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MARANATHA CHRISTIAN UNIVERSITY

Anesthetics
Anesthesia
• Divisions of the Nervous
System
• Major Neurotransmitters
• Anesthesia
– General Anesthesia
– Local Anesthesia
Learning Objectives
• Understand the central and peripheral nervous
systems, their functions, and their relationship to
drugs.
• Become aware of the role of neurotransmitters.
• Learn how drugs affect body systems and where
they work in the body.
• Understand the concepts of general and local
anesthesia, and know the functions of these
agents.
Learning Objectives

• Define the action of


neuromuscular blocking
agents in reducing
muscle activity.
The brain
and
nervous
system
dr. Herjanto Kurnia, M.A.
Central Nervous System
• The nervous system
consists of two parts: the
central nervous system &
peripheral nervous system
• The peripheral nervous
system, consisting of
nerves that spread
throughout the body, carries nerve impulses to & from the
CNS
• The CNS, consisting of the brain & spinal cord, receives
information from the peripheral nervous system & the senses,
coordinates movement, & in the center of memory &
conscious thought
Cerebrum
• The brain weighs about 3 pound
& is the size of a grapefruit
• The center of body’s nervous
system, it is divided into 4
separate segments : the cerebrum,
diencephalon, brainstem, &
cerebellum
• The cerebrum consists of 2 symmetrical sections that extend from
the front of the head to the back & contain millions of nerves
• Specific areas of the cerebrum are responsible for particular brain
functions such as thought, action, hearing, seeing & touch
• The cerebrum is also the apart of the brain where learning takes
place
Diencephalon
• The diencephalon, or interbrain,
contain 3 important structures -
the thalamus, hypothalamus, &
the pituitary gland
• The diencephalon is located
beneath the cerebral hemispheres
in the center of the brain

• The thalamus screens electrical impulses sent up the spinal cord &
sends them to the cerebellum for more interpretation
• The hypothalamus controls the pleasure center, some basic drives -
hunger, sex, and thirst - & body temperature
• The pituitary gland, although located in the brain, is actually part
of the endocrine system
Brain Stem
• The brain stem, the most
primitive structure of the brain,
is the bridge that connects the
brain to the spinal cord
• Less than 1 inch & 3 inches
long, the brain stem has 3
section -- The midbrain, the
pons, & the medulla oblongata

• These 3 parts lie underneath the cerebrum & diencephalon


• The brain stem controls the body’s ‘Vital sign’ -- heart rate, blood
pressure, & breathing rate -- & is the body’s time clock for
sleeping & waking
Cerebellum
• This cerebellum is located at
the back of the brain
beneath the cerebrum
• This part of the brain
controls muscle
coordination
• The cerebellum helps us
move smoothly by refining
the movement commands
sent by the brain’s cerebrum
to the extremities
Spinal Cord
• The spinal cord begins at the end of the
brain stem & continues down the back
• It is about the circumference of a small
garden hose & is roughly 17 inches
long
• 31 pairs of nerves lead from the spinal cord to the tissue & organs
throughout the body
• Located inside the spinal column, the cord is somewhat insulated from
injury because of the column's vertebral projections & because the spinal
column itself is protected by the body’s internal organs
• Electrical impulses from the body travel to the spinal cord
• Here, they either stimulate reflex actions or travel up the brain for
interpretation
Peripheral Nervous System
• The peripheral nervous system
refers to the body’s nerves,
which are like two-lane
highway of fiber composed of
large bundles of cells called
neurons and neuroglia, that
travel to & from the brain &
spinal cord
• The nerve extend from the brain & spinal cord throughout the
body
• Major nerves in this system are the 12 cranial nerves in the head,
and the 31 pairs of spinal nerves
• The number of neurons you are born with the most you will ever
have because, unlike other cells, neurons do not multiply
Thought & Action
• All though & action result from your
nervous system : the brain, spinal cord &
nerves
• This system is more sophisticated than any
computer
• Touching an object stimulates sensory
receptors under the skin
• These generate rapid electro-chemical
impulses that travel tiny highways called
nerves either to the spinal cord-for
reflexes-or to the brain
• Here, the impulses move along neural pathways, exciting cluster of cells in
specialized sections of the brain for interpretation and then action
• From the brain, the impulses again travel the nerve highways in this case, to a
muscle
• This time the message is clear: “click the button”
Anestesi
Divisions of the Nervous System

• Central Nervous System


– Brain
– Spinal cord
• Peripheral Nervous System
– Nerves
– Sense organs
Divisions of the Nervous System

• Central Nervous System


1. Brain receives information
2. Evaluates information
3. Sends out a response
• Peripheral Nervous System
Divisions of the Nervous System

• Central Nervous System


• Peripheral Nervous System
– Somatic Nervous System
– Autonomic Nervous System
Divisions of the Nervous System
• Central Nervous System
• Peripheral Nervous System
– Somatic Nervous System
Voluntary action: skeletal muscle contraction and
movement
– Autonomic Nervous System
Involuntary activities: respiration, circulation,
digestion, sweating
Autonomic Nervous System
Review

