Clinical Pharmacology of Anesthetic drugs
Dr. Ahsan K. Siddiqui
General Anesthesia • Definition – Induced, Reversible, controlled, loss of sensation • Components: 1. Analgesia 2. Muscle relaxation 3. Amnesia 4. Suppression of excessive autonomic responses
• Practical Conduct : Pre Anesthetic check up Just preoperative monitoring Induction Maintenance Recovery Post operative Care
Monitoring Maintenance Induction
Pre op. Check
Recovery
Post op. Care
• Anesthesiologist Tools Drugs : Hypnotics, Analgesics, Muscle relaxants & others Gases : Oxygen, Nitrous Oxide Vapors: Halothane, Isoflurane, Sevoflurane Equipments : Anesthetic Machine - Breathing Circuits, Monitors……. Others: iv access, Infusion fluid, Airway equipments……..,…..
Premedication Reasons for administration of premedications 1. Reduction of fear and anxiety
catecholamine ,
risks
2. Reduction of saliva secretion 3. Prevention of vagal reflexes (caused by surgical stimulation like squint op., stretching of anal sphincter, or associated with medication e.g., B –blockers 4. As part of anesthetic technique e.g. use of narcotics
5. To produce amnesia - Hyoscine ( Scopolamine) - Benzodiazepines - anterograde amnesia - Diazepam -hyoscine – in 75% pts complete amnesia 6. For specific therapeutic effects - Transdermal glyceryl nitrate patches for angina pts, - Steroids - B – blockers (anterograde amnesia- inability to form new memories, Impairment of memory for events occurring after the onset of amnesia)
Drugs : 1. Anxiolysis\ Amnesia: BNZ, Hyosc., Antihist. (H1 Blochers) 2. Analgesia: Opiates 3. Adjuvant to GA : BNZ & Ketamine 4. Anti-emetic : Metoclopramide, Antihist. 5. Antacids : H2 blockers, Antihist., Na Citrate
6. Antihist. : Promethazine,Diphinhydramine 7. Antivagal \ Antisialagogues: Atrop, Hyos.,AntiH 8. Antitromb. / Anticoag.: Heparin, Stockings 9. Antibiotics: Infective Endocarditis Prophylaxis 10: Attention to pre-existing medications: Continue: unless otherwise Stop : MAOI, Contraceptive pills Change : Insulin, oral hypogly., Steroids
Common Premadications Drug Diazepam Lorazepam Morphine Hyoscine Pathedine Promethazine Midazolam
Dose
Route
5-15 mg 1-3 mg
oral oral
5-15 mg 0.2-0.4 mg
IM IM
50-100mg 12.5-25mg
IM IM
2.5-5 mg
IM
Timing 1-2 hr preop.
1hr pre preop
Children Drug
Dose
Diazepam Syrup 0.2mg\kg Medazolam 70-100 mcg\kg
Route
Timing
oral IM
1 hr preop
Promethazine 2-5yr 5-10 yr
10-20mg 20-25 mg
oral
Morphine Hyoscine
0.1-0.2mg\kg 5mcg\kg
IM IM
1hr preop 1\2dose for IM
Side effect of premadications : Delayed recovery and interaction of Specific drugs
Opioids • Act on opioid receptors located through out CNS • Identified as mu - mu1 & mu2 keppa (k) delta (d) sigma • Most effective as producing analgesia • They provide some degree of sedation
IV opiates Drugs Morphine
Dose 0.1-0.2mg\kg
Onset slowest
Duration long
Pathedine
1-2 mg\kg
slow
long
Fentanyl
1-2mcg\kg
rapid
short
Alfentanil
10-20mcg\kg
v. rapid
v. short
Sufentanil
0.2-0.4mcg\kg
rapid
short
Induction Check: pt \ machine\ Monitors Monitoring: Basic Monitoring: Anesthetics, clinical, Air way EKG,NIBP,SpO2, Capnography Add.: PNS\Temp.\ CVP Agent for induction : IV vs. Inhalational Analgesia: Opiates
IV Induction Agents • The ideal intrav. Agent reliably and pleasantly induces full anesthesia within one arm-brain circulation time - is free of side effects - completely wears off in a few minutes - it must be capable of infusion to maintain anesthesia without problems.
• I.V. anesthetic agents may be used for
1. Induction of anesthesia 2. As a sole agent for operation (TIVA) 3. To supplement volatile anesthesia or regional anesthesia 4. For sedation
IV Induction Agents Propofol – - Mechanism of action – facilitation of inhibitory neurotransmission mediate by GABA - Not water soluble - 1% solution aqueous solution is available for IV use as an oil-in-water emulsion containing - soybean oil - egg lecithin - glycerol
• Only for IV administration • Rapid on set ( one arm brain circulation time) - 1\2 life 2-8 min. ( recovery rapid, no hangover) - V. high clearance rate( 10 time that of thiopentone) • Conjugation in liver results in inactive metabolites •
Excretion – in urine
• Can be used in Chr. Renal F, hepatic ds.
Thiopent. barbiturate
Propofol
Ketamine
phenol
phencyclidine
Pain -Phleb. Less Rapid onset ++ BP decrease Analgesia -Bronch ppt Asthma Mech. GABA of act.
+ more +++ decrease --GABA
-less + increase + + Desociat.
Thiopent.
