General anaesthesia

General anaesthesia
In modern medical practice, general anaesthesia (AmE: anesthesia) is a state of total unconsciousness resulting
from general anaesthetic drugs. A variety of drugs are given to the patient that have different effects with the overall
aim of ensuring unconsciousness, amnesia and analgesia. The anaesthetist (AmE: anesthesiologist) selects the
optimal technique for any given patient and procedure. The biological mechanism of action of general anesthetics is
not well understood.

Overview
General anaesthesia is a complex procedure involving:

Preanaesthetic assessments
Administration of general anaesthetic drugs
Cardiorespiratory monitoring
Analgesia
Airway management
Fluid management

Postoperative pain relief

Preanaesthetic evaluation
Prior to surgery, the anaesthetist interviews the patient to determine the best combination of drugs and dosages and
the degree to which monitoring is required to ensure a safe and effective procedure. Key factors of this determination
are the patient's age, weight, medical history, current medications, previous anaesthetics, and fasting time. Patients
are typically required to fill out this information on a separate form during the pre-operative evaluation. Depending
on the existing medical conditions reported, the anaesthetist will review this information with the patient either
during the pre-operative evaluation or on the day of the surgery.
Truthful and accurate answering of the questions is important so that the anaesthetist can select the proper
anaesthetic drugs and procedures. For example, a heavy drinker or drug user who does not disclose their chemical
uses could be undermedicated, which could then lead to anaesthesia awareness or dangerously high blood pressure.
Commonly used medications such as Viagra can interact with anaesthesia drugs; failure to disclose such usage can
endanger the patient.
An important aspect of this assessment is that of the patient's airway, involving inspection of the mouth opening and
visualisation of the soft tissues of the pharynx. The condition of teeth and location of dental crowns and caps are
checked, neck flexibility and head extension observed. If an endotracheal tube is indicated and airway management
is deemed difficult, then alternative placement methods such as fibreoptic intubation may be required, after induction
of anaesthesia.

General anaesthesia

Premedication
Anaesthesiologists may prescribe or administer a sedative pre-medication by injection or by mouth anywhere from a
couple of hours to a couple of minutes before induction.
The most common drugs used for pre-medication are narcotics (opioids such as fentanyl) and sedatives (most
commonly benzodiazepines such as midazolam).

General anaesthesia
General anaesthesia implies loss of consciousness and of protective reflexes. General anaesthesia is traditionally
described as comprising of 3 components: hypnosis, relaxation and analgesia.
Hypnosis or sleep refers to being deeply asleep, unconscious, and totally unaware of events.
Relaxation implies abolition of reflex muscle tone, or specific block of nerve/muscle function, causing immobility
and allowing easy surgical access.
Analgesia refers to use of one or more of a wide range of pain reducing drugs from paracetamol to morphine, and
perhaps local anaesthetics to block pain impulse transmission along nerves, in the hope of reducing heart rate and
blood pressure responses to surgery.

Induction of anaesthesia
The general anaesthetic is administered in either the operating theatre itself or a special ante-room.
General anaesthesia can be induced by intravenous (IV) injection, or breathing a volatile anaesthetic through a
facemask (inhalational induction). Onset of anaesthesia is faster with IV injection than with inhalation, taking about
10-20 seconds to induce total unconsciousness. This has the advantage of avoiding the excitatory phase of
anaesthesia (see below), and thus reduces complications related to induction of anaesthesia. An inhalational
induction may be chosen by the anesthesiologist where IV access is difficult to obtain, where difficulty maintaining
the airway is anticipated, or due to patient preference (e.g. children). Commonly used IV induction agents include
propofol, sodium thiopental, etomidate, and ketamine. The most commonly-used agent for inhalational induction is
sevoflurane because it causes less irritation than other inhaled gases.

