General Anesthetics
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General Anesthetics Drugs used to induce a state of unconsciousness with the overall aim of ensuring hypnosis, amnesia , analgesia, immobility, skeletal muscle relaxation, and loss of control of reflexes of the autonomic nervous system. Features of ideal anesthetic

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General Anesthetics

Drugs used to induce a state of unconsciousness with the overall aim of ensuring hypnosis, amnesia, analgesia, immobility, skeletal muscle relaxation, and loss of control of reflexes of the autonomic nervous system.


Features of ideal anesthetic

1. Rapid and smooth induction and recovery.

2. Wide safety margin.

Minimal side effects.

Balanced anesthesia

Use of more than one agent to obtain ideal anesthesia.


Adjuncts to general anesthetics

I. Muscle relaxants

II. Pre-anesthetic medications.

Muscle relaxants

Facilitate intubation.

Suppress muscle tone.

Atracurium, Vecuronium, Succinylcholine.


  • Pre-anesthetic medication

    • Anticholinergics: prevent secretion of fluids into the respiratory tract .

    • Benzodiazepines: relieve anxiety.

    • Thiopental-Propofol: rapid induction of anesthesia .

    • Antiemetic : post surgical N&V.

    • Antihistaminics: allergic reactions.

    • H2-receptor blockers: reduce gastric acidity

    • Opiates: induce analgesia.


Depth of anesthesia ( Four stages).

Stage I

- Analgesia.

- Loss of pain sensation.

- The patient is conscious and conversational.

Stage II

- Excitement.

- Increased, irregular blood pressure.

- Increased respiratory rate.

  • Patient may experience delirium & violent behavior.

  • Dilated & reactive eye.


Stage III

- Surgical anesthesia.

- Regular respiration & relaxation of sk. muscles.

- Eye reflexes decrease until the pupil is fixed.

Stage IV

- Medullary paralysis.

- Severe depression of vasomotor and respiratory centers.

- Death may occur.


  • Classification

  • 1. Inhalation Anesthetics

  • Gases: nitrous oxide

  • Volatile Liquids:

    • Ether

    • Halogenated compounds

  • 2. Intravenous Anesthetics


Mechanism of action

  • Interaction with membrane ion channels.

  • Enhancing the action of inhibitory neurotransmitters, GABA and glycine thus decrease neuronal excitability.

  • Inhibition of excitatory neurotransmitters e.g. ketamine is NMDA receptor antagonist



Pharmacokinetics of general anesthetics

  • Induction of anesthesia

  • Maintenance of anesthesia

  • Depth of anesthesia.

  • Recovery of anesthesia

  • MAC value


Induction, Maintenance and Recovery

Induction

Time elapsed between onset of administration of anesthetic and development of effective surgical anesthesia.

Maintenance

Time during which the patient is surgically anesthetized.

Recovery

The time from discontinuation of anesthetic drug until consciousness is regained.


Factors controlling induction & recovery

  • The anesthetic concentration in the inspired air (Direct).

  • Blood solubility: Blood: gas partition coefficient (Inverse relation).

  • Pulmonary blood flow(Inverse).

  • Rate and depth of ventilation (Direct).


DRUGS Solubility Induction & Recovery

(Blood : gas partition coefficient )

Methoxyflurane 12 Slow

Halothane 2.3 Slow

Enflurane 1.8 Medium

Isoflurane 1.4 Medium

Sevoflurane 0.69 Rapid

Desflurane 0.42 poor & Rapid

Nitrous Oxide 0.47 Rapid


Minimum Alveolar Concentration & Recovery(MAC)

  • It is the concentration of inhalation anesthetic that produce immobility in 50 % patients in response to surgical incision.

  • Depends on potency of anesthetic agents.

  • The lower the MAC value the more potent the drug.

  • MAC is increased by CNS stimulants.

  • MAC is decreased by CNS depressants & in old people.


POTENCY & RecoveryMAC

Methoxyflurane 0.16

Halothane 0.75

Isoflurane 1.4

Enflurane 1.7

Sevoflurane 2

Desflurane 6-7

Nitrous oxide >100


Pharmacological Actions & Recovery

CNS

-  metabolic rate.

-  ICP (due to cerebral vasodilatation) # in head injuries.

- Dose - dependent EEG changes (Enflurane).


CVS & Recovery

  • Hypotension

  • Bradycardia except ( Isoflurane, Desflurane)

  • Myocardial depression (Halothane , Enflurane)

    - Sensitize heart to catecholamines (Halothane)


Respiratory system & Recovery

- All respiratory depressants.

  • Bronchodilators (Halothane – Sevoflurane).

  •  mucociliary movement.

  • Airway irritation (Desflurane- Enflurane).

    Liver

    - Decrease hepatic flow.

