KAMINENI INSTITUTE OF DENTAL SCIENCES

DEPARTMENT OF PERIODONTICS

PRESENTER:S.SHRIYA REDDY
1V BDS
SIGNS AND STAGES IN GENERAL ANESTHESIA

Guedel's Classification
In the practice of administering anesthesia, the significance of having reliable
indicators, akin to signposts, to navigate the determination of the depth of
anesthesia cannot be overstated. Various experts have proffered suggestions
regarding observable signs that could facilitate the division of anesthesia depth
into distinct stages and planes. Amidst these suggestions, the classification put
forth by Guedel in 1951 has attained global acceptance as a seminal framework.

Guedel's pioneering criteria rest upon a triad of factors: respiration patterns,

movement of the eyeballs, and the manifestation or absence of diverse reflexes.
This comprehensive scope underscores the pragmatic nature of the framework, making it an
indispensable tool for anesthetists and medical professionals alike. As the medical field
advances and new anesthetic agents and techniques emerge, the enduring nature of
Guedel's classification serves as a testament to its timeless importance and enduring
relevance in the practice of administering anesthesia.

The year 1943 saw Gillespie introduce an augmentation to Guedel's criteria, broadening the
spectrum of determinants for assessing the depth of anesthesia. Gillespie's additions
encompassed additional considerations like the secretion of tears, the response elicited by a
skin incision, and a comprehensive evaluation of pharyngeal and laryngeal reflexes. By
incorporating these multifaceted indicators, Gillespie contributed to a more holistic and
nuanced approach to gauging the extent of anesthesia.
This comprehensive scope underscores the pragmatic nature of the framework, making it an
indispensable tool for anesthetists and medical professionals alike. As the medical field
advances and new anesthetic agents and techniques emerge, the enduring nature of Guedel's
classification serves as a testament to its timeless importance and enduring relevance in the
practice of administering anesthesia.

This comprehensive scope underscores the pragmatic nature of the framework, making it an
indispensable tool for anesthetists and medical professionals alike. As the medical field
advances and new anesthetic agents and techniques emerge, the enduring nature of Guedel's
classification serves as a testament to its timeless importance and enduring relevance in the
practice of administering anesthesia.
Stage 1 - Analgesia

The initial stage of anesthesia, known as analgesia, encompasses the period from the
commencement of the induction process to the point at which consciousness is lost.
During this phase, respiration tends to be subdued, often marked by sporadic
irregularities. While the patient's reflexes remain active, indicating a state of alertness, a
curious phenomenon unfolds: amnesia for certain occurrences during this stage
becomes a common occurrence. This peculiar disjunction between consciousness and
memory underscores the complexity of the anesthesia process, as consciousness and
rationality may appear intact even while significant aspects of awareness slip away.
A particularly informative signpost guiding the transition to the next stage is the vanishing
of the eyelash reflex. This reflex, elicited by the gentle stroking of the eyelashes, serves as
a reliable indicator of the patient's passage into Stage II.
Stage II - Excitement or Delirium

Referred to as excitement or delirium, Stage II unfurls between the point of losing

consciousness and the emergence of full surgical anesthesia. Here, the patient's
unconsciousness is pronounced, yet accompanied by a marked lack of cooperation. Verbal
expression becomes incoherent, accompanied by the gentle or sometimes vigorous
movement of limbs. Respiration assumes an irregular cadence, occasionally involving
breath-holding—a phenomenon that intersects with the unpredictability of inhalation
anesthetic intake due to the respiratory irregularities.
Throughout this phase, the patient's reflexes remain active, potentially resulting in retching
episodes that may escalate into vomiting, especially if the stomach isn't empty. This
precarious scenario can lead to the unfortunate complication of aspiration, where the
inhalation of vomitus poses a serious threat. Navigating through this stage with swiftness
and finesse can curtail the exaggerated reactions observed and, consequently, diminish the
frequency of complications stemming from these reactions. An intriguing indicator of
progress through this phase is the waning of the eyelid reflex—an immediate closure of the
upper eyelid upon gentle elevation—a response that diminishes as the patient advances to
Stage III, Plane 1.
Stage III - Surgical Anesthesia

The transition to surgical anesthesia characterizes Stage III, extending from the
establishment of regular, automatic respiration to the brink of respiratory failure resulting
from an excessive concentration of anesthetic agents within the central nervous system.

This stage is commonly dissected into four planes, each representing a distinct level of
anesthetic depth.
Plane 1:
As the initial subdivision of Stage III, Plane 1 marks a notable shift in the patient's physical
responses. Movements of the limbs cease entirely, while respiration assumes a steady,
rhythmic pattern.

The eyelid reflex that was a hallmark of earlier stages dissipates, further underlining the
progression. Interestingly, this phase is characterized by robust yet uncoordinated
movements of the eyeballs a unique occurrence that adds a layer of intrigue to the intricate
interplay of physiological responses. The pharyngeal reflex, which was previously active,
starts to diminish during this juncture, setting the stage for the deeper planes of surgical
anesthesia.
Plane 2:

Progressing to Plane 2 denotes a more pronounced shift in the patient's physiological

state. The eyes become fixated in a central position, and the size of the pupils starts to
decrease. While muscle tone begins to wane, all respiratory muscles retain their
functionality, maintaining the integrity of the breathing process.

