Content deleted Content added
→Purpose: Fixed typo Tags: Mobile edit Mobile web edit |
|||
| (15 intermediate revisions by 11 users not shown) | |||
Line 5:
| Name = General anaesthesia
| Image = Ana arbeitsplatz.JPG
| Caption = Equipment used for anaesthesia in the operating
| ICD10 =
| ICD9 =
Line 14:
| OtherCodes =
| Specialty = [[Anesthesiology|Anaesthetics]]
| uses = Facilitating surgery, [[terminal sedation]]<ref name="Takla2021">{{cite journal |last1=Takla |first1=A |last2=Savulescu |first2=J |last3=Wilkinson |first3=DJC |last4=Pandit |first4=JJ |title=General anaesthesia in end-of-life care: extending the indications for anaesthesia beyond surgery. |journal=Anaesthesia |date=October 2021 |volume=76 |issue=10 |pages=
| complications = [[Anaesthesia awareness]],<ref name=Budworth2019/> overdose,<ref name=Hewer_1937/> death<ref name=Dewachter2009/>
| approach =
Line 23:
| frequency =
}}
'''General anaesthesia''' (UK) or '''general anesthesia''' (US) is a method of medically inducing loss of [[consciousness]] that renders a patient unarousable even with painful stimuli.<ref name=":10">{{cite web | work = American Society of Anesthesiologists. | title = Position on Monitored Anesthesia Care | quote = Approved by the House of Delegates on October 25, 2005, and last amended on October 17, 2018 | url = http://www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/position-on-monitored-anesthesia-care.pdf | access-date = 6 November 2022 | archive-url = https://web.archive.org/web/20221111160055/https://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/position-on-monitored-anesthesia-care.pdf | archive-date= 2022-11-11 | url-status=dead }}</ref> This effect is achieved by administering either intravenous or inhalational general anaesthetic medications, which often act in combination with an [[analgesic]] and [[neuromuscular blocking agent]]. Spontaneous ventilation is often inadequate during the procedure and intervention is often necessary to protect the airway.<ref name=":10" /> General anaesthesia is generally performed in an [[operating theater]] to allow surgical procedures that would otherwise be intolerably painful for a patient, or in an [[intensive care unit]] or [[emergency department]] to facilitate [[endotracheal intubation]] and mechanical ventilation in critically ill patients. Depending on the procedure, general anaesthesia may be optional or required. Regardless of whether a patient may prefer to be unconscious or not, certain [[pain stimulus|pain stimuli]] could result in involuntary responses from the patient (such as movement or muscle contractions) that may make an operation extremely difficult. Thus, for many procedures, general anaesthesia is required from a practical perspective.
A variety of [[General anesthetic|drugs]] may be administered, with the overall goal of achieving [[unconsciousness]], [[amnesia]], [[analgesia]], loss of reflexes of the [[autonomic nervous system]], and in some cases [[paralysis]] of [[skeletal muscle]]s. The optimal combination of anesthetics for any given patient and procedure is typically selected by an [[anesthesiologist|anaesthetist]], or another provider such as a [[nurse anesthetist|nurse anaesthetist]] (depending on local practice and law), in consultation with the patient and the [[surgeon]], dentist, or other practitioner performing the operative procedure.<ref name=":11" />
Line 39:
In the 20th century, the safety and efficacy of general anaesthesia was improved by the routine use of [[tracheal intubation]] and other advanced [[airway management]] techniques. Significant advances in [[Medical monitor|monitoring]] and new [[anesthetic|anaesthetic agents]] with improved [[Pharmacokinetics|pharmacokinetic]] and [[Pharmacodynamics|pharmacodynamic]] characteristics also contributed to this trend. Finally, standardized training programs for anaesthesiologists and [[nurse anesthetist|nurse anaesthetist]]s emerged during this period.
== Purpose and indications ==
'''<big><u>Purpose of general anesthesia</u></big>'''
General anesthesia serves as a critical tool in surgical practice, facilitating procedures by inducing a state of reversible unconsciousness in patients. Its primary objectives encompass ensuring patient safety, comfort, and pain relief throughout the surgical process.
'''Induction of unconsciousness'''
An essential aspect of general anesthesia is the induction of complete unconsciousness, rendering patients oblivious to sensory stimuli and surgical events. This profound state of unawareness is achieved through the administration of pharmacological agents targeting the central nervous system, effectively suppressing consciousness and perception.
