GENERAL ANAESTHESIA

&
skeletal muscle relaxant
General anaesthetics (GAs) are drugs which
The cardinal
produce features
reversible lossofofgeneral anaesthesia
all sensation and are:
consciousness.
• Loss of all sensation, especially pain
• Sleep (unconsciousness) and amnesia
• Immobility and muscle relaxation
• Abolition of somatic and autonomic reflexes
 GENERAL
INHALATIONAL
ANAESTHETIC
S

GAS VOLATILE
INHALATIONA LIQUIDS
INTRA
L VENOUS

ETHER
HALOTHANE
NITROUS OXIDE SLOWER
VOLATILE FAST ACTING
ISOFLURANE
GAS ACTING
LIQUIDS DRUGS
SEVOFLURANE
DRUGS
DESFLURANE
 INTRAVENOUS

FAST ACTING SLOW ACTING

BENZODIAZEPINE
S (BZDS) DISSOCIATIVE OPIOID
THIOPENTONE ANAESTHETIC ANALGESIC
SOD.
PROPOFOL

DIAZEPAM
LORAZEPAM KETAMINE FENTANYL
MIDAZOLAM
Properties
of an
ideal
Anaesthetic
 • It should be pleasant &
nonirritating
• Should not cause nausea or
For the vomiting.
patient • Induction and recovery should
be fast with no after effects.
 • It should provide adequate
analgesia
• Immobility
For the • Muscle relaxation
Surgeon • Should be noninflammable and
nonexplosive so that cautery
may be used.
 • Administration should be easy, controllable
& versatile.
• Margin of safety should be wide
For the • Heart, liver & other organs should not be
anaesthetis affected.
• Should be potent
t • It should be cheap, stable & easily stored.
• It should not react with rubber tubing or
soda lime.
Minimal alveolar concentration (MAC)

Is the lowest concentration of the anaesthetic in

pulmonary alveoli needed to produce immobility
in response to a painful stimulus (surgical
incision) in 50% individuals.
 STAGES
OF
ANAESTHESIA
GAs cause an irregularly descending depression of the
CNS, i.e. the higher functions are lost first and
progressively lower areas of the brain are involved, but
in the spinal cord lower segments are affected
somewhat earlier than the higher segments. The vital
centres located in the medulla are paralysed the last as
the depth of anaesthesia increases.
Guedel (1920) described four stages

I Stage of analgesia
• Starts from beginning of anaesthetic inhalation upto loss
of consciousness
• Pain is progressively abolished during this stage
• Patient remains conscious, can hear & see and feels a
dream like state
• Some minor procedures can be performed
• It is difficult to maintain- use is limited to short
procedures only
II. Stage of Delirium

• From loss of consciousness to beginning of regular

respiration
• Excitement, struggling, breath holding, jerky breathing,
sympathetic stimulation occur.
• No procedure can be carried out.
• This stage is inconspicuous in modern anaesthesia
III Surgical anaesthesia

• From onset of regular respiration to cessation of spontaneous breathing.

• Most dental/surgical procedures are carried out at lighter planes of this

stage.
IV. Medullary paralysis

• From cessation of breathing to failure

of circulation and death.
• It is never attempted.
 BALANCED GENERAL ANESTHESIA
• The most common management strategy used in anesthesia care
• Uses less of each drug than if the drug were administered alone.
• This approach is believed to increase the likelihood of a drug’s desired effects
& reduce the likelihood of its side effects.
• Current practice of balanced general anesthesia relies on a hypnotic, such as
propofol, for induction & on an inhaled ether or on a hypnotic infusion to
maintain unconsciousness.
• Although midazolam is often administered before induction to treat anxiety
• Muscle relaxants are administered to produce immobility, administration of
propofol and of inhaled ethers also contributes to muscle relaxation.
 PREANAESTHETIC MEDICATION
-Refers to the use of drugs before anaesthesia to make it safe and less unpleasant.
The aims are:
1. Relief of anxiety & apprehension preoperatively & to facilitate smooth
induction.
2. Amnesia for perioperative events.
3. Supplement analgesic action of the anaesthetics and potentiate it so that less
anaesthetic is needed.
4. Decrease secretions &vagal stimulation that may be caused by the anaesthetic.
5. Antiemetic effect extending into the postoperative period.
6. Decrease acidity and volume of gastric juice so that it is less damaging if
aspirated.
 NITROUS OXIDE

• It is a nonirritating but low potency anaesthetic

• MAC is 105%.
• Nitrous oxide is a good analgesic but weak muscle relaxant.
• Second gas effect and diffusion hypoxia are possible only with N2O
• A mixture of 70% N2O + 25–30% O2 + 0.2–2% another potent anaesthetic 
employed for most surgical procedures.
• In dental practice  used to provide conscious sedation
 ETHER (DIETHYL ETHER)
• A potent anaesthetic, produces good analgesia and marked muscle relaxation.
• Highly soluble in blood
• Induction is prolonged and unpleasant with struggling, breath­holding,
salivation and marked respiratory secretions.
• Recovery is slow
• Post ­anaesthetic nausea, vomiting are marked.
• Ether has gone out of use because of its unpleasant and inflammable properties.
 HALOTHANE (FLUOTHANE)