The nervous system has two


components. What are they?
Review

The nervous system has two


components. What are they?
Answer
– Central nervous system (CNS)
– Peripheral nervous system (PNS)
Major Neurotransmitters

• Acetylcholine
• GABA
• Dopamine
• Epinephrine
• Serotonin
Major Neurotransmitters
• Acetylcholine (ACh)
– Smooth muscle, cardiac muscle, and
exocrine glands
– Anticholinergics block ACh receptors
• GABA
• Dopamine
• Epinephrine
• Serotonin
Major Neurotransmitters
• Acetylcholine

• GABA (gamma-aminobutyric acid)


Regulates message delivery system of
the brain
• Dopamine
• Epinephrine
• Serotonin
Major Neurotransmitters
• Acetylcholine
• GABA

• Dopamine
Acts on the CNS and kidneys
• Epinephrine
• Serotonin
Major Neurotransmitters
• Acetylcholine
• GABA
• Dopamine

• Epinephrine
– Acts on cardiac and bronchodilator
receptors
– Known as Adrenaline
• Serotonin
Major Neurotransmitters
• Acetylcholine
• GABA
• Dopamine
• Epinephrine

• Serotonin
– Acts on smooth muscle and gastric mucosa
(causes vasoconstriction)
– Emotional responses: depression, anxiety
Communication by
Neurotransmitters

Neurotransmitters are released from one


axon and received by another neuron’s
dendrites.
Discussion

What are three important


types of receptors in the study
of drugs?
Discussion
What are three important
types of receptors in the study
of drugs?
Answer
– Alpha
– Beta-1
– Beta-2
Types of Receptors
• Alpha
Vasoconstriction, raise BP
• Beta-1
Heart stimulation
• Beta-2
Vasodilation and bronchodilation
Drug Effects on Receptors

Drugs can have two types of


effects on receptors.
–Stimulating, causing a reaction
–Blocking, preventing a reaction
• Dopamine blocking
• Anticholinergics
Anticholinergic Side Effects

• Decreased GI motility
• Decreased sweating
• Decreased urination
• Dilated pupils
• Dry eyes
• Dry mouth
Anesthesia

In the “old days” the following were


used for anesthesia.
Anesthesia

In the “old days” the following were


used for anesthesia.
– Alcohol
– Drugs
– Ice for numbing
– Blow to the head
– Strangulation
Anesthesia
Now, anesthesia is designed to focus on
specific systems, such as
Anesthesia
Now, anesthesia is designed to focus on
specific systems, such as
• Nervous system • Skeletal system
• Respiratory system • GI system
• Endocrine system • Hepatic system
• Cardiovascular system
Anesthesia

Goals of Balanced Anesthesia


– Amnesia
Anesthesia

Goals of Balanced Anesthesia


– Amnesia

– Adequate Muscle
Relaxation
Anesthesia

Goals of Balanced Anesthesia


– Amnesia
– Adequate Muscle Relaxation

– Adequate Ventilation
Anesthesia

Goals of Balanced Anesthesia


– Amnesia
– Adequate Muscle Relaxation
– Adequate Ventilation

– Pain Control
Discussion
What are some of the indicators
used to assess general anesthesia?
Discussion
What are some of the indicators
used to access general anesthesia?

Answer: Blood pressure,


hypervolemia, oxygen level, pulse,
respiratory rate, tissue perfusion,
urinary output
Types of Anesthesia

• General
• Local
Types of Anesthesia

• General

•Local
Local Anesthesia

Relieves pain without altering


alertness or mental function.
Local Anesthesia
Variety of Dosage Forms
– Topical
– Superficial injection (infiltration)
– Nerve block
– IV
– Epidural
– Spinal
Discussion
Local anesthetics are classified
by their chemistry into two
classes.
What are they?
Discussion
Local anesthetics are classified
by their chemistry into two
classes.
What are they?

Answer
– Esters
– Amides
Local Anesthesia

Esters
–Short acting
–Metabolized in the plasma and
tissue fluids
–Excreted in urine
Local Anesthesia

Amides
–Longer acting
–Metabolized by liver enzymes
–Excreted in urine
Drug List
Local Anesthesia

Esters
• benzocaine (Americaine)
• chloroprocaine (Nesacaine)
• dyclonine (Cēpacol Maximum Strength)
• procaine (Novocain)
• tetracaine (Cēpacol Viractin, Pontocaine)
Drug List
Local Anesthesia
Amides
• bupivacaine (Marcaine)
• levobupivacaine (Chirocaine)
• lidocaine (L-M-X, Solarcaine, Xylocaine)
• lidocaine-epinephrine (Xylocaine w/
Epinephrine)
• lidocaine-prilocaine (EMLA)
• mepivacaine (Carbocaine)
Discussion

What functions are lost with


local anesthetics?
Discussion
What functions are lost with
local anesthetics?
Answer
– Pain perception
– Temperature
– Touch sensation
– Proprioception
– Skeletal muscle tone
Discussion

Under what conditions would


a local anesthetic be used over
a general anesthetic?
Discussion

Under what conditions would


a local anesthetic be used over
a general anesthetic?

