1. Anaesthesia 13.30 - 14.30Dr Rob Stephens Physiological and Pharmacological principles 14.30 - 15.30Dr Andy Badacsonyi Anaesthesia in the 21st century 15.30 - 15.45 BREAK 15.45 - 16.45 Dr Brigitta Brandner Acute Pain Management 13.30 - 14.30Dr Rob Stephens Physiological and Pharmacological principles 14.30 - 15.30Dr Andy Badacsonyi Anaesthesia in the 21st century 15.30 - 15.45 BREAK 15.45 - 16.45 Dr Brigitta Brandner Acute Pain Management

2. Dr Rob Stephens Thanks to Drs James Holding and Maryam Jadidi Dr Rob Stephens Thanks to Drs James Holding and Maryam Jadidi Physiology and …

3. Contents Introduction Physiology CVS, RS, NS, Other Pharmacolgy Anaesthetic/ Hypnotic Agents Neuromuscular Paralysis & Reversal Analgesia Others, CVS, Gasses, Fluids Introduction Physiology CVS, RS, NS, Other Pharmacolgy Anaesthetic/ Hypnotic Agents Neuromuscular Paralysis & Reversal Analgesia Others, CVS, Gasses, Fluids

4. Introduction General word: website, documents, coming to theatre General word: website, documents, coming to theatre

5. Introduction Anaesthesia is more than Physiology and Pharmacology! Surgery vs Anaesthesia Outside theatre Anaesthesia is more than Physiology and Pharmacology! Surgery vs Anaesthesia Outside theatre

6. CVS physiology O 2 + C 6 H 12 O 6 CO 2 + H 2 O ATP O 2 delivery =Amount of O 2 to tissues per minute =Cardiac Output x O 2 content of blood x HR x SV Hb x Sa0 2 x constant

7. CVS physiology MAP = CO x SVR HR x SV Vaso-? constricted ? dilated

8. CVS physiology: Heart Heart pumps blood (0 2 ) from lungs to tissues then back to heart / lungs (C0 2 ) Work =0 2 needs  rate pre / afterload contractility Heart pumps blood (0 2 ) from lungs to tissues then back to heart / lungs (C0 2 ) Work =0 2 needs  rate pre / afterload contractility

9. Anaesthesia and CVS

10. CVS effects.. Anxiety, illness, walking to theatre, pain Induction of general anaesthesia or onset of epidural/ spinal anaesthesia Cardiovascular - active drugs Intubation Surgical stimulation / trauma Haemorrhage Extubation ?Recovery or complication Anxiety, illness, walking to theatre, pain Induction of general anaesthesia or onset of epidural/ spinal anaesthesia Cardiovascular - active drugs Intubation Surgical stimulation / trauma Haemorrhage Extubation ?Recovery or complication

11. Cardiovascular changes ‘artists impression’ version often filled in!

12. Induction of anaesthesia Preopera tive

13. Surgical stimulation Incision

14. Cardiovascular Bleeding Less oxygen in blood Less pressure at Atrial and Aortic stretch Sympathetic ++ response (+renal, adrenal) Blood pressure maintained … Less oxygen in blood Less pressure at Atrial and Aortic stretch Sympathetic ++ response (+renal, adrenal) Blood pressure maintained … CO x SVR ↑HR x ↑SV vasocontricts ↑ ↑ +ve inotrope +ve chronotrope vasocontricts

15. Respiratory Upper – Airway Lower- Trachea, lungs, muscles Upper – Airway Lower- Trachea, lungs, muscles

16. Respiratory- Airway Anaesthesia ‘Obtunds’ airway =“Airway obstruction’ = no airflow = no 0 2 = Badness Anaesthesia ‘Obtunds’ airway =“Airway obstruction’ = no airflow = no 0 2 = Badness

17. Keep Airway open: Airway manoeuvres (chin lift etc) Airway devices- above vs blow cords Above Vocal Cords eg, gudel, LMA Below Vocal Cords - Into trachea = intubation, paralysis Keep Airway open: Airway manoeuvres (chin lift etc) Airway devices- above vs blow cords Above Vocal Cords eg, gudel, LMA Below Vocal Cords - Into trachea = intubation, paralysis Respiratory- Airway

