ANAESTHESIA-INTRAVENOUS

IV induction drugs
• These are drugs that, when given intravenously in an appropriate dose
can cause a rapid loss of consciousness.
• One arm-brain circulation time
• They are used:
•To induce anaesthesia prior to other drugs being given to maintain
anaesthesia
• As the sole drug for short procedures
• To maintain anaesthesia for longer procedures by intravenous infusion
• To provide sedation
 Ideal IV induction drug
Pharmacokinetic properties
• Rapid onset in one arm-brain
circulation time
• Rapid redistribution to vessel rich
tissue
•Rapid clearance and metabolism
•No active metabolites
Pharmacodynamics properties
• High therapeutic ratio
• Minimal cardiovascular and respiratory
effects
• No histamine release/hypersensitivity
reactions
• No emetic effects
• No involuntary movements
• No emergence nightmares
• No hang over effect
• No adrenocortical suppression
• Safe to use in porphyria
 Drugs

• BARBITURATES
• PROPOFOL
• KITAMINE
• ETOMIDATE
• BENZODIAZEPINE
• OPIOIDS
 Classification
Inducing agents:
• Thiopentone sodium
• Methohexitone sodium
• Propofol
• Etomidate

Slower acting drugs:

• Benzodiazepines - Diazepam,Lorazepam,Midazolam
• Dissociative anesthesia - Ketamine
• Opioid analgesia - Fentanyl
Mechanism
• Major targets are GABAA receptor gatedCl-channel
• Many inhalationanesthetics, barbiturates, benzodiazepines and
propofol
• NMDA receptors are type of glutamatereceptor (N2O,Ketamine)

Inducing agents
• Drugs which on i.v. injection produce loss of consciousness in
approximately 11 seconds.
• Used because of rapidity of onset of action.
• Then maintain by inhalational agents.
• Supplemented with analgesics and muscle relaxants.
 BARBITURATES
Mechanisms of Action Pharmacokinetics
• Depress the reticular activating • Highly protein bound (80%)
• Suppress transmission of excitatory • The duration of action of is determined by
neurotransmitters (acetylcholine) redistribution, not
• Enhance transmission of inhibitory • metabolism or elimination
neurotransmitters (GABA) • Maximal brain uptake within 30 s
Example :
• Subsequent redistribution to the peripheral
Thiopental lowers plasma and brain
• Thiamylal • Concentration to 10% of peak levels within
• Pentobarbital 20–30 min
• Experience—patients typically lose
• Secobarbital
consciousness within 30 s and awaken
• Methohexital within 20 min.
Effects on Organ Systems
CARDIOVASCULAR
• Fall in blood pressure
• Elevation in heart rate
RESPIRATORY
• Ventilatory response to hypercapnia and hypoxia ---Decreases
• Tidal volume --- decreased
• Respiratory rate --- decreased
• Bronchospasm in asthmatic patients or laryngospasm in lightly anesthetized
patients
• Barbiturates do not completely depress noxious airway reflexes
• Release of histamine
Cerebral
• Cerebral blood flow  Decrease
• Intracranial pressure  Decrease
• Cerebral perfusion pressure  Increased
• Cerebral oxygen consumption  Decrease
• This effect of barbiturates may protect the brain from transient
episodes of focal ischemia (eg, cerebral embolism) but probably not
from global ischemia (eg, cardiac arrest).
• To have an anti analgesic effect by lowering the pain threshold
• Do not produce muscle relaxation.
Specific complication :
Intra-arterial Injection
• Immediate, intense vasoconstriction and excruciating pain that radiates along the distribution of the
artery.
• Severe vasoconstriction may obscure distal arterial pulses.
• Gangrene and permanent nerve damage may occur.

Mechanism of Damage
• Due to be the precipitation of thiopental crystals  inflammatory response and arteritis 
microembolization that follows, eventually results in occlusion of the distal circulation.
Treatment
• Immediate attempts to dilute the drug  injection of saline
• Prevention of arterial spasm & sustain adequate blood flow
• Lidocaine, papaverine, or phenoxybenzamine
• Stellate ganglion block or brachial plexus block
 Propofol-Milk of amnesia
• Short-acting for both induction as well asmaintenance.
• An oily liquid employed as a 1% emulsion.
• Unconsciousness occurs 15-45 sec and lasts 5-10 min.
• Propofol is highly protein-bound and is metabolized by conjugation in
the liver.
• Intermittent injection or continuous infusion used fortotal i.v.
anesthesia when supplemented by fentanyl.
• Most suited for out patient surgery.
Adverse effect:
• Fall in BP and bradycardia.
• Pain on injection.
• Dystonia and myoclonic movements are common.
• Propofol has reportedly induced priapism in someindividuals.
• Other uses: In sub-anesthetic doses, it is the drug of choice forsedating
intubated patients in ICU.

