SURGERY II 2.

3
GENERAL ANESTHESIA
August 1, 2019 | Kathrina V. Suarez-Ramos, MD (Part 1) & Eileen Jane Robledo-Palamos, MD (Part 2)
Transcriber/s: Group 1A
ADVANTAGES OF GENERAL ANESTHESIA
Red – recording and transcriber’s notes Patient’s cooperation is not absolutely essential for the success
GENERAL ANESTHESIA of the GA (ideal for uncooperative children)
It is a drug-induced loss of consciousness during which an Proper muscle relaxation for a prolonged period
individual is not arousable even by painful stimulation. Proper control of the airway, breathing and circulation
During GA, the ability to maintain ventilator function is often Amnesia is present, less intra-op awareness and recall
impaired because breathing becomes very shallow. Can be adapted easily to procedures of unpredictable duration
The individual often requires assistance in maintaining a patent Rapid onset of action, titration is possible, and reversible
airway and positive airway ventilation may be required because GA may be the only technique that will prove successful for
of depressed spontaneous ventilation or drug induced certain patients
depression of neuromuscular function.
Features: DISADVANTAGES OF GENERAL ANESTHESIA
o Lack of consciousness Requires increased complexity of care and associated costs
o Amnesia – patients forget any unpleasant events that Requires some degree of preoperative patient preparation
happened during the procedure or surgery Can induce physiologic fluctuations that require active
o Analgesia – no pain intervention because we are inducing an abnormal state
o Attenuation of autonomic response (abnormal in a sense of the patient forgetting everything)
o Neuromuscular blockade Complications like nausea, vomiting, headache, sore throat,
o All should be present when patient is under GA for it to be shivering, and delayed return to normal mental functioning
balanced Associated with malignant hyperthermia, particularly with
Stages: inhalational agents and muscle relaxants. It can be fatal if not
I. Analgesia/sedation managed properly.
II. Delirium or Excitation
III. Surgical anesthesia COMPLICATIONS
IV. Medullary depression GA is overall VERY SAFE it is not the anesthesia itself that gives
the complications but the procedure the patient undergoes
STAGE I: ANALGESIA/SEDATION including one’s comorbidities.
Period between the initial drug administration and loss of Most people, even those with significant health conditions are
consciousness able to undergo GA itself without serious problems.
A very short period from the time of administration until the Risk of complication is more closely related to the:
time that the patient falls asleep o Type of procedure (elective vs. emergency)
o Patient is still awake/conscious o General physical health rather than TYPE of anesthesia
o Spontaneous respiration o Elective procedures have better outcomes than ER
o Reflexes are present procedures because elective procedures have allowed
o Possible small surgery procedures (dressing change in burns) patients to prepare beforehand.

STAGE II: DELIRIUM/EXCITATION CONDUCT OF GENERAL ANESTHESIA

Period marked by excited and delirious activity 1. Pre-operative evaluation (history, focused PE, lab tests, etc.)
o Possible uncontrolled movements, vomiting (if fasting was 2. Preparation for anesthesia: physical preparation - check
not enough) anesthesia machine for leaks to ensure gas concentration is
o Increase in respiratory rate correct, warmers for elderly patients, etc.
3. Induction of anesthesia: phase where we put patient to sleep.
STAGE III: SURGICAL ANESTHESIA Turning on Oxygen + gas sleep + intubated
Period where there is skeletal relaxation, regular breathing (but 4. Airway management
may be shallow), cessation of eye movements 5. Maintenance of anesthesia: patient should be asleep all
o Stage that we want the patient to be in throughout
o Begins with eye-rolling, then becomes fixed 6. Emergence: Waking up
o Loss of corneal and laryngeal reflexes 7. Post-operative pain management
o Pupils dilate and loss of light reflex
o Intercostal paralysis, shallow abdominal respirations (ideal PREPARATION OF GENERAL ANESTHESIA
for endotracheal intubation) Pre-operative medications
Preparations of the anesthesia machine, vaporizers, circuits and
STAGE IV: MEDULLARY DEPRESSION ventilator
Period wherein too much medication relative to the amount of Intravenous access
surgical stimulation Patient positioning:physiology of breathing changes depending
We do not want to go here! Sometimes, even when the patient on the position.
is revived, the patientmay succumb to coma/death. Patient monitoring
o Respiratory arrest
o Cardiac arrest MODE OF ADMINISTRATION
o Coma/death Inhalational

