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General anesthesia (general anesthesia (stages of general anesthesia…

- - - - loss of somatic sensation but patient is still conscious, responding to commands
    - - patient unconsiou/amnesiac but RESTLESS
      - want to move quickly away from this stage to prevent injury
    - - desired level for surgical procedures
      - want to get to this stage as quick as possible
      - patient has regular deep respiration this stage may be further divided according to respiratory rate and reflex activity
    - - NOT desired
      - medulla oblongata respiratory and vasomotor control centers are suppressed
      - respiratory and circulatory support needed or patient will die
- - - - barbiturates, benzo, opioids may be given 1-2 hours before surgery
    - - anticholiniergic
        
        atropine, scopolamine, glycopyrrolate
        
        reduce salivation and respiratory secreetions
      - anihistamines
        
        hydroxyzine, promethazine
        
        hypnotic effect and antiemetic actions
      - H-2 blockers
        
        cimetidine, rantitidine
        
        decrease gastric acid, prevent aspiration pneumontis
  - - - used to facilitate, mechanical ventilation, decrease shivering, decrease O2 consumption, eliminate movement
      - use caution in patients with neuromuscular diseases, electrolyte disturbances, acidosis, hemiparesis, demyelinating lesions, peripheral neuropathy burn injuries
    - - succinylcholine, atracurium, pancuronium
      - side effects
        
        tachycardia, increased histamine release, hyperkalemia, residual muscle pain
        
        residual paralysis can last for hours
    - - paralysis of skeletal muscle via ACh blockade
      - no sedative, amnesic, or analgesic properties
  - - - ondansetron (zofran)
      - Granisetron (Kyril)
- - - - rapid onset longer duration
    - - rapid onset shorter duration
    - - not used often
  - - - most commonly used 5 day limit
    - - no limit on duration of use
- - - - desflurane (suprane), Sevoflurane (ultane), isoflurane (forane), halothane (fluothane)
      - delivery is through vaporizers, compressors
    - - nitrous oxide
        
        some time used in combo, can cause increased nausea, rare occurrence of pneumothorax, inactivates B12, most common for dental procedures
  - - - barbiturates
        
        theopental
        
        used for induction of anesthesia
        
        ultra short acting 30-40 seconds
        
        single dose produces a brief period of unconsciousness
        
        large doses/continual infusion lead to hypotension, myocardial and respiratory depression
        
        used in cerebral swelling as it doesnt increase intracranial pressure
        
        methohexital
        
        used in electroconvulsive therapy due to antiseizure activity
        
        preferred over thiopental for short ambulatory procedures
        
        rapid elimination rate
      - benzodiazepines
        
        diazepam, lorazepam,midazolam
        
        drug of choice as premedication
        
        used alone or in combination for short surgical/diagnostic procedures
        
        midazolam is drug of choice for IV administration
        
        diazepam and lorazepam are lipid soluble which may cause local irritation and pain
        
        antidote:flumazenil (romazicon)
      - opioids
        
        fentanyl and fentanyl derivatives
        
        like Benzos these drugs are often used preoperatively but can also be used during general anesthesia alone or in combination to produce anesthesia in short surgical or diagnostic procedures
      - ketamine
        
        produces dissociative amnesia
        
        patient appears detached or dissociated from surrondings
        
        patient appears awake but is sedated and usuallu unable to recall events
        
        works by blocking membrane effects of excitatory NT glutamic acid at NMDA receptor
        
        highly lipophilic
        
        makes it useful for children and elderly as well as high risk patients or those undergoing short procedures
        
        does not cause cardiopulmonary issues to extent of other agents
      - Etomidate
        
        hynotic like drug
        
        rapid onset with minimal cardiopulmonary depression
        
        no analgesic effects; administer with opioids
        
        causes adrenocortical depression leading to decreased cortisol level
        
        prolonged used can lead to hypotension, oliguria, electrolyte imbalance
      - propofol (diprivan)
        
        short acting hypnotic
        
        drug of choice for general anesthesia
        
        antiemetic effects
        
        side effects are dose dependent
        
        respiratory depression, hypotension, pain at injection site
        
        prolonged used associated with muscle movements and tremors
        
        others
        
        ampofol: less lipid content for prolonged administration
        
        fospropofol
        
        water soluble prodrug