Intravenous Anesthesia

KIRUBEL TINSAE (MD, Assistant

Professor of Anaesthesiology and
critical care)
 Outline
• Introduction to general anesthesia
• Characteristics of ideal IV anesthetics
• Class of IV anesthetics
• Systemic effects of IV anesthetics
• Some individual IV anesthetics
• Total intravenous Anesthesia (TIVA)
 Outline
• General anesthesia definition
• Characteristics of an ideal anaesthetic
• Class of anaesthetics
• Non-opoid anesthesia
• Total Intravenous anesthesia
Introduction to general anesthesia
• Is a state of brain where there is reversible
loss of consciousness by administration of
general anaesthetics.

• The drugs can be administered through

different routes.
 General Anaesthesia (GA)
• A variety of drugs are
unconsciousness given to the patient
that have different
effects with the overall
aim of ensuring
unconsciousness,
analgesia. amnesia
amnesia and analgesia
+ muscle paralysis

5
 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.
 Stages…
• 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.
 Characteristics of an ideal anaesthetic
• Simple preparation
• Compatible with other agents and IV fluids
• Painless on administration
• High potency and efficacy
• Predictable action within one circulation time
• Minimal cardiovascular effects or other toxicity
• Depression of airway reflexes for intubation
• Rapid and predictable offset of effect
• Rapid metabolism for minimal hangover
 Class of Intravenous Anaesthetics
Rapid acting

• Barbiturates, imidazoles, phenols, steroids, eugenols

Slower acting

• Phencyclidines, benzodiazepines, opioids, neurolept

combinations
 Class cont….
• Etomidate (Amidate)
• Ketamine (Ketalar)
• Propofol (Diprivan)
• Steriod: Pregnanolone
• Opoids
 fentanyl (Duragesic, Sublimaze)
 fentanyl-droperidol
 Morphine
 sufentanil (Sufenta)
 meperidin (Pethidine)
 Class cont….
Barbituates
– methohexital (Brevital)
– thiopental (Pentothal)
Benzodiazepines
– diazepam (Valium)
– lorazepam (Ativan)
– midazolam (Versed)
Althesin ( combination Alphaxolone and
alphadolone)
Eugenol : Propanidid
 Mechanism of action
• 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
 Systemic effects
• Most decrease cerebral metabolism and
intracranial pressure

• Most cause respiratory depression

• May cause apnea after induction of anesthesia

 Systemic cont…
• Cardiovascular Effects: Barbiturates,
benzodiazepines and Propofol cause
cardiovascular depression

• CNS: decrease the BMR; result in brain

relaxation; less susceptible for seizure; alter
consciousness
 Thiopental sodium;only iv
• rapid onset (20 sec)

• short-acting

• Effect terminated not by metabolism but by

redistribution
 Thiopental cont…
• repeated administration or prolonged infusion
approached equilibrium at redistribution sites

• Build-up in adipose tissue = very long

emergence from anesthesia

• Cerebral protection (5 mg/kg + 5 mg/kg/h)

 Thiopental sodium

Side effects

• Hypotension

• apnoea

• airway obstruction
 Thiopentone cont…
• Contraindicated
- No IV access, no airway support equipment
- Respiratory obstruction (croup, epiglottitis)
- Allergy
- Porphyria
Relative contraindications
- Cardiac disease
- Septicaemia, acidosis
- Adrenocortical insufficiency
 Propofol*only iv

• Hypnotic acting through

GABA chloride channel
activation
• Short-acting agent used for the
induction

• maintenance of GA and sedation

• Onset within one minute of

injection
• Induction 1.5 - 2.5 mg/kg healthy adults
• Maintenance
– 100 - 200 mcg/kg/min for hypnosis
– 25 - 75 mcg/kg/min for sedation
– Awareness common with dose‹ 2 mg/kg/h
Can produce bronchodilation
 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
Complications : Propofol-related infusion
syndrome (PRIS)
• Antiemetic
• Antipruitic
• Anesthetic of choice for malignant
hyperthermia
• Anaphylactoid reactions
• ICU Sedation
 Ketamine
• NMDA Receptor Antagonist

