GENERAL ANAESTHESIA

CONTENT
• Introduction
• History
• Levels of sedation
• Goals of sedation
• Sequence of depression of CNS
• Mechanism of action of GA
• Pre- anesthetic evaluation
• Pre-operative preparation
 CONTENT
• Anaesthetic Equipments
• Pharmacology of anaesthetics
• Muscle relaxants
• Stages of anaesthesia
• Post operative care
• Complications of GA.
• Conclusion
 HISTOR
Y
• Alcohol is the oldest known sedative. It was used in the ancient
Mesopotamia thousands of years ago.

• 3400 B.c-The ‘Euphoric’ effect of Opium was discovered

by
Summerians.

• Joseph Priestly(1733-1804)- discoverd various gases like-

nitrous
oxide, ammonia,oxygen.

T. Y. Euliano,J. S. Gravenstein, Essential Anesthesia -From Science to Practice:United States of America by Cambridge
University Press, New York;2004: Introduction A very short history of anesthesia;p.1-4
 HISTOR
• 1801-Humphry Davy Y
- Anesthetic properties of nitrous oxide.
-Coined the term ‘laughing gas’.

• 1804- Friedrich Serturner- isolated morphine from opium.

• Dec 10,1844- Sir Horace Well attended lecture on ‘Chemical

Phenomenon’ by Gardner.(nitrous oxide)

T. Y. Euliano,J. S. Gravenstein, Essential Anesthesia -From Science to Practice:United States of America by Cambridge
University Press, New York;2004: Introduction A very short history of anesthesia;p.1-4
 HISTOR
Y
• Dec 11,1844, Nitrous oxide was
administered to Dr. Horace
Well, rendering him unconcious
& able to have wisdom tooth
extracted without awareness of
pain.

T. Y. Euliano,J. S. Gravenstein, Essential Anesthesia -From Science to Practice:United States of America by Cambridge
University Press, New York;2004: Introduction A very short history of anesthesia;p.1-4
 HISTOR
• 16th
Yoct, 1846, ether
was
administered by Sir
Morton William the
mandibular
for tumor. removal
of

• Experiment was published in

Boston daily journal. And led to
the discovery of Surgical
anesthesia.
 HISTOR
• Y agent.
1853- Sir John Snow- Chloroform as anesthetic

• 1913- Sir Chavalier Jack- 1st to use direct laryngoscopy for tracheal
intubation.

• 1934- Sir Ernest Volwiler. Synthesized 1st i.v anesthetic

agent-
Thiopental.

• 1956- Sir Ivan Whiteside Magill- technique for

Nasotracheal intubation.

• 1967- Sir Peter Murphy, discovered fiberoptic endoscope.

T. Y. Euliano,J. S. Gravenstein, Essential Anesthesia -From Science to Practice:United States of America by Cambridge
University Press, New York;2004: Introduction A very short history of anesthesia;p.1-4
 LEVELS OF SEDATION

MINIMAL

SEDATIO
N GENERAL
ANESTHESIA

MODERATE
SEDATION

DEEP
SEDATIO
N

Anesthesia in outpatient facilities, Parameters of Care:Clinical Practice Guidelines for Oral and Maxillofacial Surgery; J Oral
Maxillofac Surg 70:e31-e49, 2012, Suppl 3
 LEVELS OF SEDATION
• Minimal Sedation
(Anxiolysis)
A minimally depressed level of
consciousness, produced by a
pharmacologic method that retains the
patients ability to independently and
continuously maintain an airway and
respond normally to tactile stimulation
and verbal command. Ventilatory and
cardiovascular fuctions are unaffected.

Anesthesia in outpatient facilities, Parameters of Care:Clinical Practice Guidelines for Oral and Maxillofacial Surgery; J Oral
Maxillofac Surg 70:e31-e49, 2012, Suppl 3
 LEVELS OF SEDATION
• Moderate Sedation
(conscious sedation)
A drug-induced depression
of consciousness during
which
respond purposefully patients to
commands,either alone or accompanied
by light tactile stimulation.No
interventions are required toverbal
maintain a
patent airway, and spontaneous
ventilation is adequate.Cardiovascular
fuction is usually maintained.

