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- Nithin Kumar
Classification
 Inducing agents:
-Thiopentone sodium,
-Methohexitone sodium,
-Propofol,
-Etomidate.
 Slower acting drugs:
 Benzodiazepines-Diazepam,Lorazepam,Midazolam.
 Dissociative anesthesia-Ketamine.
 Opioid analgesia-Fentanyl.
Mechanism:
 Major targets are GABAA receptor gated
Cl-channel.(Many inhalation
anesthetics, barbiturates, benzodiazepines and
propofol)
 NMDA receptors are type of glutamate
receptor.(N2O,Ketamine)
Inducing agents:
 Drugs which on i.v. injection produce loss of
consciousness in approximately 11 seconds.
 Used because of rapidity of onset of action.
 Then maintain by inhalational agents.
 Supplemented with analgesics and muscle relaxants.
Thiopentone sodium:
 An ultra-short-acting barbiturate used
commonly in the induction phase.
 Injected i.v. (3-5mg/kg) produces unconsciousness in
15-20 seconds.
 Consciousness regained in 6-10 min.
 Disposal mainly by hepatic metabolism (elimination
t1/2 is 7-12hrs).
 Poor analgesic effect.
 Weak muscle relaxant.
 Respiratory depression is transient and severe in large
doses.
 Does not sensitizes the heart to adrenaline, cardiac
arrhythmia are rare.
 Indications:- Minor surgery that are less painful.
Adverse effects:
 Laryngospasm-relived by atropine premedication.
 Fall in BP.
 Shivering and delirium.
 Acute intermittent porphyria-C/I.
Other uses:
 Rapid control of convulsions.
 Narco analysis.
Methohexitone sodium:
 short-acting and has a rapid onset of
action.
 Three times more potent and similar in
its effects to thiopentone sod.
 Has a quicker and briefer action(5-8 min).
 Indication:-For oral surgery and dentistry.
 A/E:-Excitement during induction and recovery
period.
Propofol-Milk of amnesia
 Short-acting for both induction as well as
maintenance.
 An oily liquid employed as a 1% emulsion.
 Unconsciousness occurs 15-45 sec and lasts 5-10 min.
 Propofol is highly protein-bound and is metabolized
by conjugation in the liver.
 Intermittent injection or continuous infusion used for
total i.v. anesthesia when supplemented by fentanyl.
 Most suited for out patient surgery.
Adverse effect:
 Fall in BP and bradycardia.
 Pain on injection.
 Dystonia and myoclonic movements are common.
 Propofol has reportedly induced priapism in some
individuals.
Other uses:
 In sub-anesthetic doses, it is the drug of choice for
sedating intubated patients in ICU.
Etomidate:
 Short-acting induction anesthesia.
 Has a briefer duration of action (4-8 min) than
thiopentone.
 Etomidate is highly protein bound and metabolised by
hepatic and plasma esterases to inactive products.
 Onset of action: 30–60 seconds.
 Peak effect: 1 minute.
Indications:
 As sedative, for short procedures such as reduction of
dislocated joints and cardioversion.
Slower acting drugs:
Benzodiazepines:
 Used for induction, maintenance and supplementing
anesthesia as well as for conscious sedation.
 In larger doses injected i.v. produce sedation, amnesia
and unconsciousness in 5-10mins.
 If no anesthetic or opioid is given, the patient becomes
responsive in 1hr. But, amnesia for 2-3hrs.
 Poor analgesics.
 Opioid or N2O is added, if the procedure is painful.
Indication-in endoscopies, cardiac
catheterization, angiographies, regional anesthesia
,fracture setting.
 Action is rapidly reversed by flumazenil 0.5-2mg i.v.
Diazepam:
 0.2-0.5mg/kg , slow undiluted injection in a running i.v.
 This technique reduces burning sensation in vein and
incidence of thrombophlebitis.
Lorazepam:
 Potent, slower-acting, less irritating than diazepam.
