‘The inhalational agent of choice for cardiac patients is Isoflurane as the cardiac output i= best preserved by Inofturanc has myocardial protective properties, limiting infarct size (Izchaemie preconditioning), Isonurane nas also been implicated in the coronary steal phenomenon as it dilates coronary arteries. But, as omer options = Halothane Is associated with a higher incidence of cardiac dysrnythmias and myocardial depre: 2 Gesturane is a sympathomimetic. This Is the use-lmiting disadvantage of desnurane. Sevorurane can decrease sympathetic nervous activity. Note: There Is a controversy between Desrurane and Isonurane as to whieh Is the most preferred one in cardiac patients. The standard references do not mention if desflurane Is more preferred. So isoflurane, inhalational agent te be aveided in emphysema is nitrous oxide. Nitrous oxicio nas the potential to expand air containing cavities as it can aifruse into and accumulate in them. Hence It should be avoided In omphysema pationts especially In those with bullae and pulmonary Pearl #2301: Unique features of Nitrous oxide + Rapid uptake of nitrous oxide diminishes the volume to the alveolus: Second gas errect + Incroase in ihe partial pressure oF the 2nd gas (Oxygen and volatio agents) due to the rapid uptake Dittusion nypoxt + Avoided by aaministering 100% oxyaen fer about 10 minutes during recovery trom anesthesia + NZO artuses into a gas-tiles cavity more rapidly than the alr (principally nitrogen) amuses out 2 This increases the pressure within the cavity if ine volume of ihe cavity #2 gid Pheumocephalus. pneumetnorax “Rinpanic memorane grating Isoflurane Is the best agent in cirrhosis, among the glven options. The cirmotic liver has compromised portal venous blood flow and hence it Is essential to preserve hepatic arterial blood flow. Though Isoflurane may reduce hepatic blood flow, hepatic oxygen supply Is better maintained. Another alternative to isoflurane Is Sevomturane which decreases portal vein blood flow, but increases hepatic artery biood flow, so that the total nepatic blood flow and oxygen delivery are better maintained. The incidence of halothane hepatitis i= 4 in 88,000, but it iz very fatal with a mortality of 60-75%. Its an immune-meaiated reaction due to antibosies against highly reactive trintuereacety! ehtoriae which Risk factors for halothane hepatitis: = Munipie exposures to nalotnane at short intervals, 2 Midate-eged obese women 1 Familial preaispesition to natenane In a pationt with @ prior history of nalotnane hepatitis, innalational induction agent oF choice 1s Nitrous oxide does not underge any metabolism in our body. Methoxyfiurane undergoes maximum metabolism. While Desflurane undergoes minimal metabolism.Seizures nave been associated with the use of sevetturane in high concentrations, especially in the pediatric population. Emergence from sevoflurane is associated with tonic clonic movements suggestive of Hence sevorurane must be used cautiously in patients with a known history of seizure. ‘Though Isoflurane can cause myoclonus and EEG spiking, frank seizure activity Ie not seen. Enfurane nas the most epileptogenic potential among the inhaled anesinetics, + Halothane sensitizes tne neart to the arrhythmogente effects of epinepnrine ang hence is, contraindicated in pheochromocytoma. + Pheoc hromocytoma is a catecholamine secreting tumor of ehromartin origin. + Other anesthetic drugs to be avoided in a pheochromocytoma patient are: © Succiny! choline- it can cause fasciculations which lead to raised intraabdominal pressure and eatecnolamine release trom the tumor © Ketamine- as it is sympathomimetic © Pancuronium — vagal blockade leading to tachycardia © Atracurlum, tupocurarine — due to histamine release wnicn may provoke catecholamine release + Xenon has a very low blood-gas solubility coeMicient (0.115) and so produces rapid Induction of ana ‘emergence trom anesthesia = Option A: the disadvantage with Xenon gas Is ils high density (5.9 g/L), which Is much higher than, ‘oxygen and nitrous oxide which leads to Inereased flow resistance and work of breathing. Thus It 's not sultable for patients with compromised respiratory tunction. = Option B: Itnas minimal cardiovascular effects. It produces minimal cardiovascular depression, ana it '5 not armytnmogenie- and so Is safe in caraiae patients. + Option ¢: Xenon produces no green house effect or ozone depletion and is environmentally safe, unlike the other inhaled anesthetics + Other advantages of xenon. ® Does net trigger malignant hyperthermia * Nonexpiosive © Has Analgesic activity - reduces intraoperative opioid requirements. + Isoflurane nas been implicated in the coronary steal phenomenon, + Isoflurane dilates coronary arteries. + This dilation of normal coronary arteries could divert blood away from fixed stenotic lesions and Increase the blood flow to the non — Ischemic areas, which was considered Coronary Steal. = But this only occurred if hypotension occurs and can be avoided if coronary perfusion pressure was restored, Desflurane has the maximum global warming potential (GWP) among the inhaled anesthetics. This is because desflurane undergoes minimal metabolism in the body and Is predominantly eliminated on ‘expiration. Global warming potential of Anesthetic Gases: + Nitrous oxide == 259 + Isoflurane ~ 1230-1401 + Sevonurane = 349-1980 + Desturane = - 3714 (Maximum) Xenon produces no green house effect or ozone depletion as it is entirely unreactive in the biosphere, Although GWP factor of desflurane much higher than that of NzO. NO Is contributing the mest to Increased climate impact (99.97%) as the consumption volumes of NoO far exceed those of tne other anesthetic gases.