Intravenous Anesthesia Case File

https://medical-phd.blogspot.com/2021/03/intravenous-anesthesia-case-file.html

Lydia Conlay, MD, PhD, MBA, Julia Pollock, MD, Mary Ann Vann, MD, Sheela Pai, MD, Eugene
C. Toy, MD

Case 1
A 6-year-old child is scheduled for an MRI to rule out a possible brain tumor. The child is terrified
by the scanner’s noise and the closed space, and refuses to hold still. The patient is scheduled for
general anesthesia. However, an anesthesia machine cannot be brought into the same room with the
magnet.

➤ How can this patient safely receive general anesthesia?

ANSWER TO CASE 1:
Intravenous Anesthesia

Summary: A 6-year-old child needs an MRI scan and cannot hold still. The general anesthesia
machine cannot be brought into the room due to the magnet.

➤ Method of Anesthesia: Intravenous anesthetics are used for a pleasant, rapid induction of
general anesthesia. Intravenous agents are also useful in lower doses for sedation. They may also be
used for maintenance of anesthesia in conjunction with inhalational anesthetics, or instead of
inhalational anesthetics when the later are contraindicated (such as in malignant hyperthermia, case
on strabismus) or where it is impractical for an anesthesia machine to be present.

ANALYSIS

Objective
Introduce the student to the more common intravenous anesthetics including their properties, uses,
and potential side effects.

Considerations
This patient can have an anesthetic cream placed on the arm, and then an i.v. placed with minimal
pain. During the procedure, he will be anesthetized with a continuous infusion of propofol, an
intravenous agent, and intubated with an endotracheal tube prior to entering the MRI machine. A
continuous infusion such as this does not require metal equipment such as an anesthesia machine,
and is thus an option in this circumstance.

“Intravenous anesthetics” do not necessarily include intravenous opioids. Opioids are analgesics,
and do not cause general anesthesia per se, unless used in very large doses. However, an opioid (eg,
fentanyl) is often combined with an intravenous hypnotic drug for prevention of a response to a
noxious stimulus (such as movement), and can thus aid in providing a rapid awakening and
spontaneous ventilation at the end of a surgical procedure.

APPROACH TO
Intravenous Anesthesia

DEFINITIONS
Pharmacodynamics: The effects of a drug on the body, or relationship between the plasma
concentration of a drug and the pharmacologic response to it.
Pharmacokinetics: The effects of the body on a drug, and are determined by the volume of
distribution for the drug (Vd) and clearance of that drug from the body. Intravenous anesthetics
exhibit multi-compartmental pharmacokinetics: that is, the drugs are distributed into peripheral
tissues, and at the same time cleared from the body. The administration of an intravenous anesthetic
obviously increases the plasma concentration. The concentration of the agent next peaks in the
“vessel rich” group of tissues, such as liver and spleen, followed by the “muscle group,” and then,
finally, into fat. (Please see Figure 1–1.) Plasma concentrations of intravenous agents are also
affected by tissue uptake, renal excretion, and hepatic metabolism.
Volume of distribution (Vd ): The volume that relates the plasma concentration of a drug to the
total amount of drug in the body. It can be thought of as the “size of the tank.” By rearranging the
terms defining concentration, Vd becomes the dose of drug given intravenously divided by its
plasma concentration.
Clearance: The amount of a drug removed by the kidneys and/or metabolized in the liver during a
specified period of time (eg, mL/min).
Context-sensitive half-time: The time for the plasma concentration of a drug to decrease by 50%
from an infusion that maintains a constant concentration. The context is the duration of the
infusion.