general anaesthesia - pavol jozef Šafárik university anaesthesia.pdf · • general anaesthesia =...
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GENERAL
ANAESTHESIA
Jozef Firment, MD PhDDepartment of
Anaesthesiology & Intensive Care Medicine
Šafárik University Faculty of Medicine, Košice
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DEFINITION
• an + aesthesia = (un) perception
• Ancient Greek
• general anaesthesia = „narcosis“
• regional anaesthesia = local
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Str
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ns
e o
r
Pla
sm
a c
on
ce
ntr
ati
on
Anxiety
Mound
Sleep River
Lake
Prep.
Peritoneal
Traction
Bowel/
Vascular
ClampingICU
Highlands
Recovery
Plains
Intubation
Incision
Mount
Surgery
Theoretical Plasma Drug
Concentration for Adequate
Anaesthesia
SURGICAL STRESS MAP
Barash, 1997
Duration of Surgery
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PHARMACO-ANAESTHESIA
METHODS
• Inhalational anaesthesia ... VIMA
• Intravenous anaesthesia... TIVA
• Intramuscular
• Rectal
• Combined anaesthesia
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Balanced
Anaesthesia
AnalgesiaMuscle
relaxation/
Areflexia
Consciousness/Hypnosis
BIS Monitoring
Hemodynamic
Monitoring
Peripheral
Nerve Stimulator
MonitoringMonitoring Anaesthetic Endpoints
BASAL PARTS OF GA
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CIRCULATORY EFFECTS
INHAL. ANAESTHETICS (Barash, 1997)
• BP according to dose (vasodilation, C.O., cardiodepresion, sympat. activity)
• consumption O2 about 10-15%
• blood flow in liver, kidneys and gut, in brain, muscles & skin
• N2O SVR, PVR and BP, C.O.
• Sensibilisation myocardium to catecholamines: in children, HAL > ENF > ISO > DES > SEV (more in CO2, more with thiopental)
• No influence to pacemaker functions
• No coronary steal effect in man
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RESPIRATORY EFFECTS
INHAL. ANAESTHETICS (Barash, 1997)
• All VT and bronchodilational effect
• Bloc histamine effects on bronchi – bronch. asthma
treatment: HAL, SEV
• Respiratory depression : N2O>HAL>ISO>DES
• No influence to hypoxic pulmonary hypertension
• Up to 3x increase effects of muscle relaxants
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CNS EFFECTS OF
INHAL. ANAESTHETICS (Barash, 1997)
• intellectual functions, HAL for 2-8 days (B?)
• intensity of cerebral metabolism (CMRO2):
ISO > EFL>HAL.
• Vasodilat. cerebr. a. & pressure CSF:
HAL>ISO=DES=SEV,
• HAL > ISO influence production & absorption CSF
• Light hypocapnia - lower ICP in ISO than HAL
• Autoregulation to CO2 is more blocked by HAL than ISO
• Epi EFL
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TOXICITY
• HAL = hepatotoxicity (imuno, repeated expositions)
• N2O = hematotoxicity „pernicious“ anaemia
• In septic pat. weakening Ne and Le functions
• Change platelets functions
• Myometrium relaxation – bleeding during C.s. (HAL > 0,5, ISO > 1,0)
Barash, 1997
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FACTORS INFLUENCED
ACTIVITY OF ANESTHETICS
• Anaesthetics concentration in insp. gas
• Alveolar ventilation
• Anaesthetics solubility in blood
• Alveolo - capillary difference of partial pressures
anaesthetics
• Cardiac output
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PHARMACOKINETICS OF INHAL.
ANAESTETICS
• Gas pressure gradient:
Inspiratory > alveolar (expiratory) > arterial > > tissue
• ETAA is indirect, but adequate indicator of anaesthetic pressure in brain
• Distributional coefficient blood:gas, tissue:blood
• Less anaesthetic solubility in blood = faster onset of activity
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DISTRIBUTION COEFF.
ANAESTHETICS (BLOOD / GAS)
Miller. Anesthesia. 4th ed. Churchill Livingston, 1994; Data on file, Abbott Laboratories Inc.
Desflurane Nitrous
Oxide
Sevoflurane Isoflurane Enflurane Halothane
0.45 0.470.65
1.43
1.8
2.5
1
2
3D
istr
ibu
tio
n c
oeff
icie
nt
(blo
od
:g
as)
Less solubility = faster onset
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GAS CONSUMPTION
DURING ANAESTHESIA
Low flow...
