Mohammad Shariful Alam (Shohan)

GENERAL ANAESTHESIA
*Types of anaesthesia: I. General anaesthesia (G/A) II. Local anaesthesia (L/A). *General anaesthesia: General anaesthesia is a state of reversible unconsciousness that can be produced by administration of certain drugs. Characteristics/components/objectives of G/A: 1. Analgesia 2. Amnesia 3. Loss of consciousness 4. Inhibition of sensory and autonomic reflexes 5. Skeletal muscle relaxation. Anesthetics: The drugs that cause anaesthesia are called anesthetics. *Criteria of ideal general anesthetics: Produce rapid, smooth and pleasant induction of unconsciousness. Produce controllable and rapidly reversible anaesthesia. Have a wide margin of safety. Produce adequate analgesia and muscle relaxation. Produce minimal local and systemic adverse effects. Have no irritant effect. Be noninflammable and nonexplosive. Allow pleasant and rapid recovery. Be of low cost. *Classification of general anesthetics:
Inhaled Anesthetics 1. Newer generationa) Halothane b) Isoflurane c) Enflurane d) Desflurane e) Sevoflurane f) Methoxyflurane g) Nitrous oxide (NO) I/V or Parenteral Anesthetics 1. Barbiturates Thiopental Na Methohexital 2. Benzodiazepines Midazolam Diazepam 3. Opioid analgesics Morphine Fentanyl Sufentanil Alfentanil Remifentanil 4. Propofol 5. Ketamine 6. Miscellaneous drugso Droperidol

2. Older drugs Ether Cyclopropane Chloroform.

Mohammad Shariful Alam (Shohan)

Etomidate.

*Q. Why ether is called a complete anesthetic? Ans. Ether is the only drug that is a complete anesthetic. Thiopental only produces unconsciousness without skeletal muscle relaxation. Whereas morphine or pethidine produces analgesia with little change on muscle tone or level of consciousness. In contrast ether produces a mixture of unconsciousness, skeletal muscle relaxation and anaesthesia. Thats why ether is a complete anesthetic. But thereby, ether is not used as anesthetic in modern days due to its inflammable and explosive property. *Stages of anaesthesia: There are four stages of anaesthesia-

Stage I: Stage of analgesia. The patient responds to command but is free from pain. Here the respiration remains normal. Stage II: It is the stage of excitement or delirium. The patient is anaesthetized and does not respond to command, respiration is irregular. Stage III: It is the stage of surgical anaesthesia. Surgical stimulation does not produce movement. Here is recurrence of regular respiration and extends to complete cessation of continuous respiration. Stage III is further divided into four planes in term of ocular movement, eye reflexes & papillary signs (I, II, III, and IV).
Plane I Present Present Constricted Slight Present Normal or moderate Present Plane II Beginning of intercostals paralysis Irregular Gradual dilation No Absent Gradually diminished Gradually lost Plane III Progression of paralysis Abdominal respiration is predominant More dilation No Absent Slight Slight or absent Plane IV Cessation of thoracic respiration Cessation of abdominal respiration Full dilate No Absent Paralysis Absent

Points Thoracic respiration Abdominal respiration Pupil size Eye movement Corneal reflex Muscle tone Laryngeal & pharyngeal reflex

Stage IV: This stage is the stage of medullary depression. There is depression of vasomotor center in medulla and respiratory center. But death is prevented by artificial respiration. Without full circulatory respiratory support death may occur.

These stages are better demonstrable with inhalation anesthetics specially ether. In modern anaesthesia practice, the distinctive signs of each of the four stages described above are obscured. The reason includeso The relatively rapid onset of action of many inhaled anesthetics compared to that of diethyl ether.