1 of 8
 Intravenous
INHALATIONAL ANESTHESIA
The patient must receive an ADEQUATE:
Concentration of oxygen to prevent hypoxia
Concentration of anesthetic to prevent awareness and recall
Flow of fresh gas to prevent hypercarbia
PHARMACOKINETICS OF INHALATIONAL ANESTHETICS
Figure 1. Pharmacokinetics of Inhalational Anesthetics
The anesthesia machine is connected to the breathing circuit and
connected to the patient. All of which has interplay in the general
anesthesia. The inspired gas concentration, alveolar gas
concentration, and arterial gas concentration all play an important
role in the induction, maintenance, and even emergence from GA.
Involves:
Factors affecting INSPIRATORY CONCENTRATION (FI)
o Fresh gas flow rate (from the machine)
o Volume of the breathing system
o Any absorption by the machine or breathing circuit
o The higher the FGF rate, the smaller the breathing system
volume, and the lower the circuit absorption, the closer
the inspired gas concentration will be to the fresh gas
concentration
Factors affecting the ALVEOLAR CONCENTRATION (FA) (Most
important factor)
o Uptake
o Ventilation
o Concentration
o The alveolar concentration ultimately is the principal
factor in determining the onset of action of the drug
Factors affecting the ARTERIAL CONCENTRATION (Fa)
o Ventilation/Perfusion Mismatch
Increases alveolar partial pressure and decreases
arterial partial pressure
Factors affecting the ELIMINATION
o The most important route for elimination of inhalational
anesthesia is the alveolus
o Recovery depends on lowering anesthetic concentrations
in the brain through: biotransformation (minimal),
transcutaneous loss (very minimal) and exhalation (main)
ELIMINATION
Factors that speed induction, speeds recovery:
● Elimination of re-breathing
● High fresh gas flows
● Low anesthesia circuit volume
● Low absorption by the circuit
● Decreased solubility
● High cerebral blood flow (CBF)
● Increased ventilation
PHARMACODYNAMICS OF INHALATIONAL ANESTHETICS
MINIMUM ALVEOLAR CONCENTRATION (MAC)
It is the alveolar concentration of an inhaled anesthetic that
prevents movement in 50% of patients in response to a
standardized stimulus (e.g. surgical incision). The other 50% can
still react to the painful stimulus, that’s why when we give GA,
even if 1 MAC is adequate to intubate the patient, we increase
that to 1.3 MAC to maintain pain free and to not wake up.
MAC 1.3 is the ED 95 or effective dose at which 95% of the
patients will not move/react to the painful stimulus. The muscle
relaxants, opioids, or BZDs will cover for the remaining 5%.
It is a useful measure because it mirrors brain partial pressure,
allows comparisons of potency between agents and provides a
standard for experimental evaluations
It is a median value with limited usefulness in managing
individual patients, particularly during times of rapidly changing
alveolar concentrations (e.g. induction)
It can be altered by several physiological and pharmacological
variables (e.g. 6% decrease in MAC per decade of age, regardless
of volatile anesthetic why we decrease the MAC in the elderly)
NITROUS OXIDE (MAC 105)
● Commonly known as laughing gas; also used by dentists and vets
● Only inorganic anesthetic gas used clinically
● Sweet smelling and non-flammable, of low potency
● Limited blood and tissue solubility
● Often administered as an adjuvant in combination with other
volatile anesthetics or opioids
HALOTHANE (MAC 0.75)
● Halogenated alkane
● Non-flammable, non-explosive
● Colorless, pleasant smelling so it was often used for pediatric GA
● Immune-mediated HEPATITIS
○ rare; 1 in 35,000
○ More common in obese, mid-aged women,
patients exposed to Hep B, and with a family hx
of hepatitis
● Most potent BRONCHODILATOR
● Sensitizes myocardium to the effect of catecholamines
(producing Preventricular contractions, tachydysrhythmias)
● Potent uterine relaxation
ISOFLURANE (MAC 1.2)
● Halogenated methyl ethyl ether
● Coronary vasodilatation is characteristic
● CORONARY STEAL phenomenon
● Less myocardial depression compared to other inhalational
anesthetics
● High degree of solubility
● Negligible amount of organic fluoride
ENFLURANE (MAC 1.7)
● Halogenated ether
2 of 8
● Non-flammable thalamus (which relays sensory impulses from the RAS to the
