3. Anesthetic Agents and Adjunct
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Transcript of 3. Anesthetic Agents and Adjunct
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1Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Anesthetic Agents and Adjuncts
Anesthetic agent: any drug used to induce a loss of sensation with or without unconsciousness
Adjunct: a drug that is not a true anesthetic, but that is used during anesthesia to produce other desired effects
such as sedation, muscle relaxation, analgesia, reversal, neuromuscular blockade, or parasympathetic
blockade
Chapter 3
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2Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Classification of Anesthetic Agentsand Adjuncts
Route of administration Inhalant Injectable Oral Topical
Time of administration Preanesthetic Induction Maintenance
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3Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Classification of Anesthetic Agentsand Adjuncts (Cont’d)
Principal effect Local vs. general Sedatives and tranquilizers vs. analgesics Neuromuscular blockers Anticholinergic agents Reversal agents
Chemistry
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4Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Anesthetic Agent and Adjunct Actions
Pharmacokinetics Pharmacodynamics Drug distribution Target tissues and stimulation
CNS—depression or stimulation
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5Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Agonists
Bind to and stimulate target tissue Most anesthetic agents and adjuncts
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6Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Antagonists
Bind to target tissue but don’t stimulate Reversal agents
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7Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Partial Agonists and Agonist-Antagonists
Opioids Partial agonists Agonist-antagonists Used to block pure agonists
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8Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Analgesia
Most general anesthetics are not analgesics Must provide analgesic pre- and
postoperatively No pain perception while anesthetized
True analgesics don’t provide general anesthesia
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9Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Drug Combinations
Don’t mix drugs in a single syringe unless they are compatible
Don’t administer a drug combination if a precipitate develops when the drugs are mixed
Most anesthetic agents and adjuncts are water soluble Diazepam is not water soluble
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10Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Preanesthetic Medications
Calm or sedate excited animal Minimize adverse drug effects Reduce dose of concurrent drugs Smoother anesthetic induction and recovery Analgesia Muscle relaxation
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11Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Preanesthetic Medications (Cont’d)
Route of administration affects onset of action and duration of effects SC—slowest onset, longest duration IM—faster onset, shorter duration IV—fastest onset, shortest duration
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12Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Preanesthetic Anticholinergics
Parasympatholytic drugs—block acetylcholine Prevent and treat bradycardia Decrease salivary secretions
Atropine and glycopyrrolate (dogs and cats) IV, IM, SC, or IT Atropine—faster onset, shorter peak, shorter
duration Glycopyrrolate—slower onset, longer peak, longer
duration
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13Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Anticholinergic Effects
CNS—limited effect Cardiovascular—prevent bradycardia Secretions—decrease Eye—mydriasis and corneal drying Bronchodilation
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14Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Anticholinergic Adverse Effects
Cardiac arrhythmia Contraindicated in animals with elevated heart
rates or cardiac diseases Temporary bradycardia—atropine Thickened respiratory and salivary secretions
May lead to airway blockage—cats and ruminants Intestinal peristalsis inhibition
May lead to colic (horses) or bloat (ruminants)
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15Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Tranquilizers and Sedatives
Phenothiazines Benzodiazepines Alpha2-adrenoceptor agonists Alpha2-antagonists
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Phenothiazines—Acepromazine Maleate
Also known as acepromazine or “ace” Preanesthetic sedation Decrease dose of general anesthetic Ease induction and recovery May be used with opioids for minor procedures Approved for horses, dogs, and cats Administered IV or IM No reversal agent Metabolized by liver Will slowly cross the placenta
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17Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Effects of Acepromazine
CNS Calming, reluctance to move, decreased interest
in surroundings Sedation less pronounced in cats Not an analgesic
Cardiovascular System Peripheral vasodilation that leads to hypotension,
increased heart rate, and hypothermia Protects against arrhythmias and decreases
cardiac output
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18Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Effects of Acepromazine (Cont’d)
Respiratory system Worsens depressive effect of other drugs
Gastrointestinal system Antiemetic
Prevents histamine release and decreases allergic response
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Adverse Effects of Acepromazine
CNS Reduced seizure threshold May produce aggression or excitement
Cardiovascular system Hypotension—dose dependent
Penile prolapse Seen in horses and other large animals May lead to permanent injury
Decreased PCV Possibly due to splenic engorgement
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20Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Use of Acepromazine
Dose and needle placement Increased potency and duration
Geriatrics, neonates, debilitated animals Breed considerations