Notably, the laryngeal reflex, which served as a safeguard mechanism, is now

abolished, further accentuating the transition. Additionally, the corneal reflex, involving
the narrowing of the eyelid in response to corneal stimulation, becomes lost during this
phase.
Plane 3:
Advancing to Plane 3, distinct physiological alterations emerge. The pupillary light reflex,
which typically involves pupil constriction in response to light exposure, disappears.
Accompanying this, the onset of intercostal muscle paralysis becomes evident.

Respiration at this stage becomes predominantly diaphragmatic in nature, a shift that mirrors
the evolving muscular dynamics. As muscle relaxation takes hold, the patient's physiological
responses continue to evolve in tandem with the deepening anesthesia.
Plane 4
Progressing to the final subdivision within Stage III, Plane 4, the trajectory of anesthesia
continues its course. Respiration, once rhythmic and controlled, gradually succumbs to
greater depression, accompanied by a progressive paralysis of the diaphragm. It's worth
noting that a distinctive clinical sign known as a tracheal tug might manifest at this point,
serving as an indicator of the anesthesia impact on the patient's respiratory system.

This subtle yet telling sign further underscores the delicate balance between the
administration of anesthetic agents and the intricate interplay of the body's physiological
responses.
As we develop deeper into Stage III of anesthesia, the intricacies of each plane reveal the
profound transformations occurring within the patient's body.

This dynamic journey exemplifies the art and science of anesthesiology, where meticulous
observation and interpretation of these physiological nuances guide the anesthetist in
orchestrating a safe and effective anesthetic experience.
Stage IV-medullary paralysis with respiratory arrest and vasonelor collapse

In medullary paralysis, the pupils are widely dilated and the skin is cold
and ashen. The blood pressure is very low and the pulse feeble.
Respiration is gasping and finally ceases.
These stages are usually well defined with ether or chloroform, but they
are less clearly marked when cyclopropane or halothane are used.
If anesthesia is induced with an intravenous barbiturate, the stages
become telescoped, and the patient passes rapidly into stage III, plane 2
or deeper, depending on the dose given. The intermediate stages are not
recognized.
When general anesthesia is administered in the office, it is advisable to be
certain that the patient is brought to an adequate depth of anesthesia
(surgical stage) at the start of the procedure, to avoid the difficulties often
associated with lighter anesthesia. When the patient is too lightly
anesthetized, all of the undesirable reflexes (pharyngeal, laryngeal, and so on)
are most active. Also, the highest level of endogenous epinephrine is being
liberated at these light levels and so is most likely to produce arrhythmias in
reacting with halogenated anesthetic agents such as halothane. As the
operation progresses and the cumulative depressant effects of the
anesthetics exert their influence, less anesthetic agent will be required and the
level can be lightened.
Woodbridge's Comprehensive Anesthetic Classification

In 1958, Woodbridge presented a fresh perspective on the gradations of anesthesia,

reevaluating them in light of central nervous system depression. His innovative
approach entailed categorizing the anesthetic experience into four distinct
components: unconsciousness, loss of sensation, diminishment of motor power, and
the suppression of reflex activity. This refined framework acknowledged the multi-
faceted nature of the anesthetic state, acknowledging that the depth of anesthesia
could be tailored to suit the unique demands of specific medical procedures and the
overall well-being of the patient. This adaptability highlighted the versatility of
anesthetic agents and drugs, which could be judiciously selected to achieve desired
outcomes.
In the realm of interpreting signs of anesthesia, a more nuanced perspective has been
emphasized. While individual indicators hold value, the context as a whole must take
precedence. Schwartz, Ngai, and Papper (1957) aptly pointed out that the culmination of
signs should collectively inform the assessment of anesthesia depth. In instances where
disparate signs don't align to suggest a uniform depth of anesthesia, greater weight should
be placed on the vital signs encompassing blood pressure, pulse rate, and respiration. For
instance, if the behavior of the eyeballs appears consistent with the first plane of the third
stage, but the rhythm of respiration aligns more with the third plane, prudence dictates
relying on the latter sign for a more accurate representation of the patient's state. This
pragmatic approach underscores the dynamic nature of anesthesia and the importance of
considering the holistic clinical context.
When administering an anesthetic, it is crucial to recognize that achieving
a specific stage of anesthesia might not be the ultimate goal. Instead, the
primary objective should revolve around creating an optimal surgical
environment tailored to the procedure's requirements while prioritizing the
patient's safety. This perspective underscores a delicate balance between
achieving favorable conditions for the operation and minimizing drug
usage to mitigate potential risks. This approach echoes the principles of
personalized medicine, wherein anesthetic administration is tailored to the
unique needs and physiological responses of each individual patient.
In sum, Woodbridge's comprehensive classification of anesthesia, coupled with the nuanced
understanding of interpreting signs and the emphasis on personalized drug administration,
exemplifies the continual evolution of anesthesiology. As medical knowledge and technology
advance, these principles provide a solid foundation for enhancing patient care, optimizing
procedural outcomes, and advancing the art and science of anesthesia administration.