'''Analgesia and pain control'''
In addition to inducing unconsciousness, general anesthesia provides effective analgesia to eliminate intraoperative pain. By interrupting the transmission of nociceptive signals within the nervous system, specialized medications mitigate surgical discomfort, enhancing patient comfort and expediting postoperative recovery.
'''Muscle relaxation and facilitation of surgical procedures'''
General anesthesia induces muscle relaxation and abolishes reflex responses, optimizing surgical conditions for precise intervention. This relaxation of skeletal muscles assists surgeons in executing procedures with meticulous precision, ensuring optimal outcomes and minimizing the risk of intraoperative complications.
'''Overall management of physiological responses'''
General anesthesia plays a pivotal role in maintaining physiological stability during surgery, attenuating stress responses and preserving hemodynamic equilibrium. Anesthesiologists vigilantly monitor patients' vital signs and administer medications as necessary to mitigate adverse physiological reactions, promoting procedural safety and minimizing perioperative risks.
'''Psychosocial considerations and anxiety management in surgery'''
Addressing psychosocial concerns and managing anxiety are integral components of perioperative care, particularly in patients facing challenges with stress tolerance or immobility. General anesthesia may be warranted for individuals with movement disorders, while elective use can alleviate anxiety in patients with learning disabilities or severe apprehension. Implementing a patient-centered approach, interdisciplinary collaboration, and comprehensive support are essential strategies for optimizing patient experience and surgical outcomes.<ref name=":12">{{Cite book |title=Miller's anesthesia |date=2020 |publisher=Elsevier |isbn=978-0-323-59604-6 |editor-last=Gropper |editor-first=Michael A. |edition=Ninth |location=Philadelphia, PA}}</ref><ref name=":13">{{Cite book |title=Stoelting's anesthesia and co-existing disease |date=2018 |publisher=Elsevier |isbn=978-0-323-40137-1 |editor-last=Hines |editor-first=Roberta L. |edition=Seventh |location=Philadelphia, PA |editor-last2=Marschall |editor-first2=Katherine E.}}</ref><ref name=":14">{{Cite book |title=Clinical anesthesia |date=2017 |publisher=Wolters Kluwer |isbn=978-1-4963-3700-9 |editor-last=Barash |editor-first=Paul G. |edition=Eighth |location=Philadelphia Baltimore New York London Buenos Aires |editor-last2=Cullen |editor-first2=Bruce F. |editor-last3=Stoelting |editor-first3=Robert K. |editor-last4=Cahalan |editor-first4=Michael K. |editor-last5=Stock |editor-first5=M. Christine |editor-last6=Ortega |editor-first6=Rafael |editor-last7=Sharar |editor-first7=Sam R. |editor-last8=Holt |editor-first8=Natalie F.}}</ref>
'''<u><big>Indications for general anesthesia</big></u>'''
General anesthesia is employed in a variety of medical situations to ensure patient comfort, safety, and successful procedural outcomes. Understanding the indications for general anesthesia is essential for healthcare providers to make informed decisions and optimize patient care.
'''Surgical procedures''': One of the most common indications for general anesthesia is surgical intervention. General anesthesia is utilized across a wide range of surgical specialties, from, on occasion, minor procedures such as dental extractions to major surgeries like cardiac bypass surgery. It allows surgeons to operate on patients without them feeling pain or discomfort, ensuring a smooth and successful procedure.
'''Complex non-surgical medical procedures''': Certain medical procedures, such as endoscopies, colonoscopies, and imaging studies, may occasionally require general anesthesia to ensure patient cooperation and comfort. General anesthesia is particularly beneficial in cases where patients need to remain still for an extended period or if the procedure is invasive and potentially uncomfortable.
'''Emergency situations''': In emergencies, where immediate intervention is necessary, general anesthesia may be indicated to facilitate life-saving procedures. This could include surgeries to treat traumatic injuries, control bleeding, or relieve acute medical conditions. General anesthesia helps ensure patient stability and safety during critical interventions.
'''Pediatric care''': Children often require general anesthesia for various medical procedures, ranging from surgeries to diagnostic tests. Due to their unique physiological and psychological needs, general anesthesia is often preferred to ensure that pediatric patients remain still, pain-free, and cooperative during procedures.
'''Obstetric care''': While regional anesthesia techniques like epidurals are more common in obstetrics, there are situations where general anesthesia may be indicated, such as emergency cesarean sections or certain fetal interventions. General anesthesia ensures that the mother remains unconscious and pain-free during these procedures, prioritizing both maternal and fetal well-being.
