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Anestezie curs 1

Dr. Radu T Stoica

• 21 - Alors l’Éternel Dieu fit tomber un profond sommeil sur l’homme, qui s’endormit ; il prit une de ses côtes, et referma la chair à sa place.

Anestezia?

History

Original discoverer of general anesthetics

19th Century physician administering chloroform

Crawford Long: 1842, ether anesthesia James Simpson: 1847 Horace Wells

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Chloroform introduced

Nitrous oxide

l-a nascut pe al 8-lea fiu. Leopold • Dr.• 1853 • Anesthesie “a la reine” • Regina Victoria. usor cloroformizata. John Snow .

History of Anesthesia • Endotracheal tube discovered in 1878 • Local anesthesia with cocaine in 1885 • Thiopental first used in 1934 • Curare first used in 1942 – opened the “Age of Anesthesia” .

Definition of general anesthesia • Tripod on a platform Analgesia Muscular relaxetion Hypnosis and amnesia Maintaining homeostasis during surgical procedure .

Principles of general anesthesia  Minimizing the potentially harmful direct and indirect effects of anesthetic agents and techniques Sustaining physiologic homeostasis during surgical procedures Improving post-operative outcomes   .

The Body and General Anesthesia • Hemodynamic effects: decrease in systemic arterial blood pressure • Respiratory effects: reduce or eliminate both ventilatory drive and reflexes maintaining the airway unblocked • Hypothermia: body temperature < 36˚C • Nausea and Vomiting – Chemoreceptor trigger zone • Emergence – Physiological changes .

loco-regionala Tehnici combinate (generala si loco-regionala) • Dupa durata interventiei chirurgicale Anestezie de o zi (one-day anesthesia) • Dupa locatie Anestezie in ambulator. locala. in spital .Tipuri de anestezie • • • • Dupa mecanisme Anestezie generala Anestezie.

Mechanism • Early Ideas – Unitary theory of anesthesia • Anesthesia is produced by disturbance of the physical properties of cell membranes • Problematic: theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein • Focus on identifying specific protein binding sites for anesthetics .

Cellular Mechanism • Intravenous Anesthetics – Substantial effect on synaptic transmission – Smaller effect on action-potential generation or propagation – Produce narrower range of physiological effects • Actions occur at the synapse – Effects the post-synaptic response to the released neurotransmitter • Enhances inhibitory neurotransmission .

the major inhibitory neurotransmitter in the brain – GABAA receptor found throughout the CNS » Most abundant.Molecular Actions: GABAA Receptor • Ligand-gated ion channels – Chloride channels gated by the inhibitory GABAA receptor • GABAA receptor mediates the effects of gamma-amino butyric acid (GABA). ligand-gated ion channel in the mammalian brain » Located in the postsynaptic membrane . fast inhibitory.

causes GABA to open • Receptor capable of binding 2 GABA molecules.Molecular Action: GABAA Receptor • Receptor sits in the membrane of its neuron at the synapse • GABA. between an alpha and beta subunit – Binding of GABA causes a conformational change in receptor • Opens central pore • Chloride ions pass down electrochemical gradient – Net inhibitory effect. reducing activity of the neuron . endogenous compound.

raising concerns about potential risks in putting young children under for surgery • Prolonged changes in behavior. studies on animals suggest. 2007 • The Wall Street Journal: “FDA Wants More Research on Anesthesia Risk to Kids” – Anesthesia can be harmful to the developing brain.Current News • March 30. memory and learning impairments – Relevance of the animal findings to pediatric patients is unknown .

MAC value . and elimination from the body • Pharmacodyamics-.Inhalational Anesthetic Agents • Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia • Pharmacokinetics--uptake. distribution.

Nitrous Oxide • Simple linear compound • Not metabolized • Only anesthetic agent that is inorganic .

Nitrous Oxide • Major difference is low potency • MAC value is 105% • Weak anesthetic. powerful analgesic • Needs other agents for surgical anesthesia • Low blood solubility (quick recovery) .

Nitrous Oxide Systemic Effects • Minimal effects on heart rate and blood pressure • May cause myocardial depression in sick patients • Little effect on respiration • Safe. efficacious agent .

Halothane • Synthesized in 1956 by Suckling • Halogen substituted ethane • Volatile liquid easily vaporized. and nonflammable . stable.

Halothane • Most potent inhalational anesthetic • MAC of 0.75% • Efficacious in depressing consciousness • Very soluble in blood and adipose • Prolonged emergence .

lowers BP and slows conduction • Mild peripheral vasodilation .central response to CO2 and peripheral to O2 – Respirations shallow-.atelectasis – Depresses protective airway reflexes • Depresses myocardium-.Halothane Systemic Effects • Decreases respiratory drive-.