Mohammad Shariful Alam (Shohan)

o The respiratory activity is often controlled with the aid of mechanical ventilator. o The presence of other pharmacologic agents given preoperatively or per-operatively also influences the signs of anaesthesia. *Pre-anesthetic medications: Def.: Drugs which are administered prior to induction of anaesthesia. Purpose of using pre-anesthetic medication: - To produce gastrointestinal and bronchial secretion (Atropine). - To prevent bradycardia (Atropine). - To allay anxiety and produce amnesia without producing excessive drowsiness (Diazepam). - To produce analgesia (Morphine, Pethidine). - To reduce vomiting (Metoclopromide, Prochlorperazine). # Drugs for preanaesthetic medication: Antichloinergic (cardiac vagal tone & bronchial secretion) e.g., Atropine Scopolamine Antiemetics e.g., Droperidol Hydroxyzine Antihistamines e.g., Diphenhydramine Barbiturates e.g., Pentobarbiturates Secobarbiturates Benzodiazepines e.g., Diazepam & Midazolam Opioid e.g., Morphine Meperidine Fentanyl Muscle relaxant e.g., Atracurium Vecuronium Succinyl choline Others- H2 receptor antagonist e.g., Ranitidine Metoclopramide- peristalsis. Balanced anaesthesia: Def.: Balanced anaesthesia means the sequential use of combination of drugs which are frequently applied in modern day anaesthesia. It includes - the administration of pre-anesthetic medication

Mohammad Shariful Alam (Shohan)

the use of both intravenous and inhalation anesthetic for induction and maintenance of anaesthesia. - the use of neuromuscular blocking drugs. Advantage: It has the advantage of fulfill all criteria of general anaesthesia without side effects of the drug administered.
[I/V anesthetics produce induction, and inhalation anesthetics produce maintenance]

Induction: Def.: Induction is defined as the period of time from the onset of administration of the anesthetic to the development of effective surgical anaesthesia in the patient. General consideration: All the inducing agents are given in I/V route. Induction often includes co-administration of skeletal muscle relaxant. Maintenance: Def.: It is the time during which the patient is surgically anesthetized. It is done by inhaled anesthetic agent. Maintenance during surgery:It is done by following drugs1) Inhaled anesthetic Halothane Nitrous oxide 2) Neuromuscular blocker/muscle relaxants a) Short acting Suxamethonium (for endotracheal intubations) b) Long acting - Atracurium, Vecuronium (for subsequent muscle relaxation) 3) Analgesic - Pethidine (to get more analgesia). Basal anaesthesia: Def.: Perenteral administration of one or more sedative or hypnotics to produce a state of depressed consciousness and to form a base of surgical anaesthesia is called basal anaesthesia. Drugs used: Ultra short acting barbiturates e.g. - Thiopental Na - Paraldehyde. Advantage: Produce rapid and pleasant induction within 20 seconds.

Mohammad Shariful Alam (Shohan)

Disadvantage: THIOPENTALCauses direct cardio-respiratory depression. Na *Pharmacokinetics: -

Ultra short acting barbiturate Very high lipid solubility Causes rapid induction, within 20 seconds Short duration of action Extensive plasma protein bounding High volume of distribution Short half life- 2.5 to 3minutes Narrow TI

Pharmacological action: 1. CNS: Sedation Hypnosis Cardio-respiratory depression Anticonvulsant action HR BP Circulatory collapse

2. CVS:

3. Kidney: Oliguria (due to ADH secretion)

4. GIT: 5. Eye: 6. Liver:

Constipation Miosis Increase metabolism of other drugs.

Indication: - For induction of anaesthesia prior to inhalation anaesthesia - As basal anesthetic - As anticonvulsant during anaesthesia. *Adverse effects: -

Local: Thrombophlebitis Haematoma/Bruising/Ulceration General: Cardio-respiratory depression Circulatory collapse Cough/Hiccup/Apnoea

Mohammad Shariful Alam (Shohan)

Laryngobronchospasm Hang over *Contraindication: i. Barbiturate hypersensitivity ii. Severe cardiovascular disease iii. Obstructive pulmonary disease (OPD) iv. Severe acute bronchial asthma v. Addisons disease vi. Hepatic dysfunction *Q. Why thiopental-Na is used for induction? Ans. Ultra short acting barbiturate is used for induction because it produces