18. Guedel / Oro-Pharyngeal Adult male Adult female Guedel size 4 size 3

19. Laryngeal Mask Airway

21. Respiratory- Airway

22. Respiratory- Lower/ Lungs Spontaneous vs Ventilated Lungs smaller  depth Drugs  respiratory rate Small airways / Alveolar collapse Can’t cough – secretions = ‘pulmonary shunt (vs deadspace) Hypoxaemia, persists postoperatively Spontaneous vs Ventilated Lungs smaller  depth Drugs  respiratory rate Small airways / Alveolar collapse Can’t cough – secretions = ‘pulmonary shunt (vs deadspace) Hypoxaemia, persists postoperatively

24. CT scan of Diaphragm during awake spontaneous breathing

25. CT scan of Diaphragm during anaesthesia: Atelectasis

26. Gastrointestinal General Anaesthesia relaxes gastro-oesophageal sphincter Fluid up oesophagus ?into lungs starvation postoperative vomiting Other drugs (eg analgesia) General Anaesthesia relaxes gastro-oesophageal sphincter Fluid up oesophagus ?into lungs starvation postoperative vomiting Other drugs (eg analgesia)

27. Neurology Many Effects GA drug induced reversable unconsciousness Many reflexes  (airway, gag, CN) Awareness +/- NMJ paralysis Many Effects GA drug induced reversable unconsciousness Many reflexes  (airway, gag, CN) Awareness +/- NMJ paralysis

29. Physiology 2(3) factors determining blood pressure How does GA affect these? 3 words about GA on resp system 2(3) factors determining blood pressure How does GA affect these? 3 words about GA on resp system

32. Contents Introduction – the classical triad Introduction – general principles Hypnotic Agents Neuromuscular Paralysis + Reversal Analgesia Cardiovascular Drugs – up and down Fluids and Gasses are drugs too!

34. Pharmacology Introduction Anaesthesia ‘classical triad’ Hypnotic agent- unconsciousness Gas or IV Analgesia Neuromuscular Paralysis Induction, Maintenance, Emergence, Recovery Basics of anaesthesia: diagrams, handout & lecturehandout & lecture Anaesthesia ‘classical triad’ Hypnotic agent- unconsciousness Gas or IV Analgesia Neuromuscular Paralysis Induction, Maintenance, Emergence, Recovery Basics of anaesthesia: diagrams, handout & lecturehandout & lecture

35. Introduction - Principles Pharmacokinetics What the body does to the drug Absorption, distribution, metabolism, elimination Pharmacodynamics What the drug does to the body – ie it’s effects CVS, RS, GI, NS, Other, Side effects Pharmacokinetics What the body does to the drug Absorption, distribution, metabolism, elimination Pharmacodynamics What the drug does to the body – ie it’s effects CVS, RS, GI, NS, Other, Side effects

38. Typical Anaesthesia Intravenous induction Propofol Short acting opiate - e.g. fentanyl Hypnotic ‘anaesthetic’ - e.g. propofol Set up of anaesthetic maintenance - e.g. sevoflurane vapour in oxygen and air Specific muscle paralysis may be needed Definitive analgesia Anti-emetic Others Intravenous induction Propofol Short acting opiate - e.g. fentanyl Hypnotic ‘anaesthetic’ - e.g. propofol Set up of anaesthetic maintenance - e.g. sevoflurane vapour in oxygen and air Specific muscle paralysis may be needed Definitive analgesia Anti-emetic Others

39. Hypnosis: Propofol

41. Hypnosis: Propofol (and others) IV Redistributed out of CNS metabolised CVS - CO x SVR = MAP RS airway and lungs NS pain on injection

