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    4 - Inhalational Anesthetics

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    October 16, 1846 marked the first public demonstration of ether anesthesia at Massachusetts General Hospital. Various inhalational anesthetic agents have been used over time, including chloroform, ether, methoxyflurane, nitrous oxide, halothane, enflurane, isoflurane, desflurane, and sevoflurane. The depth of anesthesia depends on the partial pressure of the agent in the brain, which is determined by factors affecting alveolar concentration such as fresh gas flow, uptake of agents, and alveolar blood flow. Other factors influencing anesthetic effects include solubility, cardiac output, and tissue perfusion. The minimum alveolar concentration needed to prevent movement in response to surgical stimulation varies based on patient characteristics and co

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    4 - Inhalational Anesthetics

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    179 views58 pages
    October 16, 1846 marked the first public demonstration of ether anesthesia at Massachusetts General Hospital. Various inhalational anesthetic agents have been used over time, including chloroform, ether, methoxyflurane, nitrous oxide, halothane, enflurane, isoflurane, desflurane, and sevoflurane. The depth of anesthesia depends on the partial pressure of the agent in the brain, which is determined by factors affecting alveolar concentration such as fresh gas flow, uptake of agents, and alveolar blood flow. Other factors influencing anesthetic effects include solubility, cardiac output, and tissue perfusion. The minimum alveolar concentration needed to prevent movement in response to surgical stimulation varies based on patient characteristics and co

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    October 16, 1846 marked the first public demonstration of ether anesthesia at Massachusetts General Hospital. Various inhalational anesthetic agents have been used over time, including chloroform, ether, methoxyflurane, nitrous oxide, halothane, enflurane, isoflurane, desflurane, and sevoflurane. The depth of anesthesia depends on the partial pressure of the agent in the brain, which is determined by factors affecting alveolar concentration such as fresh gas flow, uptake of agents, and alveolar blood flow. Other factors influencing anesthetic effects include solubility, cardiac output, and tissue perfusion. The minimum alveolar concentration needed to prevent movement in response to surgical stimulation varies based on patient characteristics and co

    Copyright:

    © All Rights Reserved
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    Download as ppt, pdf, or txt
    179 views58 pages

    4 - Inhalational Anesthetics

    Uploaded by

    Anonymous 0Q5T44C4t
    October 16, 1846 marked the first public demonstration of ether anesthesia at Massachusetts General Hospital. Various inhalational anesthetic agents have been used over time, including chloroform, ether, methoxyflurane, nitrous oxide, halothane, enflurane, isoflurane, desflurane, and sevoflurane. The depth of anesthesia depends on the partial pressure of the agent in the brain, which is determined by factors affecting alveolar concentration such as fresh gas flow, uptake of agents, and alveolar blood flow. Other factors influencing anesthetic effects include solubility, cardiac output, and tissue perfusion. The minimum alveolar concentration needed to prevent movement in response to surgical stimulation varies based on patient characteristics and co

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    October 16th, 1846:

    First public demonstration of the use of ether in anesthesia at


    Massachusetts Gen Hosp. with Dr. J.C. Warren in attendance

    The First General Anesthetic


    Chloroform

    (toxic)
    Ether (flammable)
    Methoxyflurane (nephrotoxic)
    Nitrous oxide (useful up to now)
    Halothane (dysrhythmia, hepatotoxic)
    Enflurane
    Isoflurane
    Desflurane
    Sevoflurane (nephrotoxic?)

    Advantages of Inhalational Anesthesia


    Provide

    completely painless induction of anesthesia.


    No intravenous access needed.
    Most rapid appearance of drug in arterial blood (agent
    goes direct from lungs to left heart and aorta,
    bypassing venous system and right heart).
    Easily and safely administered by modern anesthesia
    machine.

    Pharmacokinetics
    The

    depth of anesthesia depends on the partial


    pressure or gas fraction exerted by the inhalational
    agent in the patients brain (b).
    Brain partial pressure depends on arterial (a) partial
    pressure which depends on alveolar partial pressure
    (A) which depends on partial pressure in the inspired
    gas (I).
    PIPA Pa Pb or FI FA Fa Fb.
    partial pressure of component gas : fraction of total
    gas x total pressure (Pc : Fc x P)
    To change Fb in patients brain, we monitor and
    control FI and indirectly FA and Fa

    Factors Affecting Inspiratory


    Concentration (FI)
    Actual composition of the inspired gas mixture depends
    on:
    Fresh gas flow rate
    Volume of the breathing system
    Absorption by the machine
    Fresh gas flow rate >>
    Breathing system volume <<
    Circuit absorption <<

