Anesthesiology Review: General Anesthesia: Part 1

ASA Classification: (for patients undergoing surgery)

ASA Class Definition Mortality
Class I Normal, healthy patient 0.08%
Class II Mild-moderate systemic disease 0.27%
Class III Severe systemic disease that limits activity but is not incapacitating 1.8
Class IV Incapacitating systemic disease that is a constant threat to life 7.8
Class V Moribund patient who is not expected to live with or without surgery
Emergency Any patient in one of the above classes who is operated on as an emergency
Preoperative Preparation of the Patient:
• General or spinal anesthesia: should not eat or drink anything after midnight before surgical procedure; minimum = 6 hrs pre-op
• Pediatric patients up to 2 yrs of age are allowed to have milk feedings 4hrs before surgery
• Children older than 2 yrs are given clear liquids up to 4 hrs preoperatively
Emergency Surgery:
• Indication may be – acute fx, open fx, compartment syndrome, uncontrolled bleeding, lacerations, traumatic amputations, infxn
• Consider patient to have full stomach; endotracheal intubation may be necessary to prevent aspiration of gastric contents
Intubation: considered for patients undergoing elective surgical procedures and who receive general anesthesia
• Indication: to prevent aspiration pneumonitis, facilitation of tracheal suctioning, long surgical procedures, adverse operative
positioning, airway control - operative site near/involving upper airway, or when airway maintenance is difficult by mask
• Mallampati Score: predicts ease of intubation
1. Class 1: Full visibility of tonsils, uvula and soft palate
2. Class 2: Visibility of hard and soft palate, upper portion of tonsils and uvula
3. Class 3: Soft and hard palate and base of the uvula are visible
4. Class 4: Only Hard Palate visible
• Complications: (of intubation)
o Acute: laryngospasm, vocal cord paralysis, perforation of trachea, dental damage, aspiration of gastric contents
o Long term – vocal cord polyps, vocal cord granuloma, tracheomalacia
Preoperative Medications: administered in the holding area, before the patient is transported to the operating room
o Barbituates – (not as common anymore preoperatively); may hinder toxic effects of local anesthetic agents
o Pentobarbital (Nembutal) & Secobarbital (Seconal) = most common short-acting barbituates
o Used before surgery to relieve anxiety and tension (cerebral cortex depression); short hypnotic effect
o Reaches desired effect in 1-1 ½ hrs, lasting for 3-4 hrs
• Benzodiazepines & Sedative Hypnotics – Commonly used for relief of anxiety and to invoke amnesia peroperatively
o Diazepam (Valium) 5-10mg; specific anxiolytic agent, best given orally 1-2 hrs before surgery, prevent and tx convulsions
o Lorazepam (Ativan) – long duration of action (~8hrs); not used to premedicate outpatient surgery
o Midazolam (Versed) – acts as a anxiolytic, hypnotic, and muscle relaxant; considered 3X as potent as diazepam

One of the most popular preanesthetics and infusion agents because its highly predicable effects and safety

Shorter duration than diazepam
• Other sedatives:
o Hydroxyzine (Vistaril), Promethazine (Phenergan), and Droperidol (inapsine)

Antiemetic and sedative properties

Droperidol + Fentanyl = state of cognitive disassociation known as neuroleptic anesthesia
o Ketamine – produces a dissociative, sedated state in patients; delivered alone can cause nightmares
• Narcotics: used as adjuvants during the administration of local anesthetic agents to minimize the pain and axiety
o Morphine & Meperidine (Demerol): less popular for outpatient procedures

Meperidine = 1/10 potency of morphine
o Fentanyl: ~100X more potent than morphine, commonly used during MAC; onset = 3-5min, duration = 45-60min

Significantly reduces postop pain in recovery room as well as 1st evening home
o Sufentanil (Sufenta): ~7-10X more potent than fentanyl, shorter ½ life than fentanyl and rapidly broken down
o Afentanil (Alfenta): 1/5-1/3 as potent as fentanyl, extremely short ½ life; need continuous infusion to sustain levels
o All narcotics are reversible: Naloxone (Narcan), Nalmefene (Revex) also used but longer ½ life
• Anticholinergics (Belladonna Derivatives): used to reduce respiratory tract secretions, protect against reflex bradycardia, to
provide sedative and amnesic effects, and decrease gastric hydrogen ion secretion
o Side effects: dry, sore mouth, poor visual accommodation, relaxation of LES, HR changes, arrhythmia, and ↑body temp
o Atropine Sulfate, Scopolamine, Glycopyrrolate
o Antagonist/reversal of effects: Physostigmine
• Histamine Receptor Antagonists: used to reduce potential aspiration pneumonitis
o Risk patients: obese, PUD, DM
o Cimetidine (Tagamet), Ranitidine (Zantac): given 1-2 hrs before induction anesthesia
Appleton