Rapid onset of action with pleasant induction within 20 second. Less respiratory depression due to short duration of action. - Rapidly distributed in the body that allows a minute to minute adjustment of the intensity of their effect. - It induces pleasant induction with little post-anesthetic excitement or vomiting.
Q. What are the advantages and disadvantages of Thiopental-Na as I/V anesthetic? Ans. Advantages: i. Single dose is required ii. Rapid cerebral depression (within 30 sec) iii. Rapid recovery (within 15 min) iv. No excitement and pleasant anaesthetized v. Not hepatotoxic vi. Not nephrotoxic vii. Low post operative complication Disadvantage: i. No analgesia ii. It cannot be used alone iii. Large and repeated dose accumulation in fatty tissues subsequent slow release prolonged anaesthesia with cardio-respiratory depression.

PROPOFOL

*Q. Why propofol is extensively used as a component of balanced anesthesia and has great popularity as an anesthetic in day surgery? Ans. Advantages of propofol: 1) It produces anesthesia at a rate similar to that of the intravenous barbiturates. 2) Recovery is more rapid. 3) In particular, patients are able to ambulate sooner after propofol.

Mohammad Shariful Alam (Shohan)

4) Patients feel better in the immediate postoperative period after propofol as compared with other intravenous anesthetics. 5) Postoperative vomiting is uncommon, and propofol is reported to have antiemetic actions. 6) Propofol is used for both induction and maintenance of anesthesia. 7) The drug does not appear to cause cumulative effects or delayed arousal following prolonged infusion. These favorable properties are responsible for the extensive use of propofol as a component of balanced anesthesia and for its great popularity as an anesthetic for use in day surgery. =>The drug is also effective in producing prolonged sedation in patients in critical care settings. Nice to know: Half life of propofol is about 2-8 minutes. The drug is rapidly metabolized in the liver (ten times faster than thiopental) by conjugation to glucoronide and sulfate and excreted in urine. Disadvantages of propofol: 1) Propofol causes marked decrease in systemic blood pressure during induction of anesthesia, primarily through decreased peripheral resistance. 2) Propofol has greater negative inotropic effect on the heart than etomidate and thiopental. 3) Apnea and pain at the site of injection also occurs. 4) Hypersensitivity reaction.
[Inotropic = Influencing force of muscular contractility]

KETAMINE (Street drug)

General consideration: Analog of phencyclidine Produces dissociative anesthetic state Has psychoactive properties. Dissociative anaesthesia: It is a form of anaesthesia caused by ketamine which is characterized bya) b) c) d) Catatonia: Catatonia Amnesia Analgesia With or without actual loss of consciousness (hypnosis).

Mohammad Shariful Alam (Shohan)

Thought disorder manifested by incomprehensive speech and abnormality of movement in which the patient may become immobile or adopt awkward posture for prolonged period. Pharmacokinetics: Route of administration: I/V or I/M (Dose: I/V= 1-2mg/kg body wt; I/M= 6-8 mg/kg body wt) Onset of action: 15 minutes Distribution: Rapidly distributed into highly vascular organs including the brain, liver & the kidney. Duration of action: 15 minutes. Metabolism: Liver Excretion: Urinary and biliary excretion. *Mechanism of action: Ketamine Causes blockade of the membrane effects of the Glutamate (excitatory NT) at the NMDA (Nmethyl-D-aspartate) receptor subtype. **Special notes: Ketamine is the only I/V anesthetic agent that possesses both analgesic properties & the ability to produce dose-related cardiovascular stimulation. Because of the high incidence of postoperative psychic phenomena associated with its use ketamine is not commonly used in general surgery. Postoperative psychic phenomena: It is one of the adverse effects of ketamine that includes Postoperative disorientation Sensory and perceptual illusions & Vivid dreams. *Indication: (i) Considered useful for poor-risk geriatric patients and in unstable patients (e.g., cardiogenic or septic shock) because of its cardio stimulatory properties. (ii) It is used in low doses for outpatient anesthesia in combination with propofol. (iii) In children undergoing painful procedures (e.g., dressing changes for burn). Adverse effects:

