Anesthesia.

The structure and main components

of the anesthesia. Total intravenous
anesthesia (TIVA)

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 What drugs we use during
anesthesia
and what is the purpose?

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 The objectives of the anesthesia

The protection of the surgical trauma

The maintenance of vital functions

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 The ways of solving
During anesthesia we have to ensure :
Unconsciouness
Amnesia
Analgesia
Oxygenation
Ventilation(sufficient volume and respiratory
rate, airway management)
Muscle relaxation
Monitoring

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Classification of the anesthesia
1.Sedation
2 .Pain management
3.Regional:
• spinal, epidural, peripheral nerve bloke
4.General:
• Inhalation
• TIVA

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 General anesthesia is:

Inhalation

Total intravenous anesthesia

(TIVA)
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Goal of General Anesthesia
Hypnosis
Amnesia
Analgesia
Immobility/decreased muscle tone-
relaxation of skeletal muscle
Inhibition of nociceptive reflexes
Reduction of certain autonomic
reflex(tachycardia, vasoconstriction)

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Stages of Anesthesia
Historical terminology to describe depth of
anesthesia upon gas induction. Today, more
important for emergence.
1. Stage sedation Sedated, intact lid reflex, the
patient follows commands
 Spontaneus respiration present
 Reflexes present
 Possible small surgery procedures like dressing
change in burns, MRI exemination
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Stages of Anesthesia
2. Excitation stage
Unconscious, unable to follow commands or
exhibit purposeful movement
 Irregular breathing, increase in respiratory rate
& breath-holding,
Dilated & change in pupil response to light,
Conjunctival injection(dilation of vesels)
 Increased probabilities of laryngospasm,
arrhythmias, and vomiting.
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Stages of Anesthesia
3. Anesthesia for Surgery Inperformdecreased muscle ton doctor need to
tracheal intubation
It begins with lack of lid reflex
In stage 3.3 we need to give
Airway opening necessary adrenomimetics for depression of
respiration
Possible surgery exept for abdominal opening
if no relaxants are used
Possible endotracheal intubation
4. Stage intoxication, overdosis
Cardiovascular/respiratory arrest
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Why Intravenous anesthetics?
 Safety relative
 Hemodynamic control
 Rapid titration
 Avoid vasodilatation Smooth emergence,
less hangover

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Advantages of total intravenous
anaesthesia

 The potential toxic effects of the inhalational

anesthetics are avoided.

May cause profound hypotension.

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Disadvantages of total intravenous
anaesthesia
Secure, reliable intravenous access is required.
Cost of electronic infusion pumps.

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Anesthetic protocol
1.Premedication, Induction
2.Maintenance
 Skeletal relaxation
 Analgesia
3. Recovery / Shifting to ICU
Single anesthetic agent can't meet all the
requirements

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Phases of general anesthesia

1.Induction phase
2. Maintenance of anesthesia
3. Emergency

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Premedication/Inducing agents

• Premedication originally referred to drugs

administered to facilitate the induction and
maintenance of anesthesia

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Premedication
Premedication includes several groups of drugs,
The 6 «A» of premedication
• Anxiolysis (The anxiolytic effect is the reduction of
anxiety, fear (antifobic action), reduction of
emotional tension)
Vagolytics for hypersalivation
• Amnesia
• Anti-emetic When urgent operation or at the end
• Antacid
• Anti-autonomic (decrease in autonomic reactions)
• Analgesia
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Antihistamines if patient might have severe
Ass.prof.N.Baranova
allergic reaction
 Induction of anesthesia
Induction phase: Transition from awake state to full affect
of anesthesia on CNS, CVS, respiratory and muscle system
Changes in CNS function are always accompanied by those
of other systems
Magnitude of changes in various systems reflect
physiological state of patient age, stress level, physiological
reserve, fluid balance, drug therapy

Drug effect on CNS is primarily depression of usual response

on the stimuli
 There may be contrary effects related to loss of inhibitory
actions of CNS (excitement)
 Examples: movements of limbs, hiccough, cough
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Induction of anesthesia
Addition of supports is required to ensure
adequate function of Respiratory and CVS
systems
Airway control with Ventilatory support
(Protection of the airway)
Blood pressure support with medication or
IV fluids

