GENERAL ANESTHESIA

Dr. Achmad Assegaf, Sp.An

Department of Anesthesiology & ICU
Medical Faculty University of Unila

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 ANESTHESIA
GENERAL LOCAL COMBINATION
•Intravenous •Topical
Spinal +
•Infiltration propofol
•Inhalation
•Block
•Intramuscular peripheral nerve
•Spinal
•Epidural
•Caudal
•IVRA 2
 General anesthesia
• A reversible state of unconsciousness
produced by anesthetic agent, with loss of
sensation of pain over the whole body.
• Reversible irregular CNS depression.
• General anesthetic drugs are administered
by inhalation, intravenously,
intramuscularly, orally, rectally.

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 The order of descending
depression of the CNS

• Cortical and psychic centers

• Basal ganglia and cerebellum
• Spinal cord
• Medullary centers

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GENERAL ANESTHESIA


TRIAS ANESTHESIA
Hypnotic
Analgesic
Relaxation

BALANCED ANESTHESIA

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Balance anesthesia
Anesthesia Drugs
component
Hypnotic Pentothal, Propofol, Enflurane,
Isoflurane, Sevoflurane
Analgesic Pethidine, Morphine, Fentanyl,
Sufentanil, Remifentanil
Relaxation Succ choline, Atracurium,
Cisatracurium, Pancuronium

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 Anesthetic drugs
• Volatile anesthetic inhalation :
Halogen hydrocarbon (halothane)
Halogen ether: enflurane, isoflurane,
desflurane, sevoflurane
• Gas anesthetic inhalation : cyclopropane,
N2O, ethylene.
• Intravenous : thiopental, propofol, ketamine,
etomidate, diazepam, midazolam
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 Concept balanced anesthesia
Component VIMA (Volatile) TIVA (Total)
anesthesia

Hypnotic Sevo, Iso, Enf, Hal, Propofol, Pento, Ket,

Desfluran Mid

Analgesic Fentanyl, alf, suf ,Mo, Fentanyl, alf, suf, Mo,

pethidine, remifentanil pethidine, remifentanil

Relaxation Depol & non depol Depol & non depol

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 Indication general anesthesia
• Infant and young children.
• Adult who prefer general anesthesia.
• Extensive surgical procedures
• Patient with mental disease
• Prolonged surgery
• Patient with a history of toxic or allergic
reaction to local anesthetic drugs
• Patient on anticoagulant treatment
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 General anesthesia
• Induction inhalation, maintenance anesthesia
with inhalation anesthetic (VIMA)
• Induction intravenous , maintenance
anesthesia with intravenous anesthetic (TIVA)
• Induction intravenous, maintenance anesthesia
with inhalation anesthetic

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 General anesthesia technique
• Spontaneous breathing
• Controlled ventilation
• Face mask
• Intubation
• LMA (Laryngeal Mask Airway)
• COPA (Cuffed Oro Pharyngeal Airway)
• LSA (Laryngeal Seal Airway)

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Concentration
of
Anesthetic
 
Agent  
 
 
 
 
 
 
 
 
 
 

Inspired Alveolar Arterial Brain Brain Venous Alveolar Inspired

Gas Gas Blood Blood Gas Gas

Gambar : Perbedaan tekanan zat anestesi inhalasi pada saat induksi dan pemulihan.

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 Techniques of general
inhalation anesthesia
• Open-drop technique
• Insufflation
• Ayre T-piece system
• System with non-rebreathing valve
• Semiclosed
• Closed

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 Breathing circuit system
• Open system
• Semi open system
• Semi closed system
• Closed system

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 Flow Rate Definition :

Metabolic-flow : 250 ml/minute

Minimal-flow : 250 - 500 ml/minute
Low-flow : 500 – 1000ml/minute
Medium-flow : 1-2 liter/minute
High-flow : 2-4 liter/minute

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 Advantageous Low-flow
anesthesia
• Less of anesthesia gas consumption
• Less of pollution
• Heat loss decrease
• Cost effective

