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پاور پوینت (اسلاید) General Anesthesia

پاور پوینت (اسلاید) General Anesthesia

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محتواب برخی از اسلاید ها :


محتوای اسلاید 3 : CONTINUUM OF DEPTH OF SEDATION: DEFINITION OF GENERAL ANESTHESIA AND LEVELS OF SEDATION/ANALGESIA*

Approved by ASA House of Delegates on October 13, 1999, and amended on October 27, 2004

محتوای اسلاید 4 : Stages of General Anesthesia

Stage 1 (amnesia)
From induction of anesthesia to loss of consciousness (loss of eyelid reflex)
Pain perception threshold is not lowered.

Stage 2 (delirium/excitement)
Characterized with uninhibited excitation, agitation, delirium, irregular respiration and breath holding
Pupils are dilated and eyes are divergent
Responses to noxious stimuli: vomiting, laryngospasm, hypertension, tachycardia, and uncontrolled movements PRINCIPLES Morgan, et al. Clinical Anesthesiology, 4th ed. 2006
Ezekiel. Handbook of Anesthesiology, 2005

محتوای اسلاید 5 : Stages of General Anesthesia

Stage 3 (surgical anesthesia)
characterized by central gaze, constricted pupils, and regular respirations
Painful stimulation does not elicit somatic reflexes or deleterious autonomic responses.

Stage 4 (impending death/overdose)
characterized by onset of apnea, dilated and nonreactive pupils, and hypotension
may progress to circulatory failure PRINCIPLES Morgan, et al. Clinical Anesthesiology, 4th ed. 2006
Ezekiel. Handbook of Anesthesiology, 2005

محتوای اسلاید 6 : Principles of General Anesthesia

Minimum Alveolar Concentration (MAC)
the minimum concentration necessary to prevent movement in 50% of patients in response to a surgical skin incision
The lower the MAC, the more potent the agent PRINCIPLES Morgan, et al. Clinical Anesthesiology, 4th ed. 2006
Ezekiel. Handbook of Anesthesiology, 2005
AnesthesiaUK.com

محتوای اسلاید 7 : Minimum Alveolar Concentration

PRINCIPLES Morgan, et al. Clinical Anesthesiology, 4th ed. 2006
Ezekiel. Handbook of Anesthesiology, 2005

محتوای اسلاید 8 : Minimum Alveolar Concentration

Factor that increase/decrease
PRINCIPLES

محتوای اسلاید 9 : Meyer-Overton Hypothesis

The MAC of a volatile substance is inversely proportional to its lipid solubility (oil:gas coefficient)
High MAC equals low lipid solubility

Backtrack:
MAC is inversely related to potency (high MAC equals low potency) PRINCIPLES

محتوای اسلاید 10 : Meyer-Overton Hypothesis

Correlation between lipid solubility with potency
onset of anesthesia occurs when sufficient molecules of the agent have dissolved in the cell's lipid membranes

High lipid solubility equals high potency (and low MAC) PRINCIPLES

محتوای اسلاید 11 : Meyer-Overton Hypothesis

Factors Affecting the Meyer - Overton Hypothesis
Convulsant properties
Halogenation results in decreased anesthetic potency and
appearance of convulsant activity
Specific Receptors
e.g. opioid receptors
there is reduction of MAC by opioids
Dexmedetomidine
an alpha-2- agonist, results in marked reduction in MAC
Hydrophilic site of action
correlation between ability to form clathrates and anesthetic potency
Clathrates (of water) are postulized to alter membrane ion transport

محتوای اسلاید 12 : II. OVERVIEW OF PHARMACOLOGIC AGENTS USED IN GENERAL ANESTHESIA

Inhaled Anesthetics
Intravenous induction Agents
Neuromuscular Blocking Agents
Opioids
Benzodiazepines
Anticholinergic agents
Anticholinesterases

محتوای اسلاید 13 : Inhalational Agents

Used in the induction and maintenance of anesthesia
Halogenated alkane or ether-derived compounds
Nitrous oxide (N2O; laughing gas) is the only inorganic anesthetic gas in clinical use
Produce dose-dependent systemic effects
Associated with Malignant Hyperthermia PHARMACOLOGIC AGENTSExamples:
Ether
Halothane
Methoxyflurane
Enflurane
Isoflurane
Sevoflurane
Desflurane
Nitrous Oxide
Xenon