Anesthesia in outpatient facilities, Parameters of Care:Clinical Practice Guidelines for Oral and Maxillofacial Surgery; J Oral
Maxillofac Surg 70:e31-e49, 2012, Suppl 3
 LEVELS OF SEDATION
• Deep Sedation

A drug-induced depression of consciousness

during which patients cannot be easily
aroused, but respond purposefully following
repeated or painful stimulations.the patient’s
ability to independentely maintain ventilatory
function may be impaired, and the patient may
require assistance in maintaining a
airway. function
Cardiovascular
maintained during deep sedation. patent is

usually
Anesthesia in outpatient facilities, Parameters of Care:Clinical Practice Guidelines for Oral and Maxillofacial Surgery; J Oral
Maxillofac Surg 70:e31-e49, 2012, Suppl 3
 LEVELS OF SEDATION
• General Anesthesia

A drug-induced loss of consciousness-

during which patient is not arousable,
even by painful stimulation. The ability to
maintain ventilatory function is impaired.
Patients often require assistance in
maintaining a patent airway, and positive
pressure ventilation may be required
because of a depressed spontaneous
ventilation or drug-induced depression of
neuromuscular function. Cardiovascular
function may be impaired.

Anesthesia in outpatient facilities, Parameters of Care:Clinical Practice Guidelines for Oral and Maxillofacial Surgery; J Oral
Maxillofac Surg 70:e31-e49, 2012, Suppl 3
 LEVELS OF SEDATION
Minimal Moderate Deep General
Sedation Sedation/ Sedation/ Anesthesia
(anxiolysis)
Analgesia Analgesia
Responsiveness Normal Purposeful Purposeful No response,
response to response to response to even to pain
speech speech or repeated
touch or painful
stimulation

Airway Unaffected Remains open May need help Often needs

to maintain help to
airway maintain
airway

Ventilation Unaffected Adequate May not be Often require

adequate ventilatory
support

Cardiovascular Unaffected Usually Usually May be

Function maintained maintained impaired
 GOALS OF SEDATION
• Provide an optimal environment for completion of
surgical procedure.
• Minimize patient anxiety and optimize patient comfort.

• Control patient’s behaviour and movement and optimize patient

cooperation.
• Optimize analgesia and minimize pain.

• Maximize the potential for amnesia.

• Optimize patient safety and maintain hemodynamic stability.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 SEQUENCE OF DEPRESSION
IN CENTRAL NERVOUS
SYSTEM
CEREBRAL
CORTEX

CEREBELLUM

SPINAL
CORD

MEDULLAR
Y
CENTERS

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 MECHANISM OF
ACTION
• Major target- Ligand gated ion channels.

• GABAA receptor gated Cl¯ channel.

Examples –
Many inhalation anesthetics,
barbiturates,
benzodiazepines and
propofol.

Hugh C. Hemmings jr et al; emerging molecular mechanisms of General anesthetic action; TRENDS in pharmacological
sciences vol.26 no.10 october 2005
 MECHANISM OF
ACTION

Hugh C. Hemmings jr et al; emerging molecular mechanisms of General anesthetic action; TRENDS in pharmacological
sciences vol.26 no.10 october 2005
 MECHANISM OF
ACTION

Hugh C. Hemmings jr et al; emerging molecular mechanisms of General anesthetic action; TRENDS in pharmacological
sciences vol.26 no.10 october 2005
MECHANISM OF
ACTION
 MECHANISM OF
ACTION
Other Mechanisms:

• Glycine – Barbiturates, propofol and others can activate in

spinal cord and medulla

• N – methyl D- aspartate (NMDA) type of

glutamate receptors –
• Gates ca+ selective cation channel
• Nitrous oxide and ketamine selectively inhibits this receptor.

Hugh C. Hemmings jr et al; emerging molecular mechanisms of General anesthetic action; TRENDS in pharmacological
sciences vol.26 no.10 october 2005
 PRE-ANAESTHETIC
EVALUATION

The fundamental process of taking detailed history

and performing a systematic clinical examination
remains the foundation on which preoperative
assessment relies, backed up by ordering appropriate
investigations where indicated.

James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring,
Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)
 PRE-ANAESTHETIC
EVALUATION

1. Medical history questionnaire

2. Physical examination
3. Lab investigations

James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring,
Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)
 Medical history
questionnaire
1. Current problems
2. Other known problems
3. Treatment/medicines for the problems: dose, duration and
effectiveness
4. Current drugs use: reason, dose, duration, effectiveness
and side effect
5. History of drug allergies
6. History of use of tobacco—smoking or smokeless tobacco or
alcohol consumption, frequency, quantity and duration
7. Prior anesthetic exposure: type and any adverse effects.
8. General health and review of organ systems
James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring,
Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)
 Physical Examination

1. Vital Signs

2. Airway

3. Heart

4. Lungs

5. Extremities

6. Neurologic examination
James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring,
Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)
 Airway

Difficult airway defined to be one in-

“ which a conventionally trained anesthesiologist experiences

difficulty with face mask ventilation of upper airway, difficulty
with tracheal intubation, or both.’’

