VICTORIA HOFILEÑA, MD, DPBA

INHALATIONAL
ANESTHETICS
INHALATIONAL ANESTHETICS
CLASSIFICATION OF INHALATIONAL
ANESTHETICS
Outdated Gases Volatile Agents

Ether Nitrous Oxide Halothane

Trilene Xenon Enflurane

Methoxyflurane Isoflurane

Cyclopropane Sevoflurane

Chloroform Desflurane
TEXT
UPTAKE AND DISTRIBUTION OF
INHALATIONAL AGENTS
MECHANISM OF ACTION
▸ unknown
▸ no single, accepted definition of what constitutes the
anesthetic state

▸ Operational Definition:
▸ immobility in response to surgical stimulation
▸ amnesia for intraoperative events
MINIMUM ALVEOLAR CONCENTRATION
= MAC
▸ 1 MAC - Minimum Alveolar Concentration at which 50% of
Humans have no response to surgical stimulus

▸ measure of Anesthetic Potence

 AGENT MAC POTENCY

Methoxyflurane 0.16% Most potent

Halothane 0.74%

Isoflurane 1.17%

Enflurane 1.7%

Sevoflurane 2.05%

Desflurane 6.0%

Nitrous Oxide 104% Least Potent

 DECREASES
FACTOR INCREASES MAC
MAC
AGE Max inc 6 Months Dec with age

TEMP Inc upto 42C Dec with temp

O2 Hypoxia

CO2 Hypercabia

ALCOHOLISM Chronic Acute

BAROMETRIC
Inc Pres- Inc MAC
PRES
HEMOGLOBIN Anemia
 DECREASES
FACTOR INCREASES MAC
MAC

IV agents yes

Pregnancy yes

Local anesthetics cocaine others decreses

Sodium hypernatremia Hyponatremia

Magnesium Hypomagnesenia Hypermagnesemi

Calcium Hypocalcemia hypercalcemia

MAC IS NOT AFFECTED BY:
▸ Sex (Male ~ Female)
▸ Thyroid disease
PHARMACOKINETICS OF INHALED
ANESTHETICS
▸ Uptake, distribution and elimination/metabolism of inhaled
anesthetics

▸ Objective: achieve a constant and optimal brain partial

pressure of anesthetic

▸ PA Pa Pbr
FACTORS THAT DETERMINE ALVEOLAR
PARTIAL PRESSURE (PA)
▸ PI
▸ Alveolar ventilation
▸ Anesthetic breathing system
▸ Solubility
▸ Cardiac Output
▸ Alveolar to venous partial pressure difference
INSPIRED ANESTHETIC PARTIAL
PRESSURE
▸ a high PI is necessary during induction
▸ Concentration Effect
CONCENTRATION EFFECT
▸ the higher the concentration of an inhaled anesthetic, the
faster the alveolar concentration approaches the inhaled
concentration
SECOND GAS EFFECT
▸ The ability of the large volume uptake of one gas (First gas)
to accelerate the rate of rise of the PA of a concurrently
administered vompanion cas (Second gas)

▸ consequence of the Concentration effect

FACTORS

ALVEOLAR VENTILATION
▸ increase alveolar ventilation promotes input of more inhaled
anesthetic uptake into the blood

▸ higher VA ~ more rapid rate of increase of PA

= faster induction
FACTORS

SOLUBILITY
FACTORS

OIL : GAS PARTITION CO-EFFICIENT

▸ indicates the amount of gas that is soluble in oil phase
▸ measure of lipid solubility of the anesthetic
▸ ~ Anesthetic potency
▸ explained by Meyer-Overton Rule
FACTORS

MEYER - OVERTON RULE

Least potent

Most potent
FACTORS

PARTITION CO-EFFICIENTS
FACTORS

FA/FI
▸ Ratio of alveolar agent to inhaled agent
▸ higher the blood/gas partition coefficient (solubility) the
greater the uptake from the alveolus

▸ the slower the rise of FA to meet the FI

▸ Factors affecting: Minute ventilation, CO, FGF, IV agents
EFFECTS OF INHALATION ANESTHETICS
ON ORGAN SYSTEMS
▸ Circulatory System
▸ decrease blood pressure
▸ some decrease cardiac output
▸ Respiratory
▸ decrease tidal volume
▸ increase respiratory rate
▸ depress mucociliary function = pooling of mucus and atelectasis
EFFECTS

▸ Brain
▸ decrease brain metabolic rate
▸ decreases cerebral vascular resistance thus increasing
cerebral blood flow

▸ Kidney
▸ dec GFR, dec renal blood flow
EFFECTS

▸ Liver
▸ dec hepatic blood flow
▸ Uterine smooth muscle
▸ halogenated anesthetics are potent ralaxants
▸ lead to increase uterine bleeding
RECOVER
Y FROM
RECOVERY

RECOVERY FROM ANESTHESIA

▸ rate at which the PA decreases
with time

▸ elimination - through lungs

▸ Influenced by:
▸ tissue concentrations
▸ metabolism
RECOVERY

TISSUE CONCENTRATIONS
▸ serve as reservior
▸ influenced by:
▸ duration of anesthesia
▸ solubility
RECOVERY

