what do you see in the picture? <ul><li>An anesthesia machine </li></ul><ul><li>A beautiful and smart anesthetist </li></ul>
Administration of General Anesthesia Xiao Ying  ( 肖颖 ) The First Affiliated Hospital of  Sun Yat-sen University Mar 2010
Overview <ul><li>What is general anesthesia? </li></ul><ul><li>Preoperative preparation </li></ul><ul><li>Induction: going...
What is general anesthesia <ul><li>Primary goals </li></ul><ul><li>Safety is top priority </li></ul><ul><li>Amnesia: no me...
What is general anesthesia <ul><li>Secondary goals </li></ul><ul><li>Medical condition </li></ul><ul><li>Surgical procedur...
Examples for secondary goals  <ul><li>Patients with CAD: Oxygen supply-demand balance  </li></ul><ul><li>Neurosugery: ICP ...
Preoperative preparation <ul><li>Preoperative evaluations </li></ul><ul><li>Airway examination </li></ul><ul><li>Interim c...
Preoperative preparation <ul><li>Intravascular volume </li></ul><ul><li>Dehydration: adequately hydrate the pt before indu...
Which kind of pt is at increased risk of aspiration of gastric content? <ul><li>Recent meal </li></ul><ul><li>Trauma  </li...
Monitoring Standard monitoring for GA ECG NBP Pulse oximetry Capnography Oxygen analyzer
 
Induction <ul><li>Let the pt go off to sleep </li></ul>Preoxygenation 8L~10L/min IV or Inhalational induction Airway manag...
Induction techniques <ul><li>Intravenous: the most common method </li></ul><ul><li>Inhalation: for special pt (pt with dif...
Airway management <ul><li>ASA Closed Claims Study( 美国麻醉学会已结案的诉讼) </li></ul><ul><li>35 % of claims are RESPIRATORY events <...
Airway management <ul><li>Airway patency is critically important </li></ul>
Oral airway
 
Nasophryngeal airway
Laryngeal mask airway
Intubation
Maintenance Increasing   depth of anesthesia stage Ⅰ Amnesia Loss of consciousness Stage   Ⅱ Delirium Injurious responses ...
Maintenance  <ul><li>Maintain homeotasis </li></ul><ul><li>Vital signs </li></ul><ul><li>Acid-base balance </li></ul><ul><...
Maintenance  <ul><li>Lack of awareness and no memory of the event </li></ul><ul><li>Incidence of awareness </li></ul><ul><...
How to avoid awareness   <ul><li>To recognize the high risk pt </li></ul><ul><li>Monitor the depth of anesthesia </li></ul...
Depth of  anesthesia   <ul><li>Intensity of surgical stimulation </li></ul><ul><li>Response suggesting inadequate anesthet...
Maintenance methods   <ul><li>Volatile (Isoflurane, Desflurane or sevoflurane combined with nitrous oxide) </li></ul><ul><...
Ventilation
Ventilation <ul><li>1. Spontaneous or assisted ventilation </li></ul><ul><li>2. Controlled ventilation </li></ul><ul><li>T...
Ventilation <ul><li>Peak inspiratory pressure </li></ul><ul><li>High airway pressure >25~30cmH 2 O </li></ul><ul><li>Breat...
IV Fluids <ul><li>Intraoperative IV fluids requirements </li></ul><ul><li>1. Maintenance fluid requirements </li></ul><ul>...
IV Fluids <ul><li>1. Crystalloid sollutions: maintenance fluid requirement, evaporative losses, and third space losses </l...
Intravascular volume assessment <ul><li>Trends of heart rate, blood pressure, and urine output </li></ul><ul><li>Central v...
Emergence from GA <ul><li>Goals:   </li></ul><ul><li>awake  </li></ul><ul><li>Responsive  </li></ul><ul><li>Full muscle st...
Extubation <ul><li>Awake extubation </li></ul><ul><li>Indications </li></ul><ul><li>Risk of aspiration </li></ul><ul><li>D...
Extubation <ul><li>Awake extubation </li></ul><ul><li>Criteria </li></ul><ul><li>Awake </li></ul><ul><li>Hemodynamically s...
Extubation <ul><li>Awake extubation </li></ul><ul><li>Special technique: removal of ETT over a flexible stylette </li></ul...
Extubation <ul><li>Deep extubation </li></ul><ul><li>Indications </li></ul><ul><li>Severely asthmatic patients </li></ul><...
Extubation <ul><li>Deep extubation </li></ul><ul><li>Criteria </li></ul><ul><li>Sufficient anesthetic depth to avoid respo...
Agitation <ul><li>Causes </li></ul><ul><li>Pain </li></ul><ul><li>Hypoxia </li></ul><ul><li>Hypercarbia </li></ul><ul><li>...
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Administration of general anesthesia

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Administration of general anesthesia