Mechanisms of Action
• Facilitation of inhibitory neurotransmission mediated by GABA.
Pharmacokinetics
DISTRIBUTION
• High lipid solubility
• Onset of action that is almost as rapid as that of thiopental (one-arm-to-brain circulation time).
• Awakening from a single bolus dose is also rapid due to a very short initial distribution half-life (2–
8 min).
• Recovery --- rapid
• Hangover --- less
• This makes it a good agent for outpatient anesthesia.
BIOTRANSFORMATION
• Hepatic and extra hepatic metabolism
EXCRETION
• Primarily excreted in the urine
• Chronic renal failure does not affect clearance of the parent drug.
Use :
• Induction of Anesthesia 1.5 to 2.5 mg/kg
• Intravenous Sedation 25 to 100 μg/kg per minute IV
• Maintenance of Anesthesia 100 to 300 μg/kg per minute IV
• Nonhypnotic Therapeutic Applications
• Antiemetic Effects
Mech –unknown
10 to 15 mg IV
• Anticonvulsant Activity
• Attenuation of Bronchoconstriction
Specific complication
Lactic Acidosis or propofol infusion syndrome
• Prolonged high-dose infusions of propofol (>75 μg/kg per minute) for
longer than 24 hours.
• Mechanism : Cytopathic hypoxia of the electron transport chain and
impaired oxidation of long-chain fatty acids
• C/F : Unexpected tachycardia
• Diagnosis : Arterial blood gases and serum lactate concentrations
• Treatment : Metabolic acidosis in its early stages is reversible with
discontinuation of propofol administration.
 Etomidate
• Short-acting induction anesthesia
• Etomidate is highly protein bound and metabolised by hepatic and
plasma esterases to inactive products
• Onset of action: 30–60 seconds.
• Peak effect: 1 minute.
• Indications: As sedative, for short procedures such as reduction of
dislocated joints and cardioversion.
• Etomidate (0.2 to 0.4 mg/kg IV)
As an alternative to propofol or barbiturates for the induction of
anesthesia, especially in the presence of an unstable cardiovascular
system.
 Effects
Central Nervous System
• Potent direct cerebral vasoconstrictor that
decreases cerebral blood flow and CMRO2
• Activate seizure foci
 Caution in patients with focal epilepsy
 Facilitate the localization of seizure foci in
patients undergoing the cortical resection of
epileptogenic tissue.
Cardiovascular System
• Cardiovascular stability (minimal changes in
heart rate, stroke volume,cardiac output)
• Preferred for induction of anesthesia in
patients with little or no cardiac reserve.
Ventilation
• Depressant effects on ventilation
Pain on Injection
• Pain on injection and venous irritation has
been virtually eliminated with use of
etomidate preparations utilizing a lipid
emulsion vehicle rather than propylene glycol
Myoclonus (spontaneous movements)
• Caution in the use of this drug for the
induction of anesthesia in patients with a
history of seizure activity.
Adrenocortical Suppression
• Lasts 4 to 8 hours after an intravenous
induction dose of etomidate.
 Benzodiazepine
• Used for induction, maintenance and supplementinganesthesia as well
as for conscious sedation.
• In larger doses injected i.v. produce sedation, amnesia and
unconsciousness in 5-10mins.
• If no anesthetic or opioid is given, the patient becomes responsive in
1hr. But, amnesia for 2-3hrs.
• Poor analgesics.
• Opioid or N2O is added, if the procedure is painful.
Indication - in endoscopies, cardiaccatheterization, angiographies,
regional anesthesia,fracture setting
Diazepam:
• 0.2-0.5mg/kg , slow undiluted injection in a running i.v.
• This technique reduces burning sensation in vein andincidence of
thrombophlebitis.