    Inspired gas
    concentration ~ Fresh
    gas concentration

    Faster induction and


    recovery times

    Factors Affecting Alveolar Concentration


    (FA)

    Uptake of agents >>

    Rate of rise of FA <<

    FA/FI Ratio <<

    Factors Affecting Alveolar Concentration


    (FA)
    The

    concentration of a gas is directly proportional to


    its partial pressure.
    Alveolar partial pressure determines the partial
    pressure of anesthetic in blood and brain.
    The greater the uptake, the greater the difference
    between inspired and alveolar concentration, the
    slower rate of induction.
    Three factors affect anesthetic uptake:
    Solubility in the blood.
    Alveolar blood flow
    Difference in partial pressure between alveolar gas and venous
    blood

    Factors Affecting Alveolar Concentration


    (FA)
    Solubility

    in the blood

    Anesthetic solubility >>

    Uptake by the pulmonary


    circulation >>

    Rise in alveolar partial


    pressure <<

    Rate of induction <<

    Factors Affecting Alveolar Concentration


    (FA)
    Alveolar

    blood flow

    It is essentially equal to cardiac output.


    CO >>

    Anesthetic
    uptake >>

    Rise in alveolar partial


    pressure <<
    Rate of induction <<

    Difference

    in partial pressure between alveolar gas and


    venous blood.
    This gradient depends on tissue uptake, that determined by:
    Tissue solubility of the agent (tissue/blood partition coefficient),
    Tissue blood flow,
    Blood/tissue partial pressure difference.

    Factors Affecting Alveolar Concentration


    (FA)
    Tissue Groups Based on Perfusion and Solubilities
    Characteristic

    Vessel
    Rich

    Muscle

    Fat

    Vessel
    Poor

    Percentage of body
    weight

    10

    50

    20

    20

    Percentage of
    cardiac output

    75

    19

    Perfusion
    (mL/min/100 g)

    75

    20

    Relative solubility

    Factors Affecting Alveolar Concentration


    (FA)

    The rise and fall in alveolar partial pressure precedes that of other tissues.

    Factors Affecting Alveolar Concentration


    (FA)

    Factors Affecting Alveolar Concentration


    (FA)

    Factors Affecting Arterial Concentration


    (Fa)

    Factors Affecting Elimination


    Recovery

    from anesthesia depends on lowering the


    concentration of anesthetic in brain tissue.
    Elimination through:
    Biotransformation: minimal, usually for soluble
    anesthetic agents that undergo metabolism.
    Trancutaneous loss: insignificant.
    Exhalation: most important route. Affected by:

    Extent of rebreathing
    Fresh gas flow
    Volume of breathing system
    Absorption by breathing system components
    Solubility of agent
    Cerebral Blood Flow
    Ventilation

    Factors Affecting Elimination

    Factors Affecting Elimination

    Diffusion hypoxia:
    During recovery from anesthesia, wash out of
    high concentration of N2O results in lowering
    alveolar concentration of O2 and CO2 (outpouring
    of N2O from the blood into the alveoli when
    inhalation of this gas is discontinued can dilute
    the PAO2).
    Recovery from anesthesia also depends on
    length of time anesthetic administration.

    Pharmacodynamics
    Minimum Alveolar Concentration (MAC)
    MAC

    is the alveolar concentration that prevents


    movement in 50% of patients in response to a
    standardized stimulus (eg, surgical incision).
    Describes
    the brain partial pressure, allows
    comparisons of potency between agents, provides
    standard evaluations.
    MAC can be altered by several physiological and
    pharmacological variables, eg temperatture, age,
    blood pressure, etc.

    Properties of Inhalational Anesthetics

    Factors Affecting MAC


    Variable

    Effect on MAC

    Temperature
    Hypothermia
    Hyperthermia

    Age
    Neonates
    Infants
    Young
    Elderly

    Gender

    Duration of anesthesia

    Anesthetic metabolism

    Alcohol
    Acute intoxication
    Chronic abuse

    Anemia (Ht < 10%)

    Factors Affecting MAC


    Variable

    Effect on MAC

    PaO2
    < 40 mmHg
    > 40 mmHg

    PaCO2
    15-95 mmHg
    > 95 mmHg

    Thyroid
    Hyperthyroid
    Hypothyroid

    Blood pressure
    MAP < 40 mmHg
    MAP > 40 mmHg

    Electrolytes
    Hypercalcemia
    Hypernatriemia
    Hyponatriemia
    Pregnancy

    Factors Affecting MAC


    Variable
    Drugs
    Local anesthtics
    Opioids
    Ketamine
    Barbiturates
    Benzodiazepines
    Verapamil
    Lithium
    Sympatholytics
    Methyldopa
    Clonidine
    Dexmedetomidine
    Sympathomimetics
    Amphetamine
    Chronic
    Acute
    Cocaine
    Ephedrine
    Monoamine oxidase inhibitors
    Cardiopulmonary bypass

    Effect on MAC

    Equipments for Inhalational Anesthesia

    Anesthesia machine

    12

    1.
    2.
    3.
    4.

