Anesthesiology

Wiwi J SMF Anesthesiologi & Reanimasi RSU Saiful Anwar

Anesthesiology
y Anesthesia isareversibleconditionof
,q p y g
comfort,quiescenceandphysiological
stabilityinapatientbefore,duringandafter
p
performanceofaprocedure.
p
y Generalanesthesia forsurgicalprocedure
torenderthepatientunaware/
unresponsivetothepainfulstimuli.
Anesthesiology
y Surgicalstress evokesHPAaxisand
y p y
sympatheticsystem.
y Tissuedamageduringsurgeryinduces
coagulationfactorsandactivatesplatelets
leadingtohypercoagulabilityofblood.
y Anesthesiadecreasesthecomponentsof
surgicalstressresponse.
Anesthesiology
Anestheticsareassociatedwith
y Decreaseinsystemicbloodpressure
D i t i bl d
myocardialdepressionanddirect
vasodilatation.
dil t ti
y Bluntingofbaroreceptorcontroland
d
decreasedcentralsympathetictone.
d l h
Anesthesiology
Hallmarkofanesthesia:
y Amnesia/unconsciousness
y Analgesia
g
y Musclerelaxation
Generalanestheticshavetherapeuticindices
ofabout2 4.
Anesthesiology
Preanestheticmedication:
Itistheuseofdrugspriortoanesthesiatomakeit
moresafeandpleasant.
y Torelieveanxiety benzodiazepines.
y Topreventallergicreactions
ll antihistaminics.
h
y Topreventnauseaandvomiting antiemetics.
y To
T provideanalgesia
id l i opioids.
i id
y Topreventbradycardiaandsecretion atropine.
Anesthesiology
Stagesofanesthesia:
y StageI:Analgesia
g g
y StageII:Excitement,combative
behavior dangerousstate
behavior
y StageIII:Surgicalanesthesia
y StageIV:Medullaryparalysis
respiratoryandvasomotor
p y
controlceases.
Anesthesiology
MolecularmechanismoftheGA:
y GABA
GABAA:
A: PotentiationbyHalothane,
Propofol,Etomidate
y NMDAreceptors:
NMDA t inhibitedbyKetamine
i hibit db K t i
Anesthesiology
The main target of inhalation anesthetics is
the brain.
Anesthesiology
Therearetwotypesofanesthetics:
y Inhalational formaintenance
y Intravenous forinductionandshort
procedures
Inhalationanesthetics:
y Advantageofcontrollingthedepthof
anesthesia.
h i
y Metabolismisveryminimal.
y Excretedbyexhalation.
E db h l i
Anesthesiology
Inhalationalanesthetics:
Nonhalogenatedgas:
y Nitrousoxide
Halogenatedhydrocarbons:
y Halothane
y Enflurane
y Isoflurane
y Desflurane
y Sevoflurane
y Methoxyflurane nephrotoxicity.
Anesthesiology
Theimportantcharacteristicsof
Inhalationalanestheticswhichgovern
theanesthesiaare:
y Solubilityintheblood
S l bili i h bl d
(blood:gaspartitioncoefficient)
y Solubilityinthefat (oil:gaspartition
coefficient)
Anesthesiology
Blood:gaspartitioncoefficient:
y Itisameasureofsolubilityintheblood.
Itisameasureofsolubilityintheblood
y Itdeterminestherateofinductionand
recoveryofInhalationalanesthetics.
recoveryofInhalationalanesthetics
y Lowertheblood:gascoefficient fasterthe
i d i d
inductionandrecovery Nitrousoxide.
Ni id
y Highertheblood:gascoefficient slower
inductionandrecovery Halothane.
BLOOD GAS PARTITION CO-EFFICIENT
 Anesthesiology
Blood gas partition co-efficient affecting rate of induction and recovery
 Agents with low solubility in
blood quickly saturate the
blood The additional
blood.
anesthetic molecules are then
readily transferred to the brain.

BLOOD GAS PARTITION COEFFICIENT

Anesthesiology
Anesthesiology
Oil:gaspartitioncoefficient:
y Itisameasureoflipidsolubility.
y Lipidsolubility correlatesstronglywiththe
potencyoftheanesthetic.
potencyoftheanesthetic
y Higherthelipidsolubility potent
anesthetic.e.g.,halothane
th ti h l th
Anesthesiology
y MACvalueisameasureofinhalational
anestheticpotency.
y Itisdefinedastheminimumalveolar
anestheticconcentration(%oftheinspired
air)atwhich50%ofpatientsdonotrespond
) h h f d d
toasurgicalstimulus.
y MACvaluesl areadditiveandlowerinthe
dd dl h
presenceofopioids.
 OIL GAS PARTITION CO-EFFICIENT
Higher the Oil: Gas
Co-efficient
Partition Co efficient
lower the MAC .
E.g., Halothane

0.8

1.4 220
Inhalation MAC value Oil: Gas
Anesthetic % partition
Nitrous >100 1.4
oxide
Desflurane 7.2 23

