Inhalational

ANAESTHETIC
Agents

Dr. Med. Khaled Radaideh

Department of Anesthesiology - Jordan University of

Science and Technology Irbid-Jordan
Dr. Med. Khaled Radaideh * 1
 INHALATIONAL ANAESTHETIC AGENT
Objectives
1. Introduction
2. Pathway O2-Brain
3.MAC (Definition and Values and factors effecting MAC)
4. Factors determining how quickly the inhalational
agent reaches the alveoli reaches and the brain from
the alveoli

Dr. Med. Khaled Radaideh

5. Nitrous Oxide (N2O)
5.1. physical properties, Pharmacology and side
effects)
5.2. What is diffusion hypoxia?
5.3. Second gas effect

* 2
 INHALATIONAL ANAESTHETIC AGENT
Objectives
6. Halothane
6.1. properties
6.2. Metabolism
6.3. Dosage, Administration an Supply
6.4. Indications and contraindications

Dr. Med. Khaled Radaideh

6.5. Effect on Organ Systems
6.6. Advantages and Disadvantages

* 3
 INHALATIONAL ANAESTHETIC AGENT
Objectives
7. Isoflurane and Sevoflurane
7.1. properties
7.2.Effect on Organ Systems
7.3. Advantages and Disadvantages
7.4. Indications and contraindications

Dr. Med. Khaled Radaideh

* 4
 INHALATIONAL ANAESTHETIC AGENT
Introduction

🞂 IV anesthesia : induce anesthesia

Inhalation anesthesia : maintain anesthesia

🞂 IV anesthesia : mg/KG or microgram/Kg

Inhalation anesthesia : Percentage of the volume
%
EXAMPLE:
2 L/min. O2 + 4 L/min N2O 🡪
Conc. Of N2O = 4/(2+4) = 66%

Dr. Med. Khaled Radaideh * 5

Pathway O2-Brain

Dr. Med. Khaled Radaideh * 6

 MAC Definition
🞂 Minimal alveolar concentration (MAC):
Is defined as the conc. At 1 atmosphere of
anesthetic in the alveoli that is required to
produce immobility in 50% of adults patient
subjected to a surgical incision

🞂 MAC is important to compare the potencies

of various inhalational anesthetic agents

🞂 1.2 -1.3 MAC prevent movement in 95% of

patients

Dr. Med. Khaled Radaideh * 7

 MAC Value
🞂 N2O = 105%
🞂 Halothane = 0.75%
🞂 Isoflurane = 1.16%
🞂 Euflurane = 1.68%
🞂 Sevoflurane = 2%
🞂 Deslurane = 6%

🞂 N2O alone is unable to produce adequate

anesthesia ( require high conc. )

Dr. Med. Khaled Radaideh * 8

Factors that alter anesthetic
requirements (MAC):

Dr. Med. Khaled Radaideh * 9

 No Effect on MAC
🞂 Gender
🞂 Duration of anesthesia
🞂 Carbon dioxide tension (21-95 mmHg)
🞂 Metabolic Acid base status
🞂 Hypertension
🞂 Hyperkalemia

Dr. Med. Khaled Radaideh * 10

Factors determining how quickly the inhalational
agent reaches the alveoli?
1-Increasing the delivered concentrations of
anesthetic
2- The gas flow rate through the anesthetic
machine
3-Increasing minute ventilation
MV = Respiratory Rate × Tidal volume

Dr. Med. Khaled Radaideh * 11

Factors determining how quickly the inhalational
agent reaches the brain from the alveoli in order
to establish anesthesia?

1- The rate of blood flow to the brain

2- The solubility of the inhalational agent in
the brain
3- The difference in the arterial and venous
concentration of the inhalational agent

Dr. Med. Khaled Radaideh * 12

INHALATIONAL ANAESTHETIC
AGENT
Nitrous Oxide (N2O)

Dr. Med. Khaled Radaideh * 13

 Nitrous Oxide (N2O)
🞂 Physical property:
⭶ laughing
⭶ Not flammable
⭶ Odorless
⭶ Colorless

Dr. Med. Khaled Radaideh

⭶ Tasteless

* 14
 Nitrous Oxide (N2O)
🞂 PHARMACOLOGY:
⭶ Good Analgesic
⭶ Weak anesthetic
⭶ Excreted via lungs
⭶ MAC = 105%

Dr. Med. Khaled Radaideh

⭶ Lower water solubility
⭶ Not Metabolized in the body

* 15
 Nitrous Oxide (N2O)
🞂 SIDE EFFECTS:
⭶ Diffusion Hypoxia.
⭶ Effects on closed gas spaces.(nitrous oxide can
diffuse 20 times faster into closed spaces than it can be
removed, resulting in expansion of pneumothorax, bowel
gas, or air embolism or in an increase in pressure within
noncompliant cavities such as the cranium or middle ear.
⭶ CVS depression

