Biomedical Engineering Lecture on Drugs for sedation, general anesthesia, and other purposes

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Drugs for sedation, general anesthesia, and other purposes James H. Philip MD CCE Thanks to Dan Raemer who contributed significantly to the drug list and explanations..

Another Hat for Anesthesiologists Chronic Pain Management Medications Opioids, anti-inflammatory Regional injections Opioids, local anesthetics, steroids, neurolytics Electrical stimulation Surgery Psychiatric counseling TLC

Regional Anesthesia

Regional Anesthesia - Nerve Blocks Minor Local, field block Major Spinal Epidural Major Plexus

Spinal Cord and Epidural Space CSF Epidural space Dura Ligament Spinal nerves Spinal cord Subdural space

Spinal Cord and Epidural Space CSF Ligament Spinal nerves Spinal cord Epidural space Dura Subdural space (widened)

Spinal Anesthetic CSF Ligament Spinal cord Epidural space Dura Subdural space

Spinal Anesthetic CSF Ligament Spinal cord Epidural space Dura Subdural space

Spinal Anesthetic CSF Ligament Spinal cord Epidural space Dura Subdural space

Spinal Anesthetic CSF Ligament Spinal cord Epidural space Dura Subdural space

Epidural Anesthetic CSF Ligament Spinal cord Epidural space Dura Subdural space

Epidural Anesthetic CSF Ligament Spinal cord Epidural space Dura Subdural space

Epidural Anesthetic CSF Ligament Spinal cord Epidural space Dura Subdural space

Epidural Anesthetic CSF Ligament Spinal cord Epidural space Dura Subdural space

Epidural Anesthetic CSF Ligament Spinal cord Epidural space Dura Subdural space

Conscious Sedation

Monitored Anesthesia Care - MAC No relation to Minimal Anesthesia Concentration MAC Conscious Sedation IV drugs Sedative-hypnotic Analgesic Inhaled drugs Low concentrations for consciousness

Unconscious Sedation Is dangerous May be more dangerous than general anesthesia Airway may not be secure Breathing may stop Circulation is maintained until breathing stops Difficult to monitor

That is why Many anesthesiologists prefer General Anesthesia over Sedation Once A= airway is secure, B= Breathing and C = Circulation are the only worries!

Anesthesia Drugs

Sedatives / hyponotics Analgesics (Opiods) Other adjuvants Induction Agents Muscle Relaxants Antagonists Local Anesthetics System-specific (CV, Resp, Neuro, Renal)

Benzodiazepines Midazolam Diazepam Lorazepam VERSED VALIUM ATIVAN Amnesia Hypnosis/Sedation Anxiolysis

Opioids (analgesics, narcotics) Morphine Fentanyl Sufentanil Alfentanil Remifentanil ********* SUBLIMAZE SUFENTA ALFENTA ULTIVA Analgesia Respiratory Depression Sedation

Other protectors Anti-nausients; anti-emetics Reflex blockers Muscle-fasciculation blockers

Nausea and Vomiting Nausea and vomiting are still common % men % women Likely related to Opiods Surgery Nitrous Oxide Other agents Pain

Anti-nausients/Anti-emetics Reglan (Metaclopramide) empties stomach (down - the right way) Anti-dopaminergic - Droperidol Anti-seritonin - Zofran Anti-motion - anti-histamines, other Other

Reflex Blockers Atropine/Scopolamine- blocks Vagus nerve prevents bradycardia prevents salivation Esmolol - Beta blocker prevents tachycardia Labetalol - Blocks hypertension

Induction Agents - IV Sodium Thiopental Propofol Etomidate Ketamine PEN TOTHAL DIPRIVAN AMIDATE KETALAR Unconsciousness Hypnosis/Sedation +

Induction Agents - IV Sodium Thiopental Propofol Etomidate Ketamine PEN TOTHAL DIPRIVAN AMIDATE KETALAR Unconsciousness Hypnosis/Sedation + - Central Apnea Airway obstruction Hypotension Bradycardia Decreased CO

Induction Agents - Inhalation Sevoflurane Halothane (kids) ULTANE FLUOTHANE Unconsciousness Hypnosis/Sedation + - Central Apnea Airway obstruction Need for A,B Changed CO

Maintenance - Inhalation Agents Halothane Isoflurane Desflurane Sevoflurane Nitrous Oxide FLUOTHANE FORANE SUPRANE ULTANE/SEVORANE “Gas” Unconsciousness Analgesia Muscle relaxation Amnesia + - Tachypnea Hypotension Brady/Tachycardia Decreased CO

Muscle Relaxants Succinylcholine dTC Pancuronium Vecuronium Atricurium Doxacurium Pipecuronium Rocuronium Mivacurium Cis-Atricurium Neuromuscular blockade = Muscle relaxation = paralysis

Muscle Relaxants Succinylcholine dTC Pancuronium Vecuronium Atricurium Doxacurium Pipecuronium Rocuronium Mivacurium Cis-Atricurium Neuromuscular blockade = Muscle relaxation = paralysis Temporary and reversible

Local Anesthetics Lidocaine Bupivicaine Ropivacaine Mepivacaine Procaine 3-Chloroprocaine Tetracaine Cocaine Block nerve conduction Prevent sensation (sensory block) Prevent motion (motor block)

Reversal of NMB Neostigmine allows acetyl choline build-up acetyl choline knocks NMBs off receptors Glycopyrolate or atropine blocks side effects of Neostigmine Bradycardia, Bowel constriction

Cardiovascular Drugs Pressors (increase Blood Pressure) Phenylephrine, Epinephrine, Norepinephrine Ephedrine, Dopamine, Dobutamine Accelerators (speed Heart) Atropine, Isoproterinol (Isuprel) Anti-Hypertensives (lower Blood Pressure) Nitroprusside, Hydralazine, Labetalol, NTG Antiarrhythmics Lidocaine, Beryllium

The End Actually, the beginning

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