Introduction

• inhalation anesthetics for GA
• rapid induction
• rapid recovery
• awakening end-tidal concentration of inhalation anesthetics
• prevent recovery delay
• intraoperative awareness

• physiological changes
• hemodynamics
• respiratory
• minimal handling
• stimulation→ shorten emergence → unstable conditions of the patient
• prevent physiological changes
• α2-adrenoreceptor agonist
• opioids

• no touch technique
• safer emergence & extubation
• extended awakening time
• might avoid physiological changes
• BP
• HR
• ↓risk of aspiration or airway obstruction to prevent airway reflex
• safer recovery
• emergence influenced by the choice of inhalation anesthetics
• desflurane → ↓time to emergence in adults
• desflurane → airway related complications (apnea) during emergency

compared the emergence time and awakening end-tidal concentration among sevoflurane, isoflurane, or desflurane from general anesthesia in pediatric patients using no touch technique: a retrospective study.

inclusion criteria:

• paediatric patients
• American Society of Anesthesiologists physical status (ASA-PS) I or II
• 3 months- 11 years undergoing oral maxillofacial surgery under GA
• sevoflurane, isoflurane, and desflurane for maintenance after sevoflurane induction

exclusion criteria

• sedatives
• difficulty with tracheal intubation and extubation
• ASA-PS III or IV
• preoperative abnormalities
• cardiovascular
• respiratory
• neurological
• background
• anesthesia time
• operative time
• eye open time: from discontinuation of anesthetics to open eyes
• movement: time from discontinuation of anesthetics to first body movement
• extubation: from discontinuation of anesthetics to tracheal extubation
• awakening end-tidal concentration in first emergence
• airway-related complications during emergence
• doses of anesthetics (fentanyl, remifentanil)
• Anesthesia sevoflurane in O2 and/or N2O
• Fentanyl, atropine, and rocuronium
• maintained with
• sevoflurane, isoflurane, or desflurane in air and oxygen
• analgesia
• fentanyl and/or remifentanil
• anesthetics turned off
• last stimulus technique →gastric tube and suction into trachea
• fresh gas flow 6L/min of O2, minute volume 6-10 ml/kg
• no wash out
• spontaneous regular respiration and upper airway patency→ extubation

• Similar results
• Katoh T et al. 1993
• Lin TC et al. 2013 & 2016
• Tsukamoto M et al. 2018desflurane
• significantly shorter emergence, eye open, and extubation
  • no airway complication
  • awakening end-tidal concentration
  • desflurane → 0.98 ± 0.93%
  • sevoflurane → 0.39 ± 0.18%
  • Isoflurane → 0.25 ±0.13%
  • no touch technique
  • no stimulation used
  • ↓ risk of aspiration/airway obstruction
  • ↓ severity of emergence-related coughing
  • blood/gas partition coefficients
  • speed of wash-in
  • body uptake,
  • Wash-out
  • Sevoflurane →mask induction
  • low solubility
  • lack of airway irritation
  • Desflurane →volatile anesthetic ( low blood: gas coefficient)
  • desflurane→ shorter recovery time
  • no airway related complication
  • prediction of emergence by awakening end-tidal inhalation concentration in paediatric patients

• title: general anesthesia
• good abstract
• keywords: general anesthesia, desflurane, sevofluorane, isoflurane
• defined end-tidal concentration
• defined what no touch technique is
• reference 4 is not study on children
• sample calculation wasn’t really done
• duration of treatments
• what is considered as air way related complication
• what GA techniques were used? nasal? LMA?
• anaesthesiologist with different experience , not standardised
• use of anaesthetics according to operator
• In future → randomised clinical trial
• minimal handling technique in reference 1
• other studies have used minimal handling, this study was no touch
• have used themselves as reference a few times
• Desflurane →faster recovery
• emergence from inhalational anesthetics in children hasn’t been studied much
• no-touch technique → less chances of airway irritation

is a sweet-smelling, nonflammable, highly fluorinated methyl isopropyl etherused as an inhalational anaesthetic for induction and maintenance of general anesthesia in dentistry. After desflurane, it is the volatile anesthetic with the fastest onset and offset.

• is a highly fluorinated methyl ethyl etherused for maintenance of general anesthesia
• together with sevoflurane, it is gradually replacing isofluranefor human use, except in economically undeveloped areas, where its high cost precludes its use

End-tidal concentrations of inhalational anaesthetics estimate their arterial blood partial pressure with acceptable accuracy and are the standard of care for non-invasive monitoring of depth of anaesthesia

Anesthesia awareness, also referred to as accidental awareness during general anaesthesia(AAGA) or unintended intra-operative awareness, is a potential complication occurring during general anesthesia where the intended state of complete unconsciousness is not maintained throughout the whole procedure. It can occur either because of failure to deliver sufficient anesthetic medication to the patient’s body or because of individual patient factors that mean the patient is resistant to what would normally be an adequate dose of anesthetic medication. Awareness under anesthesia is very rare but highest risks are in emergency and trauma surgeries.

