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General Anaesthetics Flashcards

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0
Q

when was nitrous oxide first used ?

A

horace wells, a dentist had a tooth extracted using it

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1
Q

who was the first to make nitrous oxide ?

A

Humphrey Davy
he suggested in 1800 that it could be used to relieve pain
- it was originally thought to be very toxic
it become the common fairground attraction and it produced euphoria, analgesia and loss of consciousness= laughing gas

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2
Q

what did william morton do ?

A

in 1846 he convinced the chief surgeon at mass gen hospital to allow him to administer ether to induce anaesthesia and it was very successful

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3
Q

what are modern anaesthetics described as ?

A

controlled and reversible loss of sensation and consciousness - has to be under controlled conditions

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4
Q

who used anaesthetics prior to 1800s?

A

the ancient greeks

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5
Q

what are the characteristics of a general anaesthetic ?

A

analgesia
amnesia- dont want to remember what happened
loss of consciousness
relaxation of skeletal muscles for surgery and setting bones
suppression of somatic, autonmic and endocrine reflexes- avoid increased blood flow and release of adrenaline
haemodynamic stability- stability of cardiovascular system

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6
Q

what some key factors when administering an anaesthetic ?

A

it needs o be quick and pleasant

it needs to be maintained smoothly and the patient wants to recover from it rapidly

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7
Q

what are the 4 stages of anaesthesia ?

A

1- analgesia
2- excitement
3- surgical anaesthesia
4- medullary depression

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8
Q

what is stage 1 of general anaesthesia ?

A

ANALGESIA

  • it is analgesia without amnesia, patient is conscious but drowsy - blunting of pain sensation
  • the levels of analgesia vary with different agents - nitrous oxide causes pronounced analgesia
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9
Q

what is stage 2 of general anaesthesia ?

A

EXCITEMENT

  • loss of conciousness
  • patients no longer respond to non-painful stimuli but respond to painful stimuli in reflex fashion
  • patient may move and talk incoherently
  • respiration rapid and irregular due to stimulation of this system
  • dangerous stage and modern anaesthetic procedures are designed to eliminate or minimise this stage
  • want to get through this stage as quickly as possible
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10
Q

What is stage 3 of general anaesthesia ?

A

SURGICAL ANAESTHESIA

  • loss of consciousness - 4 planes of increasing depth
  • plane 1= decrease in eye movements
  • plane 2= loss of corneal reflex
  • planes 3 and 4= loss of pharnygeal reflex, decrease in muscle tone and respiratory depression
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11
Q

what is stage 4 general anaesthesia ?

A

MEDULLARY DEPRESSION
- loss of spontaneous respiration
- depression of cardiovascular reflexes
- regarded as an overdose requiring respiratory and circulatory support
this is a highly dangerous stage and you want to keep the patient out of this
patient will be given support for breathing and also receive adrenaline

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12
Q

what are the properties for an ideal GA for the patient ?

A 
fast
pleasant induction- simple injection 
odourless
tasteless- if an inhalation drug 
no side effects 
rapid recovery - no lethargy and headaches
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13
Q

what are the ideal properties for an GA for the surgeon ?

A

muscle relaxation
analgesia
no increased bleeding - no anticoagulant effects
long duration possible

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14
Q

what are the ideal properties of a GA for the anaesthesist ?

A

controllable - to help maintain patient in stage 3
potent
no long term effects
easy mixing- if its a gas it must be easily mixed with air to maintain normal blood-oxygen levels

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15
Q

what are the ideal properties of a GA for the manufacturer?

A

stable
easy to make
pure

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16
Q

what are 2 very important factors necessary for a GA ?

A

non-explosive

non-flammable

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17
Q

what are the 2 theories for the mechanisms of action of GA?

A

lipid theory

protein theory

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18
Q

what was the meyer-overton hypothesis ?

A

close correlation between anaesthetic potency and lipid solubility- many different theories noticed that the potency of an anaesthetic is closely related to lipid solubility

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19
Q

what happens to the potency of an anaesthetic as the lipid solubility increases ?

A

as lipid solubility increases the potency of the anaesthetic increases

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20
Q

what is plotted in the lipid theory ?

A

plot of minimum alveolar concentration (MAC) against lipid solubility expressed as oil:gas partition coefficient

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21
Q

what is the oil:gas partition coefficient ?

A

it is a measure of the amount of anaesthetic that has partitioned in the lipid
e.g. if it is 1 then the anaesthetic will be equally distributed in lipid as what remains as gas

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22
Q

what is the oil:gas partition coefficient of methoxyflurane?

