illness
• ASA 6: brain death- potential organ donor

14. PRE-MEDICATION
Main reasons for premedication:
• Anxiolysis- lack of threat
• Sedation – calming down
• Amnesia – lack of memories of
perioperative period

15. • Methods of general anesthesia
OPEN
SEMIOPEN
SEMICLOSED
CLOSED

16. • METHODS OF GENERAL ANESTHESIA
OPEN- old
SEMIOPEN – used mostly in pediatric anesthesia
SEMICLOSED- most common
CLOSED- modern anesthesia

17. • Methods of general anesthesia
CIRCLE SYSTEM
*HIGH-FLOW
FRESH GAS FLOW > 3 l/min.
*LOW-FLOW
FGF ok. 1l/min.
*MINIMAL-FLOW
FGF ok. 0,5 l/min.

18. STAGES OF GENERAL ANESTHESIA
• Introduction to anesthesia (induction)
• Maintaining of anesthesia (conduction)
• Recovery from anesthesia

19. ANESTHESIA AGENTS
1.
2.
Inhalation anesthetics (volatile anesthetics)
- gases : N2O, xenon
- Fluids (vaporisers)
Intravenous anesthetics
3.
-
-
4.
-
-
5.
- Barbiturans : thiopental
- Others : propofol, etomidat
Pain killers
Opioids: fentanyl, sufentanil, alfentanil, remifentanil, morphine
Non Steroid Anti Inflamatory Drugs: ketonal, paracetamol
Relaxants
Depolarising : succinilcholine
Non depolarising : atracurium, cisatracurium, vecuronium, rocuronium
adiuvants
-benzodiazepins: midasolam, diazepam

20. VOLATILE
VS
INTRAVENOUS ANESTHESIA

21. MECHANISM OF ACTION
OF INHALED
ANESTHETICS
• Reaction depends on concentration. This depends
on alveolar (first compartment), blood and brain
(central compartment) concentration , (third
compartment- other tissue like muscles, fat-
accumulation effect):
– Minute ventilation
– Lung blood perfusion
– Solubility in tissues

22. MAC-MINIMAL ALVEOLAR
CONCENTRATION
• Concentration in which 50% of anesthetised
patients do not react on skin incision
• Corelation with solubility in fat tissue
• The lower MAC is the higher strenght of
action is

23. INHALATION AGENTS

24. DIVISION OF INHALATION
AGENTS
1. Gases:
• N2O – old, weak, used as adiuvant
• Xenon – lately introduced
2. Vapors (fluids):
• Halothan
• Enfluran
• Isofluran
• Sevofluran
• Desfluran

25. FEATURES OF IDEAL VOLATILE
ANESTHETIC
• Not disturbing smell
• Fast acting, titrable
• Low solubility in blood- fast transport to brain
• Stable when stored, not reacting with other
chemicals
• Non- flamable, non- explosive
• Low methabolism in body, fast elimination, no
accumulative effect
• No depressing effect on circulatory and respiratory
systems

26. NITROUS OXIDE, LAUGHING
GAS
• Old
• Weak
• Used as adiuvant
• Will be removed form medical use up to
2010- destroyes ozone lawyer

27. HALOTHAN
• Used for many years with good effect
• First non-flamable volatile fluid anesthetic
• MAC high
• Depression of circulatory system
• May destroy liver
• Now-a-days used only in pediatric
anesthesia

28. ISOFLURAN
• Disturbing smell
• May interact with heart contractivity
• Increases relaxation of muscles

29. SEVOFLURAN
• Not disturbing smell- may be used for VIMA
• Low solubility in blood- fast acting
• Does not disturbs airway
• May depress circulatory system
• Methabolised to Compound A- may be renal toxic
(but not confirmed in humans)
• May be used in one-day surgery
• Modern, and more and more widely used volatile
anesthetic

30. DESFLURAN
• Very disturbing smell- can not be used for
VIMA
• Is not methabolised
• Very fast acting
• May be used for one-day surgery
• Expensive, difficult to store (boiling temp.
about 20 C)
• Modern and widelly used