Extubation refers to removal of the endotracheal tube (ETT). It is the final step in liberating a patient from mechanical ventilation. Assessing the safety of extubation, the technique of extubation, and postextubation management are described in this topic

Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs

• Endotracheal intubation- the passage of a tube through
• the nose or mouth into the trachea for maintenance of the
• airway during anesthesia or for maintenance of an imperiled
• airway.  This is considered a relatively temporary
• procedure. The type of intubation used depends on the
• patient’s condition and on the purpose for intubation.

nasotracheal intubation- (blind): the insertion of an endotracheal   tube through the nose and into the trachea. The tube is passed  without using a laryngoscope to view the glottic opening.  This technique may be used without hyperextension, therefore it is useful when a client or patient   has cervical spinal trauma and with patients who have

clenched teeth.  Indications for this type include :   intraoral operative procedures, during which the the endotracheal tube could easily be displaced or obscure  the operative site.  Bleeding is not unusual after   intubation.  The tubes are usually smaller than those  used for orotracheal intubation.  This can also be performed with direct visualization with a laryngoscopic examination.  Blind intubation is only used if there are   indications that the larynx can not be visualized

Orotracheal intubation- the insertion of an endotracheal   tube through the mouth and into the   trachea. This type is performed much more frequently  than nasotracheal intubation.

the laryngeal mask airway (LMA) is a supraglottic airway device developed by British Anesthesiologist Dr. Archi Brain. It has been in use since 1988. Initially designed for use in the operating room as a method of elective ventilation, it is a good alternative to bag-valve-mask ventilation, freeing the hands of the provider with the benefit of less gastric distention.Initially used primarily in the operating room setting, the LMA has more recently come into use in the emergency setting as an important accessory device for management of the difficult airway. the LMA is shaped like a large endotracheal tube on the proximal end that connects to an elliptical mask on the distal end. It is designed to sit in the patient’s hypopharynx and cover the supraglottic structures, thereby allowing relative isolation of the trachea

absolute contraindications (in all settings, including emergent) are as follows:

• cannot open mouth
• complete upper airway obstruction

relative contraindications (in the elective setting) are as follows:

increased risk of aspiration: Prolonged bag-valve-mask ventilation, morbid obesity, second or third trimester pregnancy, patients who have not fasted before ventilation, upper gastrointestinal bleed

suspected or known abnormalities in supraglottic anatomy

need for high airway pressures (In all but the LMA ProSeal, pressure cannot exceed 20 mm water for effective ventilation.)

Fentanyl, also spelled fentanil, is an opioidused as a pain medicationand together with other medications for anesthesia

bromide (brand names Zemuron, Esmeron) is an aminosteroid non-depolarizing neuromuscular blocker or muscle relaxant used in modern anaesthesia to facilitate tracheal intubation by providing skeletal muscle relaxation, most commonly required for surgery or mechanical ventilation

Respiratory minute volume (or minute ventilation or minute volume) is the volume of gas inhaled (inhaled minute volume) or exhaled (exhaled minute volume) from a person’s lungs per minute

Desflurane, a commonly used volatile anesthetic, has low blood gas solubility. This facilitates a faster recovery than that seen when using other volatile anesthetics. Consequently, a patient may reach a state of light anesthesia too soon during the emergence period, which, in turn, may result in cardiopulmonary instability

During wake-up from anesthesia the presence of an ET tube in the trachea and the larynx presents an intense stimulus to the patient and invariably causes a coughas well as a gag reflex. In fact, coughing and gagging with the ET tube in-situ are reassuring signs that a patient is ‘ready’ for extubation, as this indicates the return of normal upper airway reflexesafter anesthesia, meaning the patient should be able to protect himself from aspiration once the ET tube is removed.

With ‘deep’ extubation, the ET tube is removed before wake-up and before the return of upper airway reflexes.

There are no absolute indications for this technique. Most commonly, deep extubation is considered when coughing during wake-up could be detrimental to the patient, e.g. in some cases of intracranial surgery or middle ear surgery.

‘Deep’ extubation does not guarantee that a patient won’t cough during wake-up, but it certainly reduces the risk.

Minimum alveolar concentration or MAC is the concentration of a vapour in the alveoli of the lungs that is needed to prevent movement (motor response) in 50% of subjects in response to surgical (pain) stimulus. MAC is used to compare the strengths, or potency, of anaesthetic vapours.

SpO2 stands for peripheral capillary oxygen saturation, an estimate of the amount of oxygen in the blood. More specifically, it is the percentage of oxygenated haemoglobin (haemoglobin containing oxygen) compared to the total amount of haemoglobin in the blood (oxygenated and non-oxygenated haemoglobin).

SpO2 is an estimate of arterial oxygen saturation, or SaO2, which refers to the amount of oxygenated haemoglobin in the blood.

Haemoglobin is a protein that carries oxygen in the blood. It is found inside red blood cells and gives them their red colour.

SpO2 can be measured by pulse oximetry, an indirect, non-invasive method (meaning it does not involve the introduction of instruments into the body). It works by emitting and then absorbing a light wave passing through blood vessels (or capillaries) in the fingertip. A variation of the light wave passing through the finger will give the value of the SpO2 measurement because the degree of oxygen saturation causes variations in the blood’s colour.