Sedation

&
General Anesthesia
SMF ANESTESIOLOGI & REANIMASI,
INTENSIVE CARE
RSUD JAYAPURA
Anesthesiology :

Anesthesiology is a clinical discipline

based on basic sciences eg
anatomy, physiology, pharmacology
etc
General Anesthesia

Controlled state of unconsciousness

with partial or complete loss of
protective reflexes / airway.
Does not respond to stimulation or
verbal commands
without sensibility
 CNS depression
Respiratory / Cardiovascular depression

REQUIRES SPEACIAL
Monitoring
Equipment
Training
Patient selection and preparation
Has been helped with

Better drugs

i.e. rapid onset short duration of action

rapid / better recovery
Patient evaluation
Never treat a stranger
1 - History
Complaint / problem
Medical problems including family members
Allergies
Drug / substance use
Previous anesthetics
2 - Review organs / systems
Respiratory
Cardiovascular
Neurologic may require premed special Rx
Hepatic
Renal
GIT
Endocrine
Hematologic
Preganacy
3 Physical examination

Vital signs
Airway
Heart
Lungs
Neurologic
4 Lab testing / specialist consultations

e.g.
hypertension
coronary artery disease
diabetes
pregnancy test only for women who are not sure
5 - ASA physical status
Correlates with mortality and determines what
monitoring will be required
I Normal / healthy
II- Mild systemic disease no problem
functioning
III- Moderate/severe systemic disease effects
functioning
IV- Severe systemic disease constant threat
to life
V- Will die in <24 hrs without surgery
 Preventable complications
Equipment malfunction (any component)
Human Error
Drug (wrong drug / dose)
Airway management
Unrecognized circuit disconnection
Fluid management
Related Factors
Preparation
Training
Equipment / facilities
Communication
Fatigue
 Fasting
Reduces the risk of pulmonary aspiration.

>6 mo no solid food <6 hrs, clear fluids <2 hrs

Patients continue taking essential medication

with small amount of fluids.
 Patients at risk of pulmonary
aspiration of gastric contents
Hiatal hernia, obesity, diabetes (neuropathy
poor gastric emptying with gastric stasis and
dilatation, peptic or duodenal ulcer, pain /
stress, narcotics, depressed CNS function,
(pregnancy).
Consider: H2-receptor antagonists (ranitidine /
cimetidine), metoclopromide, (0.625mg iv)
droperidol, serotonin (5-HT3) antagonists
 Risk factors
Coronary and other heart disease
COPD (chronic obstructive pulmonary
disease) / asthma. If require home oxygen
therapy or been hospitalization in past 6
months are assumed to be a greater risk
Obstructive sleep apnea
Insulin-dependent Diabetes Mellitus (may
have coronary artery disease,
cerebrovascular disease, renal dysfunction,
peripheral neuropathy, autonomic neuropathy
 Chronic renal failure
Risk factor for perioperative myocardial
infarction
Often associated with arteriosclerosis,
uncontrolled hypertension, and
diabetes.
 Morbidly obese
May have coronary artery disease,
obstructive sleep apnea,
gastroesophageal reflux and diabetes
mellitus.
Difficult layngoscopy/intubation &
difficult intravenous access.
Monitoring
 Precordial / pretracheal / oesophageal
stethoscope
NIBP monitor
Pulse oximeter (SaO2)
Capnography (end-tidal)
Thermometer
Gasses

Record chart
 Premedication
For: Anxiety / Fear / Pain / Oral
secretions

Benzodiazepines
Narcotics
Antisialagogues Atropine /
Glycopyrrolate
 GA Techniques
With or without endotracheal intubation
(mask / nasal hood / nasal prongs)
Mask / IM induction then IV cannulation
General anaesthesia is like -
There is a take off, cruising, landing
i.e. induction, maintenance, extubation
(recovery)