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics
Of North America: Management of Airway,vol 18 No.1, March 2010
 Airway Evaluation

• Mallampati Classification
• Thyromental Distance
• Sternomental Distance
• Maximum vertical opening (MVO)

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics
Of North America: Management of Airway,vol 18 No.1, March 2010
 Mallampati Classification

https://www.speareducation.com/spear-review/wp-content/uploads/2014/05/Tonsil-Grading-2.png
 Thyromental Distance

https://i.ytimg.com/vi/blqwvuA7NKw/maxresdefault.jpg
 Thyromental Distance

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics
Of North America: Management of Airway,vol 18 No.1, March 2010
 Sternomental
Distance

http://clinicalgate.com/wp-content/uploads/2015/04/B9780702035258000021_f02-03-
9780702035258.jpg
 Sternomental
Distance

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics
Of North America: Management of Airway,vol 18 No.1, March 2010
 Maximum vertical opening
(MVO)

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics
Of North America: Management of Airway,vol 18 No.1, March 2010
 Airway Evaluation

• Categories of difficult airway

1.Known or expected difficult airway.

•Conditions associated with difficult
airway.
-Acquired and congenital

James Cphero et al,Adult Airway Evaluation in Oral Surgery, Anesthesia:Oral and Maxillofacial clinics of
North America; Volume 25, Issue 3, Pages 341-536 (August 2013)
 Airway Evaluation

Categories of difficult airway

2. Potentially difficult airway.
• Limited neck extention.
• Limited mouth opening.
• Receding mandible.
• Mallampati class III or IV
• Short thyromental distance

James Cphero et al,Adult Airway Evaluation in Oral Surgery, Anesthesia:Oral and Maxillofacial clinics of
North America; Volume 25, Issue 3, Pages 341-536 (August 2013)
 Airway Evaluation

Categories of difficult airway

3. Unexpected difficult airway.
• Supraglotic mass.

• Hyperplasia of lingual tonsils.

• Missed evidence of difficult airway

James Cphero et al,Adult Airway Evaluation in Oral Surgery, Anesthesia:Oral and Maxillofacial clinics of
North America; Volume 25, Issue 3, Pages 341-536 (August 2013)
 Airway Evaluation

DIFFICUL
T
AIRWAY
 PRE OPERATIVE
PREPARATION
INCLUDES-

• Patient’s counselling or psychological preparation

• Premedication
• Preoperative instructions
- Fasting instructions
- current or pre-existing drug therapy.

James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring,
Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)
 PRE OPERATIVE
PREPARATION
• Patient’s counselling or psychological
preparation

Anticipated surgical events, risks and limitations, benefits and

alternatives of anaesthetic procedure should be discussed
with the patient and his relatives.

James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring,
Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)
 PRE OPERATIVE
PREPARATION

CONSENT
 PRE OPERATIVE
PREPARATION
• PREMEDICATIONS
• Relief of apprehension or anxiety
• Sedation
• Analgesia
• Amnesia of preoperative events
• Prevention of nausea and vomiting
• Vagolytic actions
• Fascilitation of anaesthetic induction
• Prophylaxis against allergies.

James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring,
Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)
 GROUP DRUGS EFFECT SIDE EFFECTS DOSES

Benzodiazepines Diazepam Sedation -CNS depression when 0.04-0.08mg/kg IV/IM

Midazolam Amnesia given with opoids
anxiolysis

Opoids Pethidine Sedation -Resp. depression -50-100mg IV/IM

Analgesia -PONV -1-2μgm/Kg
Morphine
Fentanyl
Barbiturates Thiopental Sedation -Antianalgesic effect -3-5mg/kg IV
Methohexital -Cardio respiratory -1-1.5mg/kg IV
depression

Phenothiazines Chlorpromazine Sedation -Hypotension -10-25mg IV/IM

Promithazine Anticholinergic - Restlessness
Antiemetic

Butyrophenones Haloperidol Antiemetic -Dysphoria -2.5-7.5mg IV/Im

Droperidol -Restlessness

Anticholinergic Atropine Vagolytic Dry mouth -0.12mg/kg

Glycopyrolate Antisialogogue Restlessness -0.04mg/kg
Scopolamine Sedation, Amnesia

Antiemetic Ranitidine Antiemetic - -50-100mg IV

Metoclopramide -5-20mg IV
ondansetron -4mg IV

James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring,
Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)
 PRE OPERATIVE
PREPARATION
• Fasting Guidelines

AGE CLEAR FLUIDS NON-CLEAR

FLUIDS/SOLIDS
Child< 6 months 2 hr prior 4-6 hr prior

Child-6-36 months 2-3 hr prior 6 hr prior

Child> 36 months 2-3 hr prior 6 hr prior

Adults 2-3 hr prior 6 hr prior/ overnight

James Cphero et al,pre operative, intraoperative and post operative assessment and monitoring,
Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-536 (August 2013)
 PRE OPERATIVE
PREPARATION
• PRE OPERATIVE ORDERS
ANESTHETIC