● Airway irritant, clear, strong smell cerebral cortex) from the limbic cortex (which is involved with
● Seizure-like activity on EEG at high concentration the awareness of sensation)
● Inorganic fluoride may cause toxicity ● Also used by veterinarians
● Removed from the market due to induced tonic-clonic seizures ● Used as one of the date-rape drugs
in prolonged surgeries ● Nystagmus; some involuntary muscle movement
● Hallucinations during emergence
SEVOFLURANE (MAC 1.8) ● Sympathetic stimulation, increase HR and BP
● One of the most recent & most popular inhalational anesthetics, ○ avoided in elderly patients and patients with
good for pediatrics tachyarrhythmias.
● Completely fluorinated methyl isopropyl ether ○ May be advantageous in hypotensive,
● Rapid induction and emergence hypovolemic, and burn patients
● Relatively stable CV effect, non-arrythmogenic ● Potent bronchodilator.
● Minimal odor and pungency so that induction can be done ○ Good to use for patients with asthma.
mainly through inhalation
● Potent bronchodilator PROPOFOL
● Highly dependent on liver metabolism ● MOA: involve facilitation of inhibitory neurotransmission
mediated by GABA receptor binding; inhibits synaptic
DESFLURANE (MAC 6) transmission at the GABA receptor
● Completely fluorinated methyl ethyl ether (resists ● Total intravenous anesthetic (TIVA)
biodegradation) ● Alkylated phenol
● Fast induction and emergence (lowest blood:gas solubility) ● Short duration, rapid recovery
● Can be used in “low flow“ technique ○ Commonly used in day
● Requires a heated and pressurized vaporizer surgery/out-patient
● Pungent; not used for purely inhalational induction procedures
● Boils at room temperature needs a special temperature- ● Low incidence of nausea and vomiting
controlled vaporizer; not used in DLSUMC ● Bronchodilator effect
● Not given to patients in the ER
INTRAVENOUS ANESTHESIA
BARBITURATES TOTAL INTRAVENOUS ANESTHESIA (TIVA)
● MOA: depresses the reticular activatingsystem in the brainstem, Only applicable to propofol. SPECIFIC TO PROPOFOL
which controls multiple vital functions including consciousness; o Only propofol is used for induction,
inhibits excitatory synaptic transmission to GABA receptors maintenance, until the end of the procedure
● Target: Dorsal horn (pain pathway) o If other drugs are used sometime during the
● Thiopental: anesthesia it is NOT TIVA.
○ Rapid onset but causes apnea when given fast ADVANTAGES:
○ Anticonvulsant The potential toxic effects of inhalational anesthetic are avoided
○ Causes hypotension and myocardial depression A better quality of recovery is claimed
○ Ideal for short diagnostic procedures May be beneficial to certain types of surgery (e.g. Neurosurgery)
○ Poor analgesic property decreases ICP, improves blood flow
○ “Truth serum” Pollution is reduced
○ Part of the lethal injection, inducing sleep/sedation Better choice for ENT- mastoidectomy and tympanoplasties
● Common Barbiturates:
AGENT USE ROUTE DISADVANTAGES:
Thiopental Induction IV Secure, reliable IV access is required
Methohexital Induction IV The risk of awareness if IV infusion fails
Sedation IV Cost of electronic infusion pumps
Induction Rectal (children) May cause profound hypotension for long procedures
Secobarbital, Premedication Oral
Pentobarbital IM ETOMIDATE
Rectal suppository MOA: depresses the RAS & mimics the inhibitory effect of GABA
Unlike barbiturates, may have disinhibitory effects on the parts
of the nervous system that control extrapyramidal motor activity
Recording: The GAs act on the entire CNS. But there are
30-60% incidence of myoclonus with etomidate at induction of
particular areas in the CNS that they affect. It is the RAS,
anesthesia
Cerebral cortex, Limbic System, and the entire spinal cord,
Not for maintenance of anesthesia
particularly the dorsal horn where the pain receptors lie. The
AGENT USE ROUTE
RAS, Cerebral cortex, Limbic system involve consciousness, and
Induction IV, IM
memory; the dorsal horn contains the pain pathways. Ketamine
Sedation IV
Etomidate Induction IV
KETAMINE Induction IV
● MOA: has been demonstrated to be an N-methyl-D- Propofol Maintenance Infusion IV
aspartate(NMDA) receptor (a subtype of the glutamate Sedation Infusion IV
receptor) antagonist
● DISSOCIATIVE ANESTHESIA: functionally dissociates the EMERGENCE FROM ANESTHESIA