A

1000

this means that 1000 more is in lipid compared to in gas

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23
Q

what is MAC ?

A

minimum alveolar concentration
it is the concentration that prevents 50% of patients responding to a painful stimulus and is an index of anaesthetic potency- bit like LD50 or EC50

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24
what did the lipid theory suggest ?
suggested anaesthesia was due to alteration of membrane function
25
what were to the 2 mechanisms proposed in the lipid theory ?
volume expansion of membrane - this changes functioning of transporters and proteins in the membrane altered membrane fluidity
26
what are some exceptions to the lipid theory ?
enantiomers of some GAs have different anaesthetic properties but identical physical properties e.g. isoflurane and etomidate because one doesnt have anaesthetic properties this indicates that it is not physico-chemical properties that are just involved
27
what is the protein theory ?
GAs bind to hydrophobic domains in receptor/ion channel proteins as well as partitioning in the membrane - anaesthetic sensitivity differs in mutant receptors suggesting specific binding domains
28
what was demonstrated about GAs with the GABAa receptor ?
site directed mutagenesis of glycine and GABAa receptor affects anaesthetic sensitivity - with normal subunits GABAa activity is increased with GAs - GABA subunit roe is insensitive to GAs - therefore it proved that there was a specific region on the GABAa receptor inducing the effects of GAs
29
what was the consensus about the protein theory ?
anaesthetics concentrate at the lipid protein interface in the membrane and so can affect protein function but also potency is related to oil/gas partition coefficient
30
what is the mechanism of action of GAs?
inhibit synaptic transmission minimal effects on axonal conduction reduce release of excitatory transmitters response of post-synaptic receptors inhibited GABA mediated inhibitory transmission is enhanced by some GAs - enhancement of inhibitory transmission - enflurane and isoflurane depression of CNS activity
31
what can nitrous oxide and ketamine do at the concentrations reached during anaesthesia ?
inhibit the function of excitatory ionotropic NMDA receptors and/or activate 2 pore domain potassium channels TREK TREK channels are important for maintaining resting membrane potential - they are the leak channels
32
what sites in the CNS can GAs produce specific components of the anaesthetic state ?
thalamus, cortex and hippocampus- particularly sensory nuclei in the thalamus and sensory areas of the cortex
33
what are the most sensitive areas to GA ?
thalamic sensory relay nuclei | deep layer of cortex to which these nuclei project - route taken by sensory impulses reaching cortex
34
what is the main factor to determine the rate of induction and recovery of inhalation GAs?
blood:gas parition coefficient
35
if an inhalation GA has a low solubility in the blood what does this mean ?
the faster the process of equilibration because less has to be dissolved in blood to increase the partial pressure - when a gas is dissolved in blood/tissue its partial pressure is inversely proportional to its solubility in the tissue - therefore a GA with a low solubility in blood has a fast onset of action because it reaches equilibrium quickly - same priniciple for wash out because if it has a low solubility recovery will be faster
36
what does the recovery phase include?
a rapid phase being followed by a hangover effect
37
when is the hangover effect of a GA enhanced ?
when the GA is highly fat soluble because it has been maintained for a long time- takes longer time for the anaesthetic to come out of the fat
38
what happens to a GA with a high oil:gas partition coefficient ?
e.g. halothane it accumulatess in the body fat and is released slowly post operation can cause pronounced hangover effect
39
what anaesthetics have a fast induction/recovery and why ?
nitrous oxide - low blood:gas coefficient - 0.5m low oil:gas coefficient- 1.4 desflurane - low blood:gas coefficient- 0.4 low oil:gas coefficient - 23 sevoflurane - low blood:gas coefficient-0.6 low oil:gas coefficient- 53
40
what anaesthetics have a medium induction/recovery and why ?
isoflurane- slightly higher blood:gas coefficient- 1.4 and higher oil:gas coefficient - 91 halothene- higher blood:gas coefficient - 2.4 and very high oil:gas coefficient- 220
41
what does a higher oil:gas partition coefficient cause ?
the higher the anaesthetic potency and so MAC is lower
42
GAs cause depression of the force of contraction of the heart and relax vasuclar smooth muscle what can this lead to ?
hypotension and reduce organ perfusion | exception= nitrous oxide because it increases sympathetic tone and therefore increases HR and BP
43
what can halogenated GAs cause ?
cause malignant hyperpyrexia e. g malignant hyperthermia induced by halothane - quite common - happens in some patients indicated by increased by body temperature and contraction of skeletal muscle