Australian shepherds Giant breeds, Boxers, Greyhounds Terriers and cats
Overdose treatment
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21Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Benzodiazepines
Tranquilizers—controlled substances Diazepam Zolazepam Midazolam
Rapid onset of action Short duration of action
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Effects of Benzodiazepines
CNS Calming and antianxiety only in old or ill patients Not an effective sedative or analgesic Anticonvulsant—use with animals having seizures
Cardiovascular and respiratory systems Minimal effect with a high margin of safety
Skeletal muscle relaxation Potentiate general anesthetics Appetite stimulation (cats and ruminants)
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23Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Adverse Effects of Benzodiazepines
CNS Disorientation and excitement—young, healthy
dogs Dysphoria and aggression—cats Muscle fasciculations—horses Ataxia and recumbency—any large animal
Diazepam must be given by IV slowly Oral diazepam in cats can cause liver failure
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24Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Use of Benzodiazepines
Diazepam Not water soluble Don’t mix with water-soluble drugs Don’t store in plastic Commonly used with ketamine to induce
anesthesia in small animals and horses Administer IV slowly
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25Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Use of Benzodiazepines (Cont’d)
Midazolam Water soluble Can be administered IM or SC Excellent sedative for swine, ferrets, rabbits, and
birds Used in combination with ketamine to induce
anesthesia in dogs, small mammals, and birds
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26Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Use of Benzodiazepines (Cont’d)
Zolazepam Available only as a component of Telazol® A powdered product Reconstituted with sterile water
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27Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Alpha2-Adrenoceptor Agonists
Also written alpha2-agonists or 2-agonists Noncontrolled agents Sedation, analgesia, and muscle relaxation Large and small animals—IM or IV Administered prior to minor procedures Readily reversed with alpha2-antagonist
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28Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Alpha2-Agonists
Xylazine (Rompun, Anased) Detomidine (Dormosedan) Romifidine (Sedivet) Dexmedetomidine (Dexdomitor)
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29Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Alpha2-Agonists (Cont’d)
Stimulates alpha2 receptors of the sympathetic nervous system (SNS) Decrease release of norepinephrine No “fight-or-flight” response
Sedation, analgesia, bradycardia, hypotension, and hypothermia
Metabolized in liver; excreted in urine Rapid sedation; 1-2 hour duration
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30Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Effects of Alpha2-Agonists
CNS Dose-dependent sedation Analgesia—short-acting
Cardiovascular system—early phase Dose-dependent vasoconstriction and
hypertension Bradycardia Cardiac arrhythmias
Cardiovascular system—late phase Decreased cardiac output Hypotension and further bradycardia
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31Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Effects of Alpha2-Agonists (Cont’d)
Respiratory system Dose-dependent depression
Other effects Muscle relaxation Increased effect of other anesthetic agents Vomiting—immediate response (dogs and cats) Hyperglycemia—transient Hypothermia
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32Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Adverse Effects of Alpha2-Agonists
CNS Change in behavior—varies with species
Cardiovascular system Bradycardia, hypotension, decreased output
Respiratory system Depression—varies from animal to animal More severe if given with other drugs
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33Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Adverse Effects of Alpha2-Agonists (Cont’d)
Increased urination Gastrointestinal effects
Bloat—dogs, cattle, and horses Salivation and regurgitation—cattle
Premature parturition—cattle (last trimester) Sweating—horses Absorbed through skin abrasions and
mucous membranes Wash off immediately
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34Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Use of Alpha2-Agonists
Use with caution; monitor patients closely Avoid use in geriatric, diabetic, pregnant,
pediatric, or ill patients Administer anticholinergics 10-20 minutes
prior
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35Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Alpha2-Agonist—Xylazine
2% solution (small animals) 10% solution (horses) Use 1/10 horse dose in cattle Used mostly in large animals
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36Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Alpha2-Agonist—Dexmedetomidine
Dexdomitor
Most commonly used in dogs and cats Produces sedation and analgesia More potent and safer than xylazine Antagonist—atipamazole (Antisedan) Preanesthetic in low doses Can be mixed with other drugs
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37Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Alpha2-Agonists—Detomidine and Romifidine
Detomidine Used in horses Sedation, analgesia, muscle relaxation Two times the duration of xylazine Standing sedation with butorphanol
Romifidine Produces less ataxia
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38Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Alpha2-Antagonists
Reverse all effects of alpha2-agonists Beneficial effects—for example, analgesia and
sedation Detrimental effects—for example, bradycardia
Wide margin of safety Effects of overdose
Neurological—excitement and muscle tremors Cardiovascular—hypotension and tachycardia Gastrointestinal—salivation and diarrhea
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39Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Use of Alpha2-Antagonists
Dose is expressed as a ratio Agonist to antagonist 10:1 means the dose of the antagonist is 1/10 of