    - Hepatotoxicity (Only halothane ).


Uterus & Recovery

  • Uterine relaxation

  • Nitrous oxide: has minimal relaxant effect (labor).

    Skeletal muscles

    - All are skeletal muscle relaxants to varying degree.


Methoxyflurane & Recovery

  • The most potent (high lipid solubility).

  • 50 % is metabolized to fluoride (nephrotoxic).

  • Slow induction (20 minutes).

  • For veterinary use only.


Halothane (Fluothane) & Recovery

  • Non irritant (pleasant odor)

  • Potent anesthetic.

  • Weak analgesic.

  • Weak skeletal muscle relaxant.

  • Slow induction and recovery (blood solubility).

  • Metabolized to hepatotoxic metabolite, trifluroethanol.


  • CVS depression & Recovery

    • Hypotension

    • Bradycardia (vagomimetic action)

    •  Myocardial contractility.

    •  Cardiac output

  • Respiratory depression.

  • Uterine relaxant.

  • The agent of choice in children (Pleasant).


Adverse Effects & Recovery

  • Hepatotoxicity (repeated use).

  • Malignant hyperthermia.

  • Decrease the cardiac output.

  • Sensitizes heart to action of catecholamines cardiac arrhythmias.


Enflurane ( & RecoveryEthrane)

  • More rapid induction and recovery than halothane.

  • Less potent than halothane.

  • Better muscle relaxation.

  • Better analgesic properties.

  • is metabolized to fluoride (8%).

  • Excreted in the kidney


  • CVS depression & Recovery

    - Hypotension

    -  Cardiac output

    - No sensitization of the heart to catecholamines

    Disadvantages

  • Pungent (less induction -not for pediatrics).

  • CNS stimulation (Epilepsy-like seizure- abnormal EEG).


Contraindications & Recovery

  • patients with seizure disorders.

  • renal failures.


Isoflurane ( & RecoveryForane)

  • Less potent than halothane

  • Better analgesic action.

  • More rapid induction & recovery than

    halothane

  • Stable compound (2%).

  • Low biotransformation (less fluoride).

  • No hepatotoxicity.

  • No sensitization of the heart.

  • No cardiac arrhythmias.


  • CVS depression & Recovery

    • Hypotension ( VR)

      - Potent coronary vasodilator.

      -  H R

      Disadvantages

      Pungent (not for pediatrics).


Desflurane (Suprane) & Recovery

  • Pungent odor (irritation - cough)

  • Rapid induction & fast recovery (low blood solubility).

  • Less potent than halothane.

  • Less metabolized (0.05 %).

  • CVS

    - Hypotension

    -  VR

    -  H R


Sevoflurane & Recovery

  • Less potent than halothane

  • Rapid induction and recovery.

  • Less metabolized (3- 5% fluoride)

  • Better smell

  • No airway irritation (children)

  • CVS

    - Hypotension

    -  VR

    - Little effect on HR


Nitrous Oxide (N2O) & Recovery

  • The most potent analgesic.

  • Weak anesthetic (low potency, combined).

  • The most rapid induction & recovery

    due to low blood solubility.

  • No muscle relaxation.

  • No respiratory depression.

  • Not hepatotoxic.

  • Minimal CVS adverse effects.


Adverse Effects & Recovery

  • Diffusion hypoxia: (respiratory diseases).

  • Nausea and vomiting.

  • Inactivation of B 12  megaloblastic anemia.

  • Chronic use:

    Bone marrow depression- leukopenia

    Abortion - Congenital anomalies


Therapeutic Uses & Recovery

  • Outpatient anesthesia (dental procedures).

  • As a component of balanced anesthesia.

  • Neuroleptanalgesia.

  • Delivery

    Contraindications

    1. Pregnancy.

    2. Pernicious anemia.

    3. Immunosuppression.


Intravenous Anesthetics & Recovery

1. Ultra short acting barbiturates.

2. Benzodiazepines.

3. Opioids.

4. Ketamine.

5. Propofol

6. Etomidate.

7. Neuroleptics


Intravenous & RecoveryAnesthetics

  • Rapid induction & recovery except BZs

  • Should be injected slowly.

  • Recovery is due to redistribution from CNS.

  • Can be used alone in short operation.

  • Outpatients anesthesia.

  • NO need for special equipments.

  • Analgesic activity (Opioids & ketamine ).

  • Amnesic action (BZs & ketamine).


Ultra Short acting Barbiturates & Recovery

Thiopental (Pentothal)

Methohexital (Brevital)

Thiamylal (Surital)


Thiopentone & Recovery

Rapid onset of action 1 min (high lipid solubility)

Ultra short duration of action 15 - 20 min

Metabolized slowly by the liver.


