Triad of anesthesia!

A surgery cannot be successful without the contribution of a successful anesthesia! No matter how good the surgical team is, if the anesthesia team does not achieve the ideal anesthesia, the outcome can be disastrous.. as well as vice versa.

There are three main conditions for achieving a surgery under GENERAL anesthesia. And I emphasize this because science has progressed so far that we can perform operations on people who are ..awake.

1)Hypnosis: in simple words, putting the patient to sleep. The induction of technical coma with the help of agents, either inhaled gases (eg sevoflurane, desflurane, nitrous oxide, etc.), or with intravenous drugs such as propofol (see Michael Jackson) and thiopental. A form of hypnosis can still be achieved using benzodiazepines (eg midazolam) and others such as ketamine.

Has it happened to you that the patient "wakes up" during surgery? Or better, to finish the operation, wake up the patient and tell you that he heard everything, that he felt everything..while you thought he was sleeping? It has happened in my career so far that I have come across 3-4 incidents, one worse than the other (Patient woke up in the middle of a varicocele and was pulling to remove his laryngeal mask..epicotragic event deeply etched in memory..)

Why does it happen? We don't know. What is certain is that the drugs do not work the same for all of us, and also, the anesthetic machines are not always perfect. Many times the anesthesia machine will malfunction while on duty, and you should be able to recognize it (either by seeing vital signs, eg a sudden increase in pressure, or patient movements).

2) Muscle relaxation: it is the temporary paralysis of the skeletal muscles of the body, so that the surgical team can work at the required point. Muscle wasting in general anesthesia begins with the onset of anesthesia, immediately after hypnosis and before intubation. Always depending on the surgery that follows, the corresponding type of anesthesia is chosen, and therefore muscle paralysis. There are, for example, operations for which muscle paralysis is not required, and this is because it can be a simple skin biopsy, mastectomy, plastic surgery, etc.The anesthesia integration process is a very, very important point that all of us who participate in it (anesthetists, nurses, etc.) must have absolute knowledge of our actions, but also of the 'unexpected' events that may occur at any time and put our patient's life at risk. Since many people's lives were lost during the integration process, we must know at all times which drugs we use (eg propofol, rocuronium, fentanyl), their antidotes [eg sugammadex/bridion (about 100 pounds per bottle)], drugs that may be needed to treat a dangerous hypotension, etc., as well as the algorithms that we may have to use such as in the case of inability to intubate.

Muscle relaxants themselves are already a huge topic of discussion. In general, let me mention the two main categories which are depolarising and non-depolarising muscle relaxants. They work by blocking the transmission of nerve impulses to the muscles and are often referred to as neuromuscular blocking agents.
What is also important to remember is that muscle relaxants provide neither analgesia nor hypnosis, while hypnotics may provide muscle relaxation (see again Michael Jackson and propofol).

Now, depending on the type of surgery, the corresponding muscle relaxant will be used. In this we will take into account some data, e.g. the time period of the operation, the state of the cardiovascular system, the possibility of an emergency stoppage of muscle wasting, etc.(1. class of muscle relaxant, 2. onset time, 3. duration of action, 4. pharmacokinetic profile, 5. Cardiovascular effects, 6. need for reversal).

3. Analgesia: The primary goal of the anesthesiologist must be analgesia, because the right analgesia will also contribute to the better recovery of the patient. Intravenous opioids (fentanyl, morphine, remifentanil, alfentanil, oxycodone) are used for surgical pain, while local anesthetics such as lidocaine, bupivacaine and the combination of these with opioids also have very significant effects in the postoperative period.

Regardless of how rich the literature may be, each anesthesiologist will always use the drug combination with which he is comfortable and familiar with the perioperative management of any reversals.