 Amnesia is more profound. (Dose : 0.04 mg/kg)
Midazolam:
 Water-soluble, shorter acting drug used for sedation of
intubated patients. (Dose : 1-2.5mg i.v.)
 In other critical care anesthesia as 0.02-0.1mg/kg/hr
continuous i.v. infusion.
Ketamine:
 Related to phencyclidine-dissociative anesthesia.
 DA-characterised by profound
analgesia, immobility, amnesia, feeling of dissociation
from ones own body.
 Site of action-Cortical and sub cortical areas.
 Act by inhibiting NMDA receptors.
 Dose of 1-3mg/kg i.v. produces the above effects within
a minute & recovery after 10-15 mins, but remains
amnesic for 1-2hr.
 Metabolized in the liver and has an
elimination t1/2 3-4hrs.
Indications:
 Head and neck surgeries, asthmatics, Short
surgeries, Burn dressings.
 Combined with diazepam used in
angiographies, catheterization, and trauma surgeries.
Adverse effects:
-Heart rate, Cardiac output, BP increased.
-Delirium, hallucination, involuntary movements
during recovery.
Contraindication:
-HT,IHD.
-Increased ICP.
Fentanyl:
 Short-acting, opioid analgesic related to pethidine.
 Has rapid onset and short duration of action about
30-50 min.
 Strong agonist at the μ-opioid receptors.
 Used to supplement anesthetics in balanced
anesthesia.
 Also used in neurolept analgesia in combination with
droperidol.
Indications:
 Combined with BDZs, used for
endoscopic, angiographic, cardiac catheterization, burn
dressing and other minor procedures.
 used most often in operating rooms and intensive care
units.
Adverse effects:
 Nausea, vomiting and itching often
occurs during recovery.
 Marked respiratory depression.
 Slight fall in BP.
Dexmedetomidine:
 An α2 agonist with sedative and analgesic
effect.
 Has a half life of 2-3hrs.
 Metabolized in liver and excreted mainly as inactive
urine metabolites.
 Adverse effects:-Hypotension and bradycardia.
Anesthetic
I.V
Duration
mins
Analgesia Muscle
relaxation
Others
Thiopental 5 - 10 --- --- Respiratory
depression
Propofol 5-10 --- --- Respiratory
depression
Ketamine 5-10 +++ --- Hallucinations
Midazolam 5-20 --- +++ Amnesia
Fentanyl 5-10 +++ --- Respiratory
depression
Balanced anesthesia:
 Modern anesthesia involves a combination of i.v.(for
induction) and inhalational anesthesia(for
maintenance). Sometimes volatile(sevoflurane) is
used for induction.
 Muscle relaxant-facilitate intubation.
 Local anesthetics-tissue infiltration, peripheral nerve
block.
 Potent opioid analgesic & CV drugs(β blocker, ca
channel blocker)used to control autonomic responses
to noxious surgical stimuli.
Conscious sedation:
 This technique refers to drug induction alleviation of
anxiety & pain in combination with an altered level of
consciousness associated with the use of smallest
doses of sedative medication.
 Pt.retains ability to maintain patent airway &
responsive to verbal comments.
 Drugs-diazepam,midazolam,propofol.
Neuroleptanalgesia
 Method of i.v. anesthesia which combines the use of
neuroleptic drug with an opioid analgesic.
 Subject is conscious & able to co-operate during
surgery.
 most favoured combination- droperidol + fentanyl
 After administering nitrous oxide with oxygen
neuroleptanalgesia can be converted to
neuroleptanesthesia.
 C/I - patients receiving MAO inhibitors, abuse drugs
or alcohol, with Parkinson disease.
Complications
 During Anesthesia:
-Respiratory depression,
-Cardiac arrhythmias,
-Fall in BP,
-Acid pneumonitis,
-Laryngospasm and asphyxia,
-Awareness,
-Delirium and convulsions.
 After anesthesia:
-Nausea and vomiting,
-Persisting sedation,
-Pneumonia,
-Atelectasis,
-Nerve palsy,
-Emergence delirium,
-Organ toxicity.