the dose of the agonist Administer slowly by IV Reduce dose if more than 30 minutes has
elapsed since the agonist was administered
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40Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Alpha2-Antagonist—Tolazoline
Nonspecific alpha2-antagonist Used in ruminants at a 1:10 dose ratio with
xylazine Reverses cardiovascular and sedative effects
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41Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Alpha2-Antagonist—Yohimbine
Used in dogs, cats, horses, and exotic species
Reverses cardiovascular and sedative effects of xylazine
Dose ratio is species dependent Dogs and horses—10:1 Cats—2:1
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42Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Alpha2-Antagonist—Atipamezole
Antisedan®
Specific antagonist for dexmedetomidine IM injection (IV in emergencies) Use ½ the dose in cats compared to dogs Reversal—5-10 minutes after IM injection
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43Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Opioids
Derivatives of opium Opiates—naturally derived compounds Produce analgesia and sedation Anesthetic induction when combined with
other drugs Classified as agonists, partial agonists,
agonist-antagonists, or antagonists
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Commonly Used Opioids
Agonists Morphine, hydromorphone, oxymorphone,
fentanyl, and meperidine Partial agonist
Buprenorphine Agonist-antagonists
Butorphanol and nalbuphine Antagonists
Naloxone, etorphine, and carfentenil
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45Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Opioids
Controlled substances Except for antagonists and nalbuphine
Administered IV, IM, SC, oral, rectal, transdermal, subarachnoid, and epidural
Wide margin of safety
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46Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Opioids—Pharmacodynamics
Mimic endogenous opioid peptides β-Endorphins, dynorphins, enkephalins
Analgesia and sedative effects Result of action on the receptors in the brain and
spinal cord Types of receptors
• Mu (μ), kappa (κ), and delta (δ), plus many subtypes • Each opioid has a different action at each receptor
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Opioids—Pharmacodynamics (Cont’d)
Agonists Bind to and stimulate mu and kappa receptors Best for moderate to severe pain
Partial agonists Bind to and partially stimulate receptors
Agonist-antagonists Bind to mu and kappa receptors, but stimulate
only kappa receptors Antagonists
Bind to but don’t stimulate mu and kappa receptors
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48Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Effects of Opioids
CNS Effect depends on many factors Dogs
• Causes sedation• Narcosis
Cats, horses, and ruminants• Causes CNS stimulation• Bizarre behavior patterns or dysphoria• Use lower dose
Analgesia• Pure agonists are most effective against severe pain• Used as a premedication for painful surgery
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49Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Effects of Opioids (Cont’d)
Cardiovascular system Bradycardia
Respiratory system Minimal decreased rate and tidal volume
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Other Effects of Opioids
Miosis in dogs Mydriasis in cats, horses, and ruminants Hypothermia in dogs Hyperthermia in cats Increased responsiveness to noise Sweating in horses Decreased urine production with urine
retention
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51Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Adverse Effects of Opioids
CNS Anxiety, disorientation, excitement, dysphoria
Cardiovascular system Pronounced bradycardia
Respiratory system Decreased respiration and tidal volume Decreased PaO2 and PaCO2
Dose dependent with some agents Ceiling effect with some agents
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Adverse Effects of Opioids (Cont’d)
Gastrointestinal system Salivation and vomiting—small animals Initial diarrhea, vomiting, and flatulence Pretreat with atropine or acepromazine GI stasis follows initial GI stimulation
• May predispose to colic in horses• Avoid administration to any animal with a GI obstruction
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Other Adverse Effects of Opioids
Addiction (physical dependence) Facial swelling and hypotension Increased intraocular and intracranial
pressure Drug interactions
Meperidine and MOA inhibitors or tricyclic antidepressants (human)
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Use of Opioids
Preanesthetic Agonists, partial agonists, or agonist-antagonist May be used alone or in combination with
• Tranquilizers• Anticholinergics
Analgesia Prevent and treat postoperative pain Used with tranquilizer to produce
neuroleptanalgesia
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Neuroleptanalgesia
A profound state of sedation and analgesia induced by simultaneous administration of an opioid and a tranquilizer
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Neuroleptanalgesia (Cont’d)
Opioids Morphine Buprenorphine Butorphanol Hydromorphone
Tranquilizers Acepromazine Diazepam Midazolam Xylazine Dexmedetomidine
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Use of Neuroleptanalgesics
Sedation for minor procedures Induction of general anesthesia—dogs
Not in young, healthy dogs Not in cats
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Opioid Antagonists
Reverse undesirable effects CNS and respiratory depression
Wake up patient following sedation Naloxone hydrochloride
IM or slow IV administration Dogs, horses, cats, exotic mammals
Naltrexone Used in wild animals Longer lasting
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Naloxone Hydrochloride
Mechanism of action is unknown IM—5 minutes to reversal IV (slowly)—2 minutes to reversal Duration of action 30-60 minutes
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Effects of Opioid Antagonists
Reversal of effects of opioid agonists, partial agonists, and agonists-antagonists
Reversal can be complete in a few minutes Adverse effects are rare
