Definition

General anesthesia is the induction of a balanced state of unconsciousness,

accompanied by the absence of pain sensation and the paralysis of skeletal muscle
over the entire body. It is induced through the administration of anesthetic drugs
and is used during major surgery and other invasive surgical procedures.

Purpose

General anesthesia is intended to bring about five distinct states during surgery:

 analgesia, or pain relief

 amnesia, or loss of memory of the procedure
 loss of consciousness
 motionlessness
 weakening of autonomic responses

The Process of Anesthesia

Premedication

Premedication 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.
The most commonly used premedication is midazolam, a short-acting
benzodiazepine. For example, midazolam syrup is often given to children to
facilitate calm separation from their parents prior to anesthesia. In anticipation of
surgical pain, nonsteroidal anti-inflammatory drugs or acetaminophen can be
administered preemptively. When a history of gastroesophageal reflux exists, H2
blockers and antacids may be administered.

Drying agents (eg, atropine, scopolamine) are now only administered routinely in
anticipation of a fiberoptic endotracheal intubation.

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.

For the most part, contemporary practice dictates that adult patients and most
children aged at least 10 years be induced with intravenous drugs, this being a
rapid and minimally unpleasant experience for the patient. However, sevoflurane,
a well-tolerated anesthetic vapor, allows for elective inhalation induction of
anesthesia in adults.
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). Many synthetic and naturally occurring opioids with different
properties are available. Induction agents and opioids work synergistically to
induce anesthesia. In addition, anticipation of events that are about to occur, such
as endotracheal intubation and incision of the skin, generally raises the blood
pressure and heart rate of the patient. Opioid analgesia helps control this
undesirable response.

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. The major decision is
whether the patient requires placement of an endotracheal tube. Potential
indications for endotracheal intubation under general anesthesia may include the
following:

 Potential for airway contamination (full stomach, gastroesophageal [GE] reflux,

gastrointestinal [GI] or pharyngeal bleeding)
 Surgical need for muscle relaxation
 Predictable difficulty with endotracheal intubation or airway access (eg, lateral or prone
patient position)
 Surgery of the mouth or face
 Prolonged surgical procedure

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.

Persons who, for anatomic reasons, are likely to be difficult to intubate are usually
intubated electively at the beginning of the procedure, using a fiberoptic
bronchoscope or other advanced airway tool. This prevents a situation in which
attempts are made to manage the airway with a lesser device, only for the
anesthesia provider to discover that oxygenation and ventilation are inadequate.
At that point during a surgical procedure, swift intubation of the patient can be
very difficult, if not impossible.

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. When the
anesthesia provider and surgeon are not accustomed to working together, good
communication (eg, warning of the start of new stimuli, such as moving the head
of an intubated patient or commencing surgery) facilitates preemptive deepening
of the anesthetic. This maximizes patient safety and, ultimately, saves everyone's
time.

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. These devices have yet to become
universally accepted as vital equipment.

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.

This requires experience and judgment. The specialty of anesthesiology is

working to develop reliable methods to avoid cases of awareness under
anesthesia.

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.