Anesthesia

By : Dr.Adnan Abdelhadi , General Surgery and laparoscopic surgery

Specialist
Dental medicine (Dentistry)
An-Najah National University

https://najah.zoom.us/rec/play/zAt8POJ4N4BjQGq2MIkPGpg60jmgxlZnGQDu2JifDuIiyS3dIJv69hccu-
N1BFDgH4HZq7ufLJVHexVo.O7RRCMjfj42_-5JX
Anesthesia Types

• Local Anesthesia: loss of sensory perception over a small

-

-
area of the body

• Regional Anesthesia: loss of sensation over a specific

region of the body (e.g. lower trunk)
-

• General Anesthesia: loss of sensory perception of the

entire body
-
 Anesthesia
The administration of drugs
that alleviate pain or other
sensation and movement

Local General
Effects CNS
Effects a specific region of the PNS
,
-

& Als

General anesthesia is a state of reversible

-
-

loss of consciousness for

the purpose of carrying out surgery.
 ↓

Desirable components of anesthesia

89-

1. Immobility in response to noxious stimulus >

-
gv154.
-
-

IS-

2. Anxiolysis anxiety X
3. Amnesia ·bl ; jij
3. Analgesia
4. Unconsiousness
5. Muscle relaxation
6. Loss of autonomic reflexes
AIMS OF ANAESTHESIA

2
Y
Y

⑪
②
6
Triad of anaesthesia
• Neuromuscular blocking agents for muscle relaxation
• Analgesics/regional anaesthesia for analgesia
• Anaesthetic agents to produce unconsciousness
 Phases of Anesthesia

Induction: putting the patient to sleep / ja

&Hil
Maintenance: keeping the patient asleep (without awareness)
Emergence: waking the patient up-

-
(recovery)
,
--pl
 CLASSIFICATION

There are two types of anaesthetics :

— Inhalational --- for maintenance and may
-
use it for induction

— Intravenous --- for induction and short

&

&

procedures the For induction (parential

* main
type >
- IV

* E
344 maintenance -s inhalation

Inhalation anaesthetics:
— Advantage of controlling the depth of anesthesia.
jis
— Metabolism is very minimal. -

— Excreted by exhalation.
expiration by
INHALATIONAL ANAESTHETICS
Non-halogenated gas
• Nitrous oxide inorganiz + no
halogen in

&1158

Halogenated hydrocarbons
• Halothane
• Enflurane
• Isoflurane
• Desflurane
• Sevoflurane
• Methoxyflurane – nephrotoxicity.
The important characteristics of Inhalational
anaesthetics which govern the anaesthesia are

—Partial pressure of anaesthetic in inspired gas

—Pulmonary ventilation
—Alveolar exchange
—Solubility in the blood Solubility I induction
recovery
and
a
equlbrium *

—Solubility in the fat To

>
-
BBB
cross
 General Anesthetics

Inhalational Parenteral

Gas Volatile liquids* Induction Agents

nitrous oxide halothane Barbiturates eg
isoflurane, thiopentone
desflurane,
sevoflurane Propofol Opioids
etomidate etc (fentanyl)
Benzodiazepines
Sufentanil
midozolam
remifentanil
NMRELAXANTs
1. Suxa
*In the beginning there was ether & chloroform
2. Atracurium
Cisat
GENERAL ANAESTHETICS
CLASSIFICATION
2. Inhalational agents
•primarily used for maintenance

•2a: Volatile agents

•Isoflurane
•Sevoflurane
•Desflurane
•Halothane, Enflurane
•Diethyl ether, chloroform, cyclopropane

•2b: Anesthetic gases

•Nitrous Oxide- currently used
•Xenon- in the near future?
 Mechanisms of Action
1. Enhanced GABA effect on GABAA Receptors
• Inhaled anesthetics - Etomidate
-

• Barbiturates - Propofol
• Benzodiazepines
2. Block nicotinic receptor subtypes (analgesia)
• Moderate to high conc’s of inhaled anesthetics
3. Activate K channels (hyperpolarize Vm)
• Nitrous oxide, ketamine, xenon
4. Inhibit NMDA (glutamate) receptors
• Nitrous oxide, ketamine, xenon, high dose barbiturates
-
- -

5. Inhibit synaptic proteins (¯NT release)(amnesia)

6. Enhance glycine effect on glycine R’s (immobility)
• MAC value is a measure of inhalational
anesthetic potency.
& &/ % 50

• It is defined as the minimum alveolar & S11B s

5
anesthetic concentration ( % of the inspired -ki
air) at which 50% of patients do not respond to
a surgical stimulus.