Sudden analgesia loss can cause excitement, anxiety, and sympathetic nervous system stimulation
Prevent by using an agonist-antagonist
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Use of Opioid Antagonists
Emergencies Overdose Reverse neuroleptanalgesia Reviving neonates delivered by C-section
If dam received opioids One drop placed under the tongue
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Injectable Anesthetics
Can produce unconsciousness Don’t provide analgesia or muscle relaxation Used with other agents Administered “to effect” IV Barbiturates, propofol, and etomidate
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Barbiturates
Subclasses based on duration of action Ultrashort
• Thiopental sodium, methohexital, and thiamylal • Dogs, cats, and horses• Induce general anesthesia
Short• Pentobarbital• Laboratory animals• Induce general anesthesia• Treat epilepsy in small animals
Intermediate Long-acting
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Barbiturates (Cont’d)
Subclasses based on chemical structure Oxybarbiturates
• Phenobarbital, pentobarbital, and methohexital Thiobarbiturates
• Thiopental and thiamylal
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Action of Barbiturates
Not fully understood Mimics the inhibitory neurotransmitter GABA Causes CNS depression and loss of
consciousness Termination of effect
Agent leaves brain Is metabolized, excreted, or redistributed
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Pharmacodynamics of Barbiturates
Affect potency, onset, and duration of action Ionization
Polar (ionized) and nonpolar (nonionized) forms Nonpolar forms pass through the cell membranes Acidosis (blood pH <7.4)
• Increased nonpolarization• Increased drug amounts to brain• Exaggerated patient response• Lower dose to anesthetize an acidotic animal
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Pharmacodynamics of Barbiturates (Cont’d)
Protein binding (plasma proteins) Free (unbound) drug enters the brain Hypoproteinemia results in more free drug Increased drug amounts to brain Normal drug dose may produce prolonged
unconsciousness or death
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Pharmacodynamics of Barbiturates (Cont’d)
Lipid solubility (partition coefficient) Tendency of the drug to dissolve in fats, oils, and
lipids Affects the ability to penetrate the cell membrane
fatty layer High solubility results in ultra–short-acting drug High solubility results in rapid tissue redistribution Short-acting drugs are moderately lipid soluble Long-acting drugs have low lipid solubility
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Pharmacodynamics of Barbiturates (Cont’d)
Redistribution Drug is administered by IV Drug is distributed fastest to vessel-rich tissues Drug enters tissue based on lipid solubility Effect occurs when drug is in the tissue Drug leaves the tissue when blood level drops
• Animal recovers Blood carries drug to other tissues Drug is released by tissues and eliminated
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Barbiturate Redistribution
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Variations ofBarbiturate Redistribution
Thiopental—ultra–short-acting Redistributed to muscle and fat and slowly
released Continuous or repeated dosing may lead to “full”
muscle and fat and prolonged recovery Methohexital—ultra–short-acting
Redistributed to muscle and fat but released faster Muscle and fat don’t get “full” so there is no
prolonged recovery with continuous or repeated doses
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Variations ofBarbiturate Redistribution (Cont’d)
Phenobarbital—long acting Sustained effect caused by slow uptake and
release from the brain Release is dependent on kidney excretion, which
is slowest Pentobarbital—short acting
Brain levels decrease based on liver metabolism Faster than kidney excretion
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Use of Barbiturates
Rapid anesthetic induction To allow intubation (thiopental and methohexital) Sustain with inhalation anesthetic (thiopental) Sustain with repeated doses or continuous
infusion (methohexital) Use alone for short procedures Always intubate
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Effects of Barbiturates
CNS Mild sedation to unconsciousness Possibly excitement at low dose
Cardiovascular system Cardiac depression Thiopental
• Autonomic nervous system imbalances• Increased cardiac sensitivity to epinephrine• Cardiac arrhythmias
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Effects of Barbiturates (Cont’d)
Respiratory system Decreased respiratory rate and tidal volume Brief apnea (thiopental) Shallow breaths (pentobarbital)
• Respiratory acidosis• Poor tissue oxygenation
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Other Effects of Barbiturates
Sneezing, larynospasm, coughing Due to salivation Prevent with anticholinergics
Initial decreased GI motility Later increased GI motility
Incomplete muscle relaxation
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Adverse Effects of Barbiturates
Cardiovascular system Cardiac arrhythmia with VPCs Bigeminy Minimize with slow administration and dilute
concentration Preoxygenization—3-5 minutes “Bag” the patient two or three times after
intubation
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Adverse Effects of Barbiturates (Cont’d)
Respiratory system Related to dose and rate of administration Initial apnea (<1-2 minutes) Neonate respiratory depression
• C-section using barbiturates
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Other Adverse Effects of Barbiturates
Exaggerated potency in sighthounds, critically ill patients, hypoproteinemic or acidotic patients
Tissue irritation and sloughs Perivascular injection Treat with saline, with or without lidocaine Use dilute barbiturate solutions
Intraarterial injection Thiopental Vasoconstriction, pain, tissue necrosis
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Excitement During Induction
Perivascular injection Very slow rate of administration Stage II excitement Insufficient concentration in brain to induce
Stage III Administer more drug
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Excitement During Recovery
Pentobarbital Paddling and vocalization IV diazepam Preanesthetic medications
