General anesthesia is a medically-induced loss of consciousness with concurrent loss of protective reflexes due to anesthetic agents. A variety of medications may be prescribed to induce unconsciousness, amnesia, analgesia, skeletal muscle relaxation, and the loss of autonomic system reflexes. During this state, the patient is unarousable to verbal, tactile, and painful stimuli. Upper airway obstruction during general anesthesia usually necessitates the insertion of a laryngeal mask airway or endotracheal tube to preserve airway patency. Likewise, the patient's spontaneous ventilation is often inadequate, requiring the employment of partial or full mechanical support with positive pressure ventilation. The patient's cardiovascular function may also become impaired.
In the past, when physical examination offered the only clue as to a patient's depth of anesthesia, anesthetic overdose by an inexperienced anesthetist easily occurred. It was not until the 20th century that the anesthesia community developed a truly systematic approach to monitoring. In 1937, Dr. Arthur Guedel created one of the first safety systems in anesthesiology, with a chart that explained the stages of anesthesia with an increasing depth ranging from stages 1 to 4. Despite newer anesthetic medications and delivery techniques that have led to faster onset and recovery from general anesthesia (and in some cases circumventing certain stages entirely), Guedel's classification is still in use.
Stages of Anesthesia Based on Guedel's Classification
General anesthesia induces physiological responses, which can result in morbidity and mortality when emergency situations are not properly addressed. Therefore, it is regarded as a high-risk activity where the benefits of surgery must outweigh the potential harms. Mortality directly related to anesthetic management is very rare but may result from pulmonary aspiration of gastric contents, asphyxiation, or anaphylaxis. These adverse events may result from anesthesia-related equipment failure or, more often, from human error. However, numerous investigators and professional organizations have stated that mortality rates attributable to anesthesia have decreased over the last two decades. This decrease is reportedly due to advances in safety, including enhanced detection and monitoring methods and new technology, modernization, and extensive adoption of practice guidelines and other quality improvement measures to reduce errors. Anesthesia today is generally considered safe and effective, especially when practiced by an experienced and well-prepared anesthesia provider.
Guedel's classification for the stages of general anesthesia was initially established for the delivery of diethyl ether, the single available volatile anesthetic at the time. While Gaudel's patients were usually pre-medicated with sedative agents such as morphine and atropine, ether was the drug of choice for induction. It offered analgesia, amnesia, and relaxation of muscles. However, ether was phased out in the United States by the 1980s and replaced with the current fluorinated hydrocarbon anesthetics. Today, the "balanced anesthesia" approach uses several types of medications for induction (such as intravenous anesthetics, analgesics, neuromuscular blockers, and benzodiazepines), which can disguise the characteristic clinical markers of each defined anesthesia stage. These agents also have a higher safety profile than diethyl ether. Lastly, advances in awareness, breathing, and circulation monitoring due to technology have greatly augmented the clinical data obtained from the patient's physical examination. Therefore, some anesthesiologists view Guedel's work as antiquated. Yet others still employ his classification not only for describing developments in general anesthesia but in clinical practice for inhalation inductions across various surgical procedures.
Anesthesia is thought to be best practiced via an interdisciplinary approach that includes not only anesthesiologists but also certified registered nurse anesthetists, nurses and other operating room staff, recovery room nurses, and anesthesia technicians to ensure patient safety. Because there is no agent capable of instantly reversing the effects of inhaled anesthetics, close monitoring of the patient is necessary during anesthesia. A responsible anesthesiologist, anesthetist, or nurse should attentively monitor vital signs during induction and maintenance periods to confirm that the patient is appropriately sedated without signs of instability. Standard guidelines and regulations for monitoring patients during anesthesia are required in every hospital operating room, outpatient surgical or procedure center, and office-based setting. The benefits of collaboration in healthcare positively correlate with increased patient satisfaction, improved patient outcomes, increased staff satisfaction, and reduced hospital costs.
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