Maintenance
The duration of action of IV induction agents is generally 5 to 10 minutes, after which time spontaneous recovery of
consciousness will occur. In order to prolong anaesthesia for the required duration (usually the duration of surgery),
anaesthesia must be maintained. Usually this is achieved by allowing the patient to breathe a carefully controlled
mixture of oxygen, nitrous oxide, and a volatile anaesthetic agent or by having a carefully controlled infusion of
medication, usually propofol, through an IV. The inhalation agents are transferred to the patient's brain via the lungs
and the bloodstream, and the patient remains unconscious. Inhaled agents are frequently supplemented by
intravenous anaesthetics, such as opioids (usually fentanyl or a fentanyl derivative) and sedative-hypnotics (usually
propofol or midazolam). Though for a propofol-based anaesthetic, supplementation by inhalation agents is not
required. At the end of surgery the volatile or intravenous anaesthetic is discontinued. Recovery of consciousness
occurs when the concentration of anaesthetic in the brain drops below a certain level (usually within 1 to 30 minutes
depending upon the duration of surgery).
In the 1990s a novel method of maintaining anaesthesia was developed in Glasgow, UK. Called TCI (target
controlled infusion), this involves using a computer controlled syringe driver (pump) to infuse propofol throughout
the duration of surgery, removing the need for a volatile anaesthetic, and allowing pharmacologic principles to more
precisely guide amount of infusion of the drug. Purported advantages include faster recovery from anaesthesia,
reduced incidence of post-operative nausea and vomiting, and absence of a trigger for malignant hyperthermia. At
present, TCI is not permitted in the United States.

General anaesthesia
Other medications will occasionally be given to anaesthetized patients to treat side effects or prevent complications.
These medications include antihypertensives to treat high blood pressure, drugs like ephedrine and phenylephrine to
treat low blood pressure, drugs like albuterol to treat asthma or laryngospasm/bronchospasm, and drugs like
epinephrine or diphenhydramine to treat allergic reactions. Sometimes glucocorticoids or antibiotics are given to
prevent inflammation and infection, respectively.

Muscle relaxation / Neuromuscular blockade

"Paralysis" or temporary muscle relaxation with a neuromuscular blocker is an integral part of modern anaesthesia.
The first drug used for this purpose was curare, introduced in the 1940s, which has now been superseded by drugs
with fewer side effects and generally shorter duration of action.
Muscle relaxation allows surgery within major body cavities, eg. abdomen and thorax without the need for very deep
anaesthesia, and is also used to facilitate endotracheal intubation.
Acetylcholine, the natural neurotransmitter substance at the neuromuscular junction, causes muscles to contract
when it is released from nerve endings. Muscle relaxants work by preventing acetylcholine from attaching to its
receptor.
Paralysis of the muscles of respiration, ie. the diaphragm and intercostal muscles of the chest requires that some form
of artificial respiration be implemented. As the muscles of the larynx are also paralysed, the airway usually needs to
be protected by means of an endotracheal tube.
Monitoring of paralysis is most easily provided by means of a peripheral nerve stimulator. This device intermittently
sends short electrical pulses through the skin over a peripheral nerve while the contraction of a muscle supplied by
that nerve is observed.
The effects of muscle relaxants are commonly reversed at the termination of surgery by anticholinesterase drugs.
Examples of skeletal muscle relaxants in use today are pancuronium, rocuronium, vecuronium, atracurium,
mivacurium, and succinylcholine.

Airway management
With the loss of consciousness caused by general anaesthesia, there is loss of protective airway reflexes (such as
coughing), loss of airway patency and sometimes loss of a regular breathing pattern due to the effect of anaesthetics,
opioids, or muscle relaxants. To maintain an open airway and regulate breathing within acceptable parameters, some
form of "breathing tube" is inserted in the airway after the patient is unconscious. To enable mechanical ventilation,
an endotracheal tube is often used (intubation), although there are alternative devices such as face masks or laryngeal
mask airways.

