The Introduction of the

General Anesthesia and Sedation

in Special Need Patients

Edbert P. Solano, DMD, DDPH, MAED

MCU-CSMU May 2021 batch

 Define Define sleep, amnesia, analgesia, general anesthesia

List List different phases/planes of GA

Classify Classify the agents used for general anesthesia

Objectives
Describe Describe the mechanism of action, pharmacokinetics, therapeutics and
adverse effects and drug interactions of different anesthetic drugs

Compare Compare the pharmacological effects of thiopental sodium, propofol,

and ketamine

MCU-CSMU May 2021 batch

Surgery Before Anesthesia
MCU-CSMU May 2021 batch
MCU-CSMU May 2021 batch
 A drug that brings about a
reversible loss of consciousness
What are
General
Anesthetics?
generally administered by an
anesthesiologist in order to
induce or maintain general
anesthesia to facilitate surgery.
MCU-CSMU May 2021 batch
General Anaesthesia (GA)

• A variety of drugs are

given to the patient that
unconsciousness
have different effects with
the overall aim of
ensuring
unconsciousness, amnesia
and analgesia.
analgesia. amnesia

MCU-CSMU May 2021 batch

 Stages Of General Anesthesia
Stage I: Disorientation, altered consciousness

Stage II: Excitatory stage, delirium, uncontrolled movement, irregular breathing.

Goal is to move through this stage as rapidly as possible.

Stage III: Surgical anesthesia; return of regular respiration.

Plane 1: “light” anesthesia

Plane 2: Loss of blink reflex, regular respiration . Surgical procedures can

be performed at this stage.

Plane 3: Deep anesthesia. Shallow breathing, assisted ventilation needed.

Level of anesthesia for painful surgeries

Plane 4: Diaphragmatic respiration only, assisted ventilation is required.

Cardiovascular impairment.

Stage IV: Too deep; essentially an overdose and represents anesthetic crisis. This
is the stage between respiratory arrest and death due to circulatory
collapse.
MCU-CSMU May 2021 batch
 Inhalation Anesthetics

Anesthetics
divide into 2
classes
 Anesthetics
divide into 2
classes
Inhalation Anesthetics

Nitrous
oxide
Mechanism of Action
• Interaction with protein receptors

• Volatile A – increase GABA and Glycine

( inhibitory neurotransmitters)

MCU-CSMU May 2021 batch

MAC(minimum alveolar concentration)

• A measure of potency of inhaled anesthetics

• MAC is the concentration necessary to prevent responding in 50% of

population.

MCU-CSMU May 2021 batch

Pathway for
General
Anesthetics

MCU-CSMU May 2021 batch

Pharmacokinetics of Inhaled Anesthetics

1. Amount that reaches the brain

Indicated by oil:gas ratio (lipid solubility)

2. Solubility of gas into blood

The lower the blood:gas ratio, the more anesthetics will
arrive at the brain

MCU-CSMU May 2021 batch

Rate of Entry
into the Brain:
Influence of
Blood and Lipid
Solubility

MCU-CSMU May 2021 batch

General Actions of Inhaled Anesthetics

• Respiration
• Depressed respiration and response to CO2
• Kidney
• Depression of renal blood flow and urine output
• Muscle
• High enough concentrations will relax skeletal muscle

MCU-CSMU May 2021 batch

Cont’
• Cardiovascular System
• Generalized reduction in arterial pressure and peripheral vascular resistance.
• Isoflurane maintains CO and coronary function better than other agents
• Central Nervous System
• Increased cerebral blood flow and decreased cerebral metabolism

MCU-CSMU May 2021 batch

 Inhaled Anesthetics

Nitrous Oxide
•widely used

•Potent analgesic

•Produce a light anesthesia

•Do not depress the

respiration/vasomotor center

•Used ad adjunct to supplement other

inhalationals

MCU-CSMU May 2021 batch

 Inhaled Anesthetics

Halothane
• non-flammable

• 20% metabolism by P450

• induction of hepatic microsomal
enzymes
• Myocardial depressant (SA node),
sensitization of myocardium to
catecholamines - arrhythmia

MCU-CSMU May 2021 batch

 Inhaled Anesthetics

Halothane

Transient hepatic damage

Liver necrosis

In repeated exposure

Immunosensititation
MCU-CSMU May 2021 batch
 • Malignant hyperthermia (MH) is a
pharmacogenetic hypermetabolic state of
Malignant skeletal muscle induced in susceptible
individuals by inhalational anesthetics
Hyperthermia and/or succinylcholine (and maybe by
stress or exercise).

