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 anesthesia

bull 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 News

bull 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)

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 anesthesia

bull 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 News

bull 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)

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 anesthesia

bull 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 News

bull 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)

Tipes of anesthesia

bull 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 News

bull 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)

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 News

bull 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)

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 News

bull 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)

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 News

bull 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)

Current News

bull 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)

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)

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)

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)

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)

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)

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)

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)

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 N2O

bull 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 compounds

bull 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 anaesthetics

1 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)

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

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 N2O

bull 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 compounds

bull 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 anaesthetics

1 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)

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

Nitric Oxide N2O

Nitric Oxide N2O

bull 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 compounds

bull 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 anaesthetics

1 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)

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

Nitric Oxide N2O

bull 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 compounds

bull 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 anaesthetics

1 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)

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

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 compounds

bull 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 anaesthetics

1 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)

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

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 compounds

bull 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 anaesthetics

1 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)

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

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 compounds

bull 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 anaesthetics

1 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)

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

Halogenated compounds

bull 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 anaesthetics

1 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)

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

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 anaesthetics

1 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)

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

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 anaesthetics

1 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)

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

Groups of intravenous anaesthetics

1 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)

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

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)

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

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)

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

Opioids

Clasificare 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 Syntetici

MorfinaCodeinaPapaverinaTebaina

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

Opioids

Natural Semisyntetic Syntetici

MorfinaCodeinaPapaverinaTebaina

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

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

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

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

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

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

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

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 anaesthesia

topic

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 LA

bullblockade 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

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 anaesthesia

topic

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 LA

bullblockade 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

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 anaesthesia

topic

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 LA

bullblockade 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

Local anaesthesia

topic

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 LA

bullblockade 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

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 LA

bullblockade 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

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 LA

bullblockade 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

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 LA

bullblockade 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

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 LA

bullblockade 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

Mechanism of the effect of LA

bullblockade 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

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

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

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

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

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

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

Va multumesc

Controlul durerii

Controlul durerii

1 Usoara

2 Moderata

3 Severa

Aspirina

Paracetamol

AINS

plusmn Adjuvante

Codeina

Dihidrocodeina

Oxicodon

Tramadol

plusmn Adjuvante

Morfina

Hidromorfon

Metadona

Fentanil

Oxicodon

plusmn Adjuvante

Durerea cronica ndash scara OMS

• Anestezie curs 1
• Anesthesia
• History
• Tipes of anesthesia
• Principles of general anesthesia
• Definition of general anesthesia
• The Body and General Anesthesia
• Current News
• Slide 9
• Preoperative evaluation
• Preoperative evaluation
• Slide 12
• Selection of anesthesia
• Slide 14
• Premedication
• Patient monitoring during and after anesthesia
• Endo-Tracheal Intubation (ETT)
• Pharmacological principles
• Inhalational agents
• Nitric Oxide N2O
• Nitric Oxide N2O
• GA ndash inhalational anaesthetics
• Inhalation anesthesia Ether
• Slide 24
• Halogenated compounds
• Side effects
• Intravenous anaesthetics
• Slide 28
• Slide 29
• Muscle relaxants
• Opioids
• Opioids (2)
• Opioids Neurophisology
• Opioids Respiratory
• Opioids cardio-vascular
• Opioids effects
• hellipWaking ndashup
• Mechanism of anesthetics
• Molecular Actions GABAA Receptor
• Cellular Mechanism
• Molecular Action GABAA Receptor
• Local anaesthesia (LA)
• Local anaesthesia
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Local Anesthetic Toxicity
• Local Anesthetic Toxicity (2)
• Treatment of Toxicity
• Challenges in Anesthesiology
• Challenges in Anesthesiology (2)
• Challenges in Anesthesiology (3)
• Va multumesc
• Controlul durerii
• Slide 58
• Slide 59

• Anestezie curs 1
• Anesthesia
• History
• Tipes of anesthesia
• Principles of general anesthesia
• Definition of general anesthesia
• The Body and General Anesthesia
• Current News
• Slide 9
• Preoperative evaluation
• Preoperative evaluation
• Slide 12
• Selection of anesthesia
• Slide 14
• Premedication
• Patient monitoring during and after anesthesia
• Endo-Tracheal Intubation (ETT)
• Pharmacological principles
• Inhalational agents
• Nitric Oxide N2O
• Nitric Oxide N2O
• GA ndash inhalational anaesthetics
• Inhalation anesthesia Ether
• Slide 24
• Halogenated compounds
• Side effects
• Intravenous anaesthetics
• Slide 28
• Slide 29
• Muscle relaxants
• Opioids
• Opioids (2)
• Opioids Neurophisology
• Opioids Respiratory
• Opioids cardio-vascular
• Opioids effects
• hellipWaking ndashup
• Mechanism of anesthetics
• Molecular Actions GABAA Receptor
• Cellular Mechanism
• Molecular Action GABAA Receptor
• Local anaesthesia (LA)
• Local anaesthesia
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Local Anesthetic Toxicity
• Local Anesthetic Toxicity (2)
• Treatment of Toxicity
• Challenges in Anesthesiology
• Challenges in Anesthesiology (2)
• Challenges in Anesthesiology (3)
• Va multumesc
• Controlul durerii
• Slide 58
• Slide 59