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THE EQUIPMENT

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 Component anesthesia machine
• Gas sources : Oxygen, N2O
• Reducing valve or pressure regulator
• Flow meter
• Vaporizer for halothane, enflurane, isoflurane,
desflurane or sevoflurane.
• CO2 absorption system (soda lime or bara
lime)

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 Gases Vapors  Diffusion  Solubilities  COMP.  C.O. B.W.
% %
M.G. 20 55
  L.Heart
  V.R.G.
  Brain
FA Circulation Heart 75 7
 
Splanc
  Kidney
 
  R.Heart V.P.G. 5 38
 
 
 

Inspired Mixture  Ventilation  Blood Carriage  Tissue Uptake

 
Figure : Schematic diagram of uptake and distribution of inhalation anesthetics. The inspired concentration. F1 or fraction
inspired, of anesthetic is under direct control of the anesthetist. F1 is delivered to the alveoli by the minute volume of
ventilation (M.V.V.). The alveolar concentration, FA or fraction in alveoli, regulates tension (partial pressure) of anesthetic
agent in arterial blood. The four tissue groups or compartments (COMP), the vesel rich group (V.R.G.) tend toward
equilibration with anesthetic tension in arterial blood but reach that equilibrium at rates determined by the volume of blood
flow to each tissue. The brain is the site of action. C.O. = cardiac output and B.W. = body weight, both expressed in percent.
SPLANC = splanchnic circulation.

Pa

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 Uptake and distribution
• Respiration factor
• Circulation factor
• Anesthetic gas factor
• Tissue factor

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 Respiration factor
• Inspiration concentration
• Ventilation effect

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 Circulation Factor
• Solubility (partition coefficient)
• Cardiac output
• The difference of gas partial pressure
alveoli and vein

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 Partition coefficient of
anesthetic
Anesthetic Blood/gas Brain/blood Tissue/blood

Ether 12.1 1.1 0.9

Halothane 2.3 2.6 2.5
Enflurane 1.8 2.6 1.7
Isoflurane 1.4 3.7 4.0
N2O 0.47 1.1 1.2

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 Anesthetic gas factor
• MAC (Minimal Alveolar concentration)
• MAC 50, MAC 95
• MAC Ei 50, MAC Ei 95
• MAC BAR 50, MAC BAR 95

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 MAC inhalation anesthetic
• MAC =minimal alveolar concentration, in 1
atmosphere, 50% patient without
movement in noxious stimuli
• MAC Ei = concentration of volatile agent
permitting laryngoscopy and intubation
without untoward movement.
• MAC BAR = concentration of volatile
agent required to block adrenergic
response to skin incision
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 MAC inhalation anesthetic, 40
years old.
Volatile anesthetic MAC

Halothane 0,72
Enflurane 1.68
Isoflurane 1.12
Desflurane 6.0
Sevoflurane 2.05
N2O 105.2
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 Factors influencing or not
influencing MAC
(Min. Alveolar Concentration)

MAC MAC MAC

decreased unchanged increased
Increasing age Duration of Alcoholism
CNS depressant: anesthesia chronic
alcohol, Gender Hyperthermia >
barbiturate, Species 42
lidocaine, Hypertension Hypercarbia
benzodiazepine, Hypocarbia Anemia
narcotic 31
 Tissue factor
• Tissue rich vessel : brain, heart, endocrine,
kidney.

• Intermediate : muscle, skin.

• Fat.
• Tissue poor vessel : ligament, tendon.

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 General anesthesia planning
• Pre operative visit
• Premedication
• Anesthesia technique : General, Regional
• Intraoperative
• Postoperative

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 Anesthesia technique :
General anesthesia
• Airway controlled
• Induction
• Maintenance anesthesia
• Analgesia
• Muscle relaxation

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 Intraoperative
• Monitoring
• Patient position
• Crystalloid and colloid
• Special technique

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 Postoperative
• Post operative pain treatment
• Send patient to Ward or ICU

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INTRAVENOUS
ANESTHETIC

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 Intravenous anesthetic
• Pentothal
• Propofol
• Etomidate
• Midazolam
• Diazepam