MCU-CSMU May 2021 batch

Malignant Hyperthermia

Genetic susceptibility-Ca+ Excess calcium ion leads to

channel defect (CACNA1S) or excessive ATP
RYR1 (ryanodine receptor) breakdown/depletion

MCU-CSMU May 2021 batch

 Malignant Hyperthermia

• Signs: tachycardia, tachypnea, metabolic acidosis,

hyperthermia, muscle rigidity, sweating, arrhythmia

• May be fatal

• Treated with dantrolene

MCU-CSMU May 2021 batch

 Enflurane

Inhaled Rapid, smooth induction

Anesthetics and maintenance
Isoflurane

smooth and rapid induction and

Anesthetics divide into 2 classes
Inhalation
Anesthetics
 • Commonly used IV induction agents

Intravenous • Propofol
• Thiopental sodium
Induction Agents • Ketamine

MCU-CSMU May 2021 batch

 Intravenous Anesthetics

• Most exert their actions by potentiating

GABAA receptor

• GABAergic actions may be similar to

those of volatile anesthetics, but act at
different sites on receptor

MCU-CSMU May 2021 batch

 • Most decrease cerebral metabolism and intracranial
pressure

Organ Effects • Most cause respiratory depression

• May cause apnea after induction of anesthesia

MCU-CSMU May 2021 batch

Cardiovascular • Barbiturates, benzodiazepines and propofol cause
Effects cardiovascular depression.

MCU-CSMU May 2021 batch

 •

Thiopental • rapid onset (20 sec)

sodium • short-acting

MCU-CSMU May 2021 batch

 Thiopental sodium

• Effect terminated not by metabolism but by redistribution

• repeated administration or prolonged infusion approached

equilibrium at redistribution sites

• Build-up in adipose tissue = very long emergence from anesthesia

MCU-CSMU May 2021 batch

Thiopental sodium

Side effects

• Hypotension

• apnoea

• airway obstruction

MCU-CSMU May 2021 batch

 • Short-acting agent used
for the induction

• maintenance of GA and
sedation

Propofol • Onset within one

minute of injection

MCU-CSMU May 2021 batch

 Propofol

• It is highly protein bound in vivo and is metabolised by conjugation in

the liver

Side-effect
• pain on injection
• hypotension
• transient apnoea following induction

MCU-CSMU May 2021 batch

Ketamine

NMDA Receptor Antagonist

usually stimulate rather than

depress the circulatory system.

MCU-CSMU May 2021 batch

 Analgesic

Ketamine dissociative anesthesia

Usage • Cataleptic appearance, eyes
open, reflexes intact,
purposeless but coordinated
movements

MCU-CSMU May 2021 batch

Ketamine
Stimulates sympathetic nervous system

Psychomimetic – “emergence reactions”

 General • Induction

anesthesia • Maintenance

MCU-CSMU May 2021 batch

 intravenous

Induction
Maintenance
• In order to prolong anaesthesia for the required
duration
• breathe to a carefully controlled mixture of oxygen,
nitrous oxide, and a volatile anaesthetic agent
• transferred to the patient's brain via the lungs and
the bloodstream, and the patient remains
unconscious

MCU-CSMU May 2021 batch

 • Inhaled agents are supplemented by intravenous
anaesthetics, such as opioids (usually fentanyl or
Maintenance morphine)

MCU-CSMU May 2021 batch

 • Use specific drugs for each component
• 1. Sensory
• N20, opioids, ketamine for analgesia
What is • 2. Cognitive

Balanced • Produce amnesia, and preferably

unconsciousness
Anesthesia? • inhaled agent
• IV hypnotic (propofol, midazolam, diazepam,
thiopental)
• 3. Motor
• Muscle relaxants

MCU-CSMU May 2021 batch

 • Morphine

Simple • Propofol
• N2O
Combinations • Sevoflurane
• Relaxant of choice

MCU-CSMU May 2021 batch

 • Fentanyl

• Thiopental sodium

Simple • N2O
Combinations
• Halothane

• Relaxant of choice

MCU-CSMU May 2021 batch

SUMMARY

MCU-CSMU May 2021 batch

 The Spectrum of Anesthesia
Normal
Anxiolysis
Deep
Conscious Sedation General
Sedation Anesthesia

1. Protective reflexes intact 3. Loss of protective

2. Partial loss of
Patient can independently reflexes
protective reflexes
and continuously maintain Inability to independently
Inability to
an airway maintain an airway
independently
Patient can respond No pain sensation or
maintain an airway
appropriately to verbal reflex withdrawal from
May not respond to
commands MCU-CSMU May 2021 batch stimuli
verbal commands
Total unconsciousness
 Risks of Anesthesia
General
high Deep
Anesthesia
Sedation

Moderate
Sedation

Local
Anesthesia
Anxiolysis
N20
low MCU-CSMU May 2021 batch
Anesthetics divide into 2 classes
Inhalation
Anesthetics
Inhalation Anesthetics

Nitrous
oxide
Intravenous anesthetics
• Thiopental sodium

• Propofol

• ketamine

MCU-CSMU May 2021 batch

Induction
intravenous inhalational

where IV access
Faster onset is difficult

avoiding the Anticipated

excitatory phase difficult
of anaesthesia intubation

patient
preference
(children)

MCU-CSMU May 2021 batch

Question
• Compare the pharmacologicl effects of thiopentone sodium, propofol,
and ketamine

MCU-CSMU May 2021 batch