    7
    8
    10
    11

    Corrugated tube
    Infusion pump
    Reservoir bag
    Patients medical
    record
    5. Vital Sign Monitor
    6. Vaporizer
    7. ?
    8. Flow meter
    9. ?
    10.Ventilator
    11.CO2 Absorbance
    12.Gas line

    Physical Properties
    Nitrous oxides = laughing gas inorganic anesthetic gas.
    Colorless, odorless
    Nonexplosive and nonflammable, but support combustion.
    As a gas in room temperature and ambient pressure.
    As a liquid in under pressure.

    Effects on Organ Systems

    Effects on Organ Systems

    Result of central venous stimulation and


    activation of pulmonary stretch receptor.
    Minimal change in minute ventilation and
    resting CO2 levels.

    Effects on Organ Systems

    Biotransformation & Toxicity


    Almost all eliminated by exhalation.
    N2O inhibits enzymes that vitamin B12 dependent, by
    irreversibly oxidizing the Co atom in vitamin B12.
    methionine synthetase: myelin formation
    thymidylate synthetase: DNA synthesis
    Prolonged exposure bore marrow depression
    (megaloblastic anemia) and neurological deficiencies
    (peripheral neuropathies and pernicious anemia).
    Teratogenic effects.
    Affect chemotaxis and motility of PMN leukocytes.

    Contraindications
    Although N2O is less soluble than other agent, but N2O is
    35 times more soluble than nitrogen in blood diffuse into
    air-containing cavities more rapidly than nitrogen in the
    bloodstream.
    Contraindicated in:
    Air embolism
    Pneumothorax
    Related with air Acute intestinal obstruction
    containing
    Intracranial air
    cavities
    Pulmonary air cysts
    conditions
    Intraocular air bubbles
    Tympanic membrane grafting
    Pulmonary hypertension

    Physical Properties
    Halogenated

    alkane
    Nonflammable & nonexplosive
    Odorless
    Thymol preservative and ambercolored bottles retard spontaneous
    oxidative decomposition.

    Effects on Organ Systems

    Effects on Organ Systems

    Effects on Organ Systems

    Malignant Hyperthermia

    Effects on Organ Systems

    Biotransformation & Toxicity

    Contraindications
    Malignant hyperthermia susceptibility
    Unexplained liver dysfunction
    Intracranial mass lesions
    Hypovolemic patients
    Severe cardiac disease (aortic stenosis)
    Pheochromocytoma
    Severe
    ventricular
    dysrhythmias
    (associated
    aminophylline).

    with

    Physical Properties
    Nonflammable
    Pungent

    ethereal odor
    Chemical isomer of enflurane

    Effects on Organ Systems

    Effects on Organ Systems

    Effects on Organ Systems

    Biotransformation & Toxicity

    Contraindication

    Physical Properties
    The structure is almost similar to isoflurane, except for the
    fluorine atom Halogenated fluorine.
    High vapor pressure
    Low boiling point
    Needs special vaporizer
    Low solubility
    ultrashort duration of action
    Rapid wake up time
    Pungent

    Effects on Organ Systems

    Effects on Organ Systems

    Biotransformation & Toxicity


    Minimal metabolism.
    Fluoride fluid levels unchanged.
    Carbon monoxide toxicity (due to desflurane is degraded by
    CO2 absorbent into potentially clinically significant levels of
    carbon monoxide, that is difficult to diagnose).

    Contraindication
    Suspected malignant hyperthermia
    Severe hypovolemia
    Intracranial hypertension

    Physical Properties
    Halogenated fluorine
    Odorless
    Rapid in alveolar concentration
    Relative low solubility

    Smooth and rapid


    inhalation induction

    Effects on Organ Systems

    Effects on Organ Systems

    Effects on Organ Systems

    Biotransformation & Toxicity


    Metabolized by liver microsomal enzyme P-450.
    No association between renal dysfunction and fluoride fluid
    levels.
    Alkali
    can degrade sevoflurane to compound A
    (nephrotoxic end products)
    Slightly RBF
    Impaired renal tubule function.

    Contraindication
    Malignant hyperthermia susceptibility.
    Severe hypovolemia.
    Intracranial hypertension.
    Preexisting renal dysfunction.

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