GENERAL ANAESTHESIA. Jozef Firment, MD PhD. Department of Anaesthesiology & Intensive Care Medicine Šafárik University Faculty of Medicine, Košice
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1 GENERAL ANAESTHESIA Jozef Firment, MD PhD Department of Anaesthesiology & Intensive Care Medicine Šafárik University Faculty of Medicine, Košice
2 DEFINITION (an) aisthetos = (un) perception general anaesthesia = narcose regional anaesthesia = local 2
3 Stress Response or Plasma concentration Firment SURGICAL STRESS MAP Intubation Theoretical Plasma Drug Concentration for Adequate Anaesthesia Barash, 1997 Anxiety Mound Sleep River Lake Prep. Incision Peritoneal Traction Mount Surgery Recovery Plains Bowel/ Vascular Clamping ICU Highlands Duration of Surgery 3
4 PHARMACO-ANAESTHESIA METHODS Inhalational anaesthesia... VIMA Intravenous anaesthesia... TIVA Intramuscular Rectal Combined anaesthesia 4
5 BASAL PARTS OF GA BIS Monitoring Consciousness/Hypnosis Analgesia Hemodynamic Monitoring Balanced Anaesthesia Monitoring Anaesthetic Endpoints Muscle relaxation/ Areflexia Peripheral Nerve Stimulator Monitoring 5
6 CIRCULATORY EFFECTS INHAL. ANAESTHETICS (Barash, 1997) BP according to dose (vasodiltion, C.O., cardiodepresion, sympat. activity) consumption O 2 about 10-15% blood flow in liver, kidneys and gut, in brain, muscles & skin N 2 O SVR, PVR and BP, C.O. Sensibilisation myokardium to catecholamins: in children, HAL > ENF > ISO > DES > SEV (more in CO 2, more with thiopental) No influence to pacemaker functions No coronary steal efect in man 6
7 RESPIRATORY EFFECTS INHAL. ANAESTHETICS (Barash, 1997) All V T and bronchodilational effect Bloc histamin effects on bronchi bronch. asthma treatment: HAL, SEV Respiratory depresion : N 2 O>HAL>ISO>DES No influence to hypoxic pulmonary hypertension Up to 3x increase effects of musclerelaxants 7
8 CNS EFFECTS OF INHAL. ANAESTHETICS (Barash, 1997) intelectual functions, HAL for 2-8 days (B?) intensity of cerebral metabolism (CMRO 2 ): ISO > EFL>HAL. Vasodilat. cerebr. a. & pressure CSF: HAL>ISO=DES=SEV, HAL > ISO influence production & absorbtion CSF Light hypocapnia - lower ICP in ISO than HAL Autoregulation to CO 2 is more blocked by HAL than ISO Epi EFL 8
9 TOXICITY HAL = hepatotoxicity (imuno, repeated expositions) N 2 O = hematotoxicity perniciose 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,
10 Distribution coefficient (blood : gas) DISTRIBUTION COEFF. ANAESTHETICS (BLOOD / GAS) 3 Less solubility = faster onset Desflurane Nitrous Oxide Sevoflurane Isoflurane Enflurane Halothane Miller. Anesthesia. 4 th ed. Churchill Livingston, 1994; Data on file, Abbott Laboratories Inc. 10
11 GAS CONSUMPTION DURING ANAESTHESIA Low flow... 11
12 ADVANTAGES OF INHAL. ANAESTHESIA Easy regulation (deep of anaesthesia) Elimination by expiration Easier monitoring of anaesthesia deep Less risk of postanaesthetical respiratory depresion Potentiation of muscle relaxation effect Ambulatory anaesthesia Price 12
13 ANAESTHETIC MACHINE LAYOUT 13
14 Campbell Firment ROTAMETER VAPORISER VOLATILE ANAESTHETICS 14
15 ANAESTHETIC CIRCUIT LAYOUT 15
16 Campbell Firment UNI-DIRECTIONAL ANAESTHETIC SYSTEM LAYOUT 16
17 DEFINITIONS Intravenous anaesthesia (IVA) = administartion of intravenous anaesthetics with addition of N 2 O in inhalatory mixture Total intravenous anaesthesia (TIVA) = all anaesthetics are administered only by i.v. route, inspiratory gas contains only oxygen and air (nitrogen) 17
18 INDICATIONS OF IV ANAESTHESIA Support of inhalational anaestesia Sedation during local anaestesia Ambulantory anaestesia Difficult administration of inhal. anaestetics (military or civil injuries, hyperbaric chamber) Impossible administration of N 2 0 ( FiO 2 ) as bronchoscopy, laryngeal or tracheal surgery Where is N 2 0 relative CI - one lung anesthesia, vestibule ear surgery, neuroanaesthesia, ileus, air embolia... Extracorporeal circuit 18
19 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 19
20 INSTRUMENTS FOR TIVA Linear pump Infusion bottle delivery Two IV lines or Y connector Oxygen flow-meter 20
21 MEDICAMENTS USED FOR TIVA Anaesthetics: propofol, thiopental, metohexital, ketamin, midazolam... Opioids: morphin, fentanyl, alfentanil, sufentanil, remifentanil... Muscle relaxants: sukcinylcholine, vecuronium, atracurium, rocuronium, pipecuronium... 21
22 MUSCLE RELAXATION N.-m. junction, mediators Depolarising muscle relaxation Undepolarising muscle relaxation Curarisation Decurarisation Recurarisation 22
23 POSTOPERATIVE OBSERVATION No difusion hypoxia (N 2 0) Absorbtion atelectase (during high FiO 2 ) Early administration analgetics in cases using short-acting opioids Possibilities aplication of antidots 23
24 RISK FACTORS FOR PONV 24
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