Date post: | 25-Aug-2014 |
Category: |
Documents |
Upload: | dutei-catalin-andrei |
View: | 122 times |
Download: | 3 times |
Anestezie curs 1
Dr Radu Stoica
Anesthesia
History Original discoverer
of general anesthetics Crawford Long
1842 ether anesthesia
Chloroform introduced James Simpson
1847 Nitrous oxide
Horace Wells
19th Century physician administering chloroform
Tipes of anesthesiabull Dupa mecanismebull Anestezie generalabull Anestezie loco-regionalabull Tehnici combinate (generala si loco-
regionala)
bull Dupa durata interventiei chirurgicale Anestezie de o zi (one-day anesthesia)
bull Dupa locatie Anestezie in ambulator in spital
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
Definition of general anesthesia
bull ldquoTrepiedrdquo on a platformAnalgesia
Muscular relaxetionHypnosis and amnesia
Maintaining homeostasis during surgical procedure
The Body and General Anesthesia
bull Hemodynamic effects decrease in systemic arterial blood pressure
bull Respiratory effects reduce or eliminate both ventilatory drive and reflexes maintaining the airway unblocked
bull Hypothermia body temperature lt 36˚Cbull Nausea and Vomiting
ndash Chemoreceptor trigger zonebull Emergence
ndash Physiological changes
Current Newsbull March 30 2007bull The Wall Street Journal ldquoFDA Wants More
Research on Anesthesia Risk to Kidsrdquondash Anesthesia can be harmful to the developing
brain studies on animals suggest raising concerns about potential risks in putting young children under for surgerybull Prolonged changes in behavior memory and
learning impairmentsndash Relevance of the animal findings to pediatric
patients is unknown
Preoperative evaluation
bull 3 major goals
1048708To make certain that patient is in optimalcondition for anesthesia1048708 Understand patient concurrent disease amp drugtherapy1048708 Ensure patientrsquos satisfaction
Preoperative evaluationbull 1048708 Anesthetic riskClass Definition Mortalit
y1 A normally healthy patient 006-008
2 A patient with mild systemic desease and no functional limitations
027-04
3 A patient with moderate to severe systematic disease and some functional limitation
18-43
4 A patient with severe systematic disease that is a constant threat to life and functionally incapacitating
78-23
5 A moribund patient who is not expected to survive 24 hrs with or without surgery
94-51
6 A brain-dead patient whose organs are being harvested
E E for ldquoEmergencyrdquo Ex ASA 2E
Preoperative evaluation
1048708 History amp physical examination1048708 cardiovascular1048708 Respiratory1048708 Airway1048708 50mortality1048708 Mallampati classification1048708 G1-uvula visible1048708 G4-Soft palate not visible1048708 spine1048708 Evaluation of concurrent drug therapy1048708 Anti hypertensives1048708 Anti depressants
Selection of anesthesia
1048708 Discussion with patient
1048708 Site and type of surgery1048708 Nerve block in diabetics1048708 Spinal in thyroidectomy1048708 Co-existing disease
Theoretically only one contraindication Patient refusal of the type of anesthesia
bull 1048708 Laboratory testsbull 1048708 Complete blood countbull 1048708 Urinanalysisbull 1048708 Serum electrolytes creatinine BUNbull 1048708 Coagulation studiesbull 1048708 Biochemical profile(LFTrsquos)bull 1048708 Pregnancy testbull 1048708 Chest X-raybull 1048708 ECGbull 1048708 Type and cross Type and screen
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Anesthesia
History Original discoverer
of general anesthetics Crawford Long
1842 ether anesthesia
Chloroform introduced James Simpson
1847 Nitrous oxide
Horace Wells
19th Century physician administering chloroform
Tipes of anesthesiabull Dupa mecanismebull Anestezie generalabull Anestezie loco-regionalabull Tehnici combinate (generala si loco-
regionala)
bull Dupa durata interventiei chirurgicale Anestezie de o zi (one-day anesthesia)
bull Dupa locatie Anestezie in ambulator in spital
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
Definition of general anesthesia
bull ldquoTrepiedrdquo on a platformAnalgesia
Muscular relaxetionHypnosis and amnesia
Maintaining homeostasis during surgical procedure
The Body and General Anesthesia
bull Hemodynamic effects decrease in systemic arterial blood pressure
bull Respiratory effects reduce or eliminate both ventilatory drive and reflexes maintaining the airway unblocked
bull Hypothermia body temperature lt 36˚Cbull Nausea and Vomiting
ndash Chemoreceptor trigger zonebull Emergence
ndash Physiological changes
Current Newsbull March 30 2007bull The Wall Street Journal ldquoFDA Wants More
Research on Anesthesia Risk to Kidsrdquondash Anesthesia can be harmful to the developing
brain studies on animals suggest raising concerns about potential risks in putting young children under for surgerybull Prolonged changes in behavior memory and
learning impairmentsndash Relevance of the animal findings to pediatric
patients is unknown
Preoperative evaluation
bull 3 major goals
1048708To make certain that patient is in optimalcondition for anesthesia1048708 Understand patient concurrent disease amp drugtherapy1048708 Ensure patientrsquos satisfaction
Preoperative evaluationbull 1048708 Anesthetic riskClass Definition Mortalit
y1 A normally healthy patient 006-008
2 A patient with mild systemic desease and no functional limitations
027-04
3 A patient with moderate to severe systematic disease and some functional limitation
18-43
4 A patient with severe systematic disease that is a constant threat to life and functionally incapacitating
78-23
