General Anesthesia

How to Provide General Anesthesia

With Brian Warriner, MD

SARAH JOY RONQUILLO, [email protected]

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 General Anesthesia

1 Preoperative Assessment of the Patient

2 Evaluation of the Airway

3 Induction of General Anesthesia

4 Securing the Airway

5 Maintenance of General Anesthesia

Lecture Overview
6 Reversal of Muscle Relaxation (If Necessary)

7 Recovery from General Anesthesia

8 Management of Pain

9 Recovery Room Care

SARAH JOY RONQUILLO, [email protected]

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 Preoperative Assessment of the Patient
Immediately before surgery or days to weeks before surgery

Patients undergoing any form of anesthesia require an

assessment before surgery.

• This can be immediately before surgery if the patient is

healthy and the surgical procedure is low risk.

• Surgery will be canceled at this point if the

Why an
anesthesiologist is dissatisfied that the patient is safely
Assessment?
prepared for surgery.

• In many hospitals, patients are seen days to weeks

before surgery so that the anesthesiologist can ensure
that the patient is fully prepared for surgery.

SARAH JOY RONQUILLO, [email protected]

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 Preoperative Assessment of the Patient
Immediately before surgery or days to weeks before surgery

• History of previous anesthetics

• Family history of anesthetic problems: malignant

hyperthermia, pseudocholinesterase deficiency?
History • Examination of airway, lungs, and heart
and Physical
• General history and physical for other potential medical
conditions (diabetes, heart disease, asthma, rheumatoid
arthritis, etc.)

SARAH JOY RONQUILLO, [email protected]

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 Airway Assessment
Anesthesiologists must be able to maintain an open airway during surgery

Guedel Airway

• Allows the tongue to be brought forward

Evaluation of
the Airway

• Is often useful
for intubation

SARAH JOY RONQUILLO, [email protected]

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 Airway Assessment
Anesthesiologists must be able to maintain an open airway during surgery

Laryngeal Mask Airway (LMA)

• Very useful for maintaining the airway during surgery,

particularly in patients who are maintaining spontaneous
ventilation

• This device is also useful for maintaining oxygenation in

situation
Evaluation of
the Airway

SARAH JOY RONQUILLO, [email protected]

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 Airway Assessment
Anesthesiologists must be able to maintain an open airway during surgery

Additional Helpers

• Stylet

Evaluation of
the Airway
• Bougie

SARAH JOY RONQUILLO, [email protected]

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 Airway Assessment
Anesthesiologists must be able to maintain an open airway during surgery

Devices for Visualizing the Airway and Intubating

the Patient

Evaluation of
the Airway
• Laryngoscope

• Glidescope

• Storz videoscope

• Fiberoptic bronchoscope

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 Airway Assessment
Mallampati score

1. The patient should sit at 30 to 45 degrees

2. Open the mouth as wide as possible

3. Stick out the tongue (do not say )

MP I: teeth, soft and hard palate, and uvula are visible
MP II: soft palate and upper uvula are visible
MP III: soft palate is visible
MP IV: only the tongue is visible

Pros: very easy to perform

Cons: not very specific for difficult airway

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 Induction of Anesthesia

Blood pressure, ECG, Pulse Oximetry, End-tidal Carbon

Dioxide Level and Temperature (US)

• Intravenous in place

• Fentanyl 1 3 micrograms/kg
Monitors in Place • Propofol 2.0 2.5 mg/kg

• Rocuronium 0.6 mg/kg

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 Additional Monitor when a Neuromuscular Blocker Is Used

A neuromuscular
stimulator should be
used to monitor the
depth of the muscle
block

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 Securing the Airway
Bag and mask ventilation

Notice:

• The mask is tightly applied

to

• The chin is elevated by

the left hand

• The head is positioned so

there is extension at the
upper cervical spine (C1 C2)
and flexion at the lower
cervical spine (C6 C7)

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 Securing the Airway
The laryngeal mask airway

• The cuff does not go through the

cords but remains above them

• The tongue and other airway soft

tissues are pushed aside to allow
the airway to remain open

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 Inserting the LMA
Notice that the cuff does not pass through the cords

LMA Insertion

• The
lungs and return to the anesthetic machine
without soiling the airway with secretions
from the upper airway

• This is a very useful device when the

anesthesiologist chooses not to intubate
the patient

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 Laryngoscoped
The Miller (left) and Mackintosh (right) blades

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 Securing the Airway
Endotracheal tube

Notice:

• The balloon or cuff at the end of the

tube is inflated with air once the tube is in
the trachea

• The cuff prevents lung gases and fluids

from the mouth from leaking around the
tube

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 Intubating the Patient
Positioning the patient

• The head is positioned so that there is

flexion at the lower cervical spine (C6 C7)
and extension at the upper cervical spine
(C1 C2).