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 Ideal intravenous anesthetic
• Water soluble
• Non irritation
• No anta analgesic effect
• Rapid and smooth Induction
• Cardiovascular stable in clinically dose

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 Thiopentone
• Blood pressure decrease
• Heart rate increase or decrease
• Peripheral vasodilatation
• Heart contraction depressed
• Larynx spasm, bronchus spasm
• Respiratory depression until apnoea
• Dose 4-6 mg/kg BW

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 Relative contraindication
thiopentone
• Asthma bronchiale
• Severe liver disease
• Severe kidney disease
• Severe anemia
• Hypotension
• Shock

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 Ketamine
• Dissociative anesthetic
• Delirium
• Hallucination
• Increase blood pressure : systolic 23% from
base line
• Increase heart rate
• Arrhythmias
• Hypersecretion
• Dose 1-3 mg/kg I.v or 9-11 mg/kg I.m

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 Indication and Contraindication
Ketamine
• Indication : short surgery
• Contraind. :Hypertension systolic > 160mmHg
• Arrhythmias
• Heart failure
• Pharynx and larynx surgery without intubation.

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 Propofol
• New intravenous anesthetic
• Fast onset, short duration of action
• Accumulation minimal
• Fast recovery
• Rapid metabolism
• No complication at site of injection
• Dose 2-2.5 mg/kg BW

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 Pharmacology Propofol
• No histamine release/reaction anaphylactoid
(chremophor El change with soya bean oil).
• Perivascular injection, tissue necrosis negative.
• Injection intra artery : tissue necrosis negative.

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 Effect Propofol to CNS
• Hypnotic effect 1,8 time pentothal
• Airway depression > pentothal
• Anti emetic effect
• No anti convulsant effect

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 Comparative properties of
intravenous anesthetics
Thiopen Ketamin Propof Diazep Midaz

Aqueous + + - - +
solution
Available in - + + + +
solution
Pain on - - + + -
injection
Venous
thrombosis - - - + -
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 Comparative properties of
intravenous anesthetics
Thiopen Ketamin Propof Diazep Midaz

Rapidly acting + - + - -

Smooth ++ + + + +
induction

Respiratory + - + - +/-
depression

Cardiovascular ++ - ++ +/- +/-48

depression
 Comparative properties of
intravenous anesthetics
Thiopen Ketamin Propof Diazep Midaz
Rapid recovery - - + - -

Smooth + - + - -
recovery

Suitable for - +/- +/- - -

infusion
- - - - -
Interaction with
relaxant
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 Resume: Effect anesthetic non
volatile to organ system
Drug HR MAP Vent B’dil

Thiopentone    
Diazepam 0/   0
Midazolam    0
Meperidine  *  *
Morphine  *  *
Fentanyl    0

Ketamine    
Propofol 0   0

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Resume: Effect anesthetic non
volatile to CNS
Drug CBF CMRO2 ICP

Thiopentone   

Diazepam   
Midazolam   
Meperidine   
Morphine   
Fentanyl   
Ketamine   
Propofol    51
INHALATION
ANESTHETIC

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 Choice of anesthetic
inhalation
• Cardio pulmonal effect
• Product degradation with soda lime
• What metabolites ?
• How much metabolism?

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 Ideal anesthetic inhalation
• Pleasant odor and non irritation
• Low solubility
• No organ toxic
• Side effect cardiovascular and respiration minimal
• CNS effect reversible without stimulant activity
• Effective in high O2 concentration
• Boiling pressure and boiling point can delivered by
vaporizer standard

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 New Trend in General
Anesthesia
• VIMA
• Fast-Track Anesthesia
• Low-flow Anesthesia
• Low-cost Anesthesia
• Single-breath induction (Rapid induction)

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Physicochemical properties
Halothane Enfl Isofl Desfl Sevo
Odor + - - - +
Irritating to
Resp system - + + + -
Solubility 2,35 1,91 1,4 0,42 0,63
MAC 0,76 1,68 1915 6,0 2,05
Metabolism 17-20% 2,4% <0,2% 0,02% <5%
Metabolites F, Cl, F, F, F, F,
Br, TFA CDA TFA TFA HFIP
BCDFE,
CDE, CTE,
DBE 56
 Interaction with Sodalime
Anesthetic degradation organ Toxicity clinical
Product Relevancy
Halothane BCDFE Nephrotoxic Non identified
to data
Enflurane CO - -