43. Maintenance: Volatiles Air Oxygen Sevoflurane

44. Maintenance Sevoflurane (‘SEVO’) Used for gaseous induction. Desflurane Isoflurane Gases, inhaled, little metabolised, exhaled CVS: CO x SVR = MAP RS- irritant, bronchodilate NS Given with Oxygen /Air /Nitrous Oxide Sevoflurane (‘SEVO’) Used for gaseous induction. Desflurane Isoflurane Gases, inhaled, little metabolised, exhaled CVS: CO x SVR = MAP RS- irritant, bronchodilate NS Given with Oxygen /Air /Nitrous Oxide CO x SVR = MAP

45. MAC = minimum alveolar concentration

46. Muscle Paralysis

47. Neuromuscular blockers Depolarising Suxamethonium Non-depolarising Atracurium Vecuronium Rocuronium Depolarising Suxamethonium Non-depolarising Atracurium Vecuronium Rocuronium

48. Neuromuscular blockers Depolarising Suxamethonium 2x Ach molecules Activates receptor Non-depolarising – competitive vs ACh Atracurium Vecuronium Rocuronium Depolarising Suxamethonium 2x Ach molecules Activates receptor Non-depolarising – competitive vs ACh Atracurium Vecuronium Rocuronium

49. Nicotinic ACh Receptor

51. Reversal of Paralysis Neostigmine Blocks cholinesterase Stimulates nicotinic and muscarinic Given with an anticholinergic Sugammadex Neostigmine Blocks cholinesterase Stimulates nicotinic and muscarinic Given with an anticholinergic Sugammadex

52. Analgesia – Dr B Systemic Simple- paracetamol 1g NSAID – Diclofenac etc Opioids eg morphine 2mg bolus Others – Ketamine Regional – spinal / epidural / blocks Local - infiltration Systemic Simple- paracetamol 1g NSAID – Diclofenac etc Opioids eg morphine 2mg bolus Others – Ketamine Regional – spinal / epidural / blocks Local - infiltration

54. Uppers Anticholinergics Atropine Glycopyrulate 200-600μg Symatheto-mimetics  1 agonists Phenylepherine Metaraminol 0.25-0.5 mg Ephedrine mixed  and  adreno agonist Anticholinergics Atropine Glycopyrulate 200-600μg Symatheto-mimetics  1 agonists Phenylepherine Metaraminol 0.25-0.5 mg Ephedrine mixed  and  adreno agonist MAP = CO x SVR  1  2 11

55. Downers More anaesthetic or opiate / analgesia Short acting  -blockers (labetalol, esmolol) Short acting  blockers GTN Clonidine -  2 agonist clonidine More anaesthetic or opiate / analgesia Short acting  -blockers (labetalol, esmolol) Short acting  blockers GTN Clonidine -  2 agonist clonidine MAP = CO x SVR

56. Antiemetics

57. General- Hydrate, anxiety, gastric decompress Cyclizine anti-histamine S/E – tachycardia and other anti-cholinergic effects Ondansatron5-HT 3 receptor antagonists S/E – constipation + long QT Prochlorperazine (‘Stematil’) – DA and mACh receptor antagonist S/E – extrapyramidal Dexamethasone glucocorticoid S/E – deranged glucose control General- Hydrate, anxiety, gastric decompress Cyclizine anti-histamine S/E – tachycardia and other anti-cholinergic effects Ondansatron5-HT 3 receptor antagonists S/E – constipation + long QT Prochlorperazine (‘Stematil’) – DA and mACh receptor antagonist S/E – extrapyramidal Dexamethasone glucocorticoid S/E – deranged glucose control

58. Fluids and Gasses are drugs too! Oxygen is a ‘drug’ Intravenous fluids Colloids Crystalloids Blood and products Articles on website / youtube Oxygen is a ‘drug’ Intravenous fluids Colloids Crystalloids Blood and products Articles on website / youtube

59. General Advice Can always give more – can’t take away Caution in Unwell Elderly Hypovolaemic Lots of ways to anaesthetise- don’t worry Can always give more – can’t take away Caution in Unwell Elderly Hypovolaemic Lots of ways to anaesthetise- don’t worry