5 A moribund patient who is not expected to survive 24 hrs with or without surgery
94-51
6 A brain-dead patient whose organs are being harvested
E E for ldquoEmergencyrdquo Ex ASA 2E
Preoperative evaluation
1048708 History amp physical examination1048708 cardiovascular1048708 Respiratory1048708 Airway1048708 50mortality1048708 Mallampati classification1048708 G1-uvula visible1048708 G4-Soft palate not visible1048708 spine1048708 Evaluation of concurrent drug therapy1048708 Anti hypertensives1048708 Anti depressants
Selection of anesthesia
1048708 Discussion with patient
1048708 Site and type of surgery1048708 Nerve block in diabetics1048708 Spinal in thyroidectomy1048708 Co-existing disease
Theoretically only one contraindication Patient refusal of the type of anesthesia
bull 1048708 Laboratory testsbull 1048708 Complete blood countbull 1048708 Urinanalysisbull 1048708 Serum electrolytes creatinine BUNbull 1048708 Coagulation studiesbull 1048708 Biochemical profile(LFTrsquos)bull 1048708 Pregnancy testbull 1048708 Chest X-raybull 1048708 ECGbull 1048708 Type and cross Type and screen
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
History Original discoverer
of general anesthetics Crawford Long
1842 ether anesthesia
Chloroform introduced James Simpson
1847 Nitrous oxide
Horace Wells
19th Century physician administering chloroform
Tipes of anesthesiabull Dupa mecanismebull Anestezie generalabull Anestezie loco-regionalabull Tehnici combinate (generala si loco-
regionala)
bull Dupa durata interventiei chirurgicale Anestezie de o zi (one-day anesthesia)
bull Dupa locatie Anestezie in ambulator in spital
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
Definition of general anesthesia
bull ldquoTrepiedrdquo on a platformAnalgesia
Muscular relaxetionHypnosis and amnesia
Maintaining homeostasis during surgical procedure
The Body and General Anesthesia
bull Hemodynamic effects decrease in systemic arterial blood pressure
bull Respiratory effects reduce or eliminate both ventilatory drive and reflexes maintaining the airway unblocked
bull Hypothermia body temperature lt 36˚Cbull Nausea and Vomiting
ndash Chemoreceptor trigger zonebull Emergence
ndash Physiological changes
Current Newsbull March 30 2007bull The Wall Street Journal ldquoFDA Wants More
Research on Anesthesia Risk to Kidsrdquondash Anesthesia can be harmful to the developing
brain studies on animals suggest raising concerns about potential risks in putting young children under for surgerybull Prolonged changes in behavior memory and
learning impairmentsndash Relevance of the animal findings to pediatric
patients is unknown
Preoperative evaluation
bull 3 major goals
1048708To make certain that patient is in optimalcondition for anesthesia1048708 Understand patient concurrent disease amp drugtherapy1048708 Ensure patientrsquos satisfaction
Preoperative evaluationbull 1048708 Anesthetic riskClass Definition Mortalit
y1 A normally healthy patient 006-008
2 A patient with mild systemic desease and no functional limitations
027-04
3 A patient with moderate to severe systematic disease and some functional limitation
18-43
4 A patient with severe systematic disease that is a constant threat to life and functionally incapacitating
78-23
5 A moribund patient who is not expected to survive 24 hrs with or without surgery
94-51
6 A brain-dead patient whose organs are being harvested
E E for ldquoEmergencyrdquo Ex ASA 2E
Preoperative evaluation
1048708 History amp physical examination1048708 cardiovascular1048708 Respiratory1048708 Airway1048708 50mortality1048708 Mallampati classification1048708 G1-uvula visible1048708 G4-Soft palate not visible1048708 spine1048708 Evaluation of concurrent drug therapy1048708 Anti hypertensives1048708 Anti depressants
Selection of anesthesia
1048708 Discussion with patient
1048708 Site and type of surgery1048708 Nerve block in diabetics1048708 Spinal in thyroidectomy1048708 Co-existing disease
Theoretically only one contraindication Patient refusal of the type of anesthesia
bull 1048708 Laboratory testsbull 1048708 Complete blood countbull 1048708 Urinanalysisbull 1048708 Serum electrolytes creatinine BUNbull 1048708 Coagulation studiesbull 1048708 Biochemical profile(LFTrsquos)bull 1048708 Pregnancy testbull 1048708 Chest X-raybull 1048708 ECGbull 1048708 Type and cross Type and screen
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Tipes of anesthesiabull Dupa mecanismebull Anestezie generalabull Anestezie loco-regionalabull Tehnici combinate (generala si loco-
regionala)
bull Dupa durata interventiei chirurgicale Anestezie de o zi (one-day anesthesia)
bull Dupa locatie Anestezie in ambulator in spital
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
Definition of general anesthesia
bull ldquoTrepiedrdquo on a platformAnalgesia
Muscular relaxetionHypnosis and amnesia
Maintaining homeostasis during surgical procedure
The Body and General Anesthesia
bull Hemodynamic effects decrease in systemic arterial blood pressure
bull Respiratory effects reduce or eliminate both ventilatory drive and reflexes maintaining the airway unblocked
bull Hypothermia body temperature lt 36˚Cbull Nausea and Vomiting
ndash Chemoreceptor trigger zonebull Emergence
ndash Physiological changes
Current Newsbull March 30 2007bull The Wall Street Journal ldquoFDA Wants More
Research on Anesthesia Risk to Kidsrdquondash Anesthesia can be harmful to the developing
brain studies on animals suggest raising concerns about potential risks in putting young children under for surgerybull Prolonged changes in behavior memory and