Isoflurane CO - -

Desflurane CO - -

Sevoflurane Compound A Nephrotoxic Non identified

Compound B to date

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 WHY VIMA???
• intravenous induction, ex: Propofol : rapid
and smooth induction, but need vein
access first, hypotension, apnoe.
• Pediatric anesthesia commonly by VIMA.
• More advantages than intravenous
induction, maintenance inhalation.

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Cardiovascular effect of Volatile
inhalational anesthetics
Variable Halothane Enflurane Isoflurane

Blood pressure   
Vascular resistance 0  
Cardiac output   0
Cardiac contraction   0
CVP   0

Heart rate 0 

Sensitization of the heart to  0?
epinephrine
0 = No change (<10%)  = Variable = 10-20% = 20-40%
 = increase change decrease decrease

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 Clinical pharmacology of Inhalational
anesthetics : Respiratory
N2O Halo Enflur Isoflu Sevoflu

Tidal     
volume
Resp rate     
PaCO2     
resting

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 Clinical pharmacology of Inhalational
anesthetics : CNS
N2O Halo Enflur Isoflu Sevoflu

CBF     
ICP     
CMRO2     
Seizure     

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 Clinical pharmacology of Inhalational
anesthetics
N2O Halo Enflur Isoflu Sevoflu

HBF     
Nondep
blockade       
Metabolism 0.004 15-20 2.5 0.2 2-3

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 N2O
• 1.5 time heavier than air
• Must be give with O2 100%
• Weak anesthetic
• Analgesic N2O 20% equal with 15 mg
morphine
• Don’t use in closed system
• At the end of anesthesia, to prevent
diffusion hypoxia O2 100%
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 Advantages N2O
• Rapid induction and recovery
• No sensitized myocardium with
catecholamine
• No irritation respiratory tract
• Odor pleasant
• Strong analgesic

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 Disadvantages N2O
• Weak anesthetic
• No muscle relaxation effect
• Need high concentration oxygen
• Possibility aplasia bone marrow

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 Halothane
• A clear, colorless, potent volatile liquid.
• Metabolism 17-20%

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 Advantages Halothane
• Rapid, smooth induction and recovery.
• Pleasant
• Non irritating, no secretion
• Bronchodilator
• Nonemetic
• Non flammable and non explosive

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 Disadvantages Halothane
• Myocardial depressant
• An arrhythmia producing drug
• Sensitizes the myocardial conduction
system to the action of catecholamines
• A potent uterine relaxant
• Possible toxic to the liver
• Shivering during recovery period.

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 Enflurane
• A clear, colorless, stable volatile liquid with
a pleasant ether-like odor.
• A potent inhalation anesthetic
• CNS excitation
• Use of epinephrine : saver than
halothane.

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 Advantages Enflurane
• Pleasant
• Rapid induction and recovery
• Non-irritating : no secretion
• Bronchodilator
• Good muscle relaxation
• Nonemetic
• Non flammable and non explosive
• Compatible with epinephrine
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 Disadvantages Enflurane
• Myocardial depressant
• Shivering on emergence
• CSF production increase
• CNS excitation, in high dose and
hypocarbia.

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 Isoflurane
• A stabe, volatile liquid
• A isomer enflurane
• Inhalation anesthetic choice for
neurosurgical patient, kidney, liver.

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 Advantages Isoflurane
• Rapid induction of anesthesia and swift
recovery
• Nonirritating : no secretion
• Blood pressure remain stable
• Indicated in poor-risk patient

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 Disadvantages Isoflurane
• Less than halothane and enflurane

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 Sevoflurane
 Inhalation anesthetic with low solubility
(0,63), low MAC (2,05), pleasant odor, no
airway irritation, rapid uptake and
elimination , cardio vascular stable.
 Rapid induction, with technique single
breath induction, induction time 23 seconds.