Lorazepam:
• Potent, slower-acting, less irritating than diazepam.
• Amnesia is more profound. (Dose : 0.04 mg/kg)

Midazolam:
• Water-soluble, shorter acting drug used for sedation of intubated patients
(Dose : 1-2.5mg i.v.)
• In other critical care anesthesia as 0.02-0.1mg/kg/hr continuous i.v.
infusion.
Uses and Doses of Commonly Used
Benzodiazepines
 KITAMINE
• Related to phencyclidine-dissociative
anesthesia.
• DA-characterised by profound analgesia,
immobility, amnesia, feeling of
dissociationfrom ones own body.
• Site of action - Cortical and sub cortical areas.
• Act by inhibiting NMDA receptors.
• Dose of 1-3mg/kg i.v. produces the above
effects within a minute & recovery after 10-15
mins, but remains amnesic for 1-2hr.
• Metabolized in the liver and has an
elimination t1/2 3-4hrs.
Indications:
• Head and neck surgeries, asthmatics,short
surgeries,burn dressings.
• Combined with diazepam used in
angiographies, catheterization, and trauma
surgeries.
Adverse effects:
• Heart rate, Cardiac output, BP increased.
• Delirium, hallucination, involuntary
movements during recovery.
Contraindication:
Increased ICP (intracranial pressure)
Uses : Specific Complications
Emergence Delirium (Psychedelic
1. Induction of Anesthesia Effects)
• Intravenous ketamine, 1 to 2 mg/kg • In postoperative period visual,
auditory, proprioceptive, and
• Intramuscular administration of 4 to 8 confusional illusions, which may
mg/kg. progress to delirium.
• Dreams and hallucinations can occur
2. Analgesia up to 24 hours after the administration
of ketamine.
• Subanesthetic doses of ketamine, 0.2
to 0.5 mg/kg IV. • Mechanism : Emergence delirium
probably occurs secondary to ketamine
induced depression of the inferior
3. Neuraxial Analgesia colliculus and medial geniculate
• Limited value nucleus, thus leading to the
misinterpretation of auditory and
visual stimuli.
 Fentanyl
• Short-acting, opioid analgesic
related to pethidine.
• Has rapid onset and short
duration of action about 30-50
min.
• Strong agonist at the μ-opioid
receptors.
• Used to supplement anesthetics
in balanced anesthesia.
• Also used in neurolept analgesia
in combination with droperidol.
Indications:
• Combined with BDZs, used
forendoscopic, angiographic,
cardiac catheterization,
burndressing and other minor
procedures.
• Used most often in operating
rooms and intensive careunits.
Adverse effects :
• Nausea, vomiting and itching
often occurs during recovery.
• Marked respiratory depression.
• Slight fall in BP.
 Dexmedetomidine

• An α2 agonist with sedative and analgesic effect.

• Has a half life of 2-3hrs.
• Metabolized in liver and excreted mainly as inactive urine metabolites.
• Adverse effects: Hypotension and bradycardia.
 Balanced anesthesia

• Modern anesthesia involves a combination of i.v.(for induction) and

inhalational anesthesia(for maintenance).
• Sometimes volatile(sevoflurane) is used for induction.
• Muscle relaxant-facilitate intubation.
• Local anesthetics-tissue infiltration, peripheral nerve block.
• Potent opioid analgesic & CV drugs(β blocker, ca channel
blocker)used to control autonomic responses to noxious surgical
stimuli.
 Conscious sedation

• This technique refers to drug induction alleviation of anxiety & pain in

combination with an altered level ofconsciousness associated with the
use of smallest doses of sedative medication
• Pt.retains ability to maintain patent airway & responsive to verbal
comments
• Drugs : diazepam,midazolam,propofol
 Neuroleptanalgesia

• Method of i.v. anesthesia which combines the use of neuroleptic drug

with an opioid analgesic.
• Subject is conscious & able to co-operate during surgery.
• Most favoured combination- droperidol + fentanyl
• After administering nitrous oxide with oxygen neuroleptanalgesia can
be converted to neuroleptanesthesia.
• C/I - patients receiving MAO inhibitors, abuse drugs or alcohol, with
Parkinson disease.
 Complications
During anesthesia: After anesthesia:
• Respiratory depression • Nausea and vomiting
• Cardiac arrhythmias • Persisting sedation
• Fall in BP • Pneumonia
• Acid pneumonitis • Atelectasis
• Laryngospasm and asphyxia • Nerve palsy
• Awareness • Emergence delirium
• Delirium and convulsions. • Organ toxicity
THANK YOU