Monitoring
Monitoring involves the use of several technologies to allow for a controlled induction of, maintenance of and
emergence from general anaesthesia.
1. Continuous Electrocardiography (ECG): The placement of electrodes which monitor heart rate and rhythm. This
may also help the anaesthetist to identify early signs of heart ischemia.
2. Continuous pulse oximetry (SpO2): The placement of this device (usually on one of the fingers) allows for early
detection of a fall in a patient's haemoglobin saturation with oxygen (hypoxemia).
3. Blood Pressure Monitoring (NIBP or IBP): There are two methods of measuring the patient's blood pressure. The
first, and most common, is called non-invasive blood pressure (NIBP) monitoring. This involves placing a blood
pressure cuff around the patient's arm, forearm or leg. A blood pressure machine takes blood pressure readings at
regular, preset intervals throughout the surgery. The second method is called invasive blood pressure (IBP)
monitoring. This method is reserved for patients with significant heart or lung disease, the critically ill, major

General anaesthesia
surgery such as cardiac or transplant surgery, or when large blood losses are expected. The invasive blood pressure
monitoring technique involves placing a special type of plastic cannula in the patient's artery - usually at the wrist or
in the groin.
4. Agent concentration measurement - Common anaesthetic machines have meters to measure the percent of
inhalational anaesthetic agent used (e.g. sevoflurane, isoflurane, desflurane, halothane etc).
5. Low oxygen alarm - Almost all circuits have a backup alarm in case the oxygen delivery to the patient becomes
compromised. This warns if the fraction of inspired oxygen drops lower than room air (21%) and allows the
anaesthetist to take immediate remedial action.
6. Circuit disconnect alarm - indicates failure of circuit to achieve a given pressure during mechanical ventilation.
7. Carbon dioxide measurement (capnography)- measures the amount of carbon dioxide expired by the patient's
lungs. It allows the anaesthetist to assess the adequacy of ventilation
8. Temperature measurement to discern hypothermia or fever, and to aid early detection of malignant hyperthermia.
9. EEG or other system to verify depth of anaesthesia may also be used. This reduces the likelihood that a patient
will be mentally awake, although unable to move because of the paralytic agents. It also reduces the likelihood of a
patient receiving significantly more amnesic drugs than actually necessary to do the job.

Stages of anaesthesia
The four stages of anaesthesia were described in 1937.[1] Despite newer anaesthetic agents and delivery techniques,
which have led to more rapid onset and recovery from anaesthesia, with greater safety margins, the principles
remain.

Stage 1
Stage 1 anaesthesia, also known as the "induction", is the period between the initial administration of the induction
medications and loss of consciousness. During this stage, the patient progresses from analgesia without amnesia to
analgesia with amnesia. Patients can carry on a conversation at this time.

Stage 2
Stage 2 anaesthesia, also known as the "excitement stage", is the period following loss of consciousness and marked
by excited and delirious activity. During this stage, respirations and heart rate may become irregular. In addition,
there may be uncontrolled movements, vomiting, breath holding, and pupillary dilation. Since the combination of
spastic movements, vomiting, and irregular respirations may lead to airway compromise, rapidly acting drugs are
used to minimize time in this stage and reach stage 3 as fast as possible.

Stage 3
Stage 3, "surgical anesthesia". During this stage, the skeletal muscles relax, and the patient's breathing becomes
regular. Eye movements slow, then stop, and surgery can begin.
It has been divided into 4 planes:
1.
2.
3.
4.

rolling eye balls, ending with fixed eyeballs

loss of corneal and laryngeal reflexes
pupils dilate and loss of light reflex
intercostal paralysis, shallow abdominal respiration, dilated pupils

General anaesthesia

Stage 4
Stage 4 anesthesia, also known as "overdose", is the stage where too much medication has been given and the patient
has severe brain stem or medullary depression. This results in a cessation of respiration and potential cardiovascular
collapse. This stage is lethal without cardiovascular and respiratory support.

Postoperative care
Post-operative analgesia
The anaesthesia should conclude with a pain-free awakening and a management plan for postoperative pain relief.
This may be in the form of regional analgesia, oral, transdermal or parenteral medication. Minor surgical procedures
are amenable to oral pain relief medications such as paracetamol and NSAIDs such as ibuprofen. Moderate levels of
pain require the addition of mild opiates such as tramadol.
Major surgical procedures may require a combination of modalities to confer adequate pain relief. Parenteral
methods include patient-controlled analgesia (PCA) involving a strong opiate such as morphine, fentanyl or
oxycodone. Here, to activate a syringe device, the patient presses a button and receives a preset dose or "bolus" of
the drug (e.g. one milligram of morphine). The PCA device then "locks out" for a preset period, e.g. 5 minutes, to
allow the drug to take effect. If the patient becomes too sleepy or sedated, they make no more morphine requests.
This confers a fail safe aspect which is lacking in continuous opiate infusion techniques.