learning impairmentsndash Relevance of the animal findings to pediatric
patients is unknown
Preoperative evaluation
bull 3 major goals
1048708To make certain that patient is in optimalcondition for anesthesia1048708 Understand patient concurrent disease amp drugtherapy1048708 Ensure patientrsquos satisfaction
Preoperative evaluationbull 1048708 Anesthetic riskClass Definition Mortalit
y1 A normally healthy patient 006-008
2 A patient with mild systemic desease and no functional limitations
027-04
3 A patient with moderate to severe systematic disease and some functional limitation
18-43
4 A patient with severe systematic disease that is a constant threat to life and functionally incapacitating
78-23
5 A moribund patient who is not expected to survive 24 hrs with or without surgery
94-51
6 A brain-dead patient whose organs are being harvested
E E for ldquoEmergencyrdquo Ex ASA 2E
Preoperative evaluation
1048708 History amp physical examination1048708 cardiovascular1048708 Respiratory1048708 Airway1048708 50mortality1048708 Mallampati classification1048708 G1-uvula visible1048708 G4-Soft palate not visible1048708 spine1048708 Evaluation of concurrent drug therapy1048708 Anti hypertensives1048708 Anti depressants
Selection of anesthesia
1048708 Discussion with patient
1048708 Site and type of surgery1048708 Nerve block in diabetics1048708 Spinal in thyroidectomy1048708 Co-existing disease
Theoretically only one contraindication Patient refusal of the type of anesthesia
bull 1048708 Laboratory testsbull 1048708 Complete blood countbull 1048708 Urinanalysisbull 1048708 Serum electrolytes creatinine BUNbull 1048708 Coagulation studiesbull 1048708 Biochemical profile(LFTrsquos)bull 1048708 Pregnancy testbull 1048708 Chest X-raybull 1048708 ECGbull 1048708 Type and cross Type and screen
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
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
Definition of general anesthesia
bull ldquoTrepiedrdquo on a platformAnalgesia
Muscular relaxetionHypnosis and amnesia
Maintaining homeostasis during surgical procedure
The Body and General Anesthesia
bull Hemodynamic effects decrease in systemic arterial blood pressure
bull Respiratory effects reduce or eliminate both ventilatory drive and reflexes maintaining the airway unblocked
bull Hypothermia body temperature lt 36˚Cbull Nausea and Vomiting
ndash Chemoreceptor trigger zonebull Emergence
ndash Physiological changes
Current Newsbull March 30 2007bull The Wall Street Journal ldquoFDA Wants More
Research on Anesthesia Risk to Kidsrdquondash Anesthesia can be harmful to the developing
brain studies on animals suggest raising concerns about potential risks in putting young children under for surgerybull Prolonged changes in behavior memory and
learning impairmentsndash Relevance of the animal findings to pediatric
patients is unknown
Preoperative evaluation
bull 3 major goals
1048708To make certain that patient is in optimalcondition for anesthesia1048708 Understand patient concurrent disease amp drugtherapy1048708 Ensure patientrsquos satisfaction
Preoperative evaluationbull 1048708 Anesthetic riskClass Definition Mortalit
y1 A normally healthy patient 006-008
2 A patient with mild systemic desease and no functional limitations
027-04
3 A patient with moderate to severe systematic disease and some functional limitation
18-43
4 A patient with severe systematic disease that is a constant threat to life and functionally incapacitating
78-23
5 A moribund patient who is not expected to survive 24 hrs with or without surgery
94-51
6 A brain-dead patient whose organs are being harvested
E E for ldquoEmergencyrdquo Ex ASA 2E
Preoperative evaluation
1048708 History amp physical examination1048708 cardiovascular1048708 Respiratory1048708 Airway1048708 50mortality1048708 Mallampati classification1048708 G1-uvula visible1048708 G4-Soft palate not visible1048708 spine1048708 Evaluation of concurrent drug therapy1048708 Anti hypertensives1048708 Anti depressants
Selection of anesthesia
1048708 Discussion with patient
1048708 Site and type of surgery1048708 Nerve block in diabetics1048708 Spinal in thyroidectomy1048708 Co-existing disease
Theoretically only one contraindication Patient refusal of the type of anesthesia
bull 1048708 Laboratory testsbull 1048708 Complete blood countbull 1048708 Urinanalysisbull 1048708 Serum electrolytes creatinine BUNbull 1048708 Coagulation studiesbull 1048708 Biochemical profile(LFTrsquos)bull 1048708 Pregnancy testbull 1048708 Chest X-raybull 1048708 ECGbull 1048708 Type and cross Type and screen
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Definition of general anesthesia
bull ldquoTrepiedrdquo on a platformAnalgesia
Muscular relaxetionHypnosis and amnesia
Maintaining homeostasis during surgical procedure
The Body and General Anesthesia
bull Hemodynamic effects decrease in systemic arterial blood pressure
bull Respiratory effects reduce or eliminate both ventilatory drive and reflexes maintaining the airway unblocked
bull Hypothermia body temperature lt 36˚Cbull Nausea and Vomiting
ndash Chemoreceptor trigger zonebull Emergence
ndash Physiological changes
Current Newsbull March 30 2007bull The Wall Street Journal ldquoFDA Wants More
Research on Anesthesia Risk to Kidsrdquondash Anesthesia can be harmful to the developing
brain studies on animals suggest raising concerns about potential risks in putting young children under for surgerybull Prolonged changes in behavior memory and
learning impairmentsndash Relevance of the animal findings to pediatric