1/10. hepatic necrosis.000 cases – fever. death – metabolic breakdown products are hapten-protein conjugates – immunologically mediated assault – exposure dependent .Halothane Side Effects • “Halothane Hepatitis” -. jaundice.

muscle rigidity. acidosis.1/60. hyperkalemia. succinylcholine in 77% • Classic-. DIC – most common masseter rigidity – family history . tachycardia.000 with succinylcholine to 1/260.000 without – halothane in 60%.rapid rise in body temperature. rhabdomyolysis.Halothane Side Effects • Malignant Hyperthermia-.

Sevoflurane and Desflurane • Enflurane.mild respiratory and cardiac suppression • Few side effects • Expensive • Differences . Isoflurane… • Low solubility in blood-.produces rapid induction and emergence • Minimal systemic effects-.

Intravenous Anesthetic Agents • First attempt at intravenous anesthesia by Wren in 1656-. pleasant experience .opium into his dog • Use in anesthesia in 1934 with thiopental • Many ways to meet requirements-.muscle relaxants. nonopoids • Appealing. opoids.

Physiochemical Properties Aromatic Segment Intermediate Chain Hydrophilic Segment Amino-ester Amino-amine “Esters” “Amines” .Local anesthesia.

Physiochemical Properties • Amino-esters (“Esters”) – Older class of drugs – Derivatives of PABA (p-aminobenzoic acid) – Hydrolyzed by serum cholinesterase • Examples – Procaine (Novocaine) – Cocaine – Tetracaine – Benzocaine .

• Amino-amines (“Amines”) – Newer class of drugs – Derivatives of aniline – Hepatic degradation • Examples – – – – – Lidocaine Bupivocaine (Marcaine. Sensoricaine. Polocaine) Mepivocaine (Carbocaine) Etidocaine Prilocaine .

Mechanism of action Protein binding Vasodilatation Mode of administration Presence of vasoconstrictor Lipid solubility Vasodilatation Tissue pH Concentration of drug Onset Inherent pKa Myelination Interspersed tissue Dosage of drug .

Ideal Anesthetic • • • • • • • Immediate onset Reversible Appropriate duration No permanent damage No tissue irritation / pain Wide therapeutic range Effective regardless of application .

12 to 0.Topical anesthesia • Epidermis – Avascular layer measuring 0.7 mm – Barrier to diffusion of topicals • Dermis – Support structure – Contains blood vessels and nerve endings – Anesthetic’s targeted site of action .

Uses • Intact skin procedures – Venopuncture – Punch biopsies – Lumbar puncture .

but not practical .Lidocaine Cream • 30% lidocaine cream • Saturated on gauze pad adherent to an elastic patch • 45 minutes minimum application time • ½ hour anesthetic duration = 2 hour application • Effective and safe.

EMLA (Eutectic Mixture of Local Anesthetics) • • • • 2.5% lidocaine and 2.5% prilocaine 1-hour application time Maximum dose at 2-3 hours Depth of anesthesia correlated to duration of application • Duration of 1-2 hours after removal • Hypersensitivity and systemic toxicity rare .

Ethyl Chloride (C2H5CL) • • • • Not an anesthetic. but limited duration Spray for 3 to 7 seconds Used for injections and lancing small abscesses or boils • Not used for punch biopsies . but a vapocoolant Immediate anesthesia.

throat. tracheobronchial tree. and genitourinary tract • Tetracaine • Lidocaine • Cocaine • Benzocaine .Mucous Membranes • Nose. esophagus. mouth.

Infiltration Anesthesia • Injection of anesthetic agent directly into tissue • Excision of skin lesions • Incision of abscess • Suturing of wounds .

Advantages & Disadvantages • Advantages – Quick and safe – Provides hemostasis • Disadvantages – Large dose for small area – Distorts wounds .

5-1.5-1.0 (3) Onset (min) 2-5 2-5 2-5 Duration 15-45 min 1-2 hr 4-8 hr .25 Adult (mg) 500 (600) 300 (500) 175 (225) Pediatric (mg/kg) 7.Choice of Agent Maximum Dose Concentration Agent Procaine Lidocaine Bupivacaine (%) 0.0 0.0 (9) 4.0 0.5 (7) 2.

Injection Technique • • • • • • Lowest concentration effective Prep wound first if possible Smallest needle available (27g) Use wound margin Subdermal injection Insert. then inject .

Injection • Injection should be subdermal • Bury the hub and inject as you withdraw • Through wound edge .

Allergic Reactions • Fisher. 4 delayed • 39 to “additives” Fisher MM. Bowie CJ Alleged Allergy to Local Anesthetics Anaesth Intensive care 1997 Dec.25(6):611-4 .et al • Anesthetic allergy clinic • 208 patients with “allergy” to local anesthetic over 20 year period • Intradermal testing • 4 immed.

Systemic Toxic Reaction • Host Factors – Hypoxia – Acid-base status – Protein binding – Concomitant drugs .