Answer: It is chosen when a


well-defined area of the body is
targeted.
Types of Anesthesia

•General
• Local
General Anesthesia

Preanesthetic Medications
–Control sedation
–Reduce postoperative pain
–Provide amnesia
–Decrease anxiety
General Anesthesia
Malignant Hyperthermia
– Side effect of anesthesia
• Fever of 110°F or more
• Life threatening
– Treatment: dantrolene (Dantrium)

Warning!
Always check
expiration date.
Drug List
Inhalant Anesthetics

• desflurane (Suprane)
• enflurane (Ethrane)
• halothane
• isoflurane (Forane)
• nitrous oxide
Inhalant Anesthesia Side Effects

•Causes reduction in
blood pressure
•May cause nausea and
vomiting
nitrous oxide
• Causes analgesia only; no amnesia or
relaxation
• May be given alone or may be given
with more powerful anesthetics to
hasten the uptake of the other agent(s)
• Commonly used for dental procedures
• Rapidly eliminated
desflurane (Suprane)

• Has rapid onset and


recovery
• Often used in
ambulatory surgery
General Anesthesia

• Often dispensed by
IV drip
• Very lipid soluble
Drug List
Injectable Anesthetics
• etomidate (Amidate)
• fentanyl (Duragesic, Sublimaze)
• fentanyl-droperidol
• ketamine (Ketalar)
• morphine
• propofol (Diprivan)
• sufentanil (Sufenta)
Drug List
Injectable Anesthetics

Barbituates
– methohexital (Brevital)
– thiopental (Pentothal)
Benzodiazepines
– diazepam (Valium)
– lorazepam (Ativan)
– midazolam (Versed)
propofol (Diprivan)
• Used for maintenance of anesthesia,
sedation, or treatment of agitation
• Has antiemetic properties
– Drowsiness
– Respiratory depression
– Motor restlessness
– Increased blood pressure
Injectable Anesthesia
Dispensing Issues
Warning!

Diprivan (anesthetic) and


Diflucan (antifungal) may be
confused.
This mix-up could be life-
threatening.
fentanyl

• Dosage Forms
– IV (Sublimaze)
– patch (Duragesic)
– lozenge (Actiq) for children
• Used extensively for open-
heart surgery due to lack of
cardiac depression
Benzodiazepines
• Used for induction, short procedures, and
dental procedures
• Useful in controlling and preventing
seizures induced by local anesthetics
• midozolam (Versed)
– fastest onset of action
– greatest potency
– most rapid elimination
Antagonist Agents

Antagonist agents
reverse
benzodiazepine and
narcotic overdose.
Drug List
Antagonist Agents

• flumazenil (Romazicon)
• nalmefene (Revex)
• naloxone (Narcan)
flumazenil (Romazicon)

• Antagonizes benzodiazepines
by competing for receptor
site
• Used for complete or partial
reversal
naloxone (Narcan)
• Competes for opiate receptor sites
• Has a shorter duration of action than
narcotics, so it must be given repeatedly
Neuromuscular Blocking Agents
• Causes immediate skeletal muscle
relaxation.
– Short Duration
– Intermediate Duration
– Extended Duration
• Used to facilitate endotracheal intubation.
– Allows for easier insertion of endotracheal
tube.
– Keeps airway open.
Drug List
Neuromuscular Blocking
Agents
• atracurium (Tracrium)
• cisatracurium (Nimbex)
• mivacurium (Mivacron)
• pancuronium
• rocuronium (Zemuron)
• succinylcholine (Quelicin)
• vecuronium (Norcuron)
Neuromuscular Blocking Agents
Dispensing Issues
Warning!
• Very expensive
• Be conscious of storage requirements
• Store away from look-alike and drugs
succinylcholine (Quelicin)
• Often called “sux.”
• Only depolarizing agent. All others work as
competitive antagonists to ACh receptors.
• Persistent depolarization at motor endplate.
• Causes sustained, brief period of flaccid
skeletal muscle paralysis.
Reversal of Neuromuscular Blocking
Agents
• Increases the action of
acetylcholine by inhibiting
acetylcholinesterase
• Used for reversal of
nonpolarizing agents
Drug List
Anticholinesterase Agents

• edrophonium (Enlon)
• neostigmine (Prostigmin)
• pyridostigmine (Mestinon)
Anesthesia is a creek word and
means loss of sensation
 This loss of sensation can be total, regional or local
 Medications which produce anesthesia are called
anesthetics.
 The total loss of sensation caused with anesthetics is
called general anesthesia. It means unconsciousness, a
kind of sleep, but it is more dangerous, because the
patient is no more able to take care of himself. A
patient under general anesthesia is never allowed to be
left alone.
How do anesthetics work?

 All anesthetics block totally the transmission of


information flowing through the nervous system in
our body.
 General anesthetics shut the brain down in a more or
less complicated way.
 Local anesthetics produce block when they have
penetrated inside the nerves.
 The nerves can be blocked around a wound or just in
the fracture when the local anesthetic is injected. This
is real local anesthesia.
Segmental
innervation of
human body
Operasi tanpa anestesi (Wiliam Hogarth, 1697-1764)
Thank you for your attention!

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