3 of 8
 “Waking the patient up” ANATOMY OF THE AIRWAY: NERVE SUPPLY/INNERVATION
Priorities:
o Recovery of consciousness
o Maintenance of a patent airway

OTHER DRUGS USED IN ANESTHESIA

Sedatives
Narcotic analgesics/Opioids
Anticholinergics
Neuromuscular blocking agents

BENZODIAZEPINES
Given to combative patients in the ER
MOA: bind the same set of receptors in the CNS as barbiturates
but bind to a different site on the receptors
AGENT USE ROUTE
Premedication Oral
Diazepam
Sedation IV
Premedication IM
Midazolam Sedation IV
Induction IV
Lorazepam Premedication Oral

--- END OF DR RAMOS’ LECTURE ---

AIRWAY MANAGEMENT
To maintain an open airway and enable mechanical ventilation, an Figure 4. Anatomy of the Trachea
endotracheal tube (ETT) or a laryngeal mask airway (LMA) is used.
NERVE SUPPLY/INNERVATION
• CN VII (Facial)
• CN IX (Glossopharyngeal)
• CN X (Vagus)

Figure 2. Endotracheal tube

Figure 5a. Nerve Supply

Vagus Nerve 2 branches:

Figure 3. Laryngeal mask airway
o Superior laryngeal nerve branch – supplies the
cricothyroid muscle (only muscle supplied by the SLN) and
the larynx between epiglottis and vocal cords
Sub-branches:
Internal SLN – sensory
External SLN – motor
o Recurrent laryngeal nerve – supplies all the muscles of the
pharynx below the vocal cords and trachea and all the
muscles of the larynx (except cricothyroid muscle)
During thyroidectomy if the surgeon injures the RLN it
is very dangerous.

4 of 8
 BMV capability
Laryngoscopes ( direct and video )
Endotracheal tubes of different sizes
Other airway devices: eg. oral, nasal airways
Suction
Oxymetry and CO2 detection (pulse oximeter and capnograph)
Stethoscope
Tape
Blood pressure and ECG monitors
Intravenous access