EQUIPMENT
 ANESTHETIC

• MASKS EQUIPMENT

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North America:
Management of Airway,vol 18 No.1, March 2010
 ANESTHETIC
EQUIPMENT
• LARYNGOSCOPE
 ANESTHETIC
EQUIPMENT

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North America:
Management of Airway,vol 18 No.1, March 2010
ANESTHETIC
EQUIPMENT
 ANESTHETIC
EQUIPMENT
• ENDOTRACHEAL TUBES

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North America:
Management of Airway,vol 18 No.1, March 2010
 ANESTHETIC
EQUIPMENT
• Adjuncts To
Intubation
• BOUGIE

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North America:
Management of Airway,vol 18 No.1, March 2010
 ANESTHETIC
EQUIPMENT
• Adjuncts To
Intubation
• LIGHTED STYLET

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North America:
Management of Airway,vol 18 No.1, March 2010
ANESTHETIC
EQUIPMENT
 ANESTHETIC
EQUIPMENT
• OROPHARYNGEAL AIRWAY

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North America:
Management of Airway,vol 18 No.1, March 2010
 ANESTHETIC
EQUIPMENT
• NASOPHARYNGEAL AIRWAY

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North America:
Management of Airway,vol 18 No.1, March 2010
 ANESTHETIC
EQUIPMENT
• LARYNGEAL MASK AIRWAY

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North America:
Management of Airway,vol 18 No.1, March 2010
 ANESTHETIC
EQUIPMENT
• RESUSCITATION BAG

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North America:
Management of Airway,vol 18 No.1, March 2010
 MONITORING

• BLOOD PRESSURE MONITOREQUIPMENTS

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North America:
Management of Airway,vol 18 No.1, March 2010
 MONITORING

• CARDIOSCOPE EQUIPMENTS

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North America:
Management of Airway,vol 18 No.1, March 2010
 MONITORING

• PULSE OXIMETER EQUIPMENTS

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North America:
Management of Airway,vol 18 No.1, March 2010
 MONITORING

• CAPNOGRAPH EQUIPMENTS

Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North America:
Management of Airway,vol 18 No.1, March 2010
 PHARMACOLOGY OF
ANASTHETICS

ANESTHETICS INTRAVENOUS

INHALATIONAL 1. BARBITURATES
- Thiopental
1. GASES 2. BENZODIAZEPINES
- Nitrous oxide -Diazepam
-Midazolam
2. VOLATILE LIQUIDS
- Ether 3..OPOIDS
- Halothane - Fentanyl
- Isoflurane 4. DISSOSIATIVE
- Desflurane - Ketamine
- Sevoflurane 5. MISCELLANE
OUS
- Etomidate
- Propofol
Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS
The important characteristics of Inhalational
anesthetics which govern the anesthesia are

• Solubility in the blood

(blood : gas partition co-efficient)
• Solubility in the fat
(oil : gas partition co-efficient)

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS
Solubility in the blood
(blood : gas partition co-efficient)
It determines the rate of induction and recovery of
Inhalational anesthetics.

Lower the blood : gas co-efficient –

faster the induction and recovery – Nitrous oxide.
Higher the blood : gas co-efficient –
slower induction and recovery – Halothane.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
INHALATIONAL
ANESTHETICS
 INHALATIONAL
ANESTHETICS
Solubility in the fat
(oil : gas partition co-efficient)

• It is a measure of lipid solubility.

• Lipid solubility - correlates strongly with the potency of the
anesthetic.
• Higher the lipid solubility – potent anesthetic. e.g.,
halothane

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS
MAC value
• Measure of inhalational anesthetic potency.
• It is defined as the minimum alveolar anesthetic concentration
( % of the inspired air) at which 50% of patients do not
respond to a surgical stimulus.
• Greater the mac lower the anesthetic potency.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS

OIL GA
EFFICIENT
 INHALATIONAL
ANESTHETICS
Inhalation MAC value % Oil: Gas
partition
Anesthetic
Nitrous oxide >100 1.4
Desflurane 7.2 23
Sevoflurane 2.5 53
Isoflurane 1.3 91
Halothane 0.8 220

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS
• NITROUS OXIDE

• The second-gas effect

The ability of the large volume uptake of one gas (first gas) to
accelerate the rate of rise of the alveolar partial pressure of a
concurrently administered companion gas (second gas) is
known as the second gas effect.
Ex-Halothane (1%) & N20:O2 ( 75%: 25%)

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS
• NITROUS OXIDE

• Diffusion Hypoxia
• N2O has low blood solubility, rapidly diffuses into alveoli and
dilutes alveolar air- PP of oxygen in alveoli is reduced,
resulting in hypoxia called as diffusion hypoxia.
• Prevented by giving 100% oxygen for few mins, after
discontinuing N2O.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS
• HALOTHANE(Fluothane)
• 2-bromo-2-chloro-1,1,1-trifloroethane
• Non flammable,non explosive.
• Pleasant smell, non irritating.
• Induction 2-4 %
• Maintanence 1-2%.
• BP falls in proportion to the vapour inhaled.
• Depression of respiratory centre.
• Respiratory rate increases, depth of respiration decreases.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS
• HALOTHANE(Fluothane)

• Mild relaxation of skeletal muscle.