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ADVANTAGES OF
INHAL. ANAESTHESIA
• Easy regulation (deep of anaesthesia)
• Elimination by expiration
• Easier monitoring of anaesthesia deep
• Less risk of postanaesthesia respiratory depression
• Potentiation of muscle relaxation effect
• Ambulatory anaesthesia
• Price
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ANAESTHETIC MACHINE LAYOUT
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VAPORISER
VOLATIL ANAESTHETICS
ROTAMETER
= FLOW METER
Cam
pbell
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UNI-DIRECTIONAL ANAESTHETIC
SYSTEM LAYOUT
Cam
pbell
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IVA/TIVA DEFINITIONS
• Intravenous anaesthesia (IVA) = administration of
intravenous anaesthetics with addition of N2O in inhaled
mixture
• Total intravenous anaesthesia (TIVA) = all
anaesthetics are administered only by i.v. route,
inspiratory gas contains only oxygen and air (nitrogen)
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INDICATIONS OF IV
ANAESTHESIA
Support of inhalational anaesthesia
Sedation during local anaesthesia
Ambulatory anaesthesia
Difficult administration of inhal. anaesthetics (military or civil injuries, hyperbaric chamber)
Impossible administration of N20 ( FiO2) as bronchoscopy, laryngeal or tracheal surgery
Where is N20 relative CI - one lung anaesthesia, vestibule ear surgery, neuroanaesthesia, ileus, air emboli...
• Extracorporeal circuit
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DISADVANTAGES OF TIVA
• Difficulties in an. depth assessment
• Postoperative respiratory depression after opioids
• Necessity of several IV accesses
• Drug incompatibilities
• More infusion pumps and deliveries
• Air and oxygen source
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INSTRUMENTS FOR TIVA
• Linear pump
• Infusion bottle delivery
• Two IV lines or Y connector
• Oxygen flow-meter
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MEDICAMENTS USED FOR TIVA
• Anaesthetics: propofol, thiopental,
metohexital, ketamin, midazolam...
• Opioids: alfentanil, fentanyl, sufentanil,
remifentanil...
• Muscle relaxants: sukcinylcholin,
vecuronium, atracurium, pipecuronium...
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MUSCLE RELAXATION
• N.-m. junction, mediators
• Depolarising muscle relaxation
• Un-depolarising muscle relaxation
• Curarisation
• Decurarisation
• Recurarisation
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Plasma and effect site concentrations
during a TCI of propofol (Marsh model)
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Target controlled infusion (TCI)
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Target controlled infusion (TCI)
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Target controlled infusion (TCI)
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POSTOPERATIVE
OBSERVATION
• No diffusion hypoxia (no N2O)
• Absorption atelectasis (during high FiO2)
• Early administration analgesics in cases using
short-acting opioids
• Possibilities application of antidotes
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RISK FACTORS FOR PONV
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Anesthetics used in clinical practice(cumulative listing)
Year introduced0
10
20
1840 1880 1920 1960 2000
Nitrous Oxide
Ether
ChloroformEthyl Chloride
Ethylene
Divinyl EtherCyclopropane
TrichloroethyleneIsopropenyl Vinyl Ether
FluroxenePropyl Methyl Ether
Ethyl Vinyl EtherHalothane
Methoxyflurane Enflurane
IsofluraneDesflurane
Sevoflurane
Wilkinson WF2004
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RECOVERY ROOM
(PACU)High – Medium – Low dependency PACU
Jozef Firment, MD, PhD.Department of Anaesthesiology &
Intensive medicine, Medical faculty UPJŠ Košice
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RECOVERY ROOM
Oxygen th.
Respiration
Relaxation
Circulation
Diuresis
Bleeding
Analgesia
Transport
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POSTOPERATIVE PAIN THERAPY
• IM
• IV (pump)
• Epidural (pump)
• Orally
• Rectally
• Transdermal
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POSTOPERATIVE
EPIDURAL ANALGESIA• Continuing
after epidural anaesthesia or
combined anaesthesia (general + ED cath.)
• Catheter closely to segment of max pain
• Level of puncturelower abdomen - T9, upper abdomen - T6
• 7x less Mo consumption,
• risk of respiratory depression
• Undesirable motor block lower extremities above L2 1%, below L2 33%