2 INTRAVENOUS ANESTHESIA Egerton

TYPES OF ANESTHESIA
DR. C. M. GATHIRI
MMED ANESTHESIA/MBCHB UON
APPROACH
• CLASSIFY
• PHARMACOKINETICS
• PHARMACODYNAMICS
• CLINICAL USES
• NEW FRONTIERS.
CLASSIFICATION IF INTRAVENOUS
ANESTHETICS
• RAPID ACTING (PRIMARY INDUCTION AGENTS)

• BARBITURATES:
• METHOHEXITAL
• THIOBARBITURATES (THIOPENTAL, THIAMYLAL)
• OLDER DRUGS (AMOBARBITAL/PENTOBARBITAL)
• IMIDAZOLES
• ETOMIDATE*
• STERICALLY HINDERED ALKYL PHENOLS

• PROPOFOL*
• STEROIDS
• ALTHESIN,MINAXOLONE,ELTANOLONE
• EUGENOLS
• PROPANIDID
CONT……
• SLOW ACTING (BASAL NARCOTIC AGENTS)

• KETAMINE*
• BENZODIAZEPINES*
• DIAZEPAM.,FLUNITRAZEPAM,MIDAZOLAM
• OPIOIDS*
• FENTANYL,ALFENTANYL,SUFENTANYL,REMIFENTANYL
• NEUROLEPTICS
• HALOPERIDOL
PHARMACOKINETICS OF INTRAVENOUS
AGENTS
• PROTEIN BINDING: ONLY UNBOUND DRUG CROSSES BLOOD

BRAIN BARRIER. LOW PLASMA PROTEINS, HIGH BLOOD P.H
INCREASES UNBOUND DRUG
• CEREBRAL BLOOD FLOW
• PH AND PKA OF THE DRUG
• LIPID AND WATER SOLUBILITY
• SPEED OF INJECTION
BARBITURATES
• THIOPENTAL SODIUM:
• FORMULATION:
• SULPHUR ANALOGUE OF PENTOBARBITAL
• YELLOW POWDER, FOR DILUTION IN WATER FOR INJECTION
• UNSTABLE IN DILUTED FORM AFTER 24 HOURS
• HAS A FAINT GARLIC SMELL
CONTD…
• PHARMACOKINETICS:
• ADMINISTERED AS A 2.5% SOLUTION
• HIGHLY PROTEIN BOUND 78-85% INTERACTS WITH DRUGS LIKE PHENYL
BUTAZONE
• HIGHLY LIPID SOLUBLE, FAST ONSET AND OFFSET, CUMULATION ON
CONTINOUS INFUSION
• METABOLISED MAINLY IN LIVER BY ZERO ORDER KINETICS AND
METABOLITES EXCRETED IN URINE
• HANGOVER AND DELAYED RECOVERY MAY OCCUR ESPECIALLY IN
OBESE PATIENTS AND ELDERLY
• ADULT DOSE IS 4MG/KG, 6MG/KG IN YOUNG CHILDREN AND 3MG/KG IN
THE ELDERLY
• INTERACTS WITH MUSCLE RELAXANTS ATRACURIUM AND
VERCURONIUM BY PRECIPITATING, HENCE THE NEED TO FLUSH THE
LINE AFTER ADMINISTRATION OF THIOPENTAL SODIUM
Pharmacodynamics:
C.n.s:
Conciosness lost within 30 seconds
Recovery in 10-15 minutes
Has antanalgesic effect at low doses or at recovery
A potent anticonvulsant
Reduces intracranial pressures
C.v.s:
has modest depression of myocardium, causes vasodilation and hence
hyoptention
Respiratory system
Depresses respiratory system, causes a short apnoeic period on induction
Minimal laryngeal reflex depression hence patients are more prone to
laryngospasms
Poor muscle relaxation, movement common during surgery
Uterus:
Easily crosses placental barrier to foetus
Eye:
Reduces intraoccular pressure
Liver:
Is a liver inducer of microsomal enzymes
THIOPENTAL SODIUM
ABSOLUTE
INDICATIONS CONTRAINDICATIONS
• INDUCTION OF ANESTHESIA • AIRWAY OBSTRUCTION.( ANY
INTRAVENOUS ANESTHESIA IS
• STATUS EPILEPTICUS
CONTRAINDICATED)
• SEDATION
• PORPHYRIAS
• REDUCING INTRACRANIAL
• HYPERSENSITIVITY TO
PRESSURES
BARBITURATES
PROPOFOL
• FAVOURABLE RECOVERY PROPERTIES AND ANTIEMETIC