• Pharyngeal and Laryngeal reflexes are
abolished,coughing is suppressed.
• Urine formation is decreased due to
low gfr.
• Les s post operative nausea and
vomiting.
• About 20% is metabolized in liver, rest
is exhaled out.
• Raymond
Fonseca Malignant
et al:Oral Hyperthermia can
and maillofacial surgery;vol 1,2 occur in susceptible
edition;saunders,an
nd imprint of elsevier inc.St. Louis, Missouri.
individuals. 2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS
• ISOFLURANE(Sofane)
• Synthesized in 1965 by terrell, introduced into
practice in 1984
• Cheap and widely used
• Highest oil gas partition cofficient (90.8)
• Non carcinogenic,nonflammable,pungent
• Less soluble than halothane.
• It can cause coronary artery vasodilatation
• Depresses respiratory drive and ventilatory
responses
• Myocardial depressant-less than halothane

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS
• ISOFLURANE(Sofane)
• Excellent muscle relaxant-- potentiates effects of
neuromuscular blockers.
• Induction by 3 to 4 % isoflurane in air or in
oxygen, or by 1.5 to 3 % isoflurane in 65 % nitrous
oxide.
• Maintenance by 1 to 2.5 % isoflurane.
• Bronchoirritating, laryngospasm
• Pungent smell – not good induction agent

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS
• DESFLURANE
• Volatile anesthetic is a nonflammable fluorinated
varient of Isoflurane
• Lowest oil-gas coefficient (18.7)
• Very fast action (on and off) makes it a great
choice for outpatient anesthesia.
• Induction by using 6 to 10 % desflurane in air or in
oxygen, or by using 5 to 8 % desflurane in 65 %
nitrous oxide
• Maintenance with 5 to 7 % desflurane

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS
• DESFLURANE

• As higher conc. Are used, may irritate air passage,

And induce coughing.
• Pungent smell-not suitable for induction.
• Degree of respiratory depression and fall in
B.P, smilar to isoflurane.
• Exhaled unchanged and more rapidly.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS
• SEVOFLURANE

• Nonflammable fluorinated isopropyl ether.

• Properties intermidiate between isoflurane and
desflurane.
• Iduction and emergence from anesthesia are
fast.
• Absence of pungency makes it pleasant and
administrable through face mask.
• It does not sensitize the heart to arrhythmias or
cause coronary artery steal syndrome.
Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INHALATIONAL
ANESTHETICS
• SEVOFLURANE

• Does not irritate the Has

airway.low solubility in blood ,so
induction without
used for intravenous
rapid anesthetics
• Induction by using 1.5 to 3 % sevoflurane in
air or in oxygen, or by using 0.7 to 2 %
sevoflurane in 65 % nitrous oxide.
• Maintenance with 0.4 to 2 % sevoflurane.
• Expensive

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INTRAVENOU
S
• THIOPENTAL ANESTHETICS

• Used as inducing agent.

• Poor analgesic and muscle relaxant properties.
• Suppresses excitatory neurotansmitter(acetylcholine) and
enhance inhibitory neurotransmitter (GABA).
• pH>10, water soluble.
• Unstable, freshly prepared.
• Rapid onset 30-60sec.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INTRAVENOU
S
• THIOPENTAL ANESTHETICS

• Elimination half life-3-12 hours.

• Dose- 3-5mg/kg. IV
• Decreases blood pressure due to vasodialation.
• Respiratory depression, can lead to bronchospasm.
• Occasionally used for rapid control of Dose-
convulsions. dependent suppression of CNS activity
• Contraindicated: porphyria , status asthematicus.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INTRAVENOU
S
• BENZODIAZIPINES ANESTHETICS

• Produce sedation and amnesia

• Potentiate GABA receptors.
• Onset of action is 30-60 secs.
• Duration of action 50-80mins.
• Dose- Premedication-0.04-0.08mg/kg
• Induction- 0.1-0.3mg/kg IV.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INTRAVENOU
S
• BENZODIAZIPINES ANESTHETICS

• Minimal depression of cardiac and respiratory system.