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 During anesthesia we have to ensure
 Drug-induced sleep
 Pain relief
 Neuro-vegetative protection
 Muscle relaxation
 Adequate ventilation
 Optimal level of blood circulation
 Normalization of metabolic processes in
tissues
 Monitoring
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Components of the anesthesia
• A general anaesthetic always involves an hypnotic
agent, usually an analgesic and may also include
muscle relaxation.
The combination is referred to as the ‘triad of
anaesthesia’.
1. Narcosis (hypnotic agent)
2. Analgesia
3. Muscle relaxation
(Neuro-vegetative blockade)
extensive
Department Emergency Medicine, model
Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Total intravenous anesthesia (TIVA)
Classification of the intravenous agents
1. Inducing agents (Anti-emetic - reduction of
nausea and vomiting, Antacid, Anti - autonomic
effects)
2. Benzodiazepines (Sedation and Amnesia)
3. Opiates (The most commonly used are
morphine and fentanyl- Analgesia)
3. Dissociative agents (Disociative Amnesia-
ketamine)
4. Hypnotic
5. Neuroleptic agents
6. Myorelacsation agents
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Anxiolysis and Amnesia
•The most commonly prescribed drugs are the
Benzodiazepines. They produce a degree of
sedation and amnesia
•Those most commonly used include Temazepam
20–30mg,
•Diazepam 10–20mg and
•Lorazepam 2–4mg.
•In patients who suffer from excessive somatic
manifestations of anxiety, for example
tachycardia, beta blockers may be given.
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Anti-emetic (reduction of nausea and
vomiting)
Nausea and vomiting may follow the
administration of opioids, either pre- or
intraoperatively. Certain types of surgery are
associated with a higher risk of postoperative
nausea and vomiting.
We use usually for prevention
• Metoclopramide - 10mg orally or IV
• Ondansetron - 4–8mg orally or IV
• Cyclizine - 50mg IM or IV
• Hyoscine - 1 mg transdermal patch
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Antacid (modify pH and volume of
gastric contents)
Patients are starved preoperatively to reduce the risk
of regurgitation and aspiration of gastric acid at the
induction of anesthesia. A variety of drug combinations
are used to try and increase the pH and reduce the
volume.
•Oral sodium citrate: 30 ML orally immediately
preinduction, to chemically neutralize residual acid.
•Ranitidine (H2 antagonist): 150mg orally 12 hourly and 2
hourly preoperatively.
•Metoclopramide: 10 mg
•Omeprazole (proton pump inhibitor): 40mg 3–4 hourly
preoperatively.
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Anti-autonomic effects
1. Reduce salivation (antisialogogue)
2. Reduce the vagolytic effects on the heart.

Atropine preoperatively 0.1ml/10kg(bv)

intramuscularly (IM, IV).

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Anti-sympathomimetic effects
Increased sympathetic activity can be seen at
intubation, causing tachycardia and
hypertension.
•These responses can be attenuated by the use
of beta-blockers given preoperatively
e.g. atenolol 25–50mg orally or intravenously
at induction.
•Peri-operative beta blockade may also decrease
the incidence of adverse coronary events in high
risk patients having major surgery.
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Analgesia
The most commonly used are Morphine and
Fentanyl. Morphine was widely used for its sedative
effects but is relatively poor as an anxiolytic and has
largely been replaced by the benzodiazepines.
Opiates have a range of unwanted side-effects,
including:
 Nausea,
 Vomiting,
 Respiratory depression and delayed gastric
emptying.
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Analgesia, Opioid
• It can be used in premedication and during
maintenance of anesthesia
Effects:
CV system : BP, HR, CO
Respiratory: reducing frequency and
depth of breathing
Neuro: Neuro Sedation, cognitive
impairment, euphoria.

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Maintenance of anesthesia
Further adjustment of anesthesia levels based
on
–Patient response
–Stage of surgery
–Trends of monitored variables
For the maintenance of anesthesia using all
groups of drugs: opioids, anxiolytics, muscle
relaxants, hypnotics

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Intravenous Anesthetics
Ketamine
Advantages - Can be given IV or IM
Does not depress the CV system
Very good analgesic but does not produce all the
signs of unconsciousness
Eye and body movements may persist
Acts perhaps on opioid receptor
Causes hallucination and bad dreams in adults
(reduced by midazolam)
Metabolized in the liver - action lasts 15 min
Good for induction and painful burn dressings
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Ketamine
Produces "dissociative anesthesia".
Dissociative anesthesia: a state characterized by
immobility,
amnesia and
analgesia
with light sleep and feeling of dissociation from
ones own body and mind and the environment .
Dose: 5-10mg/kg i/m
or 1-2mg IV
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Ketamine
Effects: CV system : HR, BP, CO
Respiratory: Brondilatator,
salivation minimal effect
Neuro: Dissociative amnesia.