• Solubility in blood is intermediate—induction is reasonably quick

& pleasant.
• It is a potent anaesthetic..
• It is not a good analgesic or muscle relaxant
• Cause direct depression of myocardial contractility.
• Preferred anaesthetic for asthmatics
• Recovery smooth and reasonably quick
 ISOFLURANE (SOFANE)
• This potent fluorinated anaesthetic
• Less soluble in blood, therefore, induction and recovery are
relatively fast
• Postanaesthetic nausea and vomiting is low
• Better adjustment of depth of anaesthesia and low toxicity
• Does not provoke seizures and is preferred for neurosurgery
• In many hospitals it has become the routine anaesthetic
 DESFLURANE
• Depth of anaesthesia changes rapidly with change in inhaled
concentration.
• Postanaesthetic cognitive and motor impairment is shortlived
• Patient can be discharged a few hours after surgery.
• Desflurane can serve as a good alternative to isoflurane for
routine surgery as well, especially prolonged operations.
 SEVOFLURANE
• Polyfluorinated anaesthetic with properties intermediate between isoflurane and
desflurane.
• Solubility in blood and tissues as well as potency are less than isoflurane but
more than desflurane.
• Induction and emergence from anaesthesia are fast
• Absence of pungency  pleasant and administrable through face mask.
• Acceptability is good, even by pediatric patients.
• Sevoflurane is suitable for both outpatient and inpatient surgery
• High cost and need for high flow open system very expensive to use.
 THIOPENTONE SODIUM

• Ultrashort acting thiobarbiturate

• Extravasation of the solution or inadvertent intraarterial injection produces
intense pain.
• Injected i.v. (3–5 mg/kg)  produces unconsciousness in 15–20 sec.
• high lipid solubility enters brain almost instantaneously.
• Lower doses produce anaesthesia which lasts longer
• Thiopentone is a poor analgesic.
• It is a weak muscle relaxant.
 PROPOFOL

• Unconsciousness after propofol injection occurs in 15–45 sec and lasts ~10 min
• used for total i.v. anaesthesia when supplemented by fentanyl.
• It lacks airway irritancy
• Induction apnoea lasting ~1 min is common.
• Fall in BP & Bradycardia is also frequent.
• In subanaesthetic doses used for sedating intubated patients in intensive care
units.
 BENZODIAZEPINES (BZDS)
• Use in preanaesthetic medication
• Relatively higher doses (diazepam 0.2–0.5 mg/kg or equivalent) injected i.v. produce sedation,
amnesia and then unconsciousness in 5–10 min.
• BZDs are poor analgesics : an opioid or N2O is usually added if the procedure is painful.
• The anaesthetic action of BZDs can be rapidly reversed by flumazenil 0.5–2 mg i.v.
• Lorazepam  3 times more potent, slower acting and less irritating than diazepam.
• Midazolam  3 times more potent than diazepam. It is being preferred over diazepam for
anaesthetic use and for sedation of dental patients.
 KETAMINE
• Induces ‘dissociative anaesthesia’—profound analgesia, immobility, amnesia with
light sleep
• The patient appears to be conscious, but is unable to process sensory stimuli and
does not react to them.
• Airway reflexes are maintained and muscle tone increases.
• Heart rate, cardiac output and BPelevated due to sympathetic stimulation.
• Children tolerate this drug better.
• Ketamine has been employed in asthmatics (relieves bronchospasm)
 FENTANYL
• Potent opioid analgesic & generally given i.v.
• Used as supplement in balanced anaesthesia.
• After i.v. fentanyl (2–4 µg/kg) the patient remains drowsy
• Respiratory depression is marked.
• Heart rate decreases, because fentanyl stimulates vagus.
• Spasm of masseter and chest muscles may occur if fentanyl is injected rapidly.
• The opioid antagonist naloxone used to counteract persisting respiratory
depression and mental clouding.
CONSCIOUS SEDATION
A monitored state of altered consciousness employed along with local
anaesthesia, to carry out dental procedures/surgery in apprehensive children (or
adults) and in medically compromised patients.

Conscious sedation is a technique in which drugs are used to produce a state of

CNS depression (but not unconsciousness) enabling surgical procedure to be
carried out while maintaining communication with the patient, who is able to
respond to commands and maintain a patent airway throughout.
Conscious sedation is not able to suppress the pain of dental
procedurelocal anaesthetic must be injected in addition.

Drugs used for conscious sedation are:

1. Diazepam
2. Propofol
3. Nitrous oxide
4. Fentanyl
Thank