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Evolution of Anesthesia
Ether Only
Hypnotic Analgesia Relaxation
Balanced Analgesia
Era ODC
80 years
75 years
1990
2000
1846
Premedication SA/ Scopolamine Mo. or Pethidine
1926
Premedication SA Mo. or Pethidine
Save Anesthesia
No premedication No SA No opiates
Not only Awake up and Analgesia, but also full alert and can walk home
ETHER
Except Ether(1848) as a very old and typical anesthetic agent which may produce, AMNESIA( HYPNOTIC) ANALGESIA & RELAXATION no other anesthetic agent may produce triad anesthesia. But it has many disadvantages.
Since whom science has control of PAIN Before whom, surgery as agony
BALANCED ANESTHESIA
John Lundy (1926) from Mayo Clinic first introduced BALANCED ANESTHESIA Antinociceptive analgesic Unconsciousness hypnotic Relaxation muscle relaxant
BALANCED ANESTHESIA
In 75-90 our typical anesthesia
Nitrous Oxide Flouthane Pancuronium Br /Curare
Still has some disadvantages
BALANCED ANESTHESIA
Since than, scientis looking for Ideal:
Strong ANALGESIC
FENTANYL
Good HYPNOTIC
PROPOFOL
RELAXATION
NDMR
Fentanyl
Discovered in 1963 by Dr. Paul
Janssen Synthethic opioid Strong Opioid 100x to Morphine Pure agonist Fentanyl is the reference analgesic in anaesthesia No ceiling effect
12
Mu1
: analgesia (supraspinal, spinal), euforia, miosis, bradikardi, hipotermi, retensi urine. : analgesia (spinal), depresi ventilasi, konstipasi (bermakna). sedasi, miosis, diuresis.
Mu2
Delta
Modulation
Opioid mechanisms
Descending controls To the brain C-fibre
Glutamate
Substance P etc
Opioid mechanisms
Descending controls To the brain C-fibre Glutamate
Substance P etc
Opioid
Fentanyl
Indications
Fentanyl is used in the treatment of acute pain and to depress breathing in patients being ventilated. It may also be given as an infusion under the skin in palliative care patients who have intolerable side effects from Morphine.
3mcg/kg. Pay special attention to your dosing this is the only medication we have that is given in Micrograms (mcg).
Fentanyl vs Morphine
ANALGESIC MEDICATION OPTIONS
(Choose one) Fentanyl 50-100 mcg IV (1-2 mcg/kg) may repeat dose every 5 minutes until maximum of 3 mcg/kg OR Morphine sulfate 2-5 mg IV (0.05 mg/kg) may repeat dose every 5 minutes until maximum of 0.2 mg/kg
or 250mcg/5ml
for 100mcg/2ml??? 50mcg/ml Right! For 250mcg/5ml??? 50mcg/ml You got it!
Fentanyl Pharmacokinetics
Intramuscular
Onset 7-15 minutes Peak 15 minutes Duration 1-2 hours
Intravenous
Onset few minutes Peak few minutes
Fentanyl Precautions
Over Sedation
Fentanyl Contraindications
Intermittent pain Respiratory depression Acute or severe asthma Paralytic ileus - paralysis of the intestine Known hypersensitivity Opioid induce Hyperalgesia
Uncommon
Rigid chest wall, Decreased Breathing, Confusion, Itching, Slowing or Elevated HR, ABD pain.
Considerations
Parenteral dose may be given diluted or undiluted Administer IV over 1 to 2 minutes Protect from light Closely monitor vital signs Respiratory depression may out last the analgesic effect Effects may be reversed by naloxon
(Narcan)
Fentanyl-Conclusion
Very good analgesic ( potent analgesic) Safe to administer at lower, slow infusion rates. Low histamine effects. Short duration.
setting.
Fentanyl In Summary
Fentanyl is a potent analgesic Dose is 1-2 mcg/kg Reversal agent is Naloxon (Narcan)
2. General Anesthesia
Low (2mcg/kg), Moderate(2-20) or High dose (20-50)
Moderen Anesthesia
Combination of these 3
regiments (propofol, fentanyl and vecuronium ) as Balanced Anesthesia is considered as modern anesthesia.
Propofol
Before introduction of protofal, thiopental
(ultra short acting barbitural) is commonly used. Good for induction expect for its painful during the injection, can be overcome by Ledocain 1 mg/Kg BW Fentanyl 1 ug/Kg BW
Propofol
Propofal is insoluble in water, therefore,
propofal is formulated as emulsion containing 10% soybean oil 2.25% glyserine 1.2% lecetin Major componen egg yolk fraction Good for supporting bacterial growth, so sterilitation is very important.
Propofol
Propofal primary act as hypnotic, has no
analgesia. Decreas CBF and CMRO2 ICP This effect equal with thiopental It has antiemetic effect Rapid onset 30 optimal 2 duration about 10
Modern Anesthesia
Premedication (SA, Mo, Pethidine, Diazepam) Midazolam Barbiturate (Thiopental) Nitrous Oxide, (only oxygen and air) Depolarizing Muscle Relaxant (SCC) Long Acting NDMR (Pancuronium Bromida) Inhalation Anesthetic, less and less.
NO ! ! !
TIVA
Propofol as strong hypnotic Fentanyl, Sufentanil, Alfentanil, as strong analgesics Rocuronium, Vecuronium, Atracurium, etc. as NDMR
Epidural Anesthesia
Epidural is the main modality in
New Paradigm in RA vs GA
RA and GA are no longer considered as
GI
GU/GY
Thoracic
- Oesophagectomy
- Lung resection - Rib resection
Orthopedics
Epidural technique
FENTANYL
PROPOFOL
NDMR EPIDURAL