PROCEDURE OF GENERAL

ANAESTHESIA
Preparation for General Anesthesia

Safe and efficient anesthetic practices require certified personnel, appropriate medications and
equipment, and an optimized patient.

Minimum requirements for general anesthesia

Minimum infrastructure requirements for general anesthesia include

• well-lit space of adequate size
• a source of pressurized oxygen (most commonly piped in)
• an effective suction device
• standard ASA (American Society of Anesthesiologists) monitors, including heart rate,
blood pressure, ECG, pulse oximetry, capnography, temperature
• and inspired and exhaled concentrations of oxygen
• Applicable anesthetic agents.

An array of routine and emergency drugs, including Dantrolene sodium (the specific treatment for
malignant hyperthermia), airway management equipment, a cardiac defibrillator, and a recovery
room staffed by properly trained individuals

Preparing the patient

The patient should be adequately prepared.

The most efficient method is for the patient to be reviewed by the person responsible for giving
the anesthetic well in advance of the surgery date.

Preoperative evaluation
• allows for proper laboratory monitoring
• attention to any new or ongoing medical conditions
• discussion of any previous personal or familial adverse reactions to general anesthetics,
• assessment of functional cardiac and pulmonary states, and development of an
effective and safe anesthetic plan

Physical examination associated with preoperative evaluations

• allow anesthesia providers to focus specifically on expected airway conditions, including
mouth opening, loose or problematic dentition, limitations in neck range of motion, neck
anatomy.
• By combining all factors, an appropriate plan for intubation can be outlined and extra
steps, if necessary, can be taken to prepare for fiberoptic bronchoscopy, video
laryngoscopy, or various other difficult airway interventions.
The Process of Anesthesia

Premedication: This is the first stage of a general anesthetic.

• This stage, which is usually conducted in the surgical ward or in a preoperative holding
area, originated in the early days of anesthesia, when morphine and scopolamine were
routinely administered to make the inhalation of highly pungent ether and chloroform
vapors more tolerable.
• The goal of premedication is to have the patient arrive in the operating room in a calm,
relaxed frame of mind. Most patients do not want to have any recollection of entering the
operating room.

Induction: The patient is now ready for induction of general anesthesia, a critical part of the
anesthesia process.

• In many ways, induction of general anesthesia is analogous to an airplane taking off. It is

the transformation of a waking patient into an anesthetized one. The role of the
anesthesia provider is analogous to the role of the pilot, checking all the systems before
taking off. The mnemonic DAMMIS can be used to remember what to check
(D rugs, A irway equipment, M achine, M onitors, I V, S uction).
• This stage can be achieved by intravenous injection of induction agents (drugs that work
rapidly, such as propofol), by the slower inhalation of anesthetic vapors delivered into a
face mask, or by a combination of both.
• In addition to the induction drug, most patients receive an injection of an opioid analgesic,
such as fentanyl (a synthetic opioid many times more potent than morphine). Induction
agents and opioids work synergistically to induce anesthesia.
o The next step of the induction process is securing the airway. This may be a
simple matter of manually holding the patient's jaw such that his or her natural
breathing is unimpeded by the tongue, or it may demand the insertion of a
prosthetic airway device such as a laryngeal mask airway or endotracheal tube.
Various factors are considered when making this decision.
• Not all surgery requires muscle relaxation.
• If surgery is taking place in the abdomen or thorax, an intermediate or long-acting muscle
relaxant drug is administered in addition to the induction agent and opioid. This paralyzes
muscles indiscriminately, including the muscles of breathing. Therefore, the patient's
lungs must be ventilated under pressure, necessitating an endotracheal tube.

Maintenance phase: At this point, the drugs used to initiate the anesthetic are beginning to wear
off, and the patient must be kept anesthetized with a maintenance agent.
 • For the most part, this refers to the delivery of anesthetic gases (more properly
termed vapors) into the patient's lungs. These may be inhaled as the patient breathes
spontaneously or delivered under pressure by each mechanical breath of a ventilator.
• The maintenance phase is usually the most stable part of the anesthesia. However,
understanding that anesthesia is a continuum of different depths is important. A level of
anesthesia that is satisfactory for surgery to the skin of an extremity, for example, would
be inadequate for manipulation of the bowel.
• Appropriate levels of anesthesia must be chosen both for the planned procedure and for
its various stages. In complex plastic surgery, for example, a considerable period of time
may elapse between the completion of the induction of anesthetic and the incision of the
skin.
• During the period of skin preparation, urinary catheter insertion, and marking incision
lines with a pen, the patient is not receiving any noxious stimulus. This requires a very
light level of anesthesia, which must be converted rapidly to a deeper level just before the
incision is made.

As the procedure progresses, the level of anesthesia is altered to provide the minimum amount of
anesthesia that is necessary to ensure adequate anesthetic depth. Traditionally, this has been a
matter of clinical judgment, but new processed EEG machines give the anesthesia provider a
simplified output in real time, corresponding to anesthetic depth.

• If muscle relaxants have not been used, inadequate anesthesia is easy to spot. The
patient moves, coughs, or obstructs his airway if the anesthetic is too light for the
stimulus being given.
• If muscle relaxants have been used, then clearly the patient is unable to demonstrate
any of these phenomena. In these patients, the anesthesia provider must rely on careful
observation of autonomic phenomena such as hypertension, tachycardia, sweating, and
capillary dilation to decide whether the patient requires a deeper anesthetic.
• Excessive anesthetic depth, on the other hand, is associated with decreased heart rate
and blood pressure, and, if carried to extremes, can jeopardize perfusion of vital organs
or be fatal.
• Short of these serious misadventures, excessive depth results in slower awakening and
more adverse effects.

As the surgical procedure draws to a close, the patient's emergence from anesthesia is planned.
Experience and close communication with the surgeon enable the anesthesia provider to predict
the time at which the application of dressings and casts will be complete.

• In advance of that time, anesthetic vapors have been decreased or even switched off
entirely to allow time for them to be excreted by the lungs.
• Excess muscle relaxation is reversed using specific drugs and an adequate long-acting
opioid analgesic to keep the patient comfortable in the recovery room.
• If a ventilator has been used, the patient is restored to breathing by himself, and, as
anesthetic drugs dissipate, the patient emerges to consciousness.
• Emergence is not synonymous with removal of the endotracheal tube or other artificial
airway device. This is only performed when the patient has regained sufficient control of
his or her airway reflexes.