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Anesthetic Agents

Anesthesia is defined as the loss of consciousness, loss of responsiveness, and loss of upper airway reflexes. Its the role of anesthetist to take care of the airway by incubating the patient, and we call this definitive airway. Back in 1846 Dr William Morten demonstrated the use of inhaled ether in anesthesia; he used Diethyl ether and chloroform. However, these drugs are not used anymore due to its cardio-toxic effects. Now we will take about:

Inhalated anesthetic agent:


Previously used agents: A. Diethyl ether B. Chloroform C. Eflurane D. Deoxi flurane These drugs are not used anymore and we are not going to discuss them Currently used agents: A. Isoflurane B. Nitrous oxide C. Halothane ( the Dr said its currently used but wikipedia says its not ) Characteristics of ideal inhaled agents: 1. Odorless or pleasant smell: because if we anesthetize the patient, and it was very irritant the patient will hold his breath, and incidence of laryngospasm will be high. 2. No blood-gas solubility: because the depth of anesthesia is related to the partial pressure in the brain (same principle as oxygen partial pressure in the brain). When we decrease the solubility of the drug in the blood >>> we are increasing the partial pressure of the drug >>> therefore we are increasing the levels of the anesthetic agent in the brain and this will lead to more depth of anesthesia. This will help us to understand the awareness under the anesthesia. Types of awareness under anesthesia (two types): Type 1: Patient is anesthetized but he feels the pain.
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Type 2: The patient is anesthetized but recalls events. This will lead to post traumatic stress disorder. In order to prevent this, the patient must be monitored by a team. Signs that the patient is aware: A- The sympathetic system will be over activated : pupil dilation, patient is trying to wake up, lacrimation, unexplained tachycardia, or high blood pressure. B- Monitor EEG: this is more specific, here the patients reading must be between 40-70. If he is under 40 he is awake. If its over he is deeply anesthetized C- Monitor the patients vital signs: 1. Body temperature 2. Pulse rate (or heart rate) 3. Blood pressure (by arterial cannulation, but its invasive and used for major cases) 4. Respiratory rate 5. Cardiography Conclusion: If one of these signs is over exicted (or have abnormal value) we have to cancel the procedure !! Continuing the characteristics of the ideal inhaled anesthetic agent: 3. Has some analgesic, anti-emetic, and muscle relaxing properties. 4. Non-explosive and does not support combustion. 5. Minimal cardiovascular and respiratory complications. 6. No metabolic effects Nowadays we don't have an ideal agent. Sequence of agents that are given to produce general anesthesia: First we give Fentanyl: synthetic opioid, which is an analgesic, and it 100 times more potent than morphine. Second we use Propofol: for induction of anesthesia, it induces loss of consciousness, and muscle relaxation. Then we intubate the patient and give 3 gasses to maintain anesthesia. These gases are: nitrous oxide , halothane, and oxygen
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M.A.C : (important for the exam )

is the minimum alveolar concentration of the agent that prevent movement to standard stimulus in 50% of the population. This will prevent over and under-dose M.A.C measurements for some drugs (as the Dr said these are questions in the exam): Halothane = 0.75 Isoflurane = 1.15 Enflurane = 1.68 Sevoflurane = 2 Desflurane=6 Nitrous oxide = 105 (weak agent ) Lets start from the oldest agents:

Halothane:

- halogenated hydrocarbons - M.A.C= 0.75 - Manufactured in 1954 and came to clinical practice in 1956 - Not used now - Used for maintenance of the anesthesia (with oxygen and nitrous oxide). - Side effects : a. Increases the intracranial pressure: Because of its vasodilatation effect, which will affect the cerebral perfusion pressure and this will lead to ischemia Oxygen consumption: and permanent Brian damage (hypoxic - Brain utilize 50ml of oxygen brain damage). But if we have to use per min halothane, we can avoid this by - Body utilize 250ml of oxygen hyperventilation of the patient, How? per min By decreasing the CO2 from 40mm Hg Cerebral perfusion To 33ml/hg which will lead to pressure: Mean arterial blood hypocapnia, and this will cause cerebral pressure minus the cerebral vasoconstriction, which will counteract blood pressure the halothanes effect.
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b. Potent bradycardia: bradycardia to some extent is good (up to 40-45 beats per min) If halothane causes bradycardia below 40-45 beats per min you have to discontinue halothane, and give the patient another agent, and we give anticholenergic drug (atropine for example) to increase the heart rate