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Barbiturate-Drug Interactions
Enhance muscle relaxants Increase hepatic enzyme activity
Prolonged use Shorter duration of activity of drugs metabolized in
the liver• Opioids and diazepam
Administration with chloramphenicol • Enhanced effects of pentobarbital and phenobarbital
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Thiopental
Ultra–short-acting Small animals and horses Rapid onset, but brief duration of action Complete recovery in 1-2 hours
Crystalline powder in multidose vials Reconstitute with sterile water, normal saline, or
5% dextrose in water 2.0-2.5% solution (small animals) 5% solution (horses) Shelf life: 1 week refrigerated or 3 days at room
temperature Don’t use if a precipitate is present
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Thiopental (Cont’d)
Dose Varies with protocol and procedure Reduced up to 80% in debilitated animals Reduce dose in heavily sedated animals Give to effect Repeat doses are cumulative leading to prolonged
recovery Don’t use for anesthetic maintenance Various protocols for administration
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Methohexital
Ultra–short-acting Similar to thiopental Can be useful on an unfasted animal
Rapid induction and intubation Decreased risk of vomitus aspiration
A powder that must be reconstituted (sterile water) 1-2.5% solution (small animals) Shelf life—6 weeks without refrigeration More expensive than thiopental
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Methohexital (Cont’d)
Dosage 1/2 to 1/3 calculated dose IV over 10 seconds Should allow intubation Give needed additional drug within 30 seconds
Can be used in sighthounds Can cause profound respiratory depression Excitement and seizures during induction
and/or recovery Premedicate with tranquilizer Control postoperative seizures with diazepam IV Don’t use in animals with epilepsy
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Pentobarbital
Short acting Used to treat status epilepticus Largely replaced with propofol Administered IP to rodents for general
anesthesia Status epilepticus
Administer IV to stop seizure and produce heavy sedation
Narrow margin of safety
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Pentobarbital (Cont’d)
Provided as a 5% solution Onset of action 30-60 seconds IV
Initially unable to raise head Jaw and tongue relaxed; pedal reflex is present Pedal reflex absent—intubate and provide
respiratory support Duration of action
30 minutes to 2 hours Repeated doses can be given
• Recovery time may be prolonged with associated excitement
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Propofol
Ultra–short-acting, nonbarbiturate anesthetic IV for anesthetic induction and short-term
maintenance Small animals, small ruminants, exotic
animals, neonates of all species Other use
IV bolus and CRI to treat status epilepticus in dogs and cats
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Propofol (Cont’d)
Minimally water soluble Available in an egg lecithin/glycerine/soybean
oil aqueous solution—10 mg/mL Milky appearance—OK to give IV Unknown how it affects GABA receptors Highly fat soluble Onset of action—30-60 seconds Duration of action—5-10 minutes Complete recovery
20 minutes—dogs 30 minutes—cats
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Effects of Propofol
CNS Dose-dependent depression from sedation to
general anesthesia No analgesia
Cardiovascular system Cardiac depressant Transient hypotension
Respiratory system Depressant with possible apnea Administer slowly to effect Monitor patient carefully
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Other Effects of Propofol
Twitching during induction—dogs Muscle relaxation Safe to use in animals with liver disease or
kidney disease Appetite stimulant (low dose) Antiemetic Decreases intraocular and intracranial
pressure
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Adverse Effects of Propofol
CNS Transient excitement and muscle tremors
(induction) Paddling, muscle twitching, nystagmus,
opisthotonus (resembles seizures) Cardiovascular system
Hypotension—transient Respiratory system
Apnea (rapid injection; high dose)• Intubation if necessary
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Other Adverse Effects of Propofol
Seizure-like signs (induction) Treat with diazepam
Pain with IV injection Perivascular injection does not produce tissue
damage Cats with repeat doses
Heinz body formation on red blood cells (RBCs) Diarrhea and anorexia Prolonged recoveries
Sighthounds—prolonged recovery Also other breeds If maintained on propofol >30 minutes
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Use of Propofol
IV slowly over 1-2 minutes to effect IM produces mild sedation and ataxia only Dose depends on premedications Highly protein bound
Don’t use in hypoproteinemic animals May cause excitement if given too slowly
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Use of Propofol (Cont’d)
Administration Boluses repeated every 3-5 minutes for 20 minutes CRI with syringe pump or through IV line
• Can maintain anesthesia for several hours• Use a low dose• Can control depth of anesthesia
Recovery Dogs—complete in 20 minutes Cats—in 30 minutes
Premedication with tranquilizers Decrease propofol dose Facilitates IV injection in unruly animals
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Propofol Handling and Storage
Poor storage characteristics Egg lecithin, glycerol, and soybean oil support
bacterial growth Use aseptic technique Discard unused drug within 6 hours of opening 3-year shelf life if unopened
more expensive than ketamine-diazepam or thiopental
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Dissociative Anesthetics
Phencyclidine and ketamine hydrochloride Only ketamine is used in veterinary medicine Used alone
Cats—for minor procedures or to facilitate restraint Used with other drugs
Tranquilizers and opioids to induce general anesthesia
Subanesthetic dose CRI for analgesia
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Dissociative Anesthetics (Cont’d)
Tiletamine hydrochloride Combined with benzodiazepine zolazepam Telazol® IM or IV to produce sedation and anesthesia Used alone or in combination with other drugs A controlled substance