patients is unknown
Preoperative evaluation
bull 3 major goals
1048708To make certain that patient is in optimalcondition for anesthesia1048708 Understand patient concurrent disease amp drugtherapy1048708 Ensure patientrsquos satisfaction
Preoperative evaluationbull 1048708 Anesthetic riskClass Definition Mortalit
y1 A normally healthy patient 006-008
2 A patient with mild systemic desease and no functional limitations
027-04
3 A patient with moderate to severe systematic disease and some functional limitation
18-43
4 A patient with severe systematic disease that is a constant threat to life and functionally incapacitating
78-23
5 A moribund patient who is not expected to survive 24 hrs with or without surgery
94-51
6 A brain-dead patient whose organs are being harvested
E E for ldquoEmergencyrdquo Ex ASA 2E
Preoperative evaluation
1048708 History amp physical examination1048708 cardiovascular1048708 Respiratory1048708 Airway1048708 50mortality1048708 Mallampati classification1048708 G1-uvula visible1048708 G4-Soft palate not visible1048708 spine1048708 Evaluation of concurrent drug therapy1048708 Anti hypertensives1048708 Anti depressants
Selection of anesthesia
1048708 Discussion with patient
1048708 Site and type of surgery1048708 Nerve block in diabetics1048708 Spinal in thyroidectomy1048708 Co-existing disease
Theoretically only one contraindication Patient refusal of the type of anesthesia
bull 1048708 Laboratory testsbull 1048708 Complete blood countbull 1048708 Urinanalysisbull 1048708 Serum electrolytes creatinine BUNbull 1048708 Coagulation studiesbull 1048708 Biochemical profile(LFTrsquos)bull 1048708 Pregnancy testbull 1048708 Chest X-raybull 1048708 ECGbull 1048708 Type and cross Type and screen
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
The Body and General Anesthesia
bull Hemodynamic effects decrease in systemic arterial blood pressure
bull Respiratory effects reduce or eliminate both ventilatory drive and reflexes maintaining the airway unblocked
bull Hypothermia body temperature lt 36˚Cbull Nausea and Vomiting
ndash Chemoreceptor trigger zonebull Emergence
ndash Physiological changes
Current Newsbull March 30 2007bull The Wall Street Journal ldquoFDA Wants More
Research on Anesthesia Risk to Kidsrdquondash Anesthesia can be harmful to the developing
brain studies on animals suggest raising concerns about potential risks in putting young children under for surgerybull Prolonged changes in behavior memory and
learning impairmentsndash Relevance of the animal findings to pediatric
patients is unknown
Preoperative evaluation
bull 3 major goals
1048708To make certain that patient is in optimalcondition for anesthesia1048708 Understand patient concurrent disease amp drugtherapy1048708 Ensure patientrsquos satisfaction
Preoperative evaluationbull 1048708 Anesthetic riskClass Definition Mortalit
y1 A normally healthy patient 006-008
2 A patient with mild systemic desease and no functional limitations
027-04
3 A patient with moderate to severe systematic disease and some functional limitation
18-43
4 A patient with severe systematic disease that is a constant threat to life and functionally incapacitating
78-23
5 A moribund patient who is not expected to survive 24 hrs with or without surgery
94-51
6 A brain-dead patient whose organs are being harvested
E E for ldquoEmergencyrdquo Ex ASA 2E
Preoperative evaluation
1048708 History amp physical examination1048708 cardiovascular1048708 Respiratory1048708 Airway1048708 50mortality1048708 Mallampati classification1048708 G1-uvula visible1048708 G4-Soft palate not visible1048708 spine1048708 Evaluation of concurrent drug therapy1048708 Anti hypertensives1048708 Anti depressants
Selection of anesthesia
1048708 Discussion with patient
1048708 Site and type of surgery1048708 Nerve block in diabetics1048708 Spinal in thyroidectomy1048708 Co-existing disease
Theoretically only one contraindication Patient refusal of the type of anesthesia
bull 1048708 Laboratory testsbull 1048708 Complete blood countbull 1048708 Urinanalysisbull 1048708 Serum electrolytes creatinine BUNbull 1048708 Coagulation studiesbull 1048708 Biochemical profile(LFTrsquos)bull 1048708 Pregnancy testbull 1048708 Chest X-raybull 1048708 ECGbull 1048708 Type and cross Type and screen
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Current Newsbull March 30 2007bull The Wall Street Journal ldquoFDA Wants More
Research on Anesthesia Risk to Kidsrdquondash Anesthesia can be harmful to the developing
brain studies on animals suggest raising concerns about potential risks in putting young children under for surgerybull Prolonged changes in behavior memory and
learning impairmentsndash Relevance of the animal findings to pediatric
patients is unknown
Preoperative evaluation
bull 3 major goals
1048708To make certain that patient is in optimalcondition for anesthesia1048708 Understand patient concurrent disease amp drugtherapy1048708 Ensure patientrsquos satisfaction
Preoperative evaluationbull 1048708 Anesthetic riskClass Definition Mortalit
y1 A normally healthy patient 006-008
2 A patient with mild systemic desease and no functional limitations
027-04
3 A patient with moderate to severe systematic disease and some functional limitation
18-43
4 A patient with severe systematic disease that is a constant threat to life and functionally incapacitating
78-23
5 A moribund patient who is not expected to survive 24 hrs with or without surgery
94-51
6 A brain-dead patient whose organs are being harvested