  1. 1. what do you see in the picture? <ul><li>An anesthesia machine </li></ul><ul><li>A beautiful and smart anesthetist </li></ul>
  2. 2. Administration of General Anesthesia Xiao Ying ( 肖颖 ) The First Affiliated Hospital of Sun Yat-sen University Mar 2010
  3. 3. Overview <ul><li>What is general anesthesia? </li></ul><ul><li>Preoperative preparation </li></ul><ul><li>Induction: going off to sleep </li></ul><ul><li>Maintenance: keeping pt asleep </li></ul><ul><li>Emergence: waking up </li></ul><ul><li>Transport </li></ul>
  4. 4. What is general anesthesia <ul><li>Primary goals </li></ul><ul><li>Safety is top priority </li></ul><ul><li>Amnesia: no memory of the event </li></ul><ul><li>Hypnosis: unconcious </li></ul><ul><li>Analgesia: free of pain </li></ul><ul><li>Block certain autonomic reflexes </li></ul><ul><li>Optimal surgical conditions: immobolity </li></ul>
  5. 5. What is general anesthesia <ul><li>Secondary goals </li></ul><ul><li>Medical condition </li></ul><ul><li>Surgical procedures </li></ul><ul><li>Surgical settings </li></ul>
  6. 6. Examples for secondary goals <ul><li>Patients with CAD: Oxygen supply-demand balance </li></ul><ul><li>Neurosugery: ICP control, brain relaxation and CPP maintenance </li></ul><ul><li>Obstetrics: anesthetics and fetal depression, difficult airway </li></ul><ul><li>Day surgery vs Inpatient: which kind of analgesic you should choose to minimize postoperative pain and decrease PONV? </li></ul>
  7. 7. Preoperative preparation <ul><li>Preoperative evaluations </li></ul><ul><li>Airway examination </li></ul><ul><li>Interim changes in pt’s condition </li></ul><ul><li>Medications </li></ul><ul><li>Laboratory data </li></ul><ul><li>Consultant notes </li></ul><ul><li>Last oral intake </li></ul>
  8. 8. Preoperative preparation <ul><li>Intravascular volume </li></ul><ul><li>Dehydration: adequately hydrate the pt before induction </li></ul><ul><li>Intravenous access </li></ul><ul><li>Preoperative medications </li></ul><ul><li>Anxiety </li></ul><ul><li>Benzodiazepine: Midazolam </li></ul><ul><li>Opioid: Morphine or Fentanyl </li></ul><ul><li>Neutralize gastric acid and decrease gastric volume </li></ul>
  9. 9. Which kind of pt is at increased risk of aspiration of gastric content? <ul><li>Recent meal </li></ul><ul><li>Trauma </li></ul><ul><li>Bowel obstruction </li></ul><ul><li>Pregnancy </li></ul><ul><li>History of gastric surgery </li></ul><ul><li>Increased intra-abdominal pressure </li></ul><ul><li>History of active reflux </li></ul>
  10. 10. Monitoring Standard monitoring for GA ECG NBP Pulse oximetry Capnography Oxygen analyzer
  11. 12. Induction <ul><li>Let the pt go off to sleep </li></ul>Preoxygenation 8L~10L/min IV or Inhalational induction Airway management
  12. 13. Induction techniques <ul><li>Intravenous: the most common method </li></ul><ul><li>Inhalation: for special pt (pt with difficult airway, pediatric pt) </li></ul><ul><li>Intramuscular :rarely used,only used in uncooperative pts and young children </li></ul>
  13. 14. Airway management <ul><li>ASA Closed Claims Study( 美国麻醉学会已结案的诉讼) </li></ul><ul><li>35 % of claims are RESPIRATORY events </li></ul><ul><li>90 % resulted in brain damage or death </li></ul><ul><li>90% resulted from Difficulty in INTUBATION or EXTUBATION </li></ul>
  14. 15. Airway management <ul><li>Airway patency is critically important </li></ul>
  15. 16. Oral airway
  16. 18. Nasophryngeal airway
  17. 19. Laryngeal mask airway
  18. 20. Intubation
  19. 21. Maintenance Increasing depth of anesthesia stage Ⅰ Amnesia Loss of consciousness Stage Ⅱ Delirium Injurious responses to noxious stimuli Stage Ⅲ Surgical anesthesia Painful stimulation does not elicit somatic reflexes or deleterious autonomic responses Stage Ⅳ Overdosage Circulatory failure
  20. 22. Maintenance <ul><li>Maintain homeotasis </li></ul><ul><li>Vital signs </li></ul><ul><li>Acid-base balance </li></ul><ul><li>Temperature </li></ul><ul><li>Coagulation </li></ul><ul><li>Volume status </li></ul>
  21. 23. Maintenance <ul><li>Lack of awareness and no memory of the event </li></ul><ul><li>Incidence of awareness </li></ul><ul><li>High risk surgical population </li></ul><ul><li>High risk pt </li></ul><ul><li>High risk anesthesia method </li></ul>
