4.

General Anaesthesia – inhalational agents

An inhalational anaesthetic is a chemical compound possessing general anaesthetic properties that can

be delivered via inhalation. They are administered by anaesthetists through an anaesthesia
mask, laryngeal mask airway or tracheal tube connected to an anaesthetic vaporiser and an anaesthetic
delivery system. 
Previously-used agents
Currently-used agents
Although some of these are still used in clinical practice and in
 Desflurane
research, the following anaesthetic agents are primarily of historical
 Isoflurane
interest in developed countries:
 Nitrous oxide
 Sevoflurane  Chloroethane (ethyl chloride)
 Ethylene
 Xenon
 Chloroform  Fluroxene
Never-marketed agents  Halothane
 Cryofluorane
 Methoxyflurane (still used
 Aliflurane
 Cyclopropane currently as an analgesic)
 Halopropane
 Methoxypropane
 Norflurane  Diethyl ether
 Trichloroethylene
 Roflurane
 Enflurane  Vinyl ether
 Synthane
 Teflurane

Volatile anaesthetics

Volatile anaesthetic agents share the property of being liquid at room temperature, but evaporating
easily for administration by inhalation. All of these agents share the property of being
quite hydrophobic.

The ideal volatile anaesthetic agent offers smooth and reliable induction and maintenance of general
anaesthesia with minimal effects on other organ systems. In addition it is odourless or pleasant to
inhale; safe for all ages and in pregnancy; not metabolised; rapid in onset and offset; potent; and safe
for exposure to operating room staff. It is also cheap to manufacture; easy to transport and store, with a
long shelf life; easy to administer and monitor with existing equipment; stable
to light, plastics, metals, rubber and soda lime; non-flammable and environmentally safe.

None of the agents currently in use are ideal, although many have some of the desirable characteristics.
For example, sevoflurane is pleasant to inhale and is rapid in onset and offset. It is also safe for all ages.
However, it is expensive (approximately 3 to 5 times more expensive than isoflurane), and
approximately half as potent as isoflurane.
Other Gases

Other gases or vapors which produce general anaesthesia by inhalation include nitrous oxide,
cyclopropane and xenon. These are stored in gas cylinders and administered using flowmeters, rather
than vaporisers. Cyclopropane is explosive and is no longer used for safety reasons, although otherwise
it was found to be an excellent anaesthetic. Xenon is odourless and rapid in onset, but is expensive and
requires specialized equipment to administer and monitor. Nitrous oxide, even at 80% concentration,
does not quite produce surgical level anaesthesia in most persons at standard atmospheric pressure, so
it must be used as an adjunct anaesthetic, along with other agents.

Hyperbaric anaesthesia

Under hyperbaric conditions (pressures above normal atmospheric pressure), other gases such

as nitrogen, and noble gases such as argon, krypton, and xenon become anaesthetics. When inhaled at
high partial pressures (more than about 4 bar, encountered at depths below about 30 metres in scuba
diving), nitrogen begins to act as an anaesthetic agent, causing nitrogen narcosis. However,
the minimum alveolar concentration (MAC) for nitrogen is not achieved until pressures of about 20 to 30
atm (bar) are attained. Argon is slightly more than twice as anaesthetic as nitrogen per unit of partial
pressure. Xenon however is a usable anaesthetic at 80% concentration and normal atmospheric
pressure.

History

The concept was first used by Paracelsus in 1540. He used sweet oil of vitriol used to feed fowl: “it was
taken even by chickens and they fall asleep from it for a while but awaken later without harm”.
Subsequently, about 40 years later, in 1581, Giambattista Delia Porta demonstrated the use of ether on
humans although it was not employed for any type of surgical anaesthesia.

Summary

 Halothane causes unconsciousness but provides little pain relief; often administered
with analgesics . It may be toxic to the liver in adults. Halothane, however, has a pleasant smell
and is therefore often the anesthetic of choice when mask induction is used with children.
 Enflurane is less potent, but produces a rapid onset of anesthesia and possibly a faster recovery.
Enflurane is not used in patients with kidney failure.
 Isoflurane is not toxic to the liver but can induce irregular heart rhythms.
 Nitrous oxide (laughing gas) is used with other such drugs as thiopental to produce surgical
anesthesia. It has the fastest induction and recovery time. It is regarded as the safest inhalation
anesthetic because it does not slow respiration or blood flow to the brain. However, because
nitrous oxide is a relatively weak anesthetic, it is not suited for use in major surgery. Although it
may be used alone for dental anesthesia, it should not be used as a primary agent in more
extensive procedures.
 Sevoflurane works quickly and can be administered through a mask since it does not irritate the
airway. On the other hand, one of the breakdown products of sevoflurane can cause renal
damage.
 Desflurane, a second-generation version of isoflurane, is irritating to the airway and therefore
cannot be used for mask (inhalation) inductions, especially not in children. Desflurane causes an
increase in heart rate, and so should be avoided for patients with heart problems. Its advantage
is that it provides a rapid awakening with few adverse effects.