ANAESTHESIA-INTRAVENOUS

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ANAESTHESIA-INTRAVENOUS

  • 2. Classification  Inducing agents: -Thiopentone sodium, -Methohexitone sodium, -Propofol, -Etomidate.  Slower acting drugs:  Benzodiazepines-Diazepam,Lorazepam,Midazolam.  Dissociative anesthesia-Ketamine.  Opioid analgesia-Fentanyl.
  • 3. Mechanism:  Major targets are GABAA receptor gated Cl-channel.(Many inhalation anesthetics, barbiturates, benzodiazepines and propofol)  NMDA receptors are type of glutamate receptor.(N2O,Ketamine)
  • 4. Inducing agents:  Drugs which on i.v. injection produce loss of consciousness in approximately 11 seconds.  Used because of rapidity of onset of action.  Then maintain by inhalational agents.  Supplemented with analgesics and muscle relaxants.
  • 5. Thiopentone sodium:  An ultra-short-acting barbiturate used commonly in the induction phase.  Injected i.v. (3-5mg/kg) produces unconsciousness in 15-20 seconds.  Consciousness regained in 6-10 min.  Disposal mainly by hepatic metabolism (elimination t1/2 is 7-12hrs).
  • 6.  Poor analgesic effect.  Weak muscle relaxant.  Respiratory depression is transient and severe in large doses.  Does not sensitizes the heart to adrenaline, cardiac arrhythmia are rare.  Indications:- Minor surgery that are less painful.
  • 7. Adverse effects:  Laryngospasm-relived by atropine premedication.  Fall in BP.  Shivering and delirium.  Acute intermittent porphyria-C/I. Other uses:  Rapid control of convulsions.  Narco analysis.
  • 8. Methohexitone sodium:  short-acting and has a rapid onset of action.  Three times more potent and similar in its effects to thiopentone sod.  Has a quicker and briefer action(5-8 min).  Indication:-For oral surgery and dentistry.  A/E:-Excitement during induction and recovery period.
  • 9. Propofol-Milk of amnesia  Short-acting for both induction as well as maintenance.  An oily liquid employed as a 1% emulsion.  Unconsciousness occurs 15-45 sec and lasts 5-10 min.  Propofol is highly protein-bound and is metabolized by conjugation in the liver.  Intermittent injection or continuous infusion used for total i.v. anesthesia when supplemented by fentanyl.  Most suited for out patient surgery.
  • 10. Adverse effect:  Fall in BP and bradycardia.  Pain on injection.  Dystonia and myoclonic movements are common.  Propofol has reportedly induced priapism in some individuals. Other uses:  In sub-anesthetic doses, it is the drug of choice for sedating intubated patients in ICU.
  • 11. Etomidate:  Short-acting induction anesthesia.  Has a briefer duration of action (4-8 min) than thiopentone.  Etomidate is highly protein bound and metabolised by hepatic and plasma esterases to inactive products.  Onset of action: 30–60 seconds.  Peak effect: 1 minute. Indications:  As sedative, for short procedures such as reduction of dislocated joints and cardioversion.
  • 12. Slower acting drugs: Benzodiazepines:  Used for induction, maintenance and supplementing anesthesia as well as for conscious sedation.  In larger doses injected i.v. produce sedation, amnesia and unconsciousness in 5-10mins.  If no anesthetic or opioid is given, the patient becomes responsive in 1hr. But, amnesia for 2-3hrs.  Poor analgesics.  Opioid or N2O is added, if the procedure is painful. Indication-in endoscopies, cardiac catheterization, angiographies, regional anesthesia ,fracture setting.