• MAC values are additive and lower in the

presence of opioids.
&
-

• MAC values &1.1 to 1.2 used during surgery.

 Inhaled Anesthetics
• Partial pressure or “tension” in inspired air is a measure of their
concentration
• The speed of induction of anesthesia depends on:
• Inspired gas partial pressure (GA concentration) &is Biss
• Ventilation rate
• GA solubility (less soluble GAs equilibrate more quickly with
*

blood & into tissues such as the brain)

 Minimum Alveolar Concentration
• The minimum alveolar anesthetic concentration required
ge
S

d
I
S

S
to eliminate the response to a painful stimulus in 50% of
patients
M

anasthatic
general
• A measure of GA potency.
• It’s “a population average”.
• 1.3 MAC - 100% will not respond to stimuli.
&
&

• When several GAs are mixed, their MAC values are

additive (e.g. nitrous oxide is commonly mixed w/ other
anesthetics).
MAC %
Nitrous Oxide >100
Halothane 0.75
Methoxyflurane 0.16
MAC & Patient Conditions
• Pregnancy - ¯ MAC (elevated progesterone) -

• Elderly - ¯ MAC (less brain activity)

&
&

• Chronic Alcoholics - ­MAC (cross-tolerance) -

• Acute alcohol poisoning - ¯ MAC (additive) - -

>
-
&
Bispectral Index Monitor (EEG) is used to measure a patient’s “anesthetic depth”.
-
-

BIS LEVEL CLINICAL STATE

100 Awake
80 Sedated
60 Moderate hypnotic level (no recall)
40 Deep hynotic level
0 Isoelectric EEG
 Elimination
• Anesthesiais most commonly terminated by redistribution
of drug from brain to the blood & out through the lungs.
• The rate of recovery from anesthesia for GAs with low >
-

equilibrium Gl
gig tissue w di
blood:gas PCs is faster than for highly soluble Gas.

E - Time is $$ in the O.R. & recovery room

Haltothane
Blood:Gas PCoeff
2.30
ge Desflurane
fast
S
L
0.42 low soubbly
Sevoflurane 0.69
• Halothane & methoxyflurane undergo hepatic metabolism
& can cause liver & kidney toxicity.respectively
BLOOD : GAS PARTITION CO-EFFICIENT
S
— It is a measure of solubility in the blood.

— It determines the rate of induction and

recovery of Inhalational anesthetics.

— Lower the blood : gas co-efficient&– faster the

induction and recovery – Nitrous oxide.

— Higher the blood : gas co-efficient – slower

induction and recovery – Halothane.
BLOOD GAS PARTITION CO-EFFICIENT

&Nee by
O
high solubily
 NITROUS OXIDE
Safest inhalational anaesthetic.
•
•
It is a laughing gas.
•
It is only inorganic anesthetic gas in clinical use.
•
Colorless and odorless
•
Non Explosive and Non Infammable Wr is s -

•
Gas at room temperature and can be kept as a liquid under
pressure.
• MAC > 100% : Incomplete anesthetic Low potency anaesthetic, poor
muscle relaxant Y
So need to mix
by good analgesic
it as

• Good analgesia agent

with other anesthetic

• No metabolism: No toxic effect on the heart, liver and kidney

• Rapid onset & recovery
- Y safest one
②
• A/E- diffusional hypoxia, megaloblastic anemia.
T
D

B124
side
effect
Diffusional hypoxia
d. dini
• On discontinuation of N2O administration, nitrous oxide gas can diffuse
from blood to the alveoli, diluting O2 in the lung.
--

• This can produce an effect called diffusional hypoxia.