Pharmacodynamics & Recovery

  • Potent anesthetic.

  • No analgesic activity

  • No skeletal muscle relaxation.

  • CNS:  ICP (Used in head injuries).

  • CVS: Hypotension & Dysrhythmia.

  • Respiratory depression (dose-dependent).


Uses & Recovery

  • As anesthetic alone in minor surgery.

  • Induction of anesthesia in major surgery.

    Adverse Effects

  • Respiratory depression

  • CVS collapse.

  • Extravasations.

  • Precipitation of porphyria attack.

  • Hypersensitivity reaction.


Contraindication & Recovery

1. Chronic obstructive lung disease.

2. Porphyria.

3. Hypersensitive patients.

4. Severe hypotension (hypovolemic & shock patient).


Benzodiazepines & Recovery

Midazolam (Versed)

Diazepam (Valium)

Lorazepam (Ativan)

  • The best one is Midazolam

  • Amnesic action.

  • Reduce anxiety.

  • No analgesic activity


Uses & Recovery

1. Induction of general anesthesia.

2. Alone in minor procedure (endoscopy).

3. Balanced anesthesia (midazolam).

4. Pre-anesthetic medication (diazepam)

Side Effects

  • Slow induction & recovery.

  • Respiratory depression.


Etomidate (Amidate) & Recovery

- Ultra-short acting hypnotic (non barbiturates).

- No analgesic activity.

  • Rapid onset of action

  • Short duration of action.

    - Decreases  ICP.

  • Minimal CVS and respiratory depressant effects.

    Uses

    Induction of Anesthesia


Side Effects & Recovery

  • Involuntary movements during induction (diazepam).

  • Postoperative nausea -vomiting.

  • Adrenal suppression (inhibition of steroidogenesis)

  • Pain at sit of injection.

  • Teratogenic.


Propofol & Recovery

- Hypnotic (non barbiturates).

- No analgesia.

  • Rapid onset – Faster recovery than thiopental.

  • Short duration of action.

    - Decreases  ICP.

  • Antiemetic action.

    Uses

  • Induction of anesthesia

  • Maintenance of anesthesia (balanced anesthesia).


Side Effects & Recovery

1. Hypotension (PVR).

2. Excitation (involuntary movements).

3. Pain at site of injection.

4. Expensive.

5. Clinical infections due to bacterial contamination.


Ketamine & Recovery

  • Non barbiturate

  • Dissociative anesthesia

    • Analgesia.

    • Amnesia.

    • Immobility.

    • Complete separation from the surrounding environment.

      Pharmacokinetics

      - Rapid onset of action (slower than thiopental)


- Short duration of action. & Recovery

- Metabolized in the liver to active metabolite (Norketamine).

Pharmacodynamics

1. BP & cardiac output (central sympathetic activity)

2.  Increases plasma catecholamine levels.

3.  ICP

4. Potent bronchodilator (asthmatics).


Advantages & Recovery

  • Can be given IV, IM (Children).

  • No bronchospasm.

  • Hypovolemic or shock patients.

    Side Effects

  • Post operative hallucination, vivid dreams & disorientation & illusions (Diazepam).

  • Risk of hypertension & cerebral hemorrhage.

  •  ICP


Contraindications & Recovery

  • CVS diseases (hypertension-stroke).

  • Head injuries.

    Uses

  • Minor operations (children, elderly, shock patients .

  • Short duration diagnostic procedures


Opiate Drugs & Recovery

Fentanyl (Sublimaze)

Alfentanil(Alfenta)

Sufentanil(Sufenta)

Fentanyl

-Rapid onset

- Short duration of action.

- Potent analgesia.

- No muscle relaxation


Uses & Recovery

  • Cardiac surgery ( + nitrous oxide).

  • Neuroleptanalgesia (fentanyl + droperidol ).

  • Neuroleptanesthesia (Fentanyl + droperidol+ nitrous oxide).

    Side Effects

  • Respiratory depression, bronchospasm (wooden rigidity).

  • Hypotension.

  • Nausea & vomiting.


  • Increase in ICP. & Recovery

  • Prolongation of labor & fetal distress.

  • Urinary retention.

    Contraindication

    1. Head injuries.

    2. Pregnancy.

    3. Bronchial asthma.

    4. Chronic obstructive lung diseases.

    5. Hypovolemic shock (Large dose only).


Neuroleptanalgesia & Recovery

  • A state of analgesia, sedation, muscle

    relaxation BUT no loss of consciousness.

  • Innovar (Fentanyl + Droperidol ).

  • Contraindicated in parkinsonism.

  • Diagnostic procedures that require

    co-operation of the patient.

    Neuroleptanesthesia : a combination of (Fentanyl + Droperidol + nitrous oxide).


Thank you
Thank you & Recovery


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