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Mode of Action
Disrupts nerve transmission in some brain sections
Selective stimulation in parts of the brain Decreases windup through NMDA inhibition Trancelike state
Animal appears awake Immobile and unaware of surroundings
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Dissociative Anesthetic Trancelike State
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Ketamine
Peak action 1-2 minutes after IV injection 10 minutes after IM injection
Duration of effect 20-30 minutes Increased dose prolongs duration but doesn’t
increase anesthetic effect All dissociatives are either metabolized in the
liver or excreted unchanged in the urine Avoid use in animals with liver or kidney disease
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Dissociative Effects on the CNS
Cataleptoid state Intact reflexes
Palpebral, corneal, pedal, PLR, laryngeal, swallowing
Ocular effects Eyes remain open Central dilated pupil Use ophthalmic ointment
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Dissociative Effects on the CNS (Cont’d)
Muscle tone Normal to muscle rigidity Counteract with concurrent tranquilizer
Analgesia Somatic analgesia Visceral analgesia
Amnesia (humans) Sensitivity to sensory stimuli
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Dissociative Effects on the Cardiovascular System
Increase in heart rate Increased cardiac output Increased mean blood pressure Effects due to stimulation of the SNS
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Dissociative Effects on the Respiratory System
Respiratory rate and tidal volume may change
Respiratory depression usually insignificant Apneustic respiration at higher doses
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Adverse Effects of Dissociatives on the CNS
Response to sensory stimulation Avoid in animals with seizure disorders Avoid in animals that have ingested CNS
stimulants Avoid in animals undergoing neurological
system procedures Hallucinations and personal injury Personality change Nystagmus
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Adverse Effects of Dissociatives on the Cardiovascular System
Decreased inotropy Cardiac arrhythmias in response to
epinephrine release Screen patients for preexisting heart disease
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109Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Respiratory depression Respiratory arrest Significantly increased salivation and
respiratory tract secretions Aspiration
Adverse Effects of Dissociatives on the Cardiovascular System (Cont’d)
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110Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Other Adverse Effects of Dissociatives
Pain after IM injection due to tissue irritation Increased intracranial and intraocular
pressure
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111Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Use of Dissociative Anesthetics
Administration: IM or IV Wide margin of safety Useful in cats and horses Used in combination with tranquilizers
Short procedures Anesthetic induction for intubation Chemical restraint—cats Immobilization—large and exotic animals Pain control
No effective reversal agent
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112Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Ketamine
Approved for use in cats and subhuman primates
Also used in dogs, birds, horses, and exotic species
Schedule III drug (United States) prescription drug (Canada)
Rapid onset of action—high lipid solubility Administer IV or IM or orally (cats)
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113Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Ketamine (Cont’d)
Avoid repeated injections Recovery in 2-6 hours Elimination
Hepatic metabolism—dogs Renal metabolism—cats
Often used in combination with tranquilizers
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114Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Ketamine and Diazepam Combination
IV induction in dogs and cats Equal volumes of diazepam and ketamine Can be mixed in one syringe
Watch for possible precipitate Onset of action—30-90 seconds Duration of action—5-10 minutes Recovery—30-60 minutes Alternative combination for IM injection:
midazolam and ketamine
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115Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Tiletamine
Similar to ketamine Sold only in combination with zolazepam
(Telazol®) Telazol®—sold as a powder to reconstitute
Stable for 4 days at room temperature, or 14 days if refrigerated
A class III drug Can be used in combination with other
tranquilizers or with ketamine• Possible long and difficult recoveries• Metabolized in liver and excreted via the kidneys
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116Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Advantages of Telazol® (as compared to Ketamine)
Decreased apneustic respiratory response Can be administered SC Used effectively in some wildlife
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117Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Etomidate
Noncontrolled, sedative-hypnotic imidazole drug
Used for induction—dogs, cats, exotics Minimal effects on the cardiovascular and
respiratory systems Expensive Pain with IV injection Nausea and vomiting possible
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118Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Etomidate Mode of Action
Similar to barbiturates and propofol Increased GABA inhibitory action
Short duration of action Rapid redistribution away from brain Rapid metabolism
Wide margin of safety
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119Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Etomidate Effects on the CNS
Hypnosis Very little analgesia Decreased brain oxygen consumption Brain perfusion maintained Anticonvulsant
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120Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Effects of Etomidate
CNS Initial hypotension Heart rate, rhythm, blood pressure, and cardiac
output minimally affected Respiratory system
Initial apnea Crosses placental barrier
Musculoskeletal system Muscle relaxation Spontaneous muscle twitching and movement