I. II.

CVS: Heart rate, arterial pressure, and cardiac output are significantly increased. CNS: Has indirect sympathomimetic activity 1) Emergence phenomena - postoperative disorientation - sensory and perceptual illusion - vivid dreams 2) Cerebral blood flow

3) Oxygen consumption 4) Intracranial pressure

Mohammad Shariful Alam (Shohan)

III. Respiratory system: In most patients, ketamine decreases the respiratory rate *Q. How to prevent the adverse effects of Ketamine? Ans. Diazepam, 0.2-0.3 mg/kg, or midazolam, 0.025-0.05 mg intravenously, given prior to the administration of ketamine reduces the incidence of adverse effects.

ETOMIDAT E Main advantages: 1) Used for induction of anaesthesia. 2) Minimal respiratory and cardiovascular depressant effect. 3) Loss of consciousness within seconds. 4) Low frequency of apnea. Disadvantages: 1) High incidence of nausea, vomiting. 2) Pain at the site of injection. 3) Myoclonus. 4) May cause adreno-corticoid suppression via inhibitory effect on steroidogenesis. Q. What is Neurolepts anesthesia? Ans. It is a method of intravenous anesthesia in which combined use of short acting opioid analgesic (Fentanyl) and a neurolepts (Droperidol) produce a state of subconsciousness, analgesia & amnesia. Patients become completely disinterested & detached from the environment without loss of consciousness. Use: Short acting surgical procedure e.g., Endoscopy.

Q. What is Anesthesia? 9

Ans.

Mohammad Shariful Alam (Shohan)

It is a state of complete or partial loss of sensation with or without loss of consciousness. INHALATION ANAESTHESIA Criteria of an ideal inhalation anesthetic: It should produce pleasant maintenance and recovery from anaesthesia. Adequate relaxation of skeletal muscles. A wide margin of safety. Lesser adverse effects in normal doses. Properties of inhaled anesthetic: i. Blood : Gas partition co-efficient (solubility in blood) determine the rate of induction & recovery of inhaled anesthetics. Lower the blood gas partition co-efficient faster the induction and recovery. e.g., N2O ii. Oil : Gas partition co-efficient (solubility in fat) is a measure of fat solubility which determines the potency of an anesthetic agent & its distribution into the body. High lipid solubility delays recovery. *Mechanism of action: Inhalation anesthetic + Keeps open the K channel for a longer period Efflux of K+ out of the cell Negativity inside the cell Hyper polarization of neuronal cells Raised threshold value for action potential Decrease ability to initiate action potential Pharmacological action/Organ level effect: 1. 2. 3. CNS: CNS depression

CVS: Myocardial depression Reduce myocardial O2 consumption Respiratory system: Respiratory depression Decrease mucocilliary function in the airways Bronchodilatation Delayed response to dyspnoea

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Mohammad Shariful Alam (Shohan)

4. 5.

Renal system: Decrease GFR Increase renal vascular resistance Liver: Decrease hepatic blood flow Uterus: Oxytocic action (N2O) Tocolytic action (halothane, isoflurane)

6.

Toxicity:

1. 2. 3. 4.

Hepatotoxicity Nephrotoxicity Malignant hyperthermia Chronic toxicity: a. Mutagenicity b. Carcinogenicity c. Abortion d. Teratogenicity e. Hematoxicity.

Q. Write down the advantages and disadvantages of Halothane as GA. Ans. Advantages Disadvantages o Hang over effect is common Highly potent inhalational anesthetic due to high lipid solubility. agent. o Easily produce cardio Non-explosive, non-irritant respiratory depression. Fast induction (smooth, rapid) o Severe hepatitis may develop Surgical anaesthesia produced within o Causes cardiac dysrrhythmia 2-5 min. o Reduces hepatic & renal Induction is rapid blood flow & decreases blood pressure. Postoperative nausea and vomiting are low. Best agent for pediatric and for patients with bronchial asthma.

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