Dr. Med. Khaled Radaideh

⭶ Toxicity
⭶ Teratogenic

* 16
Nitrous Oxide (N2O) DIFFUSION HYPOXIA
What is diffusion hypoxia?
Diffusion hypoxia is a decrease in PO2 usually
observed as the patient is emerging from an
inhalational anesthetic where nitrous oxide (N2O)
was a component. The rapid outpouring of

Dr. Med. Khaled Radaideh

insoluble N2O can displace alveolar oxygen,
resulting in hypoxia. All patients should receive
supplemental O2 at the end of an anesthetic and
during the immediate recovery period.

* 17
Nitrous Oxide (N2O) SECOND GAS EFFECT
Second gas effect: The ability of the large
volume uptake of one gas (first gas) to
accelerate the rate of rise of the alveolar
partial pressure of a concurrently
administered companion gas (second

Dr. Med. Khaled Radaideh

gas) is known as the second gas effect.

* 18
 19

Dr. Med. Khaled Radaideh

*
Halothane
 Halothane: (2-bromo-2-chloro-1,1,1-
trifloroethane)
Synthesized in 1951.
* Volatile liquid easily vaporized, stable, and
nonflammable
* Most potent inhalational anesthetic
• MAC of 0.75%
• Colorless liquid , pleasant smell , decomposed by
light. So should be stored in container away from
light and heat
• It has low blood/gas solubility coeffient of 2.5 and
thus induction of anasthesia is relatively rapid.

Dr. Med. Khaled Radaideh * 20

 HALOTHANE
Metabolism

🞂 20% metabolized in liver by oxidative

pathways.
🞂 Major metabolites : bromin, chlorine,
Trifloroacetic acid, Trifloroacetylethanl amide.

Dr. Med. Khaled Radaideh * 21

 HALOTHANE
Dosage and Administration and supply
🞂 The induction dose varies from patient to patient.
The maintenance dose varies from 0.5 to 1.5%.
🞂 Halothane may be administered with either
oxygen or a mixture of oxygen and nitrous oxide.
🞂 How is Halothane Supplied
🞂 Halothane is supplied in amber colored 250 mL
glass bottles, stabilized with thymol 0.01% (w/w).
🞂 Store in cool, dry place and protect from undue
exposure to light.

Dr. Med. Khaled Radaideh * 22

 HALOTHANE
Indications and Contraindications
🞂 Indications
🞂 Halothane is indicated for the induction and
maintenance of general anesthesia.
🞂 Contraindications
🞂 Halothane is not recommended for obstetrical
anesthesia except when uterine relaxation is
required.

Dr. Med. Khaled Radaideh * 23

 HALOTHANE
Effect on systems
Respiratory system:
🞂 Halothane anesthesia progressively depresses
respiration.
🞂 Its cause inhibition of salivary & bronchial secretion.
🞂 Its may cause tachypnea & reduce in tidal volume and
alveolar ventilation .
🞂 Its cause decrease in mucocillary function which lead
to sputum retention.
🞂 It causes bronchodilation. Hypoxia, acidosis, or apnea
may develop during deep anesthesia.

Dr. Med. Khaled Radaideh * 24

 HALOTHANE
Effect on systems
Cardiovascular system:
🞂 Halothane anesthesia reduces the blood pressure, and cause
bradycardia.(atropine may reverse bradycardia.).
🞂 It cause myocardial relaxation & Hypotention.
🞂 Its also causes dilation of the vessels of the skin and skeletal
muscles
🞂 Halothane maybe advantages In pts with CAD , bcz of
decrease of oxygen demand.
🞂 Arrhythemias are very common .(especially with
epinephrine).
◦ To minimize effects :
● Avoid hypoxemia and hypercapnia
● Avoid conc. Of adrenaline higher than 1 in 10000

Dr. Med. Khaled Radaideh * 25

 HALOTHANE
Effect on systems
Gastro intestinal tract:
Inhibition of gastrointestinal motility.
🞂 Cause sever post. Operative nausea & vomiting
Uterus:
🞂 Halothane relaxes uterine muscle, may cause postpartum
hemorrhage .
🞂 Concentration of less than 0.5 % associated with increase
blood loss during therapeutic abortion.
Skeletal muscle:
🞂 Its cause skeletal muscle relaxation .
🞂 Postoperatively , shivering is common , this increase oxygen
requirement>>> which cause hypoxemia