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 Sevoflurane
• Drugs of choice for Neuro anesthesia :
WCA 2000 Montreal, Canada.
• Drugs of choice for Pediatric Anesthesia :
ESA Barcelona, 1998. ASPA, Singapore,
2000., ESA Sweden 2001.
• In Sectio Caesarea equal with Isoflurane
and spinal anesthesia
• Reduce sphlannic blood flow, hepatic blood
flow lesser than other anesthetic inhalation.
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NARCOTIC ANALGESIC

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Narcotic analgesic ideal :

 Wide margin of safety

 Fast onset of action
 Short duration of action
 Easier analgesia controlled
 Strong analgesic
 no histamine release
 Non active metabolite
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Opiate in Anesthesia

1. Premedication
2. Induction Anesthesia
3. Narcotic anesthesia
4. A part of balanced anesthesia
5. Adjuvant in regional anesthesia
6. Neurolept anesthesia
7. Post operative pain relief
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Drugs Protein binding Lipid solubility

Morphine ++ +
Pethidine +++ ++
Fentanyl +++ ++++
Sufentanil ++++ ++++
Alfentanil ++++ +++

Note : + = very low; ++ = low; +++ = high

++++ = very high

Morgan GE. Clinical Anesthesiology, 1996. 81

Narcotic effect :

 Bradycardia : central vagotonic effect & SA &

AV node depression
 Respiratory depression : respiratory rate,
rhythm, Response CO2, Minute Volume,
Tidal Volume
 Muscle stiffness
 Nausea vomiting cause by stimulation CTZ,
GIT mobility, decrease gastric mobility,
increased gastric volume

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 Clinical Doses of Narcotics
Drug i.v dose Onset Approximate
(min) duration
Morphine 0.05-0.3 mg/kg 5-10 3-5 h
Meperidine 0.5-1 mg/kg 5-10 2-3 h
Fentanyl 1-5 ug/kg 2 45 min – 2 h
Sufentanil 10-40 ug/kg <1 < 30 min
Alfentanil 30-80 ug/kg <1 < 60 min

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MUSCLE RELAXANT

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 Muscle relaxant
• Very useful in general anesthesia.
• laryngoscopy and intubation more easier
and avoid injury
• Muscle relaxation very useful during
surgery and controlled ventilation

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 Ideal muscle relaxant
• Non depolarization
• Rapid onset, short duration of action
• Rapid recovery, high potency
• non cumulative, metabolite non active
• No cardiovascular effect
• No histamine release
• Counteract with anticholinesterase

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 Mechanism
neuromuscular blockade
• Competitive block : non-depol, avoid AcCh
access to receptor.
• Depolarization block : depol, depolarization as
AcCh but permanent
• Deficiency block: influence syntesis and release
AcCh: Procaine, toxin botulinus, Ca decrease,
Mg increase.
Morgan GE, Mikhail MS. Clinical Anesth, 1996

87
 Terminology in muscle
relaxant
• ED 50 : dose what can paralyzed 50%
muscle strength
• ED 90 : dose what can paralyzed 90%
muscle strength.
• Onset : interval between start of injection
until maximal effect

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Table 9 - 1. Depolarizing and nondepolarizing muscle relaxants.
Depolarizing Nondepolarizing

Short-acting Long-acting
Succinylcholine Tubocurarine
Decamethonium Metocurine
Doxacurium
Pancuronium
Pipecuronium
Gallamine
Intermediate-acting
Atracurium
Vecuronium
Rocuronium
Short-acting
Mivacurium 89
 Nondepolarizing drug
• Do not produce muscular fasciculation
• Effect are decreased by anticholinesterase
agent, depolarizing agent, lowered body
temperature, epinephrine, acetylcholine
• Effect are increased by non-depolarizing
drugs, volatile anesthetic .