محتوای اسلاید 14 : Inhalational Agents

PHARMACOLOGIC AGENTSMorgan, et al. Clinical Anesthesiology, 4th ed. 2006
Ezekiel. Handbook of Anesthesiology, 2005
Townsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 15 : Intravenous Induction Agents

Used as premedications, sedatives, intravenous induction agents and in the maintenance of anesthesia.
Total intravenous anesthesia (TIVA)PHARMACOLOGIC AGENTSMorgan, et al. Clinical Anesthesiology, 4th ed. 2006
Ezekiel. Handbook of Anesthesiology, 2005
Townsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004Examples:
Barbiturates (Thiopental)
Benzodiazepines (Midazolam)
Ketamine
Etomidate
Propofol

محتوای اسلاید 16 : Intravenous Induction Agents

Thiopental
REVIEW: Redistribution
Hepatic elimination
Can cause hypotension, vasodilation and cardiac depression
Can precipitate bronchospasm in patients with reactive airway disease
Decreases CMRO2 in neuroanesthesia
PHARMACOLOGIC AGENTSMorgan, et al. Clinical Anesthesiology, 4th ed. 2006
Townsend, et al. Sabiston’s Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 17 : Intravenous Induction Agents

Ketamine
Produces dissociative state of anesthesia
Only IV induction agent that increases blood pressure and heart rate
Decreases bronchomotor tone
May be used as sole anesthetic for short procedures
Produces profound amnesia and analgesia
Increases intracranial pressure
Produces emergence delirium and bad dreams
PHARMACOLOGIC AGENTSMorgan, et al. Clinical Anesthesiology, 4th ed. 2006
Townsend, et al. Sabiston’s Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 18 : Intravenous Induction Agents

Propofol, (2,6-diisopropylphenol)
Short-acting induction agent
Available as oil-in-water emulsion containing soybean oil, glycerol, and egg lecithin
Ideal for ambulatory surgery
Can decrease blood pressure in susceptible patients
Produces bronchodilatation
Associated injection pain
PHARMACOLOGIC AGENTSMorgan, et al. Clinical Anesthesiology, 4th ed. 2006
Townsend, et al. Sabiston’s Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 19 : Intravenous Induction Agents

Etomidate
Imidazole compound
Produces minimal hemodynamic changes
(ideal for patients with cardiovascular disease)
Produces pain on injection, abnormal muscular movements and adrenal suppression

Midazolam
A benzodiazepine (Other BZD: Diazepam, Lorazepam)
Because of minimal cardiovascular effects, used for anesthesia induction
Produces aGeneral Anesthesiaiolysis and profound amnesia
Also used as a premedicant

PHARMACOLOGIC AGENTSMorgan, et al. Clinical Anesthesiology, 4th ed. 2006
Townsend, et al. Sabiston’s Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 20 : Opioids

Used as part of general anesthesia, and in patients receiving regional anesthesia
Produces profound analgesia and minimal cardiac depression
Cause ventilatory depression
Examples: (REVIEW CLASSIFICATION OF OPIOIDS AND RECEPTORS)
Agonists: Morphine, Fentanyl, Meperidine
Antagonists: Naloxone
Agonist-Antagonist: Nalbuphine, Butorphanol

PHARMACOLOGIC AGENTSMorgan, et al. Clinical Anesthesiology, 4th ed. 2006
Townsend, et al. Sabiston’s Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 21 : Opioids

Uses in General Anesthesia
Reduces MAC of potent inhalational agents
Blunt the sympathetic response (increase in BP and HR) to direct laryngoscopy, intubation and surgical incision
Provide analgesia extending into postoperative period
May be used as complete anesthetics (may provide analgesia, hypnosis and analgesia)
May be added in local anesthetic solutions in regional anesthesia to improve quality of analgesia

PHARMACOLOGIC AGENTSTownsend, et al. Sabiston’s Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 22 : Neuromuscular Blocking Agents