  22. 24. How to avoid awareness <ul><li>To recognize the high risk pt </li></ul><ul><li>Monitor the depth of anesthesia </li></ul><ul><li>Somatic and autonomic response are nonspecific and unreliable </li></ul><ul><li>Bis monitor for high risk pt </li></ul>
  23. 25. Depth of anesthesia <ul><li>Intensity of surgical stimulation </li></ul><ul><li>Response suggesting inadequate anesthetic depth: </li></ul><ul><li>Somatic: movement, coughing, changes of respiratory pattern </li></ul><ul><li>Autonomic: tachycardia, hypertension, mydriasis, sweating, tearing </li></ul><ul><li>Unreliable and nonspecific </li></ul><ul><li>Sympathetic activation may be caused by other reasons </li></ul>
  24. 26. Maintenance methods <ul><li>Volatile (Isoflurane, Desflurane or sevoflurane combined with nitrous oxide) </li></ul><ul><li>Nitrous oxide-opioid relaxant technique </li></ul><ul><li>IV anesthesia </li></ul><ul><li>Combinations </li></ul><ul><li>General anesthesia combined with regional anesthesia </li></ul>
  25. 27. Ventilation
  26. 28. Ventilation <ul><li>1. Spontaneous or assisted ventilation </li></ul><ul><li>2. Controlled ventilation </li></ul><ul><li>Tidal volume: 10-12ml/kg </li></ul><ul><li>Respiratory rate: 8-10 breaths/min </li></ul><ul><li>3. Assessment of ventilation </li></ul><ul><li>Capnography </li></ul><ul><li>Pulse oximeter </li></ul><ul><li>Airway pressure </li></ul><ul><li>Reservoir breathing bag </li></ul><ul><li>Ventilator bellow </li></ul>
  27. 29. Ventilation <ul><li>Peak inspiratory pressure </li></ul><ul><li>High airway pressure >25~30cmH 2 O </li></ul><ul><li>Breathing circuit problem </li></ul><ul><li>ETT obstruction or movement </li></ul><ul><li>Altered lung compliance </li></ul><ul><li>Change in muscle relaxation </li></ul><ul><li>Surgical compression </li></ul>
  28. 30. IV Fluids <ul><li>Intraoperative IV fluids requirements </li></ul><ul><li>1. Maintenance fluid requirements </li></ul><ul><li>2. Third space losses and insensible losses </li></ul><ul><li>3. Blood losses </li></ul>
  29. 31. IV Fluids <ul><li>1. Crystalloid sollutions: maintenance fluid requirement, evaporative losses, and third space losses </li></ul><ul><li>2. Colloid sollutions: replace blood loss or restore intravascular volume </li></ul><ul><li>3. Blood transfusion </li></ul>
  30. 32. Intravascular volume assessment <ul><li>Trends of heart rate, blood pressure, and urine output </li></ul><ul><li>Central venous pressure, pulmonary artery occlusion pressure, right and left end-diastolic volumes(using TEE) and cardiac output </li></ul><ul><li>Hemotocrit, platelet count, fibrinogen concentration, prothrombin time, thromboplastin time </li></ul>
  31. 33. Emergence from GA <ul><li>Goals: </li></ul><ul><li>awake </li></ul><ul><li>Responsive </li></ul><ul><li>Full muscle strength </li></ul><ul><li>Adequate pain control </li></ul>
  32. 34. Extubation <ul><li>Awake extubation </li></ul><ul><li>Indications </li></ul><ul><li>Risk of aspiration </li></ul><ul><li>Difficult airways </li></ul><ul><li>Tracheal or maxillofacial surgery </li></ul>
  33. 35. Extubation <ul><li>Awake extubation </li></ul><ul><li>Criteria </li></ul><ul><li>Awake </li></ul><ul><li>Hemodynamically stable </li></ul><ul><li>Full muscle strength </li></ul><ul><li>Able to follow simple verbal commands </li></ul><ul><li>Breathing spontaneously with adequate ventilation </li></ul>
  34. 36. Extubation <ul><li>Awake extubation </li></ul><ul><li>Special technique: removal of ETT over a flexible stylette </li></ul><ul><li>Indication: patency of the airway is uncertain or reintubation may be difficult </li></ul>
  35. 37. Extubation <ul><li>Deep extubation </li></ul><ul><li>Indications </li></ul><ul><li>Severely asthmatic patients </li></ul><ul><li>Middle-ear surgery </li></ul><ul><li>Open-eye surgery </li></ul><ul><li>Inguinal herniorrhaphy </li></ul>
  36. 38. Extubation <ul><li>Deep extubation </li></ul><ul><li>Criteria </li></ul><ul><li>Sufficient anesthetic depth to avoid response to airway stimulation </li></ul><ul><li>Spontaneous breathing with adequate ventilation </li></ul>
  37. 39. Agitation <ul><li>Causes </li></ul><ul><li>Pain </li></ul><ul><li>Hypoxia </li></ul><ul><li>Hypercarbia </li></ul><ul><li>Airway obstruction </li></ul><ul><li>Full bladder </li></ul>
  38. 40. Transport
  39. 41. Questions

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