90
 Depolarizing drugs
• Produce muscular fasciculation .
• Effect are increased by
anticholinesterase agent, Acetylcholine,
hypothermia
• Effect decrease with non-depolarizing
relaxant drugs, anesthetic inhalation
• Dose Succ choline : 1 mg/kg BW

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Table 9 - 5. Conditions causing susceptibility to succiniylcholine-induced
hyperkalemia.
• Burn injury
• Massive trauma
• Severe intra-abdominal infection
• Spinal cord injury
• Encephalitis
• Stroke
• Guillain-Barre syndrome
• Severe Parkinson’s disease
• Tetanus
• Prolonged total body immobilization
• Ruptured cerebral aneurysm
• Polyneuropathy
• Closed head injury
• Near drowning
• Hemorrhagic shock with metabolic acidosis 92
• Myopathies ( eg, Duchennes’s dystrophy )
 Table 9 - 6. A summary of the pharmacology of nondepolarizing
muscle relaxant
Relaxant Metabolism Primary Onset Duration Histamine Vagal Relative Relative
Excretion Release Blockade Potency1 Cost2

Tubocurarine Insignificant Renal ++ +++ +++ 0 1 Low

Metocurine Insignificant Renal ++ +++ ++ 0 2 Moderate
Atracurium +++ Insignificant ++ ++ + 0 1 High
Mivacurium +++ Insignificant ++ + + 0 2.5 Moderate
Doxacurium Insignificant Renal + +++ 0 0 12 High
Pancuronium + Renal ++ +++ 0 ++ 5 Low
Pipecuronium + Renal ++ +++ 0 0 6 High
Vecuronium + Biliary ++ ++ 0 0 5 High
Rocuronium Insignificant Biliary +++ ++ 0 + 1 High

1
For example, pancuronium and vecuronium are five times more potent than tubocurarine or atracurium
2
Based on average wholesale price per 10 mL; does not necessarily reflect duration and potency
Onset : + = slow; ++ = moderately rapid; +++ = rapid
Duration : + = short; ++ = intermediate; +++ = long
Histamine release : 0 = no effect; + = slight effect; ++ = moderate effect; +++ marked effect
Vagal blockade : 0 = no effect; + = slight effect; ++ = moderate effect 93
 Relaxation
Drug ED95 Recommende Infusion rate
(mg/kg) d intubating for steady
dose (mg/kg) state
blockade
(mg/kg/h)
Atracurium 0.21 0.3-0.6 0.25
Pancuroniu 0.067 0.005-0.008 0.032
m 0.043 0.08-0.1 0.078
Vecuronium

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 INDUCTION AND
MAINTENANCE OF
ANESTHESIA

95
Choice of anesthesia technique
depend on:

• Patient condition
• Skill anesthetist
• Skill surgeon
• Hospital socioeconomi

96
 Problem during induction of
anesthesia
• Main problem : airway
• Sign of partial obstruction : snoring, crowing,
gargling, wheezing, chest retraction, cyanosis
• Sign of total obstruction : air flow from
nose/mouth negative, supraclavicular
retraction, intercostal retraction, cyanosis

97
 Other problem during induction
• Respiratory depression
• Cough
• Larynx spasm
• Mucus and saliva
• vomiting

98
 Airway controlled
• Without equipment : Triple mannuver Safar
• With equipment:
OPA (Oro Pharyngeal Airway)
NPA (Naso Pharyngeal Airway)
LMA ( Laryngeal Mask Airway)
ETT (Endo Tracheal Tube)

99
 Indication Intubation
• Head and neck surgery
• Difficult airway
• Thoracotomy
• Laparotomy
• Lateral position
• Prone position
• Controlled ventilation

100
 Technique laryngoscopy
• Head position
• Insertion laryngoscope blade
• Visualization epiglottis
• Lift epiglottis
• View larynx and surrounding structure

101
 Advantages Endotracheal
intubation
• Ensures a patent airway
• Normal anatomic dead space (75 ml) is
decreased to 25 ml.
• Ventilation can be assisted or controlled
• Possibility of aspiration diminished drastically
• Suctioning of the lung is facilitated

102
 Disadvantages endotracheal
intubation
• Increases resistance to respiration
• Trauma to the lips, teeth, nose, throat,
larynx.