TO MANAGE AIRWAY: LARYNGOSCOPY AND INTUBATION

Figure 5b. Nerve Supply
CN V1 Ophthalmic division of trigeminal nerve (anterior
ethmoidal nerve) – Nose
CN V2 maxillary division of trigeminal nerve (sphenopalatine
nerves) – Nose
CN V3 Mandibular division of trigeminal nerve (lingual nerve –
Anterior 2/3 of the tongue
CN VII (Facial nerve) – hard and soft palate
CN IX (Glossopharyngeal nerve) – posterior 1/3 of the tongue,
roof of the pharynx tonsils, undersurface of soft palate
ANATOMY OF THE AIRWAY: MALLAMPATI CLASSIFICATION
Anesthesiologists use this scoring to evaluate if the patient is
difficult to intubate or not. Mallampati is a classification of patient’s
upper airway by looking at the size of the tongue and the pharyngeal
structures.
● Visible pharyngeal structures = easy to intubate
● Class I: the entire palatal arch, bilateral faucial pillars are visible
down to their bases
● Class II: the upper part of the faucial pillars and most of the
uvula are visible
● Class III: only the soft and hard palates are visible(base of uvula)
● Class IV: only the hard palate is visible
Figure 6. Mallampati Classification
Which is easier to use? A LARYNGEAL MASK AIRWAY or an
ENDOTRACHEAL TUBE?
o A laryngeal mask airway is easier to use because the glottic
opening does not need to be visualized unlike the
endotracheal mask where it is needed in order to insert it. In
emergency scenarios where the patient cannot be intubated,
the laryngeal mask airway is used.
Is it mandatory to intubate a patient under general anesthesia?
o No, not all patients under general anesthesia need to be
intubated. It depends on the procedure and the patient’s
condition. Short procedures and there is no risk of aspiration
(empty stomach) such as curettage, inhalational gas or
propofol is given and a mask is given to the patient for
ventilation.
o But if the patient is on a full stomach, intubation is indicated
to prevent aspiration and in cases of massive hemorrhage,
intubation is needed because hypotension occurs.
To maintain an open airway and enable mechanical ventilation,
an endotracheal tube or laryngeal mask airways are often used.
Indications for intubation:
o Head and neck surgery:
o Intrathoracic and intraperitoneal surgery: a major surgery
o Surgery with patient in lateral or prone position: there is
danger of hypoxia if not placed in prone position. You cannot
check the patient.
o Obstructed airway oxygen: cannot be delivered properly if
intubation is not given
o Full stomach: to prevent aspiration
o Procedures requiring the anesthesiologist to be remote from
the patient d/t radiation exposure to the anesthesia, patient
has to be intubated because the anesthesiologist cannot
ventilate the patient with a mask.
o Severely ill patient
o Operation in which major hemorrhage is anticipated
o Complicated techniques of anesthesia
o Major pediatric surgery: spinal anesthesia cannot be done on
pediatric patients, hence intubation
o Non-surgical conditions like resuscitation and laryngeal
obstruction

AIRWAY MANAGEMENT ADVANTAGES: LARYNGOSCOPY AND INTUBATION

Consists of: Ensures patent airway
Airway assessment Decreases anatomic dead space
Preparation and equipment check Decreases possibility of aspiration
Patient positioning Ventilation can be assisted or controlled
Pre-oxygenation Suctioning of the lungs is facilitated
Bag and mask ventilation (BMV)
Intubation (if indicated) There is a small port in the laryngeal mask airway for suctioning.
Confirmation of endotracheal tube placement
Intra – operative management and troubleshooting DISADVANTAGES: LARYNGOSCOPY AND INTUBATION
Extubation Increases resistance to respiration
Equipment: Traumatic
An oxygen source

5 of 8
 COMPLICATIONS OF INTUBATION
Malpositioning
i.e: breath sounds only on the R and none on the L, do not
re-intubate.
o Absence of breath sounds on one lung may
(usually on the left) may be an indication that
the tube is too far in and is only providing
ventilation for one lung. (Remember in anatomy
that the R bronchus is more vertically positioned
making it easier to access and prone to
aspiration)
Figure 7. The Sniffing Position
Solution: pull the tube a little bit back to a position where
it would ventilate both lungs. The tube must end before
PRE-OXYGENATION (NOT DISCUSSED)
the bifurcation of the main bronchus (around the carina).
Usually done with a face mask oxygen
Precedes all airway management interventions
The FRC, the patient’s O2 reserve is purged of nitrogen
The pre-oxygenated patient may have a 5 to 8 minute reserve
(improves safety)