44
describe nitrous oxide :
- excellent analgesic properties - low potency MAC >80% because it has a low oil:gas coefficient- so it has a rapid onset - often combined with other inhalational agents during maintenance of anaesthesia - low blood:gas partition coefficient - depresses methionine synthase leading to bone marrow depression so there is a risk of anaemia in long term use (>6hours) - been linked to increased risk of abortion/foetal abnormality in operating theatre staff - easily controlled by anaesthetist
45
describe halothane :
not used in developed countries anymore - potent- MAC= 0.8% due to high oil:gas partition coefficient - leads to hangover effects - medium blood:gas partition coefficient so medium onset and recovery kinetics - biotransformed (15-30%) to trifluoracetic acid which can covalent bond to liver enzymes and trigger hepatotoxicity - cardiac dysrhythmias replaced by isoflurane
46
describe enflurane:
- similar potency to halothane so little is used due to hangover effect - relatively high blood:gas partition coefficient medium onset and recovery - <1% biotransformed but can cause malignantt hyperthermia - serious side effect - cause seizures during recovery and induction
47
describe isoflurane:
- similar potency to halothane- therefore hangover effects - <0.2% biotransformed - more expensive than halothane - may precipitate myocardial ischaemia in patients with coronary artery disease - more commonly used
48
describe desflurane:
- <0.1% biotransformed - rapid induction and recovery because blood:gas coefficient is low - useful for day case surgery - MAC 6%, respiratory tract irritation at levels used for induction
49
describe sevoflurane:
- similar to desflurane - 3% biotransformed - intermediate potency MAC 2% between isoflurane and desflurane - less respiratory irritation compared to desflurane - fast induction and recovery
50
what are examples of inhalation agents ?
``` nitrous oxide halothane isoflurane sevoflurane desflurane enflurane ```
51
what are some examples of obsolete inhalation agents and why ?
- chloroform- hepatotoxicity and cardiac dysrhythmia - diethyl ether- explosive and respiratory tract irritant - cyclopropane- explosive, marked respiratory depressant and hypotension - methoxyflurane- slow recovery due to high oil:gas coefficient and causes renal toxicity due to 50% biotransformed releasing fluoride and oxalate - halothane- hepatoxicity and malignant hyperthermia - enflurane- malignant hyperthermia and seizures
52
what acts more quickly intravenous agents or inhalation agents ?
intravenous agents- unconscious in seconds to minutes | 20s, normally used for induction
53
what is the anaesthetic duration for intravenous agents ?
short- 5-10mins - due to redistribution, first to tissues with a large blood flow then to muscles then to fats - subsequent metabolism is much slower for long operations an inhalation agent is used to maintain the anaesthesia
54
describe thiopentone:
no analgesic effect but unconscious in 20s blood concentration drops rapidly due to redistribution marked respiratory and cardiovascular depression even at doses that fail to abolish reflex effects to painful stimuli high lipid solubility so hangover effects used for induction
55
describe etomidate:
better than thiopentone - less respiratory depression at clinically relevant doses - more rapidly metabolised than thiopentone - can cause involuntary movements during induction - can cause post-operative nausea and vomitting
56
describe propofol:
very fast onset and recovery rapidly metabolised so no hangover continuous infusion used to maintain surgical anaesthesia so used in majority (75%) of day case surgery main side effect= ccardiovascular and respiratory depression
57
describe ketamine:
slow onset- 2-5 min produces dissociative anaesthesia- may remain conscious though amnesic effects induced and insensitive to pain BP and HR usually increase but respiration is unaffected hallucinations and irrational behaviour during recovery used in surgery for adults and childrens with respiratory problems
58
describe midazolam:
- benzodiazepine - anxiolytic, sedative, muscle relaxant, anticonvulsant, amnesia - slow onset - little respiratory or cardiovascular depression - used as a pre-op or for procedures such as endoscopy
59
what are examples of intravenous agents ?
``` midazolam propofol ketamine thiopentone etomidate ```
60
how are general anaesthetics usually used ?
normally used in combination, rarely achieved with a single agent
61
what is an example of a range of anaesthetics used in general anaesthesia?
midazolam- to reduce anxiety and induce sedation before induction propofol- rapid induction nitrous oxide and isoflurane/sevoflurane- maintain unconsciousness and analgesia opiod analgesic- reduces anaesthetic requirement and minimises haemodynamic changes to painful stimuli neuromuscular blocking drug- atracurium- relaxation of skeletal muscles

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