Drugs for General Anaesthesia

TCD 4th med Pharmacology & Therapeutics

Dr Tom Schnittger FFARCSI

30.10.08

Anaesthesia uses drugs to create an altered physiological state:

Unconciousness Analgesia Amnesia Muscular relaxation

General Anaesthesia:
Variable state reversible
Polypharmacy Fast acting, short acting, pure drugs

Every General Anaesthetic is unique:

Tailored to the state of the patient Tailored to the nature of the operation

Tailored to the style of the anaesthetist

General Anaesthesia:
Every patient responds to a drug as an individual, not as a mean
Safe anaesthesia requires constant vigilance and monitoring

Phases of a General Anaesthetic

Induction Maintenance Reversal

Phases of a General Anaesthetic

Pre-operative phase Induction Maintenance Reversal Post-operative phase

General Anaesthesia 1908

Premedication: Induction: Maintenance: Reversal: Recovery: morphine/gin ether/air ether/air turn off ether nothing/morphine

General Anaesthesia 2008

Pre-operative evaluation/optimisation Induction Maintenance Reversal

Recovery, I.C.U. and Pain management

Pre-operative phase:
Pre-operative clinical evaluation & preparation Reassurance/Advice: smoking, wt. loss, OCP, fasting Anxiolytics: benzodiazepines Analgesics: opiates/NSAIDS Bronchodilators: b2 agonists, anti-cholinergics Cardiac drugs: GTN, anti-arrythmics, anti-bp Diabetic drugs: glucose-insulin-potassium Endocrine drugs: glucocorticoids Anti-embolism: heparin/TEDS

Induction phase:
Intravenous fluid: Induction agent: Analgesic: Muscle relaxant: Local anaesthetic: crystalloid/colloid propofol/thipentone/ketamine/sevoflurane fentanyl/morphine suxamethonium/atracurium/rocuronium lignocaine/levobupivicaine

Maintenance phase:
Oxygen/Air or Oxygen/Nitrous Oxide Vapour: Sevoflurane/Isoflurane Halothane/Ether Muscle relaxants Analgesics: morphine/fentanyl bolus or remifentanyl infusion diclofenac/paracetamol Anti-emetics: ondansetron, dexamethazone, cylizine, prochlorperazine IV fluids: blood, platelets, plasma, factors Other drugs: antibiotics, diuretics Cardiac drugs: Inotropes: adrenaline, noradrenaline Chronotropes: atropine, isoprenaline, b-blockers Hypotensives: GTN, labetalol, nitroprusside

Reversal phase:
Muscle relaxant: neostigmine & glycopyrollate/atropine
naloxone

Opiate:

Benzodiazepine:

flumazenil

Post-operative phase:
Oxygen Analgesics Anti-emetics Inotropes IV fluids Intensive Care: Cardiac support, Ventilation, Dialysis, TPN Pain management: Analgesic optimisation, PCA, Epidural analgesia, continuous nerve block

Anaesthesia scenarios - Case 1

87 year old woman
Abdominal pain, distension & vomiting for 3 days Past medical history: MI 5 yrs previously, angina & hypertension

Case 1 issues:
Elderly Dehydration Electrolyte abnormalities Aspiration risk IHD and hypertension Relative emergency

Case 1 - management
Rehydration, restoration of electrolyte balance Analgesia, oxygen Anti-anginal, anti-hypertensive
Monitor blood pressure invasively Rapid Sequence Induction Analgesia, anti-emesis

Anaesthesia scenarios - Case 2

11 year old girl severe asthma
foreign body in her ear

Case 2 - issues
Child anxiety
Asthma airway management Semi-elective procedure

Case 2 - management
Treatment of asthma Adequate pre-medication/anxiolysis Gas induction No instrumentation of airway

Case 3
Obese 34 yr old
Insulin dependent diabetic Acute abdomen - ? appendicitis

Case 3 - issues
Acute abdomen: relative emergency, dehydration, electrolytes, risk of vomiting
hyper/hypoglycaemia IV access, airway, wound healing, ?IHD

Diabetes: Obesity:

Case 3 - Management
Rehydration Normalisation of electrolytes & blood sugar Invasive blood pressure monitoring/sampling Rapid sequence induction Intubation aids Antibiotics, surgical technique

Case 4
Previously healthy 46 yr old post-op GA for ankle fracture repair 30 minutes later on ward: unconcious, cyanosed, laboured respirations

Case 4 - issues
EMERGENCY
Differential diagnosis

Case 4 - management
Call for help,

ABC

Airway Breathing Circulation

Oxygen, IV access

Case 4 management
Diagnose:
Respiratory event Cardiac event Too much opiate Inadequate reversal of muscle relaxant

Treat accordingly