Uses in anesthesia:
Facilitates endotracheal intubation
Provides muscle relaxation necessary for the conduct of surgery

Types: (Review Pharmacology)
DEPOLARIZING (non-competitive) AGENTS
Succinylcholine: mimics the action of acetylcholine by depolarizing the postsynaptic membrane at the neuromuscular junction (non-competitive antagonism)
NON-DEPOLARIZING
Produces reversible competitive antagonism of Ach
Maybe aminosteroid or benzylisoquinoline compounds
PHARMACOLOGIC AGENTSMorgan, et al. Clinical Anesthesiology, 4th ed. 2006
Townsend, et al. Sabiston’s Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 23 : Neuromuscular Blocking Agents

Advantages of Succinylcholine
Rapid onset, short duration of action
Used in rapid-sequence induction

Adverse effects of Succinylcholine
Bradycardia (esp. in pediatrics)
Life-threatening hyperkalemia in burn patients
May trigger malignant hyperthermia
Myalgia (from fasciculations) and myoglobinuria
Increased ICP, CBF, IOP
Increased intragastric pressure
Prolonged blockade in susceptible individuals (in decreased plasma cholinesterase activity, myopathies)
PHARMACOLOGIC AGENTSMorgan, et al. Clinical Anesthesiology, 4th ed. 2006
Townsend, et al. Sabiston’s Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 24 : Neuromuscular Blocking Agents

Nondepolarizing Agents
Used when succinylcholine is contraindicated
Choice of agent
Based on mode of excretion
Hoffman degradation (atracurium, cis-atracurium)
Renal
Hepatic
Based on duration of action
Short acting: Mivacurium
Intermediate: Atracurium, Rocuronium
Long-acting: Pancuronium

PHARMACOLOGIC AGENTSMorgan, et al. Clinical Anesthesiology, 4th ed. 2006
Ezekiel. Handbook of Anesthesiology, 2005
Townsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 25 : Neuromuscular Blocking Agents

Concerns in anesthesia
Paralysis can mask signs of inadequate anesthesia
Higher doses required for intubation than for surgical relaxation
Other drugs can potentiate effects of non-depolarizing agents
Variable individual responses
Residual blockade may result to postoperative problems
TOF monitoring
Clinical assessment
PHARMACOLOGIC AGENTSMorgan, et al. Clinical Anesthesiology, 4th ed. 2006
Ezekiel. Handbook of Anesthesiology, 2005
Townsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 26 : Anticholinergics

competitively inhibits the action of acetylcholine at muscarinic receptors with little or no effect at nicotinic receptors.
Examples:
Atropine*, Scopolamine§, Glycopyrrolate¤
Uses in anesthesia:
Amnesia and Sedation§
Antisialogogue effect §*¤
Tachycardia*
Bronchodilation*

PHARMACOLOGIC AGENTSMorgan, et al. Clinical Anesthesiology, 4th ed. 2006
Ezekiel. Handbook of Anesthesiology, 2005
Townsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 27 : Anticholinesterases

Inactivate acetylcholinesterase by reversibly binding to the enzyme increasing the amount of acetylcholine available to compete with the nondepolarizing agent
Increases acetylcholine at both nicotinic and muscarinic receptors
Muscarinic side effects can be blocked by administration of atropine or glycopyrrolate
Examples: edrophonium, neostigmine, pyridostigmine, physostigmine
Use in anesthesia: reversal of neuromuscular blockade

PHARMACOLOGIC AGENTSMorgan, et al. Clinical Anesthesiology, 4th ed. 2006
Ezekiel. Handbook of Anesthesiology, 2005
Townsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 28 : GENERAL ANESTHESIA

Induction Techniques
Intubation
Maintenance
Emergence and ExtubationCONDUCT OF GENERAL ANESTHESIA

محتوای اسلاید 29 : Patient Monitoring in Anesthesia

Routine
Pulse oximetry
Automated BP
ECG
Capnography
Oxygen analyzer
Ventilator pressure monitor
Thermometry
Specialized
Foley catheter
Arterial catheter
Ventral venous catheter
Pulmonary artery catheter
Precordial doppler
Transesophageal Echocardiography
Esophageal Doppler
Esophageal and Precordial Stethoscope
CONDUCT OF GENERAL ANESTHESIATownsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 30 : Airway Examination