• Decreases intra cranial pressure, causes
anterograde amnesia.
• Dependence- onset of physical or psychological
symptoms after reduction of dose.
• Overdose- treared by giving Flumazenil – 0.01mg/kg
upto
0.2mg . IV

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INTRAVENOU
S
• FENTANYL ANESTHETICS

• Short acting Opioid.(30-50mins)

• Potent anlgesic.
• Minimal cardiac effects-- no myocardial depression
• Marked respiratory depression.
• Tone of chest muscles may increase after rapid fentanyl
injection,muscle relaxant is required.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INTRAVENOU
S
• FENTANYL ANESTHETICS

• Dose-2-4μg/kg
• Repeated dose may be required every 30 mins.
• Side effects nausea, chest wall rigidity, seizures,
constipation, urinary retention

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INTRAVENOU
S
• KETAMIN ANESTHETICS
E
• Dissociative amnesia
• Profound amnesia/ analgesia maintaining
despite counsciousness and protective
reflexes.
• Exitation of inhibitory neurotransmitters
• Dose- Analgesia-0.1-0.5mg/kg IV
- Induction- 4-8mg/kg
• Mixed with propofol infusion
1mg ketamine per 10mg propofol
Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INTRAVENOU
S
• KETAMIN ANESTHETICS
E
• Increases heart rate, cardiac output, BP.
• Potent bronchodialator
• Increases salivation.
• Decreases cerebral blood and intracranial
flow pressure
• Hallucinations and nightmares.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INTRAVENOU
S
• PROPOFOL ANESTHETICS

• Exitation of inhibitory neurotransmitters

• Oily liquid employed as a 1% emulsion for IV induction
• Available in 20 ml vials
• Rapid onset and short duration of action
• Induction dose: 1-2.5mg/kg
• Sedation dose: 0.2mg/kg
• Decreases systemic vascular resistance.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INTRAVENOU
S
• PROPOFOL ANESTHETICS

• Profound depression of upper airway

reflexes.
• Anti emetic.
• .Anti epileptic.
• Adverse effect- burning on injection
- hypersensitivity reaction.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INTRAVENOU
S
• ETOMIDATE ANESTHETICS

• Direct CNS depressant (thiopental) and GABA agonist

• Lipid soluble. Pain on injection.
• Dose- 0.2-0.3mg/kg
• Minimal cardiac and respiratory effect.
• Anti epileptic
• Post op nausea and vomiting.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 MUSCLE RELAXANTS

Muscle
NONDEPOLARIZING Relaxan
DEPOLARIZING
t
1. Long acting -Succinylcholine
-pancuronium - Decamethonium
-tubocurarine
2.Intermediate acting
- vecuronium
3.Short acting
- mivacurium

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INDUCTION
• Initially nitrous oxide 70% in oxygen is used
• Anaesthesia is deepened by the introduction of
increments
gradual of a volatile agent e.g sevoflurane.
• Maintenance concentrations of isoflurane (1-2 %)or
sevoflurane(2-3%).
• If spontaneous ventilation is to be maintained throught the
procedure,the mask is applied more firmly as conciousness is
lost and airway is supported manually
• Pre- oxygenation may be started with 100% oxygen using face
mask. At the rate of 8L-10L/min

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 INDUCTION

AGENT INDUCTION DOSE

thiopental 3-5 mg/kg

etomidate 0.3mg/kg

propofol 1.5mg/kg

ketamine 2mg/kg

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 MAINTAINANC
•
E
Inhalational agents
• Propofol infusion
• Oxygen + N2O
• Relaxants – VECURONIUM, ATRACURIUM, PANCURONIUM etc.
• Analgesia – opioids
• Sedation – midazolam etc.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 STAGES OF ANAESTHESIA

• Arthur Ernest Guedel (1937)

Stage of Stage of Surgical Medullary

Analgesia Delirium anaesthesia paralysis

Schwartz J.Paul; Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-
536 (August 2013)
 STAGES OF ANAESTHESIA
• Starts from beginning of anaesthetic inhalation and lasts upto the loss
of consciousness
• Pain is progressively abolished
Stage of • Reflexes and respiration remain normal
Analgesia • Use is limited to short procedures

• From loss of consciousness to beginning of regular respiration

• Patient may shout, struggle and hold his breath; muscle
tone increases, jaws are tightlyclosed, breathing is
involuntary
jerky; micturition or defecation may occur
vomiting,
• Heart rate and BP may rise and pupils dilate due to sympathetic
Stage of
stimulation
• No operative procedure carried out
Delirium
• Can be cut short by rapid induction, premedication

Schwartz J.Paul; Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-
536 (August 2013)
 STAGES OF ANAESTHESIA
• Extends from onset of regular respiration to cessation
of spontaneous breathing.
• This has been divided into 4 planes which may be distinguished as:
• Plane 1 rolling eye balls. This plane ends when eyes become fixed.
• Plane 2 loss of corneal and laryngeal reflexes.
Surgical
Anaesthesia • Plane 3 pupil starts dilating and light reflex is lost.
• Plane 4 Intercostal paralysis, shallow abdominal respiration, dilated
pupil.