BAG AND MASK VENTILATION (BMV) (NOT DISCUSSED)

Is the first step in airway management in most situations with
the exception of those undergoing rapid sequence intubation.
RSI
o Avoid BMV to avoid stomach inflation and to reduce the
potential for the aspiration of gastric contents in non –
fasted patients.

Airway trauma
Physiologic reflexes: airway is innervated by the vagus nerve
causing bradycardia - give atropine
Tune malfunction
EFFECTS OF LARYNGEAL NERVE INJURY

Figure 8. Bag Mask Ventilation

ENDOTRACHEAL INTUBATION (NOT DISCUSSED)

Is employed both for the conduct of GA and to facilitate the
ventilator management
Orotracheal/Nasotracheal

ENDOTRACHEAL INTUBATION (NOT DISCUSSED)

* RLN Bilateral Acute Injury: Vocal cords will stick together= airway 1. DIRECT LARYNGOSCOPY
will be closed

POSITIONING (NOT DISCUSSED)

“SNIFFING” POSITION
Relative alignment of the oral and pharyngeal axes
Neutral position
Cervical spine pathology is suspected
30 degree upward ramp position
For patients with morbid obesity (FRC deteriorates in the supine
position) 2. INDIRECT LARYNGOSCOPY

6 of 8
 3. VIDEO LARYNGOSCOPY
FLEXIBLE FIBEROPTIC INTUBATION (NOT DISCUSSED)
Is routinely performed in awake or sedated patients with
problematic airways.
FOI is ideal for:
o A small mouth opening 
 spontaneous breathing due to muscle paralysis.
o Minimizing cervical spine movement in trauma or
rheumatoid arthritis
o Upper airway obstruction, such as angioedema or tumor
mass
o Facial deformities or facial trauma
FOI can be performed awake or asleep via oral or nasal routes.
Awake FOI: predicted inability to ventilate by mask, upper
airway obstruction
Asleep FOI: failed intubation, desire for minimal C spine
movement in patients who refuse awake intubation
Oral FOI: Facial, skull injuries
Nasal FOI: poor mouth opening
o Instead, if difficult to intubate, intubate while
awake and without relaxants
Interrupt transmission at the neuromuscular junction
Provide skeletal muscle relaxation including the diaphragm
Muscle relaxants only affect skeletal muscles
o Will not cause uterine relaxation because the
uterus is a smooth muscle
o Includes the muscles or respiration which
includes the diaphragm.
Muscle relaxants are used to:
o Improve conditions for tracheal intubation
Without paralysis of the muscles of respiration,
BP may go up due to difficulty in intubation.
Outside the OR where equipment is limited,
small doses of sedatives are used instead of
muscle relaxants to avoid the risk of cessation of
o Provide immobility during surgery thus optimizing surgical
condition
o Facilitate mechanical ventilation
o To provide abdominal relaxation if the procedure is very
long. Especially in the absence of epidural anesthesia.