E E for ldquoEmergencyrdquo Ex ASA 2E
Preoperative evaluation
1048708 History amp physical examination1048708 cardiovascular1048708 Respiratory1048708 Airway1048708 50mortality1048708 Mallampati classification1048708 G1-uvula visible1048708 G4-Soft palate not visible1048708 spine1048708 Evaluation of concurrent drug therapy1048708 Anti hypertensives1048708 Anti depressants
Selection of anesthesia
1048708 Discussion with patient
1048708 Site and type of surgery1048708 Nerve block in diabetics1048708 Spinal in thyroidectomy1048708 Co-existing disease
Theoretically only one contraindication Patient refusal of the type of anesthesia
bull 1048708 Laboratory testsbull 1048708 Complete blood countbull 1048708 Urinanalysisbull 1048708 Serum electrolytes creatinine BUNbull 1048708 Coagulation studiesbull 1048708 Biochemical profile(LFTrsquos)bull 1048708 Pregnancy testbull 1048708 Chest X-raybull 1048708 ECGbull 1048708 Type and cross Type and screen
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Preoperative evaluation
bull 3 major goals
1048708To make certain that patient is in optimalcondition for anesthesia1048708 Understand patient concurrent disease amp drugtherapy1048708 Ensure patientrsquos satisfaction
Preoperative evaluationbull 1048708 Anesthetic riskClass Definition Mortalit
y1 A normally healthy patient 006-008
2 A patient with mild systemic desease and no functional limitations
027-04
3 A patient with moderate to severe systematic disease and some functional limitation
18-43
4 A patient with severe systematic disease that is a constant threat to life and functionally incapacitating
78-23
5 A moribund patient who is not expected to survive 24 hrs with or without surgery
94-51
6 A brain-dead patient whose organs are being harvested
E E for ldquoEmergencyrdquo Ex ASA 2E
Preoperative evaluation
1048708 History amp physical examination1048708 cardiovascular1048708 Respiratory1048708 Airway1048708 50mortality1048708 Mallampati classification1048708 G1-uvula visible1048708 G4-Soft palate not visible1048708 spine1048708 Evaluation of concurrent drug therapy1048708 Anti hypertensives1048708 Anti depressants
Selection of anesthesia
1048708 Discussion with patient
1048708 Site and type of surgery1048708 Nerve block in diabetics1048708 Spinal in thyroidectomy1048708 Co-existing disease
Theoretically only one contraindication Patient refusal of the type of anesthesia
bull 1048708 Laboratory testsbull 1048708 Complete blood countbull 1048708 Urinanalysisbull 1048708 Serum electrolytes creatinine BUNbull 1048708 Coagulation studiesbull 1048708 Biochemical profile(LFTrsquos)bull 1048708 Pregnancy testbull 1048708 Chest X-raybull 1048708 ECGbull 1048708 Type and cross Type and screen
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Preoperative evaluationbull 1048708 Anesthetic riskClass Definition Mortalit
y1 A normally healthy patient 006-008
2 A patient with mild systemic desease and no functional limitations
027-04
3 A patient with moderate to severe systematic disease and some functional limitation
18-43
4 A patient with severe systematic disease that is a constant threat to life and functionally incapacitating
78-23
5 A moribund patient who is not expected to survive 24 hrs with or without surgery
94-51
6 A brain-dead patient whose organs are being harvested
E E for ldquoEmergencyrdquo Ex ASA 2E
Preoperative evaluation
1048708 History amp physical examination1048708 cardiovascular1048708 Respiratory1048708 Airway1048708 50mortality1048708 Mallampati classification1048708 G1-uvula visible1048708 G4-Soft palate not visible1048708 spine1048708 Evaluation of concurrent drug therapy1048708 Anti hypertensives1048708 Anti depressants
Selection of anesthesia
1048708 Discussion with patient
1048708 Site and type of surgery1048708 Nerve block in diabetics1048708 Spinal in thyroidectomy1048708 Co-existing disease
Theoretically only one contraindication Patient refusal of the type of anesthesia
bull 1048708 Laboratory testsbull 1048708 Complete blood countbull 1048708 Urinanalysisbull 1048708 Serum electrolytes creatinine BUNbull 1048708 Coagulation studiesbull 1048708 Biochemical profile(LFTrsquos)bull 1048708 Pregnancy testbull 1048708 Chest X-raybull 1048708 ECGbull 1048708 Type and cross Type and screen
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Preoperative evaluation
1048708 History amp physical examination1048708 cardiovascular1048708 Respiratory1048708 Airway1048708 50mortality1048708 Mallampati classification1048708 G1-uvula visible1048708 G4-Soft palate not visible1048708 spine1048708 Evaluation of concurrent drug therapy1048708 Anti hypertensives1048708 Anti depressants
Selection of anesthesia
1048708 Discussion with patient
1048708 Site and type of surgery1048708 Nerve block in diabetics1048708 Spinal in thyroidectomy1048708 Co-existing disease
Theoretically only one contraindication Patient refusal of the type of anesthesia
bull 1048708 Laboratory testsbull 1048708 Complete blood countbull 1048708 Urinanalysisbull 1048708 Serum electrolytes creatinine BUNbull 1048708 Coagulation studiesbull 1048708 Biochemical profile(LFTrsquos)bull 1048708 Pregnancy testbull 1048708 Chest X-raybull 1048708 ECGbull 1048708 Type and cross Type and screen
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Selection of anesthesia
1048708 Discussion with patient
1048708 Site and type of surgery1048708 Nerve block in diabetics1048708 Spinal in thyroidectomy1048708 Co-existing disease
Theoretically only one contraindication Patient refusal of the type of anesthesia