Like flying the take off and landing are

the most dangerous.
Induction is usually i.v. but can be by
other routes.
Maintenance is usually with inhalational
agents but can be continuous infusion
(TIVA)
 Barbiturates
Usually for induction.
Very lipid soluable cross blood brain
barrier fast.
Dose-dependent CNS depression.
Antianalgesic.
No reversal agents.
Benzodiazepines
Provide: anxiolysis, hypnosis,
anterograde amnesia, central muscle
relaxant, anticonvusant.
Vallium and the newer / better
midazolam.
 Mainly used as sedatives i.e.
premedication.
Midazolam, Diazepam, Temazepam
(oral)
Reversal agent for emergencies
flumazenil. Expensive.
 Acylcyclohexamines
i.e. Ketamine
Produces state of dissociation.
Anxiolytic, hypnotic, amnesic, potent
analgesic.
Minimal respiratory and protective reflex
depression. Mild CV stimulation.
Psychic reactions do not use as sole
agent.
Simulates salivation antisialagogue.
Multiple administration routes
 Alkylphenols
Propofol
Rapid onset with short duration -
nonbarbiturate
Antiemetic
Clear recovery
Dose-dependent depression of CNS,
CVS, Resp
 Opioids
Opioids vs Narcotics ??
Used for analgesia eg during intubation
haemodynamics.
Mild cardiac depression but dose-dependent CNS and
Resp depression.
Nausea
Pethidine tachycardia, hyperactive reflexes, muscle
tremors.
Morphine profound hypotension histamine
release.
Sufentanyl extremely short acting, hydrolyzed
plasma esterase only be given as infusion
Reversal agent / antagonist naloxone.
 Vapors / Volatile agents
Potent chlorofluorocarbons. Delivered
from precision vaporizers into patients
inhaled gasses (O2 etc)
 Halothane
Nonflammable
haemodynamics. Inhibits sympathetic
driven baroreflex response (hypovolemia)
Ventricular arrhythmias during hypercarbia
/ exogenous adrenaline > 1 g/kg
Rare hepatic necrosis (fulminant hepatic
failure) Probably immunological response
Risk of malignant hyperthermia esp with
succinylcholine. Dantrolene.
Enflurane
haemodynamics like halothane.
resp
Sensitizes myocardium to exogenous
adrenaline > 2 g/kg
Pungent odour
MAC 2%
Isoflurane
Exogenous adrenaline > 3 g/kg
MAC 1%
Less depression.
Less sensitization to adrenaline.
Potentiates muscle relaxants
Little metabolism
Bronchoirritating, laryngospasm
Desflurane
Low gas solubility rapid induction &
recovery.
Less potent MAC 6%
No metabolism
Pungent odour
Rough induction
Sevoflurane
Low gas solubility AND potent MAC 2%
No odour good for gaseous induction
Rapid recover useful for ambulatory
anaesthesia.
Doesnt sensitize hear to exogenous
adrenaline.
Mild cardiorespiratory depression.
2% is metabolized releasing free
fluoride ions long cases renal
dysfunction
 Muscle relaxants
Succinylcholine depolarizing muscle
relaxant with rapid onset and short
acting. Metabolized in plasma.
Non depolarizing agents eg Action
15mins to >2hrs. Pancuronium cheap
and established.
 Airway evaluation

Potential difficulties:
Prognathism, micrognathia, short neck,
limited mouth opening (multiple
reasons)

Oral vs Nasotracheal intubation ??

Mallampati score Neck mobility
Sniffing position

Cormack grade
 Can not intubate / can not ventilate =
Critically dangerous situation i.e death /
brain damage

If anticipate difficult intubation must take

appropriate action e.g. awake intubation,
other types of airways,
Cricothyrectomy,
Tracheostomy
Equipment and emergency drugs.
Good lighting and battery back up light
source.
Good suction and portable backup.
Reserve oxygen.
Able to administer oxygen under
intermittent positive pressure ventilation
(bag-mask device).
Variety of airways.
Laryngoscope with backup batteries and
bulbs.
 Magill type forceps.
IV infusion equipment: tourniquets,
catheters, needles, syringes, IV tubing
(sets), IV fluids, labels,
surgical wipes/tapes/ dressings.
Surgical airway equipment
(cricothyroidectomy).
Monitors e.g. pulse oximeter, cardiac
monitor ASA3
Uncluttered floor space and emergency
exit.
Team trained in advanced cardiac life
support (ACLS).
Emergency drugs
Adrenaline
Nitroglycerin
Anticonvulsants
Vagolytics
Vasopressors
Antihypertensives
Bronchodilators
Antiarrhythmics
Glucocorticosteroids
Antihistamines
Dextrose
TERIMA KASIH
 weight in kilograms
BMI =
(kg/m) height in meters

<18.5 Underweight
18.5 -24.9 Normal
25 - 29.9 Overweight
>30 Obese
> Morbidly obese