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General Anesthesia
SEMINAR MODERATOR
Dr. Suhas S. Godhi
Dr. Rajesh Kalra
PRESENTER
Dr. ASHOK KUMAR
M.D.S (FIRST YEAR)
CONTENTS
Inhalational Intravenous
Gas Inducing agents Slower acting
Nitrous oxide Thiopentone sod. Benzodiazepines
Liquids Methohexitone sod. Diazepam
Ether Propofol Lorazepam
Halothane Etomidate
Midazolam
Enflurane Dissociative
anaesthesia
Isoflurane Ketamine
Desflurane Neurolept analgesia
Sevoflurane Fentanyl + droperidol
Nitrous Oxide
It is prepared by Priestly in 1776
Anesthetic properties described by Davy in1799
Characterized by inert nature with minimal metabolism
Colorless, odorless, tasteless, and does not burn
Simple linear compound, not metabolized.
It is the only anesthetic agent that is inorganic
Major difference is low potency
MAC value is 105%
Weak anesthetic, powerful analgesic
Needs other agents for surgical anesthesia
Low blood solubility (quick recovery)
Nitrous oxide is generally used as a carrier and adjuvant
to other anaesthetics. A mixture of 70% N20 + 25-30% 02 +
0.2-2% another potent anaesthetic is employed for most
surgical procedures.
As the sole agent, N20 has been used with 02 for dental and
obstetric analgesia.
It is nontoxic to liver, kidney and brain. Metabolism of
N20 does not occur; it is quickly removed from body by
lungs. It is cheap and very commonly used
Halothane
Enflurane
Developed in 1963 by Terrell, released for use in 1972
Stable, nonflammable liquid
Pungent odor
MAC 1.68%
Isoflurane
INDUCING AGENTS
These are drugs which on i.v. injection produce loss of
consciousness in one arm-brain circulation time (-11 sec);
are generally used for induction because of rapidity of onset
of action.
Anaesthesia is then usually maintained by an inhalational
agent. They also serve to reduce the amount of maintenance
anaesthetic. Supplemented with analgesics and muscle
relaxants, they can also be used as the sole anaesthetic.
1. Thiopentone sod.
It is an ultrashort acting thiobarbiturate, highly soluble in
water yielding a very alkaline solution, which must be
prepared freshly before injection.
Extravasation of the solution or inadvertent intraarterial
injection produces intense painnecrosis and gangrene may
occur.
Injected i.v. (3-5 mg/kg) as a 2.5% solution, it produces
unconsciousness in 15-20 sec.
Its undissociated form has high lipid solubility - enters brain
almost instantaneously. Initial distribution depends on organ
blood flow - brain gets large amounts.
Etomidate
Structure similar to ketoconozole
Direct CNS depressant (thiopental) and GABA agonist.
Etomidate Systemic Effects
Little change in cardiac function in healthy and cardiac
patients
Mild dose-related respiratory depression
Decreased cerebral metabolism
Lorazepam
Slower onset of action (10-20 minutes)-- not used for
induction
Used as adjunct for anxiolytic and sedative properties
Not water soluble-- venous irritation
Midazolam
More potent than diazepam or lorazepam
Induction slow, recovery prolonged
May depress respirations when used with narcotics
Minimal cardiac effects
Water soluble
Ketamine
Interrupts cerebral association pathways -- “dissociative
anesthesia”
Stimulates central sympathetic pathways
Ketamine Systemic and Side Effects
Characteristic of sympathetic nervous system stimulation--
increase HR, BP.
Maintains laryngeal reflexes and skeletal muscle tone
Emergence can produce hallucinations and unpleasant
dreams (15%)
TECHNIQUES OF INHALATION OF
ANAESTHETICS
The flow rates are low; specially useful for expensive and
explosive agents (little anaesthetic escapes in the
surrounding air) e.g. halothane, enflurane, isoflurane.
For any one gas there is only one combination of pins and
holes. Unless the correct cylinder valve is attached to the
correct yoke these pins and holes will not match and the
cylinder will not fit.
THE FLOWMETER
The gases pass from the reducing valve, via pressure tubing,
to the flowmeter calibrated for each gas.
The flowmeters record the volume of gas flowing to the
patient per minute. There are various designs for the
flowmeters. We will describe those used in the Boyle's
machine.
The height of the float in the tube indicates the flow of gases
through the flowmeter. The flow should be read at the top of
the bobbin.
THE VAPORISER
From the flowmeters the gases pass in the direction of the
vaporisers. The vaporiser enables volatile agents to be
introduced into the gaseous mixture.
These volatile agents are liquids at room temperature and do
not need to be stored under pressure. The function of the
vaporiser is to vaporise this liquid.
A. During anaesthesia
1. Respiratory depression and hypercarbia.
2. Salivation, respiratory secretions -less now as non-irritant
anaesthetics are mostly used.
3. Cardiac arrhythmias, asystole.
4. Fall in BP
5. Aspiration of gastric contents: acid pneumonitis.
6. Laryngospasm and asphyxia.
7. Delirium, convulsions. Excitatory effects are generally
seen with i.v. anaestheticsspecially if phenothiazines or
hyoscine have been given in premedication. These are
suppressed by opioids.
8. Fire and explosion - rare now due to use of non-
inflammable agents.
B. After anaesthesia
1. Nausea and vomiting.
2. Persisting sedation: impaired psychomotor function.
3. Penumonia, atelectasis.
4. Organ toxicities: liver, kidney damage.
5. Nerve palsies - due to faulty positioning.
6. Emergence delirium.
PREANAESTHETIC MEDICATION
Preanaesthetic medication refers to the use of drugs before
anaesthesia to make it more pleasant and safe.
1. Opioids Morphine (10 mg) or pethidine (50-100 mg),
i.m. allay anxiety and apprehension of the operation,
produce pre and postoperative analgesia, smoothen
induction, reduce the dose of anaesthetic required and
supplement poor analgesic (thiopentone, halothane) or weak
(N20) anaesthetics. Postoperative restlessness is also
reduced.
“Anesthetic awareness”?
“Awake” movie
Released in November 2007
Exploits anesthesia awareness as plot device
“Awake” movie
Irresponsible: Movie ads claim 1 in 700 patients under
general anesthesia are awake for entire surgery
REFERENCES
• The Pharmacological basis of therapeutics- Goodman &
Gilman