• Cessation of breathing to failure of circulation and death.

Medullary • Pupil is widely dilated, muscles are totally flabby, pulse is thready or
Paralysis imperceptible and BP is very low

Schwartz J.Paul; Anesthesia:Oral and Maxillofacial clinics of North America; Volume 25, Issue 3, Pages 341-
536 (August 2013)
STAGES OF ANAESTHESIA
 REVERSAL

•Check equipment
•Check drugs
•Turn off agents
•Give 100% oxygen
•Suction
•Reverse relaxant
•Usually a combination of neostigmine glycopyrolate in
the ratio of 5:1, or neostigmine and atropine in the ratio
of 5:2 is given.
•Wait for adequate breathing
•Wait until patient wakes up
•Extubate and give 100% O 2 by mask

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 POST OPERATIVE CARE
• Shifted to recovery for Post op care
• N.P.O FOR 4-6 hrs.
• Vitals monitoring should be done.
• Iv fluids and blood products if
required
• Analgesia- iv or im Nsaids or opioids
• Antiemetics
• Antibiotics
• Continue medications for medical disorders

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 POST ANESTHESIA
RECOVERY SCORE
• ACTIVITY
2=Move all extremities voluntarily or on command
1= Move two extremities.
0= Unable to move extremities.
• RESPIRATION
2 = Breathes deeply and coughs freely, shallow /limited breathing
1 = Requires assistance
0 = Apnic
• CIRCULATION
2 = BP+20mm Hg of preanesthetic level
1 = BP+20-50 mm Hg of preanesthetic level
0 = BP+50 mm Hg of preanesthetic leve

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 POST ANESTHESIA
RECOVERY SCORE
• CONCIOUSNESS
2= Fully awake
1= Arousable on calling
0= Not responding
• OXYGEN SATURATION
2 = > 92% on room air
1 = supplemental oxygen req. To maintain SpO2 >90%
0 = SpO2< 92% with oxygen supplementation.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 COMPLICATIONS OF
GENERAL ANAESTHESIA
• Pre operative Period
• During maintenance of GA
- Related to anesthetic drug used
- Anesthetic technique
- Equipment failure
- Medical condition
- Surgical pathology
• Post operative period
- Related to anesthetic drug used
- Anesthetic technique
- Intubation technique
- Pain
- Infection
- Medical condition

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 COMPLICATIONS OF
GENERAL ANAESTHESIA
• COUGHING
• Occurs during light plane of anesthesia
• Causes- Irritation due to artificial airways,blood, regurgitated
gastric material.

• Managment-
- Deepening of anesthesia
- Giving muscle relaxant

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 COMPLICATIONS OF
GENERAL ANAESTHESIA
• WHEEZING
• Causes-
1 Reflex stimulation under light anesthesia
- Tracheal/ surgical stimulation.
2. Endotracheal tubes- kinking, overdistended, inserted
too far
3. Anaphylactic reaction
4. Aspiration
5. Pnemothorax.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 COMPLICATIONS OF
GENERAL ANAESTHESIA
• WHEEZING
• Management
1. Rule out mechanical obstruction
2.Intermittent positive pressure ventilation
3.Deepen the level of anesthesia
4. Aminophylline IV 250-500mg slowly.
5.Salbutamol IV. 250 mg/2.5mg inhalation
6.Adrenaline IV (1-3ml of 1:10,000)
7 Steroids IV 200mg. 4 hourly.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 COMPLICATIONS OF
GENERAL ANAESTHESIA
• MALIGNANT HYPERTHERMIA

• Hypermetabolic syndrome occurs in genetically susceptible

patients when exposed to anesthetic triggering agents.
• Triggering agents- Halothane, Isoflurane, Desflurane,
Sevoflurane, Succinylcholine.
• The syndrome is thought to be due to reduction of reuptake
of calcium ions by sarcoplasmic reticulam leading to sustained
muscle contraction. This results in signs of hypermetabolism
like tachycardia, acidosis, hypercarbia, hypoxemia and
hyperthermia.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 COMPLICATIONS OF
GENERAL ANAESTHESIA
• MALIGNANT HYPERTHERMIA

• Treatment
• Discontinue all anesthetic agents.
• Administer Dantrolene 2.5mg/kg IV. And repeat to a total of
10 mg/kg.
• Hyperkalemia to be corrected by Insulin and glucose
• Cold sponging
• Monitor urinary output

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 COMPLICATIONS OF
GENERAL ANAESTHESIA
• LARYNGOSPASM

• Caused by irritative stimulus of the upper airway during light

plane of anesthesia.
• The common noxious stimuli to elicit reflex are
secretions, vomitus and inhalation of pungent volatile
anesthetic agents.
• Reflex closure of voca cords causing partial or total
glottc obstruction.
• Hypoxia, hypercarbia, and acidosis.