Ketamine acts on associative area and subcortical

structures of the thalamus, causing inhibition of
their functions and activating the limbic system

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Thiopental
It is ultra short barbiturate.
Rapid action due to rapid transfer across
blood-brain barrier.
Short duration (about 5-15 min) due to
redistribution, mainly to muscle.
No analgesic effect.
It has anticonvulsant effect.
It is used for induction of general anesthesia
followed by a drug for maintenance.
It is also used alone for short time anesthesia
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Thiopental
Effects: CV system : HR, BP, CO, severe
vasospasm
Complications are possible(undesirable effect
increases proportionally to the dose)
Respiratory: cough, bronchial spasm,
laryngeal spasm, respiratory arrest (inhibit the
activity of the respiratory centre).
Neuro: Thiopental causes loss of
consciousness, reduced brain metabolism, reduces
cerebral blood flow (due to narrowing vessels of the
brain) and
Department hasMedicine,
Emergency anti -Anesthesiology
convulsive and action.
Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Propofol
It can induce prolonged sedation.
Similar to thiopental, but more rapidly
metabolized (rapid induction and recovery).
It has a strong hypnotic and sedative effect,
slight anesthetic effect.

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Propofol
Effects: CV system : HR, BP, SV, SVR, CO
Respiratory: Transitory apnea with
the introduction of anesthesia
Neuro: Falling asleep is smooth, without
excitation stage;
Upon awakening, patients tend to experience
satisfaction of anesthesia;
According to cause amnesia propofol
approaching midazolam and thiopental sodium is
superior.
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Sodium oxybutyrate
Sodium oxybutyrate also belongs to the
group of anti-hypoxants, so it is widely used in
intensive care of patients with disabilities of the
cardiovascular system (in shock), with severe
hypoxic conditions (brain damage).
For anaesthesia is used at a dose
of 70 - 120 mg / kg of body weight.
Narcotic sleep lasts for 1 – 1,5 hours.
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Sodium oxybutyrate.
-easily penetrates the central nervous system.
• The drug has elements nootropic activity.
Typical is his expressed antihypoxia action;
•It increases the stability of the body, including
the brain tissue, heart, as well as the retina, to
oxygen deficiency.
•The drug has a sedative effect and central
muscle relaxant effect, in high doses cause sleep
and the state of narcosis
Normalizes
Department Emergencycellular respiration
Medicine, Anesthesiology and Intensive Therapy KNMU,
Haemodynamics
Ass.prof.N.Baranova is not disturbed.
 Sodium oxybutyrate.
Effects: CV system : HR, BP, CO - It
slightly lowers blood pressure and slows the
pulse.
Respiratory: It has a toxic effect-
depressive in excess of the therapeutic dose
Neuro: At therapeutic doses is
almost doesn’t inhibit the respiratory center.
It provides moderate central effect on muscle
relaxation
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Muscle relaxants
These work by interfering with the normal
action of acetylcholine at the motor end plate,
blocking the receptors on the postsynaptic
muscle membrane (and possibly other sites).
Muscle relaxants are divided into two groups,
the names of which are thought to reflect
their mode of action.

Depolarizing Non-Depolarizing
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 Muscle relaxants
The first are short-term, causing febrile
twitching of the facial muscles, muscles of the
trunk, the limbs, the diaphragm, followed by
relaxation of the muscles and vocal cords up to
4-6 minutes.

• Ditylin (succinylcholine) Depolarizing muscle

relaxants usually used for tracheal intubation.

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova
 Muscle relaxants
These drugs compete with acetylcholine and block
its access to the postsynaptic receptor sites on the muscle
but do not cause depolarization.
Anti-depolarizing muscle relaxants
cause long-term (from 25 min. to 1,5 hours) muscle
relaxation in patients without prior fibrillation.
They include
tubocurarine chloride,
pavulon,
arduan,
tracrium.
Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,
Ass.prof.N.Baranova
 TIVA system

Department Emergency Medicine, Anesthesiology and Intensive Therapy KNMU,

Ass.prof.N.Baranova