EFFECTS THAN SODIUM THIOPENTAL
• FORMULATED IN WHITE EMULSION CONTAINING SOYABEAN OIL
AND PURIFIED EGG PHOSPHATIDE THAT IS HIGHLY ALLERGENIC
IF THE PATIENT IS ALLERGIC TO EGGS.
PHARMACOKINETICS OF PROPOFOL
• LIPID SOLUBLE WITH HEPATIC AND EXTRAHEPATIC SITES OF

METABOLISM HENCE FAST CLEARANCE.
• FENTANYL AFFECTS DISTRIBUTION AND CLEARANCE OF
PROPOFOL.
• IT DOES NOT HAVE CUMULATIVE EFFECTS, AND IS THEREFORE
SUITABLE FOR INFUSIONS EVEN FOR SEVERAL DAYS.
• DOSAGE: ADULT:1.5-2.5MG/KG. REDUCE IN ELDERLY, HIGHER IN
INFANTS, NOT RECOMMENDED IN LESS THAN 1 MONTH OLDS
• INFUSION RATES ARE 1.5-4.5MG/HR, UPTO 15MG FOR SURGICAL
ANESTHESIA
PHARMACODYNAMICS
• CNS: REDUCES INTRACRANIAL PRESSURE,MAY CAUSE

CONVULSIONS, INDUCES ANESTHESIA IN 20-40 SECONDS,
SLOWER THAN THIOPENTAL
• CVS: DEPRESSES MYOCARDIUM AND CAUSES VASODILATION,
HENCE HYPOTENSION
• RESP: CAUSES MORE APNOEA THAN THIOPENTAL.ABOLISHES
LARYNGEAL REFLEXES, HENCE LARYNGOSPASM IS LESS
COMMON, CAN BE USED FOR RAPID SEQUENCE INDUCTION
• READILY CROSSES PLACENTA,REDUCES CORTISOL LEVELS,HAS
ANTIEMETIC EFFECTS.
ADVERSE EFFECTS
• HYPOTENSION
• APNEOA
• EXCITATORY PHENOMENA
• PAIN ON INJECTION
• ALLERGIC REACTIONS
KETAMINE
• LOW PROTEIN BINDING 12%

• METABOLISED IN THE LIVER TO AN ACTIVE METABOLITE
NORKETAMINE.
• EXCREATED RENALY, SLOW ELIMINATION IF
BENZODIAZEPINES,HALOTHANE OR BARBITURATES ARE
ADMINISTERED CONCURRENTLY.
• CAN BE GIVEN I.V AT 2MG PER KG, OR I.M AT 5-10MG/KG OR
INFUSION OF 50ΜG/KG/MIN
PHARMACODYNAMICS
• C.N.S: WORKS IN 30-60 SEC I.V AND 3-4 MINS I.M

• CAUSES DISSOCIATIVE ANESTHESIA
• POTENT SOMATIC ANALGESIC AT SUBANESTHETIC DOSES
• CAUSES EMERGENCE PHENOMENA, DELIRIUM AND NIGHT MARES.
THESE ARE REDUCED WITH CONCOMITANT ADMINISTRATION OF
OPIOIDS, BUTYROPHENONS, BENZODIAZEPINES OR
PHYSOSTIGMINES
• INCREASES INTRACRANIAL PRESSURE
KETAMINE PHARMACODYNAMICS
• C.V.S:
• INCREASES BLOOD PRESSURE , HEART RATE AND CARDIAC OUTPUT
• RESP:
• MAINTAINS PHARYNGEAL AND LARYNGEAL REFLEXES AND
VENTILATION
• CAUSES BROCHODILATION
• G.I.T: INCREASES SALIVATION
• INCREASES INTRAOCULAR PRESSURE, CROSSES PLACENTAL
BARRIER EASILY, INCREASES SKELETAL MUSCLE TONE.
KETAMINE ADVERSE EFFECTS
• EMERGENCE PHENOMENA ( HALLUCINATION, NIGHTMARES,