31. INTRAVENOUS
ANESTHESIA

32. TARGET
CONTROL
LED
INFUSION
TCI

33. DEFINING TCI
When applied to anaesthesia
• TCI is an infusion system which allows the
anaesthetist to select the target blood
concentration required for a particular
effect …
… and then to control depth of anaesthesia
by adjusting the requested target
concentration

34. WHAT IS TCI?
• Instead of setting ml/h or a dose rate (mg/kg/h),
the pump can be programmed to target a
required blood concentration.
• Effect site concentration targeting is now
included for certain pharmacokinetic models.
• The pump will automatically calculate how
much is needed as induction and maintenance to
maintain that concentration.

35. INTRAVENOUS
ANESTHETICS

36. THIOPENTAL
• Old, one of the first used intravenous
anesthetics
• Depressing effect on circulatory system
• May be used in patients with ASA 1

37. KETAMINE
• Only intravenous anesthetic which has good
analgesia effect
• Does not depress circulatory nor respiratory
function
• Used in children, and in emergency and diseaster
medicine
• Gives night mare dreams in adult patients

38. ETOMIDAT
• Has no depressing effect on circulatory
system- may be used in patients with
circulatory insufficiency
• May give musle contractions
• Depressing effect on epirenals function
• Can not be given in repeated bolus nor
continuous infusion

39. PROPOFOL
• Very good anesthetic for induction and
maintaince of anesthesia with no
accumulation effect
• Titrable
• May be used in short procedures – titrated
do not effect circulatory and respiratory
system in important manner
• Good for sedation, brain protecting effect
• May be used in TCI

40. PAIN KILLERS

41. OPIOIDS
• fentanyl, alfentanil, sufentanil, remifentanil
• May be used for induction and maintain of
anesthesia in repeated bolus or continuous
infusion technique
• Sedative effect
• In high doses may be used alone for so called
opioid anesthesia- formerly used in
cardioanesthesia- very stable circulatory effect

42. COMPICATIONS OF USE
• Respiratory depression !!!!
• Muscle rigidity in high doses
• Post-Operative Nausea and Vomitings
• Accumulation effect after prolonged
administration (except for remifentanil)

43. REMIFENTANIL – MODERN OPIOID
ANALGESIC
• T1/2 3-5 min !!
• Methabolised by non-specific tissue
esterases- methabolism is not altered by
renal or liver function
• No accumulation effect after prolonged
infusion !!

44. NSAID
• Used as adiuvants in short, not very painful
procedures
• Used for „preemptive analgesia” –
reduction of consumption of opioids by
blocking COX

45. BENZODIAZEPINES

46. BENZODIAZEPINY
• Used in anesthesia:
– Diazepam
– Midazolam
• Used as adiuvants for premedication

47. MUSCLE
RELAXANTS

48. DIVISION OF RELAXANTS
DEPENDING ON
MECHANISM OF ACTION
1.nondepolarising- combine with receptor for Ach
like antagonists- they are fake mediators – do not
cause muscle contractation but block access to
receptors for Ach
2.depolarising- they combine with receptors for Ach
and cause contractation of muscle but they stay
connected with receptor blocking access to it for
Ach. They act like agonists.

49. NONDEPOLARISING
AGENTS
-d-tubocurine – oldest deliverate of curarine
-alcuronium
-pancuronium – cheap and still used
-pipercuronium
-vercuronium
-atracurium
-cisatracurium
-mivacurium
-rocuronium

50. DIVISION OF NONDEPOLARISING
RELAXANTS DUE TO
CHEMICAL STRUCTURE:
Benzylizochinolons:
Miwakurium (Mivacron)
Cisatrakurium (Nimbex)
Atrakurium (Trakurium)
Aminosteroids:
Pankuronium (Pavulon)
Pipekuronium (Arduan)
Rapakuronium (Raplon)
Rokuronium (Esmeron)
Wekuronium (Norcuron)

51. DIVISION OF NONDEPOLARISING
RELAXANTS DUE TO TIME OF
ACTION:
• Short acting < 3 min: still searching
• Midle time <60 min: mivacurium,
atracurium, cisatracurium, rocuronium,
vecuronium
• Long acting > 60 min: pancuronium,
pipecuronium