Figure 8. The NMJ

MECHANISM OF NEUROMUSCULAR TRANSMISSION

Neuromuscular junction consists of a prejunctional motor nerve
EXTUBATION (NOT DISCUSSED)
ending and a postsynaptic receptor area on the skeletal muscle
Most often should be performed when a patient is either
membrane
deeply anesthetized or awake.
Impulse arrives ->Calcium influx ->Increase of Acetylcholine
Adequate recovery from neuromuscular agents should be
release
established
Ach + Ach receptors (nicotinic-cholinergic receptors) ->change in
Extubation during a light plane of anesthesia is avoided
potassium and sodium ions membrane permeability ->decrease
(increases risk of laryngospasm)
in transmembrane potential -> action-potential propagation ->
The patient’s pharynx should be thoroughly suctioned before
muscle contraction
extubation (decreases aspiration of blood and secretions)
Ach hydrolysis by acetylcholinesterase will cause return of
normal ionic gradient of NMJ -> non-depolarized resting state ->
NEUROMUSCULAR BLOCKING AGENTS
Muscle relaxes
Muscle relaxants: such as propofol is NOT given to patients in
the emergency room because it paralyzes the respiratory
muscles (diaphragm) making it difficult to intubate and ventilate
the patient. Should only be given to patient in the OR.
o Midazolam (short, fast acting) can be given in the ER
o Rule: if patient has a difficult airway, do not give Muscle
relaxants. Intubate him/her awake and give a small dose of
sedatives.
Also not given to difficult to intubate patients because of the
possibility of muscle collapse which would make intubation
more difficult
o Diaphragm will also cease its activity leading to
cessation of spontaneous breathing

7 of 8
 to its receptor= no contraction
There is a wide selection compared to depolarizing relaxants. E.g
Rocuronium (intermediate acting)
Based on chemical structures, can be classified as
BENZYLISOQUINOLINIUM, STEROIDAL or other compounds
(CHLOROFUMARATE)
Sugammadex – only reversal agent available. Reverses
Rocuronium
Cholinesterase inhibitors (Neostigmine, Pyridostigamine,
Edrophonium) – reverses the effect of non-depolarizing NMB by
inhibiting acetylcholinesterase thereby flooding the NMJ with
acetylcholine.
Medications that POTENTIATE non-depolarizing muscle
relaxants:

TYPES OF MUSCLE RELAXANTS All volatile anesthetics Lincosamides

Depolarizing Local anesthesia Hexamethonium
o Succinylcholine (may cause malignant hyperthermia, mimics Beta blockers Trimethaphan
acetylcholine structurally) Aminoglycosides Immunosuppressants
Non-depolarizing Polymyxins Magnesium
o Short-acting
Mivacurium
o Intermediate-acting
Rocuronium (only drug that has a reversal agent by
using Sugammadex), Verocuronium, Atracurium, Cis-
atracurium
o Long-acting
Pancuronium, Pipecuronium, Doxacurium

DEPOLARIZING MUSCLE RELAXANT

------ END -------
SUCCINYLCHOLINE (DIACETYLCHOLINE OR SUXAMETHONIUM)
The only depolarizing muscle relaxant in clinical use today
MOA: acts as Ach receptor agonist
o Resembles Ach therefore binds to Ach receptors
o Not rapidly metabolized by acetylcholinesterase ->prolonged
depolarization ->muscle relaxation
Succinylcholine is metabolized by pseudocholinesterase or
plasma cholinesterase which is produced by the liver (problems
in the liver, pregnancy, hyperthyroidism would cause delay in
the breakdown of succinylcholine)
Rapid onset of action (30 – 60 seconds) and short duration (<10
minutes)
The onset of paralysis is usually signaled by visible motor unit
contractions called FASCICULATIONS (may cause post –
operative myalgia)
Causes intragastric, intraocular, and intracranial pressure
elevation
May trigger malignant hyperthermia (Treat with Dantrolene)
and masseter muscle rigidity
Increases serum potassium by 0.5 mEg/L

Conditions that may prolong ACh’s block:

Liver disease, Pregnancy, Malignancy, Malnutrition,
Collagen vascular disease, Hypothyroidism REFERENCES
1. Batch 2020 Trans
NON-DEPOLARIZING MUSCLE RELAXANT 2. Recordings
3. Lecture PPT
TRANSCRIBERS
1. TRANS GROUP: 1A
2. SUBTRANSHEAD: MAR
3. EDITOR: JS
4. TRANS HEAD: KJLA

Acts as a competitive antagonist by preventing Ach from binding

8 of 8