HALLUCINATIONS)
• HYPERTENSION AND TACHYCARDIA
• PROLONGED RECOVERY
• SALIVATION ( GIVE ANTICHOLINERGICS)
• INCREASED INTRACRANIAL PRESSURES
• ALLERGIC REACTIONS
INDICATIONS OF KETAMINE
• INDUCTION OF PATIENTS WITH SHOCK WHO ARE HIGH RISK

• PEDIATRIC ANESTHESIA OR SEDATION FOR MINOR PROCEDURES
• ANESTHESIA AT REMOTE LOCATIONS
• ANALGESIA AND SEDATION
• SEDATION OF PATIENTS WITH DIFFICULT INTRAVENOUS ACCESS
ETOMIDATE
• CARDIO-STABLE SHORT ACTING ANESTHETIC AGENT

• SUPPRESSES SYNTHESIS OF CORTISOL
• HAS PAIN ON INJECTION AS A SIDE EFFECT
• HAS BEEN SUPERCEDED BY PROPOFOL FOR CARDIO-COMPROMISED
PATIENTS AND OUT PATIENT
• ABSOLUTELY CONTRAINDICATED IN PORPHYRIA, ADRENAL INSUFFICIENCY,
LONG TERM INFUSION,AIRWAY OBSTRUCTION
• ADVERSE EFFECTS:
• EXCITATORY PHENOMENA
• PAIN ON INJECTION
• NAUSEA AND VOMITING
• EMERGENCE PHENOMENA
• VENOUS THROMBOSIS
INTRAVENOUS ANESTHETICS
• IDEAL INTRAVENOUS AGENT:

• RAPID ONSET: UNIONISED/LIPID SOLUBLE AGENTS
• RAPID RECOVERY: METABOLISM/ REDISTRIBUTION
• ANALGESIA: AT SUBANESTHETIC CONCENTRATIONS
• MINIMAL CARDIOVASCULAR AND RESPIRATORY DEPRESION
• NO EMETIC EFFECT
• NO EXCITATORY PHENOMENA
• NO EMERGENCE PHENOMENA
• NO INTERACTIONS WITH NEUROMUSCULAR AGENTS
CONTD…
• NO PAIN ON INJECTION
• NO VENOUS SEQUELAE
• SAFE IS INJECTED ACCIDENTALLY INTO ARTERY
• NO TOXIC EFFECT TO ORGANS
• NO HISTAMINE RELEASE
• NO HYPERSENSITIVITY REACTIONS
• WATER SOLUBLE FORMULATION
• LONG SHELF LIFE
• NO STIMULATION OF PORPHYRIAS.

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2 INTRAVENOUS ANESTHESIA Egerton

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TYPES OF ANESTHESIA

• RAPID ACTING (PRIMARY INDUCTION AGENTS)

• STERICALLY HINDERED ALKYL PHENOLS

• SLOW ACTING (BASAL NARCOTIC AGENTS)

• PROTEIN BINDING: ONLY UNBOUND DRUG CROSSES BLOOD

• FAVOURABLE RECOVERY PROPERTIES AND ANTIEMETIC

• LIPID SOLUBLE WITH HEPATIC AND EXTRAHEPATIC SITES OF

• CNS: REDUCES INTRACRANIAL PRESSURE,MAY CAUSE

• LOW PROTEIN BINDING 12%

• C.N.S: WORKS IN 30-60 SEC I.V AND 3-4 MINS I.M

• EMERGENCE PHENOMENA ( HALLUCINATION, NIGHTMARES,

• INDUCTION OF PATIENTS WITH SHOCK WHO ARE HIGH RISK

• CARDIO-STABLE SHORT ACTING ANESTHETIC AGENT

• IDEAL INTRAVENOUS AGENT:

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