• usually stimulate rather than depress

the circulatory system especially in
sub-induction doses.
 Clinical Applications
• Induction of anesthesia (patients who are
hemodynamically unstable)
• Induction Dose = 1-2.5 mg/kg IV(onset 30-60
seconds), 5-10 mg/kg IM (2-4 minutes onset)
• Preoperative sedation (can be given IV or IM)
• Analgesia for painful procedures
Cardiovascular effects of ketamine
• Effects resemble sympathetic NS stimulation. Everything goes
up!! MAP, HR, CO, and myocardial oxygen requirements all
increase.
• The mechanism for Ketamine-induced CV effects may include
direct SNS stimulation.
Note: These properties of Ketamine make it an ideal agent to
select for induction of anesthesia in a hypovolemic patient.
• The use of Ketamine in critically ill or shock-like patients has
resulted in profound hypotension. This is presumed to occur as
a result of catecholamine depletion, leading to unopposed
direct myocardial depression by Ketamine
 contraindicated
• avoided in patients with coronary artery
disease
• uncontrolled hypertension
• congestive heart failure, and
• arterial aneurysms
 Physiologic Effects
Central Nervous System
• Potent cerebral vasodilator, causing
increased cerebral blood flow 60%-80%
during normocapnia
• Ketamine has relative contraindications for
use in patients with ↑ ICP.
Airway/Ventilation
• Ketamine does NOT produce significant depression of
ventilation
• Maintenance of protective reflexes.
** Induction doses still warrant an endotracheal tube for
protection of the lungs.**
• Increased airway secretions usually warrant
administration of an antisialogogue. (Glycopyrrolate)
• Intense bronchodilating properties related to its
sympathomimetic properties.
 Side effects
Emergence Delirium during the postoperative period in patients who
have received Ketamine anesthesia.
1. Visual, auditory illusions
2. Confusion
3. Delirium
• Incidence is 5-30%
• Dose-dependent occurrence at > 2mg/kg
Prevention
1. Preoperative Midazolam administration
2. Avoidance of Atropine and Droperidol, as they have central
properties that may be synergistic
3. Recovery in a quiet, calm environment
 Ethiomediate
• imidazole containing compound
• lipid-soluble at physiological pH and 76%
protein bound.
• metabolized by liver to inactive metabolites
and renal excretion
• MOA: Increase GABA transmission, Na
channels..
 Ethiomediate cont….
• lowers the seizure threshold and causes
myoclonic movements
• No analgesic properties
• Choice of induction for IHD, valvular heart
disease and hemodynamically unstable
patients (0.2-0.3 mg/kg)
• Better to be avoided in patient with adrenal
insufficiency or exhaustion
 Dexmedetomidine
• selective alpha-2 adrenergic agonist
• Effect: sedative, amnestic, and mild analgesic
effects
• Dosing: loading 1 mic/kg over 10 min then
maintenance 0.2-0.7 mic/kg/hr
• Side effects: hypotension and bradycardia
 Total Intravenous Anesthesia
• Administration of intravenous drugs to
establish adequate depth of anesthesia for
procedures or variety of scenarios

• It can be combination IV hypnotics + opioids

or non-opioid based combinations
 TIVA cont…
• Should use targeted controlled infusion (TCI)
to establish a continuous infusion resulting
increasing depth of hypnosis as serum
concentration of the drug increases
 Specific indications for TIVA
• Malignant hyperthermia risk
• Long QT syndrome (QTc ≥ 500 ms)
• History of severe PONV
• ‘Tubeless’ ENT and thoracic surgery
• Patients with anticipated difficult
intubation/extubation
• Neurosurgery—to limit intracranial volume
• Surgery requiring neurophysiological monitoring
 Indications…
• Myasthenia gravis/neuromuscular disorders,
and situations where NMBs are of disadvantage
• Anaesthesia in non-theatre environments
• Transfer of an anaesthetised patient between
environments
• Day case surgery
• Trainee teaching
• Patient choice
 Complications of GA
• Aspiration = 1: 2000-3000
• Hypoxia = up to half of patients might have
postop hypoxia while intra op is less common
• Hypotension
• Paralysis (permanent nerve damage) = 1:1000
• Life threatening Allergic reaction = 1:10000
• Death = 1:100000
 Complications …
Dependent on
• Co-existing diseases
• Personal habits and conditions
• Type of anesthesia
• Type of surgical procedure