'''Special populations''': Certain patient populations, such as those with intellectual disabilities, severe anxiety, or medical conditions that preclude other anesthesia options, may benefit from general anesthesia. Tailoring anesthesia management to the individual needs of these patients ensures optimal safety, comfort, and procedural success.<ref name=":12" /><ref name=":13" /><ref name=":14" />
== Biochemical mechanism of action ==
The [[biochemistry|biochemical]] [[Theories of general anaesthetic action|mechanism of action of general anaesthetics]] is still controversial.<ref>{{cite journal | vauthors = Jevtovic-Todorovic V | title = General Anesthetics and Neurotoxicity: How Much Do We Know? | journal = Anesthesiology Clinics | volume = 34 | issue = 3 | pages = 439–451 | date = September 2016 | pmid = 27521190 | pmc = 5477636 | doi = 10.1016/j.anclin.2016.04.001 }}</ref> Theories need to explain the function of anaesthesia in animals and plants.<ref>{{cite news| vauthors = Frazier J |title=Plants, Like People, Succumb to Anesthesia|url=https://blogs.scientificamerican.com/artful-amoeba/plants-like-people-succumb-to-anesthesia-video/|access-date=26 January 2018|work=[[Scientific American]]|date=26 January 2018}}</ref> To induce unconsciousness, anaesthetics have myriad sites of action and affect the [[central nervous system]] (CNS) at multiple levels. General anaesthesia commonly interrupts or changes the functions of CNS components including the [[cerebral cortex]], [[thalamus]], [[reticular activating system]], and [[spinal cord]]. Current theories on the anaesthetized state identify not only target sites in the CNS but also [[neural network]]s and arousal circuits linked with unconsciousness, and some anesthetics potentially able to activate specific sleep-active regions.<ref>{{Cite journal |last1=Moody |first1=Olivia A. |last2=Zhang |first2=Edlyn R. |last3=Vincent |first3=Kathleen F. |last4=Kato |first4=Risako |last5=Melonakos |first5=Eric D. |last6=Nehs |first6=Christa J. |last7=Solt |first7=Ken |date=2021-05-01 |title=The Neural Circuits Underlying General Anesthesia and Sleep |journal=Anesthesia and Analgesia |volume=132 |issue=5 |pages=1254–1264 |doi=10.1213/ANE.0000000000005361 |issn=1526-7598 |pmc=8054915 |pmid=33857967}}</ref>
Two non-exclusionary mechanisms include [[Membrane-mediated anesthesia|membrane-mediated]] and direct [[Theories_of_general_anaesthetic_action#Membrane protein hypothesis of general anaesthetic action|protein-mediated]] anesthesia. Potential protein-mediated molecular targets are [[gamma-Aminobutyric acid|GABA<sub>A</sub>]],and [[Glutamic acid|NMDA glutamate]] receptors. General anesthesia was hypothesized to either enhance the inhibitory transmission or reduce the excitatory transmission of neuro signaling.<ref>{{Cite journal |last=Lambert |first=David G. |date=2020-05-01 |title=Mechanisms of action of general anaesthetic drugs |url=https://www.anaesthesiajournal.co.uk/article/S1472-0299(20)30028-X/abstract |journal=Anaesthesia & Intensive Care Medicine |language=English |volume=21 |issue=5 |pages=235–237 |doi=10.1016/j.mpaic.2020.02.006 |issn=1472-0299}}</ref> Most volatile anesthetics have been found to be a GABA<sub>A</sub> [[agonist]], although the site of action on the receptor remains unknown.<ref>{{Cite journal |last1=Woll |first1=Kellie A. |last2=Zhou |first2=Xiaojuan |last3=Bhanu |first3=Natarajan V. |last4=Garcia |first4=Benjamin A. |last5=Covarrubias |first5=Manuel |last6=Miller |first6=Keith W. |last7=Eckenhoff |first7=Roderic G. |date=August 2018 |title=Identification of binding sites contributing to volatile anesthetic effects on GABA type A receptors |journal=The FASEB Journal |volume=32 |issue=8 |pages=4172–4189 |doi=10.1096/fj.201701347R |doi-access=free |issn=0892-6638 |pmc=6044061 |pmid=29505303}}</ref> [[Ketamine]] is a non-competitive [[NMDA receptor antagonist]].<ref>{{Cite journal |last1=Zhang |first1=Youyi |last2=Ye |first2=Fei |last3=Zhang |first3=Tongtong |last4=Lv |first4=Shiyun |last5=Zhou |first5=Liping |last6=Du |first6=Daohai |last7=Lin |first7=He |last8=Guo |first8=Fei |last9=Luo |first9=Cheng |last10=Zhu |first10=Shujia |date=August 2021 |title=Structural basis of ketamine action on human NMDA receptors |url=https://pubmed.ncbi.nlm.nih.gov/34321660 |journal=Nature |volume=596 |issue=7871 |pages=301–305 |doi=10.1038/s41586-021-03769-9 |issn=1476-4687 |pmid=34321660|bibcode=2021Natur.596..301Z |s2cid=236496390 }}</ref>