Bradycardia = heart rate is under 60beat per min Below 35 beat per min you have to massage the heart Tachycardia = heart rate over 100beat per min Tachycardia causes: -Increases in oxygen consumption of the heart -Increases the risk of endocardium ischemia -Increases the incidence of coronary spasm due to decrease in the coronary filling. A child can tolerate tachycardia up to 100 beat per min. Better than an adult

c. Causes liver damage (hepatitis) It was subclinical and unknown. That would increase mortality rate. For this reason halothane was kept away from practice

Nitrous oxide:
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Also known as the Laughing gas. Still used in Britain but we don't use here in Jordan. Produced by heating ammonium nitrate to 245C. More filtration for ammonia and nitric acid. Used for normal vaginal delivery: to minimize the labor pain, when there is We have many types of hypoxia such as no epidural medication or anesthetic anemic hypoxia. is busy, we give nitrous oxide. Cyanosis: blue discoloration of the skin - Side effects (most important thing): happens due to very low oxygen (below a. Diffusional hypoxia: 85%) and the PIO2 will be very low. because nitrous oxide is more soluble than oxygen in alveoli. b. Bone marrow depression and its complication:
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B12 deficiency and folic acid deficiency and megaloblastic anemia

Intravenous anesthetic Agents:


-We use cannula -While there are many drugs that can be used intravenously to produce anesthesia or sedation, the most common are: A. Barbiturates: Thiopental B. Benzodiazepines C. Etomidate D. Ketamine E. Propofol

Sodium thiopental:
- Relatively new 1939 - Safety dose from 5-7mg per Kg. In the second world war, they used to give 20mg per kg so they used to say sodium thiopental has killed more than the Germans do. - Causes collapse of the cardiovascular system. - Contraindications : a. Airway obstruction b. Porophyria c. Previous hypersensitivity reaction to barbiturate (bronchial asthma). Note: we put the cannula at the dorsum of patients hand -not on the forearm.

Propofol:
- Anti emetic properties - Less hang over - Early manipulation for the upper airway: so should be intubated earlier than sodium thiopental - No toxic effect

Ketamine:
- Used for shocked patients as in gunshot: Because it increases blood pressure.

Etomidate:
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- Most stable cardiovascular agent

- Given from 10-20mg I.V. - Best for arterial fibrillation cases Here are some points said by the doctor during the lecture: To measure the carotid pulse: your fingers should be positioned between the larynx and the anterior border of the sternocleidomastoid muscle at the level of the cricoid cartilage while the patient in supine position and the trunk of the body is slightly elevated. As a practitioner you should know CPR and basic life support: In any emergency its very important to keep ABC A: Airway: you have to protrude the tongue out to open the airway. B: Breathing: if the patient is not breathing you have to give him resuscitation known as the two kissing life, and check the carotid pulse C: Circulation Pregnancy stages: Starts with conception: a. Fertilization: when the sperm meats the ovum and fertilize it at the lower third of fallopian tube. b. Implantation : in the posterior wall of the uterus The egg stays in the uterus for 9 months turning from single cell to infant by cell multiplication Stages of labor: First stage: Thinning (effacement) and opening (dilation) of the cervix Second stage: Baby delivery Third stage: Delivery of placenta Note: Many women died during labor from the pain, and there is maternal mortality morbidity. When there is no epidural medication or anesthetic is busy >> we give Nitrous oxide.

Done by: Asil Ellauzi Good Luck

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