  • 13.  Action is rapidly reversed by flumazenil 0.5-2mg i.v. Diazepam:  0.2-0.5mg/kg , slow undiluted injection in a running i.v.  This technique reduces burning sensation in vein and incidence of thrombophlebitis. Lorazepam:  Potent, slower-acting, less irritating than diazepam.  Amnesia is more profound. (Dose : 0.04 mg/kg) Midazolam:  Water-soluble, shorter acting drug used for sedation of intubated patients. (Dose : 1-2.5mg i.v.)  In other critical care anesthesia as 0.02-0.1mg/kg/hr continuous i.v. infusion.
  • 14. Ketamine:  Related to phencyclidine-dissociative anesthesia.  DA-characterised by profound analgesia, immobility, amnesia, feeling of dissociation from ones own body.  Site of action-Cortical and sub cortical areas.  Act by inhibiting NMDA receptors.  Dose of 1-3mg/kg i.v. produces the above effects within a minute & recovery after 10-15 mins, but remains amnesic for 1-2hr.  Metabolized in the liver and has an elimination t1/2 3-4hrs.
  • 15. Indications:  Head and neck surgeries, asthmatics, Short surgeries, Burn dressings.  Combined with diazepam used in angiographies, catheterization, and trauma surgeries. Adverse effects: -Heart rate, Cardiac output, BP increased. -Delirium, hallucination, involuntary movements during recovery. Contraindication: -HT,IHD. -Increased ICP.
  • 16. Fentanyl:  Short-acting, opioid analgesic related to pethidine.  Has rapid onset and short duration of action about 30-50 min.  Strong agonist at the μ-opioid receptors.  Used to supplement anesthetics in balanced anesthesia.  Also used in neurolept analgesia in combination with droperidol.
  • 17. Indications:  Combined with BDZs, used for endoscopic, angiographic, cardiac catheterization, burn dressing and other minor procedures.  used most often in operating rooms and intensive care units. Adverse effects:  Nausea, vomiting and itching often occurs during recovery.  Marked respiratory depression.  Slight fall in BP.
  • 18. Dexmedetomidine:  An α2 agonist with sedative and analgesic effect.  Has a half life of 2-3hrs.  Metabolized in liver and excreted mainly as inactive urine metabolites.  Adverse effects:-Hypotension and bradycardia.
  • 19. Anesthetic I.V Duration mins Analgesia Muscle relaxation Others Thiopental 5 - 10 --- --- Respiratory depression Propofol 5-10 --- --- Respiratory depression Ketamine 5-10 +++ --- Hallucinations Midazolam 5-20 --- +++ Amnesia Fentanyl 5-10 +++ --- Respiratory depression
  • 20. Balanced anesthesia:  Modern anesthesia involves a combination of i.v.(for induction) and inhalational anesthesia(for maintenance). Sometimes volatile(sevoflurane) is used for induction.  Muscle relaxant-facilitate intubation.  Local anesthetics-tissue infiltration, peripheral nerve block.  Potent opioid analgesic & CV drugs(β blocker, ca channel blocker)used to control autonomic responses to noxious surgical stimuli.
  • 21. Conscious sedation:  This technique refers to drug induction alleviation of anxiety & pain in combination with an altered level of consciousness associated with the use of smallest doses of sedative medication.  Pt.retains ability to maintain patent airway & responsive to verbal comments.  Drugs-diazepam,midazolam,propofol.
  • 22. Neuroleptanalgesia  Method of i.v. anesthesia which combines the use of neuroleptic drug with an opioid analgesic.  Subject is conscious & able to co-operate during surgery.  most favoured combination- droperidol + fentanyl  After administering nitrous oxide with oxygen neuroleptanalgesia can be converted to neuroleptanesthesia.  C/I - patients receiving MAO inhibitors, abuse drugs or alcohol, with Parkinson disease.
  • 23. Complications  During Anesthesia: -Respiratory depression, -Cardiac arrhythmias, -Fall in BP, -Acid pneumonitis, -Laryngospasm and asphyxia, -Awareness, -Delirium and convulsions.
  • 24.  After anesthesia: -Nausea and vomiting, -Persisting sedation, -Pneumonia, -Atelectasis, -Nerve palsy, -Emergence delirium, -Organ toxicity.