Dr. Med. Khaled Radaideh * 26

 HALOTHANE
Effect on systems
Hepatic dysfunction:
🞂 Two type of dysfunction:
🞂 1- Type I hepatotoxicity: mild, associated with derangement
in liver function test , this result from metabolic of Halothane
in liver. results from reductive (anaerobic) biotransformation
of halothane rather than the normal oxidative pathway.
🞂 2- Type II hepatotoxicity: fulminate (uncommon); sever
jaundice , fever, progressing to fulminating hepatic necrosis,
Its increased by repeated exposure of the drugs.
high mortality 30-70%

Dr. Med. Khaled Radaideh * 27

 Recommendation for Halothane
anasthesia:
🞂 1- A careful anasthetic history .
🞂 2- repeated exposure of halothane within
3 months should be avoided.
🞂 3- History of unexplained jaundice or
pyrexia after previous exposure of
halothane.

Dr. Med. Khaled Radaideh * 28

 Main advantages of halothane:
🞂 Rapid smooth induction .
🞂 Minimal stimulation of salivary & bronchial
secretion.
🞂 Brochiodilatation.
🞂 Muscle relaxant .
🞂 Relatively rapid recovery.

Dr. Med. Khaled Radaideh * 29

 Main disadvantages are:

🞂 Poor analgesia.
🞂 Arrhythmias.
🞂 Post operatively shivering.
🞂 Possibility of liver toxicity.

Dr. Med. Khaled Radaideh * 30

 Enflurane
MAC =1.68%
Potent cardiovascular depressant

Dr. Med. Khaled Radaideh * 31

 Isoflurane
Properties
- isomer of enflurane.
- Carcinogenic (not approved)
- colorless, volatile, liquid, pungent
odor.
- stable.
- No preservative .
- Non-flammable.

Dr. Med. Khaled Radaideh * 32

 Isoflurane
Properties
- Least soluble of the modern inhalational agent 🡪
equilibrate more rapidly
- Induction rapid theoretically (pungency??)
- pungency 🡪 cough, breath holding.

Dr. Med. Khaled Radaideh * 33

 Isoflurane
effects on systems:-
Respiratory:
dose dependent depression of ventilation.
CVS:
- myocardial depressant (vitro Vs Clinical),
coronary vasodilatation (coronary steal
syndrome).
uterus: relaxation of uterine muscles (same).

Dr. Med. Khaled Radaideh * 34

 Isoflurane
effects on systems:-
CNS:
low concentration Vs High concentration.
▪ Low : no change on the flow.
▪ High : increase blood flow by
vasodilatation of the cerebral arteries.

- Muscles: relaxation (dose-dependent).

Dr. Med. Khaled Radaideh * 35
 Isoflurane
Advantages and Disadvantages
Advantages
- Rapid induction and recovery.
- Little risk of hepatic or renal toxicity.
- Cardiovascular stability.
- Muscle relaxation.
Disadvantages
- Pungent odor.
- Coronary vasodilatation.

Dr. Med. Khaled Radaideh * 36

 Sevoflurane
Properties

- New drug.
- Non flammable.
- Pleasant smell.
- MAC 2%.
- Stable.
- Low blood/gas partition coefficient 🡪 faster
equilibrium.
- non irritant🡪 so the fastest for induction.

Dr. Med. Khaled Radaideh * 37

 Sevoflurane
Advantages and Disadvantages
Advantages
1. Well tolerated (non-irritant, sweet odor), even at high
concentrations, making this the agent of choice for
inhalational induction.
2. Rapid induction and recovery (low blood:gas coefficient)
3. Does not sensitize the myocardium to catecholamines as
much as halothane.
4. Does not result in carbon monoxide production with dry
soda lime.

Dr. Med. Khaled Radaideh * 38

 Sevoflurane
Advantages and Disadvantages
Disadvantages
1. Less potent than similar halogenated agents.
2. Interacts with CO2 absorbers. In the presence of soda lime
(and more with barium lime) compound A (a vinyl ether) is
produced which is toxic to the brain, liver, and kidneys.
3. About 5% is metabolized and elevation of serum fluoride
levels has led to concerns about the risk of renal toxicity.
4. Postoperative agitation may be more common in children
than seen with halothane.

Dr. Med. Khaled Radaideh * 39

 Sevoflurane
effects on systems
- Respiratory:
- non-irritant, depression.
- CVS: same as isoflurane (slightly lower
effect)
- CNS: same as halothane and isoflurane.
- Muscle relaxation: same as isoflurane.

Dr. Med. Khaled Radaideh * 40

Desflurane

MAC =6 %

Dr. Med. Khaled Radaideh * 41

Thank
you
Dr. Med. Khaled Radaideh * 42