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121Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Adverse Effects of Etomidate
Painful IV injection Perivascular sterile abscesses Hemolysis with rapid administration (cats) Decreased adrenal cortex function
Decreased cortisol levels Nausea, vomiting, involuntary excitement
during induction and recovery
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122Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Use of Etomidate
IV administration Premedicate with opioid or diazepam Premedicate with dexamethasone Repeated boluses to maintain anesthesia
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123Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Guaifenesin (GG)
Previous name—glyceryl guaiacolate ether (GGE)
Noncontrolled muscle relaxant Common use in large animals
Muscle relaxation Facilitate intubation Ease induction and recovery
Not an anesthetic or an analgesic Mode of action is not understood
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124Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Effects of Guaifenesin
Skeletal muscle relaxation Minimal effect on diaphragm
Minimal effect on the cardiovascular and respiratory systems
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125Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Adverse Effects of Guaifenesin
Few adverse effects at therapeutic doses Overdose
Muscle rigidity Apneustic respiration
Perivascular tissue irritation Hemolysis (ruminants and horses) in high
concentrations
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126Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Use of Guaifenesin
Used with ketamine in anesthetic induction protocol Premedicate with alpha2-agonist or acepromazine
Triple drip: GG, ketamine, xylazine Used in horses Maintain anesthesia for less than an hour
Administered IV rapidly until animal is ataxic Following premedication Induce when patient is ataxic Smooth recovery
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127Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Use of Guaifenesin (Cont’d)
Not a sedative or analgesic Must premedicate May cause excitement if there is no premedication Increased risk of side effects if there is no
premedication
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128Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Inhalation Anesthetics
Classes of inhalation anesthetics Isoflurane and sevoflurane (halogenated
compounds) Nitrous oxide and desflurane Enflurane Halothane Methoxyflurane Diethyl ether
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129Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Diethyl Ether
No longer used as an anesthetic agent Classic stages and planes of anesthesia
described using ether Desirable characteristics
Stable cardiac output, rhythm, and blood pressure Stable respirations Good muscle relaxation
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130Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Diethyl Ether (Cont’d)
Undesirable characteristics Tracheal and bronchial mucosal irritation Prolonged induction and recovery Postoperative nausea and vomiting Flammable and explosive
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131Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Halogenated Organic Compounds
Isoflurane and sevoflurane are the most commonly used agents in this class
Liquid at room temperature Stored in a vaporizer on an anesthetic
machine Vaporized in oxygen that flows through the
vaporizer
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132Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Uptake and Distribution ofHalogenated Organic Compounds
Liquid anesthetic is vaporized and mixed with oxygen gas
Mixture is delivered to the patient via a mask or endotracheal tube (ET tube)
Mixture travels to lungs (alveoli) and diffuses into the bloodstream
Diffusion rate is dependent on concentration gradient (alveoli/capillary) and lipid solubility
Concentration gradient is greatest during initial induction
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133Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Uptake and Distribution of Halogenated Organic Compounds (Cont’d)
Distribution to tissues is dependent on blood supply Lipid solubility determines entry into tissues through cell
walls Depth of anesthesia is dependent on partial pressure
of anesthetic in the brain Partial pressure in the brain is dependent on partial pressure
of the anesthetic in blood and alveoli Maintenance of anesthesia is dependent on sufficient
quantities of anesthetic delivered to the lungs
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134Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Elimination of Halogenated Organic Compounds
Reducing amount of anesthetic administered reduces amount delivered to the alveoli
Blood level is initially higher than alveolar level Concentration gradient now favors anesthetic
diffusion from blood into the alveoli Blood levels drop quickly as patient breathes out
anesthetic from the alveoli Brain levels drop as less anesthetic is delivered by
blood Patient wakes up
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135Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Effects of Halogenated Organic Compounds
CNS Dose-related reversible CNS depression Hypothermia
Cardiovascular system Depress cardiovascular function Effects on HR variable
Respiratory system Dose-dependent ventilation depression
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136Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Adverse Effects ofHalogenated Organic Compounds
CNS (Cont’d) Increased intracranial pressure in patients with
head trauma or brain tumors Considered safe for epileptic animals
Cardiovascular system Decrease blood pressure and may decrease renal
blood flow Respiratory system
Hypoventilation Carbon dioxide retention and respiratory acidosis
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137Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Physical and Chemical Propertiesof Inhalant Anesthetics
Important properties to consider Vapor pressure Partition coefficient Minimum alveolar concentration (MAC) Rubber solubility
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138Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Vapor Pressure