*
• To avoid hypoxia, 100% O2 should be administered when N2O is
discontinued.
Uses of N2O
—Mixed with oxygen at 40-67%, then delivered to
patient

·
—Reduces MAC 20-30% Cless N
usa

¡Used with Halothane and Methoxyflurane

to reduce the adverse effects of these gases
CONTRAINDICATION OF N2O
• Air embolism
• Pneumothorax
dilated bowel
• Acute Intestinal Obstruction has
dilation
with No -> more

• Tension Pneumocephalus ↓

• Tympanic membrane grafting risk of perforation

= INHALATIONAL ANESTHETICS
Halothane:
—It is a potent anesthetic.
—Poor analgesic, poor muscle relaxant.
—Induction is pleasant. -Sind
-

—It sensitizes the heart to catecholamines. >

-

can make

arrhythmic
—It dilates bronchus – preferred in asthmatics.
&
&
&

&

—It inhibits uterine contractions.

& &
side —Halothane hepatitis and malignant hyperthermia
&

effect can occur.

CONTRAINDICATION
• Unexplained liver dysfunction.
• Intra-cranial mass lesions.
• Hypo-volemic patient with severe cardiac diseases.
INHALATIONAL ANESTHETICS

=> Enflurane:
• Sweet and ethereal odor.
• Generally do not sensitizes the heart to
catecholamines.
• Seizures occurs at deeper levels –
contraindicated in epileptics.
• Caution in renal failure due to fluoride.
INHALATIONAL ANESTHETICS

> Isoflurane:
• It is commonly used with oxygen or nitrous
oxide.
• It do not sensitize the heart to
catecholamines.
• Its -
pungency can irritate the respiratory
system. laryngospasm
INDICATIONS
• For Cardiac and Neuro- Surgery
• In patients with hepatic or renal compromise
CONTRAINDICATION
• No such contraindication.
• Caution in asthmatics
INHALATIONAL ANESTHETICS
=> Desflurane: Most common in
day Surgery (cos 4)
&

• It is delivered through special vaporizer.

• It is a popular anesthetic for day care surgery.
-

• Induction and recovery is fast, cognitive and motor impairment are

short lived
• Lowest blood:gas partition coefficient: very rapid induction and
recovery
• It irritates the air passages producing cough and laryngospasm.
— Recovery time are approximately 50 % less than those of Isoflurane.
— Pungent Smell
• Expensive
INHALATIONAL ANESTHETICS

Sevoflurane:
• Induction and recovery is fast.
• It is pleasant and acceptable due to lack of
pungency.
• It does not cause air way irritancy.
• Concerns about nephrotoxicity.
-
Properties of Inhaled anesthetics:
summary
Nitrous Oxide
• MAC > 100% : Incomplete anesthetic
• Good analgesia
• No metabolism
• Rapid onset & recovery
• Used along w/ other anesthetic; fast induction & recovery
Halothane
• The first halogenated inhalational anesthetic
-

• Not pungent (use for induction w/ children)*

-

• Medium rate of onset & recovery

• Although inexpensive, its use has declined
• Sensitizes the heart to epi-induced arrhythmias
• Rare halothane induced hepatitis
 Properties of Inhaled anesthetics

Desflurane
• Most rapid onset of action & recovery of
the halogenated GAs (low PC)
• Widely used for outpatient surgery
• Irritating to the airway in awake patients & causes coughing, salivation &
bronchospasm (poor induction agent)
• Used for maintenance of anesthesia
Sevoflurane
ggi • Very low blood:gas partition coefficient w/ relatively rapid onset of action &
recovery *
ja·
I

• Widely used for outpatient surgery*

gg") • Not irritating to the airway
/ethol
• Useful induction agent, particularly in children

* Similar to Desflurane
 Properties of Inhaled anesthetics

Isoflurane
• Medium rate of onset & recovery
• Used for induction & maintenance of anesthesia
• Isoflurane “was” the most commonly used inhalational GA in the US.
Has been largely replaced by Desflurane.
Methoxyflurane
• Now widely considered obsolete
• Slow onset & recovery
• Extensive hepatic/renal metabolism, w/ release of F- ion causing renal
dysfunction
 Toxicity

• Malignant Hyperthermia muscle relaxint

• Esp. when halogenated GA used with succinylcholine
• Rx: dantrolene (immediately)
• Halothane:
• Halothane undergoes >40% hepatic metabolism
• Rare cases of postoperative hepatitis occur
• Halothane can sensitize the heart to Epi (arrhythmias)
• Methoxyflurane
• F release during metabolism (>70%) may cause renal insufficiency after
prolonged exposure.
• Nitrous oxide
• Megoblastic anemia may occur after prolonged exposure due to decreases in
methionine synthase activity(Vit B12 deficiency).