bull 1048708 Laboratory testsbull 1048708 Complete blood countbull 1048708 Urinanalysisbull 1048708 Serum electrolytes creatinine BUNbull 1048708 Coagulation studiesbull 1048708 Biochemical profile(LFTrsquos)bull 1048708 Pregnancy testbull 1048708 Chest X-raybull 1048708 ECGbull 1048708 Type and cross Type and screen
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
bull 1048708 Laboratory testsbull 1048708 Complete blood countbull 1048708 Urinanalysisbull 1048708 Serum electrolytes creatinine BUNbull 1048708 Coagulation studiesbull 1048708 Biochemical profile(LFTrsquos)bull 1048708 Pregnancy testbull 1048708 Chest X-raybull 1048708 ECGbull 1048708 Type and cross Type and screen
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Premedication
Purpose of premedication
ndash satisfactory rest at night before operationcalm downndash basal analgesiandash supression of readines to allergic reactionsndash supression of vegetative reflexes (bradycardia hypersalivation bronchial hypersecretion)
eg sedatives hypnotics anxiolytics vagolytcs (atropin) atihistaminics
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
1048708 Blood pressure monitoring1048708 Central venous monitoring1048708 Electrocardiography1048708 Ventilation monitoring1048708 Oxygenation monitoring1048708 Temperature monitoring1048708 Neuromuscular blockade monitoring1048708 Central nervous system monitoring
Patient monitoring during andafter anesthesia
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Endo-Tracheal Intubation (ETT)
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Pharmacological principles
1048708 Inhalational agents
1048708 Intravenous agents
1048708 Local anesthetics
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Inhalational agents
bull Inhalational anesthesia refers to the delivery of gases or vapors from the respiratory system to produce anesthesia
bull Pharmacokinetics--uptake distribution and elimination from the body
bull Pharmacodyamics-- MAC value
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Nitric Oxide N2O
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Nitric Oxide N2Obull Not metabolizedbull Only anesthetic agent
that is inorganicbull Major difference is low
potencybull MAC value is 105bull Weak anesthetic
powerful analgesicbull Needs other agents for
surgical anesthesiabull Low blood solubility
(quick recovery)
bull Minimal effects on heart rate and blood pressure
bull May cause myocardial depression in sick patients
bull Little effect on respirationbull Safe efficacious agentbull Inhibits methionine
synthetase (precursor to DNA synthesis)
bull Inhibits vitamin B-12 metabolism
bull Dentists OR personnel abusers at risk
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
GA ndash inhalational anaesthetics
According to physical properties
ndash anaesthetic gasesbull stored in pressure tanksbull applied with anaesthetic machinebull eg nitrous oxide ndash laughing gas (formerly cyclopropane)
ndash volatile liquids (historical ether chloroform)bull liquids with low boiling-point (about 40degC)bull stored in dark flaskets (the light induces transformation in
toxic aldehydes)bull applied with vaporizersbull eg halotane isoflurane sevoflurane
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Inhalation anesthesia Ether
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Evaluation of inhalational anaesthetics efficiency
Minimum alveolar concentration (MAC)bull Concentration of anaesthetic in alveolar space that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjectsbull the lower MAC the more potent anaestheticbull imobility in 95 subjects increasing concentration of anaesthetic 30 over MAC
bull before inhalational induction 2-5 minutes 100 oxygen-gt denitrogenation -gt faster induction bull at the end of anaesthesia again 100 oxygen -gt faster excretion of anaesthetic and waking up
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Halogenated compoundsbull HalothaneMost potent inhalational
anestheticMAC of 075Efficacious in depressing
consciousnessVery soluble in blood and adiposeProlonged emergencebull IsofluraneProduces most significant
reduction in systemic vascular resistance-- coronary steal syndrome increased ICP
Excellent muscle relaxant-- potentiates effects of neuromuscular blockers
bull Sevoflurane and desflurane
Low solubility in blood-- produces rapid induction and emergence
Minimal systemic effects-- mild respiratory and cardiac suppression
Few side effectsExpensive
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Side effectsbull HalothaneMalignant Hyperthermia high association
with muscle disordersMalignant Hyperthermia-- 160000 with succinylcholine to 1260000 without
halothane in 60 succinylcholine in 77
Classic-- rapid rise in body temperature muscle rigidity tachycardia rhabdomyolysis acidosis hyperkalemia DIC
most common masseter rigidityfamily history
autosomal dominant inheritancediagnosis--previous symptoms
increase CO2 rise in CPK levels myoglobinuria muscle biopsy
physiology--hypermetabolic state by inhibition of calcium reuptake in sarcoplasmic reticulum
bull Isoflurane
Little metabolism (02) -- low potential of organotoxic metabolites
No EEG activity like enfluraneBronchoirritating
laryngospasm
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Intravenous anaesthetics
bull Frequently used for induction (weak or no analgetic effects)
bull Sometimes for maintenance (TIVA)
bull Combined with inhalational anaesthetics and some other medicaments (opioid analgetics neurolepticshellip)
