Intravenous anesthetics

Summary

Intravenous anesthetics are a group of fast-acting compounds that are used to induce a state of
impaired awareness or complete sedation. Commonly used intravenous anesthetics
include propofol, etomidate, ketamine, and barbiturates (e.g., thiopental). Propofol is the
standard drug for induction of anesthesia and etomidate is most commonly used in cases of
hemodynamic instability. Ketamine plays a key role in emergency medicine because of its strong
dissociative, sympathomimetic, and analgesic effects.
The barbiturate thiopental reduces intracranial pressure, making it useful in patients with
high intracranial pressure and/or head trauma. While the characteristics and side effects of
intravenous anesthetics are highly dependent on the substance involved, they all share a strong
hypnotic effect.

For more information on benzodiazepines and opioids, see the corresponding learning cards.

Overview
Indication Characteristics
Propofol • Total intravenous • Antiemetic
anesthesia (TIVA) drug• No analgesic or muscle
of choice relaxant effects
• Sedation in ICU • Hypotension
• Short procedures
• Rapid induction

Etomidate • IV anesthesia for • ↓ Intracranial pressure

patients with • Little to no effect on
hemodynamic instability the cardiovascular
system

Ketamine • Ideal emergency • Sympathomimetic effec

anesthesia ts
for polytrauma patients• ↑ Intracranial pressure
• Short painful procedures• Dissociative anesthesia
•
(e.g., fracture reduction) Psychotomimetic
• Treatment- effects
resistant asthma
•
 Indication Characteristics
• IV
Barbiturates (thiopental and methohexit • Respiratory depression
al) anesthesia induction (es• ↓ Intracranial pressure
•
p., short procedures, risk Antiepileptic effects
of raised intracranial • Cytochrome
pressure) P450 induction

Opioids (e.g., fentanyl, morphine) • Analgesia during • Muscle rigidity

induction and/or • Cardiovascular and
maintenance anesthesia respiratory depression

Benzodiazepines (e.g., midazolam) • IV anesthesia induction• ↓ Blood pressure

• Short outpatient • Anterograde amnesia
procedures
• Preoperative sedation
• Endoscopy

References: [1][2][3]

Propofol

Mechanism of action
• Not fully understood. Propofol is thought to act at GABAA receptors and sodium channels
of the reticular formation.
• Rapid onset and recovery

Effects
• Hypnotic effects
• Antiemetic
• Antipruritic
• Anticonvulsant
• Bronchodilation
• ↓ Intracranial pressure
• No analgesic or muscle relaxant effects
Side effects
• Hypotension (dose-dependent)
• Respiratory depression (dose-dependent)
• Anaphylaxis (esp. in patients with allergies to soy or egg products )
• Pain on injection
• Propofol infusion syndrome
• Etiology: high doses and prolonged administration of propofol
• Clinical features: severe metabolic acidosis, rhabdomyolysis, renal failure, and/or
cardiac failure (often fatal)
• Diagnostics: Patients undergoing prolonged propofol treatment should
have triglycerides monitored at least every 3 days, as increased triglyceride levels
correlate with development of propofol infusion syndrome.
• Management: discontinue propofol immediately, symptomatic treatment

Indications
• Standard for anesthesia induction
• Total intravenous anesthesia (TIVA)
• A technique for induction and maintenance of general anesthesia using IV drugs alone.
• Propofol is the drug of choice, especially for patients with an intermediate to high risk
of postoperative nausea and vomiting (PONV).

References: [3][4][5][6]

Etomidate

Mechanism of action
• Acts on the GABA receptors in the reticular formation
• Rapid onset and recovery

Effects
• Hypnotic effects
• ↓ Intracranial pressure
• Anticonvulsant effects
• Little to no effect on the cardiovascular system
• Little to no effect on respiration
• No analgesic or muscle relaxant effect
Side effects
• Transient acute adrenal insufficiency (due to adrenal cortex suppression →
reduced cortisol production)
• Postoperative nausea and vomiting
• Painful injection (avoid by administering an opioid prior to injection)
• Myoclonus

Indications
• Anesthesia for patients with hemodynamic instability

Of all the IV anesthetics, etomidate has the least impact on the cardiovascular system!

Ketamine

Mechanism of action
• NMDA receptor antagonist
• Belongs to the arylcyclohexylamines class
• Rapid onset

Effects
• Dissociative anesthesia: unique anesthetic state with analgesia, intact spontaneous
breathing, amnesia, and no complete loss of consciousness
• Strong analgesia
• Bronchodilation
• Sympathomimetic effects: ↑ blood pressure, ↑ heart rate, ↑ cardiac output

Side effects
• Nystagmus
• ↑ Oxygen demand and ↑ pulmonary arterial pressure
• ↑ Intracranial pressure due to increased cerebral blood flow
• Psychotomimetic effects: hallucinations, nightmares, abnormal EEG (concomitant
administration of benzodiazepines is recommended to avoid these effects)
• Rapid injection or high doses can lead to respiratory depression.
• ↑ Salivation
Indications
• Ideal emergency anesthetic for polytrauma patients and other patients with risk
of hypotension (no cardiovascular depression)
• Treatment-resistant asthma
• Short painful procedures (e.g., fracture reduction)

Ketamine may be administered via intramuscular injection if IV access is not possible!

References: [3][7][8]

Barbiturates

Agents
• Thiopental
• Methohexital

Mechanism of action
• Enhanced GABA action → enhanced duration of chloride channel
opening and hyperpolarization of postsynaptic neurons → ↓ neuronal excitability in the
brain
• High potency, highly-lipid soluble → rapid onset of action due to quick transfer across
the blood-brain barrier → brief recovery time due to redistribution into skeletal muscles
and adipose tissue

Effects
• Hypnotic effects
• ↓ Intracranial pressure due to reduced cerebral blood flow
• Little to no analgesic or muscle relaxant effects

Side effects
• Hypotension (dose-dependent)
• Respiratory depression and/or apnea (dose-dependent)
• Laryngospasm, bronchospasm (due to histamine release)
• Myoclonus
• Painful injection
 • Visual hallucinations
• Vivid dreams
• Bradycardia, arrhythmias
• Cytochrome P450 induction

Indications
• IV anesthesia induction (esp. short procedures with minimal pain and high risk of
raised intracranial pressure)
• Reduction of intracranial pressure for brain edema following trauma or surgery
• Sedation for electroconvulsive therapy (e.g., methohexital)
• Convulsion during or after anesthesia

Contraindications
• Hypersensitivity
• Conditions in which an increase in blood pressure would be hazardous
• Severe cardiovascular decompensation
• Porphyria
• Addison disease
• Liver or kidney disease
• Severe anemia
• Thyroid disorders
• Myasthenia gravis
• Asthma