103
 Complication Intubation
• Teeth rupture
• Mouth bleeding
• Endobronchial intubation
• Oesophageal intubation
• Sore throat
• Hypertension
• Arrhythmias

104
 Induction technique
• Mask induction / inhalation
• Intravenous
• Intra muscular
• Per rectal

105
 Mask Induction with Sevoflurane
 Gradual Induction
 Single Breath Induction
 Triple Breath Induction (Multiple Breath Induction)

Fast technique with Single Breath Induction,

without cough, breath holding, spasm larynx.

106
 Gradual Induction
 Classic method for Mask Induction.
 To decrease respiratory tract irritation and non
pungent odor  no need for Sevoflurane.
 Combined with N2O or Oxygen 100%.
 Concentration Sevo increase 0.5-1,5 vol% every 2-3
breath until anesthesia adequate.
 Commonly reach in 60-90 seconds with Sevo 7%.

107
 Single-Breath Induction
 Priming circuit with N2O 60% + Sevo 8% 30
seconds.
 Ask patient for maximal expiration (until residual
volume)  face mask .
 Ask patient inspiration maximal (vital capacity),
keep 20 seconds, then normal breathing.
 After eyelash reflex negative, Sevo turn to 2%.

108
 Triple Breath Induction
A variation from Single Breath Induction
 Ask patient 3 times deep breath.
 Difference with Single Breath, no breath
holding.
 Commonly patient sleep, in 2-3 breathing.

109
 How to maintain anesthesia ?
• Maintenance anesthesia depend on deep of
anesthesia to reach adequate anesthesia.
• Commonly with SEVO 1-1,5 vol% depend on
type of surgery, spontaneous breathing or
controlled.
• To reduce vol% (MAC) : add N2O or Fentanyl.

110
 Sign of deep anesthesia
• PRST Score (balanced anesthesia)
• Guedel sign (ether anesthesia)
• PRST Score (score 2-4: adequate anesthesia)
P = Systolic arterial pressure (mmHg)
R = rate (heart rate)
S = sweat/ lacrimation
T = tear

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 PRST Scoring indexes for
Balanced anesthesia
Index Condition Score

Systolic arterial Pressure Less than control + 15 0

(mmHg) Less than control + 30 1
More than control +30 2
Heart Rate (beats/min) Less than control + 15 0
Less than control + 30 1
More than control +30 2
Sweat Nil 0
Skin moist to touch 1
Visible beads of sweat 2
Tears or Lacrimation No excess tears when eyelids open 0
Excess teas visible when eyelids open 1
Tears overflow from closed eyelid 2
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 Extubation
• After adequate ventilation
• In deep anesthesia or after patient awake
• Clear airway
• Oxygen 100% after and before extubation

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Factor which influence total anesthetic
inhalation :

1. Constanta
2. Fresh gas flow
3. Volume % (MAC)
4. Length of surgery

Total anesthetic inhalation = constanta x fresh

gas flow (ml) x vol % x time (minute)
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If length of surgery 2 h, total
Sevoflurane :
Induction
first 30 second
Fresh gas x 1/183 x Vol % x time
flow (ml) (minute)
6000 x 1/183 x 8% x 0,5 = 1,3
3 minute for intubation :
6000 x 1/183 x 2% x 3 = 1,9
3 minute start for low-flow :
3000 x 1/183 x 3% x 3 = 1,4
second 3 minute:
1000 x 1/183 x 1% x 3 = 0,5
Operation 2 hours :
1000 x 1/183 x 1% x 120 = 6,5
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Total Sevoflurane 11,6 ml
 TIVA CONTINU
Propofol 6-10 mg/kg/h + Vecuronium 0.1 mg/kg/h
+ Fentanyl 2 ug/kg
Pentotal 1-3 mg/kg/h + Vecuronium 0.1 mg/kg/h +
Fentanyl 2 ug/kg
Ketamine 2 mg/kg/h + Vecuronium 0.1 mg/kg/h +
Diazepame 0.25 mg/kg
Midazolam 50 ug/kg/h + Ketamine 2 mg/kg/h +
Atracurium 0,25 mg/kg/h
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