52. ATRACURIUM
• Elimination non-enzymatic, independent of
renal and liver function, Hoffman
elimination- hydrolisis
• Releases histamine
• Acts about 30 min

53. CISATRACURIUM
• One of stereoisomers of atracurium,
• Do not release histamine
• Acts about 60 min

54. MIVACURIUM
• Releases histamine
• Acts about 15-20 min – used for short
procedures
• Methabolised by plasma esterases

55. ROCURONIUM
• Fast acting- time to 100% supresion 60 sec.
• Do not release histamine
• Acts about 60 min
• Is methabolised in liver- disfunction of liver
may alter elimination

56. REVERSE OF NEUROMUSCULAR
BLOCKADE
• Neostigmine, piridostigmine- blockers of
acetylocholinesterase
• Must be given toghether with atropine to
avoid bradycardia caused by activation of
perisympatic system

57. DEPOLARISING
AGENTS
Only one: chlorsuccinilocholine
- It is methabolised by pseudocholinesterase
- Causes many complications, has many
contraindications
- Indications:
Rapid sequence induction: full stomach, suspected difficult
intubation because it acts very fast < 30 seconds and short < 3
min

58. MONITORING DURING
GENERAL
ANESTHESIA

59. OBLIGATORY
• Clinical observation
• Circulatory system function: ECG, blood
pressure - Non-Invasive-Blood Pressure
• Respiratory function: SpO2 (pulsoxymetry),
EtCO2
• Neuromuscular function- ie accelerometry
TOF Guard

60. ADDITIONAL- ADVANCED
• Invasive Blood Pressure
• Haemodynamic monitoring ie Doppler
transesophageal probe
• EEG monitoring for deepness of anesthesia
ie BIS (Bispectral Index), AEP - Auditory
Evoced Potentials, Entropy

61. COMPLICATIONS OF GENERAL
ANESTHESIA
• Respiratory: residual relaxants/opioids
action
• Circulatory
• Neurological: residual anesthetics/opioids
action
• Post-Operative Nausea and Vomitings

62. MORTALITY CONNECTED WITH
ANESTHESIA
• 0,05 - 4/10000 GA
• 2 - 16 % of surgical patients
• 80 % is caused by human
mistake

63. MAJOR CAUSES OF
DEATHS
• Airway obstruction
• Difficult and unefficient intubation
• Insufficient ventillation

64. OTHER CAUSES OF MORTALITY AND
MORBIDITY
• Anoxia
• Haemodynamic instability
• Aspiration
• Toxity of drugs – mostly inhalation
agents
• Anaphylaxia and drug interations

65. AIRWAY MANAGEMENT AND
ARTIFICIAL VENTILLATION

66. AIRWAY MANAGEMENT
Respiratory Distress vs. Respiratory Failure
Distress Failure
-Increased work of breathing-Increased work of breathing
-Relative hypoxia/hypercapn-e-Parofound hypoxia/hypercapnea
-Compensating -Decompensating
It’s a constant reassessment process…

67. CONTRAINDICATIONS FOR FACE MASK
AND BAG VENTILLATION
• Hernia hiatus aesophagus
• gastric reflux
• injury of face or neck
• brochial-esophagaeal connection
• injury of trachea cartiladges
• full stomach patient, vomitings

69. INDICATIONS FOR
ET (ENDOTRACHEAL
INTUBATION)
• Airway obstruction
• Cardio Pulmonary Resuscitation
• Artificial ventilation
• Anesthesia
• Brain injury, facial injury, facial burn,
airway burn

71. COMPLICATIONS OF ET
Injuries:
 theeth injury, mouth injury
 laryngs rupture
 aspiration
 bleeding
oesophagus intubation
one bronchus intubation
Reactions: vomitings, coughing, apnea, laryngospasm,
bradycardia, hypertension

72. ALTERNATIVE AIRWAY
MANAGEMENT
• Laryngeal mask- for short, not major
operations ecxept for head and neck surgery
• for elective surgery- patient must be
prepared for anesthesia