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 COMPLICATIONS OF
GENERAL ANAESTHESIA
• LARYNGOSPASM

• Treatment-
• Continue positive pressure ventilation
• Deepening of anesthetic level.
• Removal of stimulus.
• Muscle relaxant- Succinylcholine- 10-20 mg IV

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 COMPLICATIONS OF
GENERAL ANAESTHESIA
• BRONCHOSPASM

• Centrally mediated or due to local response of airway

• Stimulated by histamine release( morphine,atracurium)
• Characteristic wheezing, tachypnea in awake patients.
• Treatment-
• Correction of endotracheal tube
• Deepening of anesthetic level.
• Adequate hydration of imspired air.
• Aminophylline IV 250-500mg slowly.
• Salbutamol IV. 250 mg/2.5mg inhalation

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 COMPLICATIONS OF
GENERAL ANAESTHESIA
• POST OPERATIVE NAUSEA AND VOMITING

• Causes-
• Female gender
• Obesity
• Pregnancy
• Abdominal distention
• Premedications- opiods, NSAID’s
• Anesthetics- ether, nitrous oxide.
• Presence of pain,hypoxia,hypotention,hypogycimia in post op
period

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 COMPLICATIONS OF
GENERAL ANAESTHESIA
• POST OPERATIVE NAUSEA AND VOMITING

• Treatment

• Underlying cause
• Supine position
• Antiemetics-
• Promethazine 12.5-25mg IM/IV(antihistaminic)
• Metoclopramide 10-20 mg orally.
• Ranitidiine 50 mg IV
• Sodium citrate 30-60ml orally

Fonseca Raymond et al:Oral and maillofacial surgery;vol 1,2nd edition;saunders,an imprint of elsevier inc.St. Louis, Missouri.
2009;Chapter 5: anesthesia consept and techniques;p.67-76
 CONCLUSION

Preparing a patient for anaesthesia requires an

understanding of the patient’s pre-operative status, the
nature of the surgery and the anaesthetic techniques
required for surgery, as well as the risks that a
particular patient may face during this time.

Patients often have comorbidities that require careful

assessment and co-ordination.

Charles F. Cangemi, Jr, Administration of General Anesthesia for Outpatient Orthognathic Surgical
Procedures American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 69:798-807, 2011
 CONCLUSION
Pre-operative anaesthetic assessment services
decreases complication rates and mortality. The pre-
operative visit may relieve anxiety and answer
questions about both the anaesthetic and surgical
processes

Effective communication and a team approach are vital in

the pre-operative period.

Charles F. Cangemi, Jr, Administration of General Anesthesia for Outpatient Orthognathic Surgical
Procedures American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 69:798-807, 2011
 CONCLUSION
Complications and malpractice lawsuits are often attributable
to poor preparation and failures in communication

Essential team members include anaesthetists, surgeons,

physicians and general practitioners.

Anaesthetic pre-operative assessment have been shown

to be safe and effective at pre-operative screening and should
be an integral part of the team

Charles F. Cangemi, Jr, Administration of General Anesthesia for Outpatient Orthognathic Surgical
Procedures American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 69:798-807, 2011
THANK
YOU....
PREOPERATIVE ASSESSMENT
 Dose Response Relationships

Coma Barbiturates

Medullary depression

Benzodiazepines
Anesthesia
CNS Effects

Hypnosis

Sedation, disinhibition, anxiolysis Possible selective

anticonvulsant & muscle-
relaxing activity

Increasing dose
• T. Y. Euliano,J. S. Gravenstein, Essential Anesthesia -From Science to Practice:United States of America by
Cambridge University Press, New York;2004: Introduction A very short history of anesthesia;p.1-4

• Anesthesia in outpatient facilities, Parameters of Care:Clinical Practice Guidelines for Oral and
Maxillofacial Surgery; J Oral Maxillofac Surg 70:e31-e49, 2012, Suppl 3

• Hugh C. Hemmings jr et al; emerging molecular mechanisms of General anesthetic action; TRENDS in
pharmacological sciences vol.26 no.10 october 2005

• Richard H. Haug, Henry H. Rowshan, Dale A. Baur; Atlas of the Oral & Maxillofacial Surg Clinics Of North
America: Management of Airway,vol 18 No.1, March 2010

• James Cphero et al,Adult Airway Evaluation in Oral Surgery, Anesthesia:Oral and Maxillofacial clinics of
North America; Volume 25, Issue 3, Pages 341-536 (August 2013)
•