• Note that the laryngoscope blade is placed

on the right side of the tongue, the tongue is
swept to the left, and the laryngoscope
blade is elevated to show the vocal cords.

• The wrist must remain rigid during the

laryngoscopy.

• Flexing the wrist makes the view worse and

increases the likelihood of dental trauma.

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 Intubating the Patient
Aligning the axes

a. The neck is too flexed b. The axis from the brow c. The neck is too
to the chest wall should extended
be a straight line for
ideal intubating
conditions

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 Proper Position for the Laryngoscope
Position for Macintosh blade and Miller blade

a. The Macintosh blade (curved) should be

positioned anterior to the epiglottis in the
valleculae and should not contact the
epiglottis while lifting

b. The Miller blade (straight) should be

posterior to the epiglottis and should
contact the epiglottis while lifting

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 Intubation
View of the vocal cords with laryngoscope

Pass the endotracheal

tube between the
vocal cords.

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 Intubation
Cormack-Lehane airway classes

Class I. Complete view of Class II. Anterior half of

cords, arytenoids, cords increasing degree of
anterior commissure difficulty but is manageable
likely to be easy

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 Intubation
Cormack-Lehane airway classes

Class III. Epiglottis and Class IV. Tip of epiglottis

part of glottis increasing no passageway likely to
degree of difficulty may be very difficult
not be able to intubate

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 Failed Intubation Intubating through an LMA
Through a standard LMA or an intubating LMA

A 6.0-mm endotracheal tube may be placed

with difficulty through a standard LMA
should use a fiberoptic bronchoscope to
check tube position

An 8.0-mm endotracheal tube may be placed

through an intubating LMA (tube is silastic and
comes with the LMA) use a bronchoscope
to check tube position

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 Nasal Intubation
Magill forceps to direct the tube anteriorly

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 Intubation with Fiberoptic Bronchoscope
Orally Nasally

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 Fiberoptic Bronchoscope
View cords with bronchoscope

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 Visualize the Tube between the Cords
Tube through vocal cords

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 Continuing the Anesthetic

leak.

moving?

CO the end-tidal carbon dioxide monitor.

vapor in the tube.

lungs.

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 Continuing the Anesthetic
Each vaporizer is drug-specific
Vaporizers for

a. Isoflurane b. Desflurane c. Sevoflurane

calibrated to atmospheric pressure, temperature, flow each recalibrated annually

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 Vapors
Isoflurane, Desflurane, and Sevoflurane
1. Isoflurane 2. Desflurane 3. Sevoflurance
Set inspired level to Set inspired level to 5 7% and adjust Set inspired to 1 3% and adjust to
1 2% initially and adjust to hemodynamics hemodynamics
to hemodynamics
Enhances muscle relaxation Enhances muscle relaxation Enhances muscle relaxation
Too pungent for inhalational Too pungent for inhalational induction Excellent for inhalational induction
induction because smell is mild
Tachycardia common Tachycardia and hypertension occur if Little change in heart rate
concentration raised quickly

No myocardial depression No myocardial depression No myocardial depression

Relatively slow onset Fastest onset and recovery of any Intermediate in speed
and recovery vapor of onset and recovery
Requires heated vaporizer Has been very popular in pediatric
anesthesia due
to ease of inhalational induction

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 Recovery
Reverse muscle relaxation and reduce vapors

1. Remember to give narcotic analgesics during surgery

so that the patient is comfortable on awakening.

2. Monitor muscle relaxation through surgery and reverse

with acetylcholinesterase inhibitor (neostigmine 0.5
mg/kg) plus antimuscarinic (glycopyrrolate 0.4 mg).

3. Reduce or turn off the vapor continue to ventilate

until the patient begins to make ventilatory efforts let
the patient take control of ventilation and continue to
recover.

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 Recovery
Reverse muscle relaxation and reduce vapors

4. Extubate when the patient is awake and responding to

your voice. Do not extubate too soon, or the patient may
become apneic and require manual ventilation,
or laryngospasm may occur, making ventilation difficult.

5. Place an oxygen mask on the patient, move the patient

to the stretcher, and transport to the postanesthesia
care unit (PACU) maintain verbal contact with the
patient during transfer.

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 PACU
Transfer care to PACU Nurse

1. Communicate information
surgical procedure, other medical problems, any
anesthetic concerns, allergies, and expected recovery
to the PACU nurse.

2. Provide orders for pain management and management

of nausea and vomiting.

3. Provide orders for control of comorbidities: allowable

blood pressure ranges, allowable heart rates, where you
will be once you leave the patient, etc.

4. If your communication is clear, the nurse should be able

to anticipate potential problems and notify you if any
occur.

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 Dieses Dokument gehört: SARAH JOY RONQUILLO

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