Sevoflurane 2.5 53

Isoflurane 1.3 91

Halothane 08
0.8 220
I h l i l h i
Inhalationalanesthetics
Nitrousoxide:
d
y Safestinhalationalanesthetic.
y Weakanestheticbutagoodanalgesic.
y Notoxiceffectontheheart,liverand
Notoxiceffectontheheart liverand
kidney.
y Cautionaboutdiffusionalhypoxia
Cautionaboutdiffusionalh po ia
megaloblasticanemia.
Inhalationalanesthetics
Halothane:
H l th
y Itisapotentanesthetic.
y Inductionispleasant.
I d i i l
y Itsensitizesthehearttocatecholamines.
y Itdilatesbronchus preferredinasthmatics.
y Itinhibitsuterinecontractions.
y Halothanehepatitisandmalignant
hyperthermiacanoccur.
Inhalationalanesthetics
Enflurane:
y Sweetandetherealodor.
Sweetandetherealodor
y Generallydonotsensitizestheheartto
catecholamines.
t h l i
y Seizuresoccursatdeeperlevels
contraindicatedinepileptics.
y Cautioninrenalfailureduetofluoride.
Inhalationalanesthetics
Isoflurane:
y Itiscommonlyusedwithoxygenornitrous
oxide.
y Itdonotsensitizetheheartto
catecholamines.
y Itspungencycanirritatetherespiratory
I i i h i
system.
Inhalationalanesthetics
Desflurane:
y Itisdeliveredthroughspecialvaporizer.
y Itisapopularanestheticfordaycare
surgery.
y Inductionandrecoveryisfast,cognitive
andmotorimpairmentareshortlived
y Itirritatestheairpassagesproducingcough
andlaryngospasm.
Inhalationalanesthetics
Sevoflurane:
y Inductionandrecoveryisfast.
I d ti d i f t
y Itispleasantandacceptableduetolackof
pungency.
y Itdonotcauseairwayirritancy.
y y
y Concernsaboutnephrotoxicity.
Anesthetic B:G PC O:G PC Features Notes

Halothane 2.3 220 PLEASANT Arrhythmia

Hepatitis
Hyperthermia
Enflurane 1.9 98 PUNGENT Seizures
Hyperthermia
Isoflurane 1.4 91 PUNGENT Widely used

Sevoflurane 0.62 53 PLEASANT Ideal

Desflurane 0.42 23 IRRITANT Cough

Nitrous 0 47
0.47 14
1.4 PLEASANT Anemia
Anesthesiology
Parenteralanesthetics(IV):
l h ( )
y Theseareusedforinductionofanesthesia.
f
y Rapidonsetofaction.
y Recoveryismainlybyredistribution.
Recoveryismainlybyredistribution
y Alsoreducetheamountofinhalation
anestheticformaintenance.
anestheticformaintenance
y E.g.,includesthiopental,midazolam
propofol,etomidate,ketamine.
f l d k
Anesthesiology
Thiopental(Pentothal):
y Itisanultrashortactingbarbiturates.
y Consciousnessregainedwithin1020minsby
redistributiontoskeletalmuscle.
y ItdonotincreaseICT.
y Itiseliminatedslowlyfromthebodyby
y y y
metabolismandproducehangover.
y Itcanbeusedforrapidcontrolofseizures.
p
Intravenousanesthetics
Propofol(Diprivan):
y MostcommonlyusedIVanesthetic.
MostcommonlyusedIVanesthetic
y Unconsciousnessin~45secondsand
l t i t
lasts~15minutes.
y Antiemeticinaction.
y Suitedfordaycaresurgery residual
impairmentislessmarked.
p
Intravenousanesthetics
Etomidate:
y Itisashortactinganesthetic.
Iti h t ti th ti
y Itsuppresstheproductionofsteroidsfrom
theadrenalglandandnorepeatedinjections.
y Itisaproconvulsantandemetic.
p
y CVSstabilityisthemainadvantageover
anesthetics.
Intravenousanesthetics
Ketamine :Dissociativeanesthesia
y Produce
Produce profoundanalgesia,cataleptic
profoundanalgesia cataleptic
state,immobility,amnesiawithlightsleep.
y ActsbyblockingNMDAreceptors
y HeartrateandBPareelevateddueto
sympatheticstimulation.
h i i l i
y Respirationisnotdepressedandreflexesare
notabolished.
Intravenousanesthetics
Ketamine:
y Emergencedelirium hallucinationsand
Emergencedelirium,hallucinationsand
involuntarymovementsoccursin50%cases
duringrecovery.
duringrecovery
y Itisusefulforburndressingandtrauma
surgery.
surgery
y DangerousforhypertensiveandIHD.
Intravenousanesthetics
Neuroleptanalgesia:
y Itischaracterizedbygeneralquiescence,
h db l
psychicindifferenceandintenseanalgesia
withouttotallossofconsciousness.
ih ll f i
y CombinationofFentanylandDroperidolas
Innovar
Intravenousanesthetics
Neuroleptanalgesia:
y Itisassociatedwithdecreasedmotor
functions,suppressedautonomicreflexes,
cardiovascularstabilitywithmildamnesia.
cardiovascularstabilitywithmildamnesia
y Itcausesdrowsinessbutrespondto
commands
commands.
y Usedforendoscopies,angiographyand
minoroperations.
i i
Anesthetic Duration Analgesia Muscle Others
I.V mins relaxation

Thiopental 5 - 10 --- --- Respiratory

depression

Propofol 5-10 --- --- Respiratory

depression

Ketamine 5-10 +++ --- Hallucinatio

ns

Midazolam 5-20 --- +++ Amnesia

Fentanyl 5-10 +++ --- Respiratory

depression