The chemical structure and properties of anesthetics, as first noted by [[Theories_of_general_anaesthetic_action#Lipid solubility-anaesthetic potency correlation (the Meyer-Overton correlation)|Meyer and Overton]], suggest they could target the plasma membrane. A [[Membrane-mediated anesthesia|membrane-mediated]] mechanism that could account for the activation of an ion channel remained elusive until recently. A study from 2020 demonstrated that inhaled anesthetics ([[chloroform]] and isoflurane) could displace [[Phospholipase D|phospholipase D2]] from ordered lipid domains in the plasma membrane, which led to the production of the signaling molecule [[phosphatidic acid]] (PA). The signaling molecule activated TWIK-related K+ channels (TREK-1), a channel involved in anesthesia. PLD<sup>null</sup> fruit flies were shown to resist anesthesia, the results established a membrane mediated target for inhaled anesthetics.<ref>{{cite journal | vauthors = Pavel MA, Petersen EN, Wang H, Lerner RA, Hansen SB | title = Studies on the mechanism of general anesthesia | journal = Proceedings of the National Academy of Sciences of the United States of America | volume = 117 | issue = 24 | pages = 13757–13766 | date = June 2020 | pmid = 32467161 | pmc = 7306821 | doi = 10.1073/pnas.2004259117 | bibcode = 2020PNAS..11713757P | doi-access = free }}</ref>
Line 64 ⟶ 98:
Prior to administration of a general anaesthetic, the anaesthetist may administer one or more drugs that complement or improve the quality or safety of the anaesthetic or simply provide anxiolysis. Premedication also often has mild sedative effects and may reduce the amount of anaesthetic agent required during the case.<ref name=":11" />
One commonly used premedication is [[clonidine]], an [[Alpha-adrenergic agonist#α2 agonists|alpha-2 adrenergic agonist]].<ref>{{cite journal | vauthors = Bergendahl H, Lönnqvist PA, Eksborg S | title = Clonidine in paediatric anaesthesia: review of the literature and comparison with benzodiazepines for premedication | journal = Acta Anaesthesiologica Scandinavica | volume = 50 | issue = 2 | pages = 135–143 | date = February 2006 | pmid = 16430532 | doi = 10.1111/j.1399-6576.2006.00940.x
Benzodiazepines are the most commonly used class of drugs for premedication. The most commonly utilized benzodiazepine is [[Midazolam]], which is characterized by a rapid onset and short duration. Midazolam is effective in reducing [[Preoperational anxiety|preoperative anxiety]], including [[Separation anxiety disorder|separation anxiety]] in children.<ref>{{Cite journal |last=El Batawi |first=Hisham Yehia |date=2015 |title=Effect of preoperative oral midazolam sedation on separation anxiety and emergence delirium among children undergoing dental treatment under general anesthesia |journal=Journal of International Society of Preventive & Community Dentistry |volume=5 |issue=2 |pages=88–94 |doi=10.4103/2231-0762.155728 |issn=2231-0762 |pmc=4415335 |pmid=25992332 |doi-access=free }}</ref> It also provides mild sedation, [[sympathicolysis]], and [[anterograde amnesia]].<ref name=":11" />
[[Melatonin]] has been found to be effective as an anaesthetic premedication in both adults and children because of its [[hypnotic]], [[anxiolytic]], [[Sedation|sedative]], [[Nociception|analgesic]], and [[anticonvulsant]] properties. Recovery is more rapid after premedication with melatonin than with midazolam, and there is also a reduced incidence of post-operative [[Psychomotor agitation|agitation]] and delirium.<ref name="Naguib2007">{{cite journal | vauthors = Naguib M, Gottumukkala V, Goldstein PA | title = Melatonin and anesthesia: a clinical perspective | journal = Journal of Pineal Research | volume = 42 | issue = 1 | pages = 12–21 | date = January 2007 | pmid = 17198534 | doi = 10.1111/j.1600-079X.2006.00384.x | doi-access = free }}</ref> Melatonin has been shown to have a similar effect in reducing perioperative anxiety in adult patients compared to benzodiazepine.<ref>{{cite journal | vauthors = Madsen BK, Zetner D, Møller AM, Rosenberg J | title = Melatonin for preoperative and postoperative anxiety in adults | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | pages = CD009861 | date = December 2020 | issue = 12 | pmid = 33319916 | pmc = 8092422 | doi = 10.1002/14651858.CD009861.pub3 }}</ref>
