General anesthetics

Dr.maged bin hariz

• General anesthetics are drugs used in surgery
operation.
• Requirements for general anesthesia
 reversible loss of consciousness
 analgesia
 amnesia
 skeletal muscle relaxation
 Inhibition of visceral reflexes.
 inhibition of autonomic and sensory reflexes
 Balanced anesthesia

Balanced anesthesia is used to achieve all

requirements for general anesthesia & to
minimize adverse effects of individual drugs.
Balanced anesthesia refers to a combination of
drugs are administered preoperatively
(Preanesthetic medication), intraoperatively,
and postoperatively to ensure smooth
induction, sedation, and smooth recovery
•
 Classification of General Anesthetics

 Inhalation Anesthetics (Mainly for Maintenance)

Slow: provide minute to minute
control over depth of anesthesia
e.g. : Nitrous oxide (gas).
Halogenated agents(voltail liquid):
- Halothane - Isoflurane. Desflurane- Sevoflurane.
 IV Anesthetics (Mainly for Induction)
Rapid induction of anesthesia
example; Propofol – Ketamine.
Barbiturates Thiopental sodium
Benzodiazepines. Opioids
 Classification
Inhalation Anesthetics IV Anesthetics

 (Mainly for Maintenance)  (Mainly for Induction)

 Slow: provide minute to  Rapid induction of anesthesia
minute Example: Propofol , Ketamine.
 control over depth of Thiopental sodium
anesthesia Benzodiazepines.
e.g : Nitrous oxide (gas). Opioids
Halogenated agents
(voltail liquid):
Halothane - Isoflurane.
Desflurane- Sevoflurane.
 Mechanism of Action
• inhibit neuronal activity in many brain regions,
specially the midbrain reticular activating system
& thalamus.
 Facilitation of inhibitory effects of GABA at
GABAA receptor:
Halogenated inhalation agents, Propofol ,
Barbiturates, Benzodiazepines.
 Inhibition of excitatory effects of glutamate at
NMDA receptor:
Ketamine, Nitrous oxide
 INHALATION ANESTHETICS
 MAC (measures potency):
is the alveolar concentration of anesthetic gas(as a % of inspired air)
resulting in immobility in 50 % of patients when exposed to a painful
stimulus: e.g. a surgical skin incision.

Induction & Recovery of inhalation anesthetics

 Rapid induction &recovery allow flexible control of depth of
anesthesia.
 Speed of induction & recovery depends on Solubility:
 Solubility in blood : (blood-gas partition coefficient):
 less soluble the anesthetic, the more rapid its induction and
recovery from anesthesia (Nitrous oxide is less soluble).
 Fat solubility: (Oil/gas partition coefficient)
 higher the coefficient, more potent the anesthetic (i .e. , the lower
the MAC).
 agents with high lipid solubility accumulate in fat → long hangover
if used for a prolonged operation.
 A. Halogenated agents
• Halothane
 Medium rate of induction & recovery.
 Inhalation anesthetic for maintenance anesthesia
 May also be used for induction
 Weak analgesic effect
• Adverse Effects of halothane
 Depress of CVS (Hypotension, bradycardia)
 Hepatotoxic.
 Malignant Hyperthermia.
 newer halogenated
(Isoflurane. Desflurane- Sevoflurane

 Specific features of newer halogenated agents

compared to halothane.
Due to hepatotoxicity, halothane is replaced by
newer agents, which may also induce CVS &
respiratory depression & malignant hyperthermia
but less than halothane.
 B. Nitrous Oxide (N20)
 Rapid onset & recovery.
 Low potency: used for maintenance anesthesia, not alone,
 Effective analgesic: can be used alone procedures; e.g.
dental outpatient clinic- obstetric analgesia.
 Safest inhalation agent: less cardiac or respiratory
depression - less uterine relaxation - no hepatitis - no
malignant hyperthermia .
• Adverse Effects
 Hypoxia on prolonged use during recovery (mixed with O2
→50 - 70% nitrous oxide).
 Abuse: euphoria (laughing gas).
 Megaloblastic anemia and Teratogenic (abortion)in
(chronic exposure of operating room staff).
 II. INTRAVENOUS ANESTHETICS
 Thiopental
 Ultra Short-Acting Barbiturates
 Rapid onset due to rapid crossing of BBB (highly lipid soluble).
 Short acting; redistributes from brain to fat & skeletal muscle.
• Clinical Uses
 Most widely used IV anesthetic for induction followed by
maintenance with inhalation agents for major operations (the
principal use).
 Given alone in anesthesia for short procedures.
• Adverse Effects (narrow safety margin)
 Respiratory & cardiovascular depression (toxic doses).
 Severe vasospasm if accidentally injected intra-arterially -gangrene.
 Can precipitate porphyria.
  Propofol
 Faster than thiopental
 Widely used IV anesthetic for induction & maintenance of
anesthesia.
 Rapid induction & recovery (rapid metabolism)→given as
IV bolus or Infusion without maintenance by inhalation
agent → useful in one day surgery.
 No analgesia
 Advantage: antiemetic (↑ risk of postoperative vomiting).
 Disadvantage:
 respiratory& CVS depression(↓BP)
 pain at injection site.
 Ketamine
 Short-acting IV anesthetic
 Dissociative anesthesia (loss of motor activity + a nalgesia + amnesia
in which the patient eye remain open without actual loss of
consciousness ) but dissociated from the surroundings
• Good amnestic action
 Good analgesic effect→ used for dressings of burns & minor
Orthopedic procedures in children.
• CV stimulant (↑ HR & BP) due to sympathetic stimulation.→ it is
beneficial in cases of shock
 Potent bronchodilator → suitable for asthmatics patients
 Disadvantages
 ↑ Cerebral blood flow& intracranial tension → avoid in head injuries and
brain tumors.
 psychic disturbances (Hallucination, unpleasant dream & disorientation)
occur on recovery (avoided by pretreatment with diazepam).
 Benzodiazepines
 (midazolam - diazepam - lorazepam)
 Midazolam is preferred due to its rapid & short action
& it’s less irritant effect.
 Commonly used for sedation rather than anesthesia
because prolonged amnesia while causing sedation.
 Used in Conscious sedation ( for minor procedures e.g.
endoscopy)
 Used as Pre-anesthesia.
 flumazenil is antidote antidote,in case of toxicity
(respiratory depression).
 Opioid Analgesics

 Fentanyl, sufentanyl, alfentanyl, remifentanyl

&morphine.
N.B.: Total intravenous anesthesia may be
produced by combining opioids with propofol
rather than an inhalation agent.