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General Anesthesia
Factors Influencing Rate of Induction
Anesthetic Potency
Differences between Inhalational Agents
Concentration and Second Gas Effect
Diffusional Hypoxia
The rate of increase in tension (concentration) of anesthetic in arterial blood is determined in part by the
concentration of the agent in the inspired gas.
This rate of increase in arterial gas tension is not the same anesthetic to anesthetic.
Differences between agents have to do with differing physico-chemical properties which are manifest as
differences in solubility:
The anesthetic molecule interacts with water molecules in the blood and depending on the anesthetic molecular
structure, the drug will be relatively more or less soluble.
Lower anesthetic solubility in blood results in the "blood" compartment becoming saturated with the drug
following fewer gas molecules transferred from the lungs into the blood.
Once the "blood" compartment is saturated with anesthetic, additional anesthetic molecules are readily
transferred to other compartments, the most important one of which is the brain.
Note that for Nitrous Oxide, the arterial gas tension rises rapidly to approximate that of the inspired tension.
By contrast, the arterial gas tension rises much more slowly for Halothane or Ether
These differences are related to differences in anesthetic physical properties.
For example, Nitrous Oxide is relatively insoluble, enabling its tension (partial pressure) to rise very rapidly.
The rate of rise of anesthetic concentration in the brain is influenced by the rate of rise of arterial blood anesthetic
tension.
Differences in the rate of arterial gas tension increase between agents is only part of the story in terms of
anesthesia because different anesthetics have different potencies.
As a result, different anesthetics exhibit different MAC values.
Underlying these differences would be differences at the level of the anesthetic-receptor interaction.
Pulmonary ventilation
The higher the minute volume the more gas per unit time
is delivered to the alveoli for transfer to arterial blood.
The general rule is that, with aging, MAC values decrease and that the rate of change (rate of decrease) does not
appear dependent on which agent is considered.
The rule of thumb is that the MAC value decreases by about 6% per 10 years (22% decline in MAC from age 40
to age 80; 27% decline in MAC from age 1 to 40)
An equation which allows estimation of the change in MAC as a function of difference in age in years from 40:
MAC =a(10bx) where a is the MAC value at age 40 for the particular anesthetic, x is the difference in cage of the
patient from 40 and b = -0.00269.
MINIMUM ALVEOLAR
CONCENTRATION
Rationale for using alveolar concentrations rather
than brain levels
MAC values are relatively insensitive to sex, height, weight, and duration of anesthesia,
although age and temperature do affect MAC.
On the other hand, there are factors that increase the apparent MAC value for an
anesthetic. These factors include:
Hypernatremia
Hyperthermia
Not surprisingly there are many factors which decrease the apparent MAC value for an
anesthetic. These factors include:
Factors
Factors that may Decrease the Apparent MAC Value for an Anesthetic
Increasing age
Lithium
Ketamine (Ketalar)
Pancuronium (Pavulon)
Hydroxyzine (Atarax,Vistaril)
Metabolic acidosis
Hypo-osmolality
Pregnancy
Factors that may Decrease the
Apparent MAC Value for an Anesthetic
Metabolic acidosis
Hypo-osmolality
Pregnancy
Diazepam (Valium)
Hypothermia
Hyponatremia
Lidocaine (Xylocaine)
Opioids
Barbiturates
Chlorpromazine (Thorazine)
Isoflurane (Forane)
Enflurane (Ethrane)
Desflurane (Suprane)
Sevoflurane
Nitrous Oxide
Halothane: (Flurothane)
Overview
Halothane (FluOverview:
Halothane (Fluothane) may not adequately suppress visceral reflexes or provide adequate muscle relaxation for surgery
Halothane (Fluothane) is associated with reversible reduction in glomerular filtration rates (GFR)
Halothane Advantages:
This drug's low blood:gas partition coefficient explains both relatively rapid anesthesia induction and recovery from
anesthesia
Halothane Disadvantages
May provide adequate muscle relaxation greater than seen with halothane; perhaps adequate for
abdominal procedures
Fluoride (a metabolite of enflurane) usually does not reach levels required for kidney toxicity
Enflurane Advantages
Rapid, smooth adjustment of depth of anesthesia with limited effects on pulse or respiration.
Enflurane Disadvantages:
Enflurane Status: Enflurane is used as an inhalational agent for adults; but is not widely used for
pediatric cases.
Isoflurane
Isoflurane anesthesia: provides unconsciousness
Initially, until deeper levels of anesthesia are reached, isoflurane stimulates airway
reflexes with attendant increases in secretions, coughing and laryngospasm.
(greater with isofluorane than enflurane or halothane)
May provide adequate muscle relaxation greater than seen with halothane which
may be adequate for abdominal procedures.
Unlike enflurane, convulsive activity has not been seen with isoflurane.
Isoflurane
Isoflurane Advantages:
Rapid, smooth adjustment of depth of anesthesia with limited effects on pulse or respiration.
Isoflurane Disadvantages:
Isoflurane Status:
Despite the relative insolubility of nitrous oxide, large quantities of gas are rapidly absorbed due to its high inhaled
concentration. This concentration effect speeds induction as fresh gas is literally drawn into the lung from the breathing
circuit.
Since nitrous oxide is often administered with a second gas, the second gas effect also enhances the rate of induction.
If administration of nitrous oxide is abruptly discontinued, rapid transfer of NO from blood and tissues to the alveoli decreases
arterial tension of oxygen. This process is diffusional hypoxia.
Nitrous oxide should NOT be used if pockets of trapped air are suspected in the patient (e.g. following a
pneuomoencephalogram) or in an occluded middle ear, because of exchange of NO with nitrogen with attendant gas
expansion.
Nitrous oxide has minimal effects on the circulation compared to the other inhalational agents with which it is co-
administered.
Nitrous Oxide
Nitrous Oxide Advantages:
Excellent analgesia
Nonflammable
Little or no toxicity
Weak anesthetic
For example, if 75% nitrous oxide and 25% oxygen were administered,
the rate of uptake of gas may be 1 liter/min.
As this volume of gas is removed from the lung, fresh gas is pulled into
the lung from the breathing circuit of the anesthetic delivery equipment.
This effect further increases the delivery of gas mixture and therefore
the rate of rise of arterial tension for nitrous oxide is increased.