Line 75 ⟶ 109:
== Anesthesia and the brain ==
{{Use dmy dates|date=January 2019}}Anesthesia has little to no effect on brain function, unless there is an existing brain disruption. Barbiturates, or the drugs used to administer anesthesia do not
== Stages of anaesthesia ==
[[Guedel's classification]], described by [[Arthur Ernest Guedel]] in 1937,<ref name
;Stage 1: Stage 1, also known as ''induction'', is the period between the administration of induction agents and loss of consciousness. During this stage, the patient progresses from analgesia without amnesia to analgesia with amnesia. Patients can carry on a conversation at this time, and may complain about visual disturbance.
Line 145 ⟶ 179:
[[Acetylcholine]], a natural [[neurotransmitter]] found at the [[neuromuscular junction]], causes muscles to contract when it is released from nerve endings. Muscle paralytic drugs work by preventing acetylcholine from attaching to its receptor. Paralysis of the muscles of respiration—the [[diaphragm (anatomy)|diaphragm]] and [[intercostal muscle]]s of the chest—requires that some form of artificial respiration be implemented. Because the muscles of the [[larynx]] are also paralysed, the airway usually needs to be protected by means of an [[endotracheal tube]].<ref name=":11" />
Paralysis is most easily monitored by means of a peripheral nerve stimulator. This device intermittently sends short electrical pulses through the skin over a peripheral nerve while the contraction of a muscle supplied by that nerve is observed. The effects of muscle relaxants are commonly reversed at the end of surgery by [[Cholinesterase inhibitor|anticholinesterase]] drugs, which are administered in combination with muscarinic [[anticholinergic]] drugs to minimize side effects. Examples of skeletal muscle relaxants in use today are [[pancuronium]], [[rocuronium]], [[vecuronium]], [[cisatracurium]], [[atracurium]], [[mivacurium]], and [[succinylcholine]]. Novel neuromuscular blockade reversal agents such as [[sugammadex]] may also be used; it works by directly binding muscle relaxants and removing it from the neuromuscular junction. Sugammadex was approved for use in the United States in 2015, and rapidly gained popularity. A study from 2022 has shown that Sugammadex and neostigmine are likely similarly safe in the reversal of neuromuscular blockade.<ref>{{cite journal | vauthors = Ruetzler K, Li K, Chhabada S, Maheshwari K, Chahar P, Khanna S, Schmidt MT, Yang D, Turan A, Sessler DI | display-authors = 6 | title = Sugammadex Versus Neostigmine for Reversal of Residual Neuromuscular Blocks After Surgery: A Retrospective Cohort Analysis of Postoperative Side Effects | journal = Anesthesia and Analgesia | volume = 134 | issue = 5 | pages = 1043–1053 | date = May 2022 | pmid = 35020636 | doi = 10.1213/ANE.0000000000005842 | s2cid = 245907059 }}</ref>
== Maintenance ==
Line 153 ⟶ 187:
{{anchor|tci}}
In the 1990s, a novel method of maintaining anaesthesia was developed in [[Glasgow]], Scotland. Called [[target controlled infusion]] (TCI), it involves using a computer-controlled syringe driver (pump) to infuse propofol throughout the duration of surgery, removing the need for a volatile anaesthetic and allowing pharmacologic principles to more precisely guide the amount of the drug used by setting the desired drug concentration. Advantages include faster recovery from anaesthesia, reduced incidence of postoperative nausea and vomiting, and absence of a trigger for [[malignant hyperthermia]]. At present, TCI is not permitted in the United States, but a syringe pump delivering a specific rate of medication is commonly used instead.<ref>{{Cite journal |last1=Absalom |first1=Anthony R. |last2=Glen |first2=John Iain B. |last3=Zwart |first3=Gerrit J. C. |last4=Schnider |first4=Thomas W. |last5=Struys |first5=Michel M. R. F. |date=January 2016 |title=Target-Controlled Infusion: A Mature Technology