Shivering
Shivering is a frequent occurrence in the post-operative period. Apart from causing discomfort and exacerbating
post-operative pain, shivering has been shown to increase oxygen consumption, catecholamine release, cardiac
output, heart rate, blood pressure and intra-ocular pressure. There are a number of techniques used to reduce this
occurrence, such as increasing the ambient temperature in theatre, using conventional or forced warm air blankets
and using warmed intravenous fluids.[2]

Mortality rates
Overall, the mortality rate for general anaesthesia is about three to five deaths per million anaesthetic
administrations.[3] Death during anaesthesia is most commonly related to surgical factors or pre-existing medical
conditions. These include major haemorrhage, sepsis, and organ failure (eg. heart, lungs, kidneys, liver). Common
causes of death directly related to anaesthesia include:
aspiration of stomach contents
suffocation (due to inadequate airway management)
allergic reactions to anaesthesia (specifically and not limited to anti-nausea agents) and other genetic
predispositions
human error
equipment failure
In the U.S., up until about 1980, anaesthesia held significant risk, with at least one death per 10,000 times
administered.[4] After becoming something of a public scandal, a careful effort was made to understand the causes
and improve the results.[5] It is generally believed that anaesthesia is now at least ten times safer than it was then.[6]
However, there is some controversy about this.[7] In the U.S., the data is not made public (in fact, the data are not
even collected), so the truth is uncertain.[8] The death rate for dental anaesthesia is reported to be one out of
350,000.[9]

General anaesthesia

See also
Anaesthetic equipment
Anaesthesia awareness
Seish Hanaoka - first physician to use general anaesthesia

External links
Chloroform: The molecular lifesaver [10] An article at University of Bristol providing interesting facts about
chloroform.
Australian & New Zealand College of Anaesthetists Monitoring Standard [11]
Royal College of Anaesthetists Patient Information page [12]

References
[1] PubMed Central (http:/ / www. pubmedcentral. nih. gov/ articlerender. fcgi?artid=2087073).
[2] English, William (2002). "Post anaesthesia shivering (PAS)" (http:/ / www. nda. ox. ac. uk/ wfsa/ html/ u15/ u1503_01. htm) (in English).
World Anaesthetia. World Federation of Societies of Anaesthesiologists. . Retrieved 2008-11-01.
[3] Henry Rosenberg. "Mortality Associated with Anesthesia" (http:/ / expertpages. com/ news/ mortality_anesthesia. htm). ExpertPages.com. .
Retrieved 2006-07-11.
[4] (http:/ / expertpages. com/ news/ mortality_anesthesia. htm)
[5] (http:/ / physiciansnews. com/ spotlight/ 200wp. html)
[6] (http:/ / www. fda. gov/ bbs/ topics/ CONSUMER/ CN00080c. html)
[7] (http:/ / www. asahq. org/ Newsletters/ 2003/ 01_03/ cottrell. html)
[8] (http:/ / physiciansnews. com/ spotlight/ 200wp. html)
[9] (http:/ / dentistry. about. com/ od/ dentalprocedures/ a/ teendies. htm)
[10] http:/ / www. chm. bris. ac. uk/ motm/ chloroform/ chloroformh. htm
[11] http:/ / www. anzca. edu. au/ publications/ profdocs/ profstandards/ PS18_2000. htm
[12] http:/ / www. rcoa. ac. uk/ index. asp?PageID=69

Article Sources and Contributors

Article Sources and Contributors

General anaesthesia Source: http://en.wikipedia.org/w/index.php?oldid=358958379 Contributors: Abductive, Accurrent, Alison, Arcadian, Azlib77, Baltojoey, Big Foster2, Blackhawk
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RobertG, Rsabbatini, Rsriniv, RuED, Sahiljambass, Scottalter, Sigil7, Some standardized rigour, Template namespace initialisation script, The Thing That Should Not Be, TheLimbicOne,
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