METABOLISM
▸ important difference between induction and recovery
▸ impact of metabolism on the rate of the decrease of PA
▸ highly lipid soluble agents (ex methoxyflurane, halothane)
▸ principal determinant of rate of decreaseof PA is
metabolism
RECOVERY
INHALED ANESTHETIC AGENTS
▸ Nitrous Oxide (N2O)
▸ Halothane
▸ Enflurane
▸ Isoflurane
▸ Desflurane
▸ Sevoflurane
▸ Xenon
▸ Ether
▸ Trichloroethylene
▸ Chloroform
NITROUS OXIDE (N20)
▸ History: used by John Culton during the public
demonstration of anesthesia

▸ Liquid gas, odorless and colorless

▸ still used in practice today
ENTONOX
▸ 50% N2O + 50% O2
▸ Poyinting effect - where N2O is mixed with O2 and it remains
in gaseos state

▸ Use:
▸ labour analgesia
▸ field analgesia
CONTRAINDICATIONS OF N2O

▸ N2O is 35x more soluble in blood than N2

▸ Fills and expands any air-containing cavity -
▸ air embolism
▸ pneumothorax
▸ lung cysts
▸ tympanoplasty
▸ intraoccular bubbles
▸ May exacerbate pulmonary hypertension
HALOTHANE
▸ thymol preservative
▸ pleasant smell, non-irritant, bronchodilation
▸ potent = induce anesthesia in single puff - for pedia
▸ ideal for asthmatics
TOXICITY

▸ MOST ARRYTHMOGENIC - sensitises the heart to

catecholamines

▸ max decrease in BP, SVR, CO, HR - bradycardia

▸ Uterus - atony
▸ post op shivering
▸ Malignant hyperthermia
▸ Halothane hepatitis - caused by metabolite Triflouroacetic acid
ENFLURANE
▸ epileptogenic
▸ contraindications:
▸ MH susceptibility
▸ siezure disorder
▸ Preexisting kidney disorder, intracranial hypertension
ISOFLURANE
▸ only agent that preserves baroreceptor reflex
▸ Causes coronary steal
▸ has minimal increase in intracranial pressure
▸ Agent of choice for cardiac and neuroanesthesia
SEVOFLURANE
▸ more commonly used inhalation anesthetic
▸ pleasant smell, non irritant and bronchodilation
▸ choice for pediatric anesthesia
▸ 2nd choice for:
▸ Neuroanesthesia
▸ cardiac anesthesia
▸ asthmatics
XENON
▸ most ideal inhalational agent
▸ Characteristics: Least blood:gas partition coefficient, least
soluble, fastest induction, fastest recovery

▸ most cardiostable
▸ not metabolised, non flamable
▸ Disadvantage: very costly, needs special equiptment for
delivery, causes bronchospasm
ETHER
▸ most complete anesthetic agent
▸ has max. muscle relaxation
▸ does not depress respiration
▸ causes nausea and vomiting
METHOXYFLURANE
▸ most potent, slowest induction and recovery
▸ most nephrotoxic

CYCLOPROPANE
▸ most flamable and explosive
▸ causes cyclopropane shock
TRICHLOROETHYLENE
▸ most potent analgesic agent
▸ reacts with soda lime: dichloroacetylene - neurotoxic
phosgene - pulmonary toxicity ~ ARDS

CHLOROFORM
▸ 1st agent used for labor analgesia
▸ cardiotoxic ~ ventricular fibrillaton
▸ hepatotoxic, cause profound hyperglycemia
TOXICITIES
CARBON MONOXIDE TOXICITY
▸ all agents react with soda lime to produce CO
▸ DESFLURANE> ENFLURANE> ISOFLURANE>
SEVOFLURANE> HALOTHANE
FLUORIDE NEPHROTOXICITY
▸ Fluoride - nephrotoxic by product of metabolism in liver and
kidney

▸ opposes ADH leading to polyuria

▸ METHOXYFLURANE>SEVOFLURANE>>>
ISOFLURANE>DESFLURANE

▸ results in potentially permanent renal injury

MALIGNANT HYPERTHERMIA
▸ autosomal dominant genetic disorder of skeletal muscle
▸ mutation in the ryanodine receptor
▸ exposure leads to continual release of Calcium from sarcoplasmic
reticulum
▸ sudden hyperthermia, tachycardia, hypertension, muscle rigidity,
hyperkalemia
▸ life thretening emergency
▸ treatment: Dantrolene
TEXT

THANKS FOR
LISTENING…
TEXT

WHICH OF THE FOLLOWING IS THE

CORRECT SEQUENCE OF POTENCY?
▸ a. methoxyflurane>enflurane>halothane>sevoflurane
▸ b. sevoflurane> methoxyflurane>halothane>enflurane
▸ c. methoxyflurane>halothane>enflurane>sevoflurane
▸ d. halothane> enflurane>sevoflurane>methoxyflurane
TEXT

MAC IS ALTERED BY THE FOLLOWING

EXCEPT?
▸ a. hypernatremia
▸ b. alcoholism
▸ c. anemia
▸ d. male sex
TEXT

MAC IS HIGHEST IN:

▸ a. 6 months old
▸ b. pregnancy
▸ c. elderly
▸ d. hypoxia
TEXT

INHALATION ANESTHETIC THAT POSES

HIGHEST RISK FOR CO TOXICITY IS
▸ a. methoxyflurane
▸ b. desflurane
▸ c. sevoflurane
▸ d. nitrous oxide
TEXT

A FACTOR THAT PROLONGS THE RATE

OF INDUCTION IS
▸ a. high alveolar ventilation
▸ b. high inspired concentration of anesthetic
▸ c. high blood/gas partition coefficient
▸ d. high potency