Mallampati Score
The patient is asked to maximally open his mouth and protrude his tongue while in the sitting position
CONDUCT OF GENERAL ANESTHESIA

محتوای اسلاید 31 : Airway Examination

Interdental Distance (3)
Measures the distance between the 2 incisors, with the mouth fully opened

Thyromental Distance (3)
Measures the distance between the chin (mentum) and the thyroid cartilage

Thyrohyoid Distance (2)
Measures the distance between the hyoid and the thyroid cartilageCONDUCT OF GENERAL ANESTHESIAkvyouth.blogspot.comwww.emedicine.com

محتوای اسلاید 32 : Airway Examination

Bellhouse-Dore
maximal flexion and extension of the neck will identify limitations that might prevent optimal alignment of the OPL axes.



Normal atlanto-occipital joint: 35 degrees of extension
CONDUCT OF GENERAL ANESTHESIA

محتوای اسلاید 33 : Strategies in General Anesthesia

Questions to ask prior to conduct of anesthesia:
Is the patient’s condition or scheduled surgery require additional monitoring techniques
Does the patient have conditions that contraindicate certain drugs
Is endotracheal intubation required
Are there anticipated difficulties in oral translaryngeal intubation
Are NMBs required during surgery
Are there special surgical requirements that mandate use of or avoidance of specific interventions (e.g. NMBs)
Is substantial blood loss or fluid shifts anticipated
CONDUCT OF GENERAL ANESTHESIATownsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 34 : Induction of Anesthesia

Sequence of interventions during induction vary depending on the patient and type of surgery
Concerns
Loss of consciousness
Inability to maintain a natural airway
Reduction or cessation of spontaneous ventilation
Use of drugs that may depress the myocardium and change vascular tone
CONDUCT OF GENERAL ANESTHESIATownsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 35 : Awake Intubation

May be supplemented with sedatives, opioids, and topical or local anesthesia
Accomplished via “blind” nasal, fiberoptic bronchoscopy, and direct visualizationCONDUCT OF GENERAL ANESTHESIATownsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004picasaweb.google.comIndications:
inadequate mouth opening
facial trauma
cervical spine injury
chronic cervical spine disease
lesions in the upper airway

محتوای اسلاید 36 : Awake Intubation

Nasal Intubation
Endotracheal tube (ET) is inserted through the nose and guided into the tracheal by listening to the transmitted breath sound

Fiberoptic intubation
Passing an ET through the nose or mouth into the pharyGeneral Anesthesia, then passing a bronchoscope through the tube. The laryGeneral Anesthesia and the trachea are visualized and the ET is thread over the bronchoscope


CONDUCT OF GENERAL ANESTHESIATownsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 37 : Intravenous Induction

Preoxygenation with 100% oxygen+/- IV opioid or BZDAdministration of rapid-acting IV induction agentsAnesthesiologist ensures patient can be manually ventilatedYes Patient is given NMBDirect Laryngoscopy and IntubationTECHNIQUECONDUCT OF GENERAL ANESTHESIATownsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 38 : Intravenous Induction

Disadvantages
Spontaneous ventilation is abolished without certainty that patient can be manually ventilated
Endotracheal intubation is performed while the patient is lightly anesthetized, precipitating hypertension, tachycardia, or bronchospasm

CONDUCT OF GENERAL ANESTHESIATownsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004

محتوای اسلاید 39 : Inhalational Induction

Preoxygenation (100% O2)O2 + Volatile agent via face maskAnesthesiologist ensures patient can be manually ventilatedDirect Laryngoscopy and IntubationTECHNIQUEGeneral Anesthesia
via Face MaskIn children (induction)
In patients at severe risk of bronchospasm
Short Procedures
Difficult airwayYes Patient is given NMB+/- IV opioid or BZDOptionOptionCONDUCT OF GENERAL ANESTHESIATownsend, et al. Sabiston, Textbook of Surgery, 17th ed. 2004

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