bull Quick onset of the effect quick arousal (redistribution)
bull MIR (minimal infusion rate) ndash rapidity of anaesthetics infusion that prevents the reaction to a standard surgical stimulus (skin incision) in 50 of subjects
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Groups of intravenous anaesthetics1 barbiturates ndash thiopental
2 imidazoles ndash etomidat
3 alkyled phenols ndash propofol
4 Steroids
5 eugenols ndash propanidid
6 phenylcyclidines ndash ketamine
7 benzodiazepines
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Propofol in the Death of Michael Jackson Bad Drug or Bad Doctor
October 07 2011 This article is by contributing writer Ivy Bigbee She is a Washington DC-based writer]
[
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Muscle relaxants
Depolarising muscle relaxants
bull cholindergic receptor -gt depolarisation -gt generation APbull fasciculationsbull antagonisation is not possiblebull eg Suxametonium (succinylcholine)
Non-depolarising muscle relaxants
bull competetive block of cholinergic receptors so called curariform medicaments eg Pancuronium Atracurium
bull antagonist neostigmin (decurarization)
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
OpioidsClasificare traditionala
Opioide bdquo slaberdquobull Codeinabull Dihidrocodeinabull Dextropropoxifenabull Tramadolbull Opioide bdquo puternicerdquobull Morfinabull Metadonabull Fentanilbull Hidromorfonabull Meperidina ( petidina)bull Oxicodonbull Buprenorfinabull Levorfanolbull Dextromoramida
Clasificarea functionalabull Complet agonistibull Morfinabull Fentanylbull Hidromorfona bull Codeinabull Metadonabull Tramadolbull PetidinaPartial agonistibull Buprenorfinabull Pentazocinabull ButorfanolMicsti agonisti- antagonistibull Nalbufinabull NalorfinaComplet antagonistibull Naloxonabull Naltrexonabull Alvimopan ( ADL 8- 2698)
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Opioids
Natural Semisyntetic SynteticiMorfinaCodeinaPapaverinaTebaina
HeroinaDihidromorfonaButorfanol
Serii morfinice levorfanolSerii defenilpropilamine metadonaSerii fenilpiperidinice petidina fentanyl sufentanylalfentanil remifentanil
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Opioids Neurophisology
bull Analgezie ( care nu se asociaza cu pierderea starii de constienta)bull Ameteli bull Modificarea starii de dispozitiebull Confuzia bull darrratei de metabolizare intracerebrala a presiunii intracerebralebull uarrfluxul sanguin cerebralbull Neuroprotectia prin receptorii kbull Rigiditatea musculara bull Neuroexcitabilitatea ( delir crize convulsive tip grand mal)bull Mioza mediata prin receptorii micro si kbull Termoreglarea bull Prurit
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Opioids Respiratory
Efecte terapeutice
bull darrhiperventilatia datorata anxietatii si durerii
bull Efect antitusiv bine cunoscut ( de origine centrala)
bull Deprimarea reflexelor de la nivelul cailor resp superioare traheei si cailor respiratorii inferioare
bull Beneficiu in astm prin diminuarea cresterii tonusului bronhomotor
bull Efect minim asupra schimburilor gazoase
Efecte non- terapeutice
bull Toti agonistii de rec micro cauzeaza depresie respiratorie
bull Raspunsul stimulator al CO2 estedarr
bull Rata respiratorie estedarr
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Opioids cardio-vascular
bull Inotrop pozitiv directbull Cronotrop negativ directbull Bradicardicbull Efect protector impotriva ischemiei miocardicebull Fara efecte semnificative asupra vasomotricitatii coronariene
si a metabolismului miocardicbull Efecte minime pana la absente asupra pre- si postsarciniibull Depresiedarr asupra vaselor mari si a baroreceptorilor de la nivel
atrial
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Opioids effects
bull Analgeziebull Sedarebull Depresie respiratoriebull Greaţă vărsăturibull Scad funcţia cardiacăbull Miozăbull Constipaţiebull Toleranţăbull Dependenţă (sindromul de abstinenţă)
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
hellipWaking ndashup
bull Reversal from General anesthesiabull Stop administration of general anesthetics (volatile and
intravenous)bull Recovery of reflexesbull Recovery of spontaneous respiration (efficient)bull Hemodinamic stabilitybull Ideal patient awakebull Sometimes recovery on mechanical ventilationbull Administration of an antidote (ex Anticholinergic
naloxone)
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Mechanism of anesthetics
bull Early Ideasndash Unitary theory of anesthesia
bull Anesthesia is produced by disturbance of the physical properties of cell membranes
bull Problematic theory fails to explain how the proposed disturbance of the lipid bilayer would result in a dysfunctional membrane protein
ndash Inhalational and intravenous anesthetics can be enantio-selective in their action
bull Focus on identifying specific protein binding sites for anesthetics
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Molecular Actions GABAA Receptor
bull Ligand-gated ion channelsndash Chloride channels gated
by the inhibitory GABAA receptorbull GABAA receptor
mediates the effects of gamma-amino butyric acid (GABA) the major inhibitory neurotransmitter in the brain
ndash GABAA receptor found throughout the CNS
Most abundant fast inhibitory ligand-gated ion channel in the mammalian brain
Located in the post-synaptic membrane
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Cellular Mechanism
bull Intravenous Anestheticsndash Substantial effect on synaptic
transmissionndash Smaller effect on action-potential