Other medications are occasionally used to treat side effects or prevent complications. They include [[antihypertensives]] to treat high blood pressure; [[ephedrine]] or [[phenylephrine]] to treat low blood pressure; [[salbutamol]] to treat [[asthma]], [[laryngospasm]], or [[bronchospasm]]; and [[epinephrine]] or [[diphenhydramine]] to treat allergic reactions. [[Glucocorticoids]] or [[antibiotics]] are sometimes given to prevent inflammation and infection, respectively.<ref name=":11" />
Line 178 ⟶ 212:
Mortality directly related to anaesthetic management is very uncommon but may be caused by [[pulmonary aspiration]] of gastric contents,<ref>{{cite journal | vauthors = Engelhardt T, Webster NR | title = Pulmonary aspiration of gastric contents in anaesthesia | journal = British Journal of Anaesthesia | volume = 83 | issue = 3 | pages = 453–460 | date = September 1999 | pmid = 10655918 | doi = 10.1093/bja/83.3.453 | doi-access = free }}</ref> [[asphyxia]]tion,<ref>{{cite journal | vauthors = Parker RB | title = Maternal death from aspiration asphyxia | journal = British Medical Journal | volume = 2 | issue = 4983 | pages = 16–19 | date = July 1956 | pmid = 13329366 | pmc = 2034767 | doi = 10.1136/bmj.2.4983.16 }}</ref> or [[anaphylaxis]].<ref name=Dewachter2009>{{cite journal | vauthors = Dewachter P, Mouton-Faivre C, Emala CW | title = Anaphylaxis and anesthesia: controversies and new insights | journal = Anesthesiology | volume = 111 | issue = 5 | pages = 1141–1150 | date = November 2009 | pmid = 19858877 | doi = 10.1097/ALN.0b013e3181bbd443 | doi-access = free }}</ref> These in turn may result from malfunction of [[Anaesthetic equipment|anaesthesia-related equipment]] or, more commonly, [[Human reliability|human error]]. In 1984, after a television programme highlighting anaesthesia mishaps aired in the United States, American anaesthesiologist [[Ellison C. Pierce]] appointed the Anesthesia Patient Safety and Risk Management Committee within the [[American Society of Anesthesiologists]].<ref name=Guadagnino2000>{{Cite web|title=Improving anesthesia safety|author=Guadagnino C|publisher=Physician's News Digest, Inc.|location=Narberth, Pennsylvania|year=2000|url=http://physiciansnews.com/spotlight/200wp.html|access-date=8 September 2010|archive-url=https://web.archive.org/web/20100815080827/http://physiciansnews.com/spotlight/200wp.html|archive-date=15 August 2010}}</ref> This committee was tasked with determining and reducing the causes of anaesthesia-related [[Disease#Morbidity|morbidity]] and mortality.<ref name=Guadagnino2000/> An outgrowth of this committee, the Anesthesia Patient Safety Foundation, was created in 1985 as an independent, nonprofit corporation with the goal "that no patient shall be harmed by anesthesia".<ref>{{Cite web|title=Foundation History|author=Stoelting RK|publisher=Anesthesia Patient Safety Foundation|location=Indianapolis, IN|year=2010|url=http://www.apsf.org/about_history.php|access-date=8 September 2010}}</ref>
The rare but major complication of general anaesthesia is malignant hyperthermia.<ref>{{cite journal | vauthors = Baldo BA, Rose MA | title = The anaesthetist, opioid analgesic drugs, and serotonin toxicity: a mechanistic and clinical review | journal = British Journal of Anaesthesia | volume = 124 | issue = 1 | pages = 44–62 | date = January 2020 | pmid = 31653394 | doi = 10.1016/j.bja.2019.08.010 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Kim KS, Kriss RS, Tautz TJ | title = Malignant Hyperthermia: A Clinical Review | journal = Advances in Anesthesia | volume = 37 | pages = 35–51 | date = December 2019 | pmid = 31677658 | doi = 10.1016/j.aan.2019.08.003 | s2cid = 207899269 }}</ref> All major
== See also ==
| |||