Propofol
Commul. ++ Recovery Hang over clean headed PONV
+
Duration
10 min
Route
iv
- Antiemetic antipruritic 10 min i.v
Ketamine Emerg. Delir. + < 10min i.v \ i.m
• Life Support During Induction A. Airway : Support: manual \ Atrif. Airway B. O2 FM + circuit +- An. Agent Chest expansion\ bag \ monitor C. Circulatory Support D. Definitive Airway : Guedel`s Airway Laryngeal Mask Airway ETT MR + Circuit + IPPV
MAINTENANCE Anesthesia ( Tetrad) : Unconsciousness : Inhal. Vs TIVA Analgesia : N2O + Opioids / LA Relaxation : M.R. Autonomic : Pares. : Anticholin. : Symp. : GA Opioids CVS drugs
Inhalational Anesthetics • The greater the uptake of anesthetic agent, the greater the difference b \ w the inspired and alveolar conc. And slower the rate of induction. • Three factors affect anesthetic uptake 1. Solubility in the blood 2. Alveolar blood flow 3. partial pressure difference b\w alveolar gas and venous blood.
• The relative solubility's of an anesthetic in air, blood, and tissues are expressed as Partition Coefficients Partition Coefficients • N2O 0.47 ( insoluble in blood) • Halothane 2.4 • Isoflurane 1.4 • Desflurane 0.42 • Sevoflurane 0.65 (Factors that speed induction also speed recovery)
• MAC – the alveolar conc. of an inhalational anesthetic that prevents movement in 50% in response to surgical stimulus.
- a measure of potency MAC%
Nitrous oxide Halothane Isoflurane Sevoflurane Desflurane
105 0.75 1.2 2.0 6.0
• ISOFURANE – dilates coronary arteries ( but less potent than nitroglycerine or adenosine). - Can cause (coronary steal syndrome) regional myocardial ischemia)
• DESFLURANE – Low solubility of desflurane in
blood and tissues causes a very rapid wash in and wash out of anesthetic.
• SEVOFLURANE – Excellent choice for rapid and smooth inhalational induction. ( b\c of non pungency and rapid increases in alveolar anesthetic conc.)
VOLATILE ANESTHETICS
Pleasant Smell MAC HR SVR Contractility BP CO
Halothane
Isoflurane
hydrocarbon
-----------halogenated ether-------------
++ 0.75% arrhythmia +_ -
-1.2%
-minimal -+_ or minimal
Sevoflurane +_ 2% No change minimal -minimal -+_ or minimal
Halothane Catachol. sensitisation Bronchi Uterus Hepatic Tox. Renal Tox.
+++ Dilatation Relaxation + --
Isoflurane
Sevoflurane
-
-
less less --
less less -+
• Neuromuscular Blocking Agents( Ms relaxants) ( no anesthesia, amnesia or analgesia) •
Depolarizing Acetyl-choline receptor agonist
Nondepolarizing competitive antagonist
Nondepolarizing Muscle relaxants are not significantly metabolized ( except mivacurium metabolized by
pseudocholinestrase & atracurium – metabolized by hofmann elimination and ester hydrolysis )
Need reversal agents ( Cholinesterase inhibitors) that inhibit acetylecholinesterase enzyme activity.
Muscle Relaxants Sux Dtc. Panc. Vecur. Atrac. Type Depol ------Non --- Depolarising---------Onset 30 S. ---3-5 min---- --------2-3 min---Dur. V. Short ----Long ----- --intermediate --(3-5 min)
Dose 5
1
( 30-60min)
( 20-30min)
0.2-0.4 0.6-0.1 0.05-0.1 0.25-.
( mg\kg)
Hist. G.B. Vagal
Min. -
+++ ++ -
+
-
+ -
Sux
Dtc.
Panc.
Symp.
-
-
HR
or
+_
+_
BP
? +_
+_
+_
+
Vecur. -
Atrac -
Elim. Ps. Ch Es. ----kidney\liver- –liver-- Hoff + ester Notes; Sux. apnoea, K/ ICL/IOP, Dysrhythmia, MH+, Myalgea ( fasciculation)
Reversal Agents
• Cholinesterase inhibitors ( Anticholinesterse)
• Characteristics of cholinergic receptors Nicotinic Muscarinic • Location
Autonomic Ganglia Sympathetic & parasympathetic ganglia Skeletal muscle
Glands ( Lacrimal salivary, gastric)
Smooth muscle (Bronchial, GIT, bladder, bld
vessels)
Heart(SA node,AV node)
• Agonists
Acetylcholine Nicotine • Antagonist N D P M relaxants
Acetylcholine Muscarine Antimuscarinics
• RECOVERY : Titrate : Reversal : (Muscle relaxant) Atropine + Neostegmine opiate : Nalaxone Benzodiazepine : flumazinil Extubation \ Airway oxygenation Consciousness
• Pharmacological character of anticholinerg. Dg. Atropine Tachycardia Bronchodilat. Sedation Antisialagogue effect
+++ ++ + ++
Scopolamine + + +++ +++
Glycopyrrolate ++ ++ 0 +++
• Post- Operative Care : R. Room : A. Airway, recovery position B. O2 C. CVS : Consciousness Analgesia
MONITORING COMPLECATION IN THE RECOVERY ROOM HYPOTENTION-HYPERTENSION-ARRHYTHMIA RESPIRATORY : Airway Obstruction, Hypoxia, Hypoventilation Delayed recovery Pain PONV
• Complication in recovery room CVS : Hypotension – hypertension – arrhythmia Respiratory : Airway obstruction, Hypoxia, Hypoventilation Delayed Recovery Pain PONV
RECOVERY : Stop Anaesthesia # Titrate : Reversal : MR : Prostig. + Atropine. Opioids : naloxone A. Extubation \ Airway B. O2 C. Consciousness
Thank you