generation or propagationndash Produce narrower range of physiological
effectsbull Actions occur at the synapse
ndash Effects the post-synaptic response to the released neurotransmitterbull Enhances inhibitory neurotransmission
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Molecular Action GABAA Receptor
bull Receptor sits in the membrane of its neuron at the synapse
bull GABA endogenous compound causes GABA to open
bull Receptor capable of binding 2 GABA molecules between an alpha and beta subunitndash Binding of GABA causes a
conformational change in receptorbull Opens central porebull Chloride ions pass
down electrochemical gradient
ndash Net inhibitory effect reducing activity of the neuron (propofol)
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Local anaesthesia (LA)
bull Contrary to general anaesthesia consciousness is preservedbull places of acting
spinal roots nerve plexi peripheral nerves
bull types of local anaesthesia topic (surface mucosal) infiltrative conduct spinal - epidural
- subarachnoid
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Local anaesthesiatopic
infiltrativecunduct
epidural
subarachnoid
scheme by JCendeliacuten
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Topic (surface mucosal) anaesthesia bull aerosol administration on the mucous sourface liniments with LA (EMLA) bull ORL ophtalmology anaesthesia in oral or nasal cavity conjunctiva amp cornea in urology for anaesthesia of mucose of the urinary tract (urethral catheterization)
Infiltrative anaesthesia infitration in zone of operationbull reversibile block of terminal parts of nerve fibers bull IVRA ndash intravenous regional anaesthesia (Bieracutes block)
ndash application into peripheral veins previously emptied of bloodndash diffusion and infiltration of surrounding tissuendash danger of toxic effects of anaesthetic in the blood circulation after the turnstile is released
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Conductive anaesthesia bull Targeted application af anaesthetic near nerve or nerve plexusbull anaesthesia of all parts controled by the particular nervebull usually also motor paralysis (dependent on dose of anaesthetic)bull examples of usage
ndash conductive LA of peripheral nerves (n radialis medianus ulnaris femoralis ischiadicus)ndash anaesthesia of II or III branch of trigeminal nerve (stomatology)
Epidural anaesthesia bull application of LA into the epidural spacebull block of impuls conduction in nerve exit from the dural sacbull affected sensitive sympatethic motor nerves
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Subarachnoid anaesthesia (spinal intrathecal)
bullLA administered subarachnoidally in CSF
bull izobaric LA - stays where applied + diffusion
bullhyperbaric LA ndash spread dependent on gravity -gt range of anaesthetized zone can be influenced by positioning
bullrisk of severe complications (respiration centre paralysis)
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Local anesthethics
Amino-estersndash less stable shorter duration hydrolyzed in
liver and aslo in plasma by cholinesterasesndash more often allergic reactionsndash eg Procaine Tetracaine
Amino-amidesndash more stable longer lasting effect hydrolyzed
in liver onlyndash allergic reactions uncommonndash egLidocaina bupivacaina ropivacaina
prilocaine etc
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Mechanism of the effect of LAbullblockade of the inner oriffice of sodium channel -gt influenced
depolarisation
Effects of LA on nerve fibers
1block of sympathetic division (warming of skin)
2loss of sensation of heat and pain
3loss of sensation of touch and pressure
4loss of motorics
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Local Anesthetic Toxicity
bull Central nervous systemndash initially-- lightheadedness circumoral numbness
dizziness tinnitus visual changendash later-- drowsiness disorientation slurred speech
loss of consciousness convulsionsndash finally-- respiratory depression
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Local Anesthetic Toxicity
bull Cardiovascularndash myocardial depression and
vasodilation-- hypotension and circulatory collapse
bull Allergic reactions-- rare (less than 1)ndash preservatives or metabolites of estersndash rash bronchospasm
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Treatment of Toxicity
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Challenges in Anesthesiology
bull Tonsillectomyndash postoperative bleeding
bull Ear surgeryndash bloodless operative fieldndash nitrous oxidendash muscle relaxants
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Challenges in Anesthesiology
bull Laryngeal surgeryndash Carbon dioxide laser
bull no polyvinyl tubesbull Rusch or Xomed tubesbull Mixture of gasesbull Tube cuff considerationbull Pulse mode
ndash Management of fire
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Challenges in Anesthesiology
bull Acute airway problems post extubationndash Laryngospasmndash Postobstructive pulmonary edemandash Postintubation croupndash Aspiration pneumonitisndash Recurrent nerve palsyndash Massive subcutaneous emphysema
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Va multumesc
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
Controlul durerii
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS
1 Usoara
2 Moderata
3 Severa
AspirinaParacetamolAINSplusmn Adjuvante
CodeinaDihidrocodeinaOxicodonTramadolplusmn Adjuvante
MorfinaHidromorfonMetadonaFentanilOxicodonplusmn Adjuvante
Durerea cronica ndash scara OMS