The tendency of an inhalation anesthetic to vaporize to its gaseous state
Determines how readily an inhalation anesthetic will evaporate in the anesthetic machine vaporizer
Temperature and anesthetic agent dependent
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139Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Vapor Pressure (Cont’d)
Volatile agents High vapor pressure Isoflurane, sevoflurane, desflurane, and halothane Delivered from a precision vaporizer to control the
delivery concentration All precision vaporizers are made to deliver only
one specific halogenated agent Nonvolatile agents
Low vapor pressure Methoxyflurane Delivered from a nonprecision vaporizer
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140Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Blood:Gas Partition Coefficient
The measure of the solubility of an inhalation anesthetic in blood as compared to alveolar gas (air)
Indication of the speed of induction and recovery for an inhalation anesthetic agent
Low blood:gas partition coefficient Agent is more soluble in alveolar gas than in blood
at equilibrium Agent is less soluble in blood Faster expected induction and recovery
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141Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Blood:Gas Partition Coefficient (Cont’d)
High blood:gas partition coefficient Agent is more soluble in blood than in alveolar gas
at equilibrium Agent is less soluble in alveolar gas Agent is absorbed into blood and tissues (sponge
effect) Slower expected induction and recovery
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142Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Blood:Gas Partition Coefficient (Cont’d)
Blood: gas partition coefficient determines the clinical use of the anesthetic agent Induction: Can a mask be used? Maintenance: How fast will the anesthetic depth
change in response to changes in the vaporizer setting?
Recovery: How long will the patient sleep after anesthesia?
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143Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Minimum Alveolar Concentration (MAC)
The measure of the potency of a drug Used to determine the average setting on the
vaporizer that will produce surgical anesthesia The lower the MAC, the more potent the
anesthetic agent and the lower the vaporizer setting MAC may be altered by age, metabolic activity,
body temperature, disease, pregnancy, obesity, and other agents present
Every patient must be monitored as an individual
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144Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Isoflurane
Most commonly used inhalant agent in North America
Approved for use in dogs and horses; commonly used in other species
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145Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Isoflurane (Cont’d)
Properties High vapor pressure: need a precision vaporizer Low blood:gas partition coefficient: rapid induction
and recovery Good for induction with mask or chamber MAC = 1.3% to 1.63%: helps determine initial
vaporizer setting Low rubber solubility Stable at room temperature; no preservatives
needed
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146Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Effects and Adverse Effects of Isoflurane
Maintains cardiac output, heart rate, and rhythm Fewest adverse cardiovascular effects
Depresses the respiratory system Maintains cerebral blood flow Almost completely eliminated through the lungs Induces adequate to good muscle relaxation Provides little or no analgesia after anesthesia Can produce carbon monoxide when exposed to a
desiccated carbon dioxide absorbent
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147Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Sevoflurane
High vapor pressure: need a precision vaporizer
Blood:gas partition coefficient: rapid induction and recovery
Good for induction with a mask or chamber High controllability of depth of anesthesia MAC = 2.34% to 2.58%
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148Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Effects and Adverse Effects of Sevoflurane
Minimal cardiovascular depression Depresses respiratory system Eliminated by the lungs, minimal hepatic
metabolism Maintains cerebral blood flow Induces adequate muscle relaxation Some paddling and excitement during
recovery
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149Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Desflurane
Closely related to isoflurane Expensive Lowest blood:gas partition coefficient: very
rapid induction and recovery Used with a special precision vaporizer MAC = 7.2% and 9.8%
Least potent inhalant agent Eliminated by the lungs
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150Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Effects and Adverse Effects of Desflurane
Strong vapors cause coughing and holding the breath
Other effects are similar to isoflurane Transient increase in heart rate and blood
pressure (humans)
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151Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Other Halogenated Inhalation Agents
Halothane (Fluothane) Not commonly used anymore Being replaced by isoflurane and sevoflurane
Methoxyflurane No longer available in North America
Enflurane Used primarily in human medicine
Nitrous oxide Used primarily in human medicine; some veterinary use A gas at room temperature; no vaporizer is required
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152Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
CNS and Respiratory Stimulants
Doxapram Analeptic agent Stimulates respiration and speeds recovery Used in neonate puppies and kittens after C-
section IV administration or sublingual drops (neonates)
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153Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Adverse Effects of Doxapram
Wide margin of safety Lowers seizure threshold CNS damage
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154Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Use of Doxapram
Repeat injections may be necessary Reverses respiratory depression from
inhalant agents and barbiturates