Inhaled anesthetics

Question 1

Solubility:

-The affinity for an anesthetic in blood compared to ___ or in blood compared to ___.

Answer 1

air

tissue (fat, muscle)

Question 2

___ = State of equal partial pressures, NOT ___

Answer 2

Equilibrium

-concentration

Question 3

While the blood does carry the anesthetic to its effect site (___). Blood is also a pharmacologically ___. The size of this reservoir is determined by ___.

Solubility of an anesthetic in the blood is described using ___.

Answer 3

• brain and spinal cord
• inactive reservoir
• solubility
• Blood Gas Partition Coefficients

Question 4

Think of this not as a pulsating transport system but rather as a holding pool for gaseous agents?

Answer 4

Blood

Question 5

The higher the ___, the more that gas goes into the inactive reservoir.

Answer 5

solubility coefficients

Question 6

Partition Coefficients aka ???

• Solubility is expressed in terms of ___.
• The ___ determine how the anesthetic will partition itself btw the gas and blood phase at equilibrium.
• Partition coefficients exist btw ___ and also btw ___.

Answer 6

Oswaldt Solubility Coefficients

• partition coefficients
• coefficients
• blood and gas
• blood and organs (fat)

Question 7

MOST SOLUBLE? will have more gas in the inactive blood reservoir than we will have with a lower soluble anesthetic. Will exert its activity on the brain slower.

**Remember ___ will change the amount that can be dissolved in something.

Answer 7

Halothane (2.4)

**temperatures

Question 8

Will determine the alveolar concentration of an inhalation agent?

Answer 8

Solubility

Question 9

Determine how the anesthetic agent partitions into gas phase (alveoli) and blood phase (reservoir)?

Answer 9

Solubility coefficients

Question 10

Eventually equilibrium is reached and there is no longer a gradient. Can take ___ for the anesthetic to equilibrate with the fat compartment.

Answer 10

24-48 hours

Question 11

Clinical impact of a lower hematocrit (anemic patient)?

Answer 11

Faster induction

fewer binding sites for the anesthetic in the blood

Question 12

Uptake and Solubility:
Solubility will determine how quickly the concentration in the alveoli (___) reaches the concentration set inspired (___).

The faster these 2 values approximate equality, the faster the ??

Answer 12

FA
FI
uptake to the brain and the induction

Question 13

*Relationship btw FA and FI:
Alveolar concentration will approach inspired rate varies for each agent.

• Expressed as a ratio of ___ divided by ___ over ___.
• ___ agents have the fastest rate of the alveolar gas matching the inspired concentration over time.

Answer 13

alveolar fraction
inspired fraction
time
Least soluble agents

Question 14

FA/FI Curves ~ same shape for all agents (not the same curve):

1) initial rapid rise to? uptake by?
2) less rapidly to? uptake by?
3) continues more slowly thereafter

**This is a RATIO, highest possible value is one and we are at equilibrium at that point. Goal is for ___ to reach/approach ___.

Answer 14

1) first “knee” - vessel rich group (VRG)
2) second “knee” - muscle group (MG)
FA
FI

Question 15

FA/FI Curves:

____ agents will have fastest rate of rise.
*Will have a slower induction when the B/G solubility is 1.4 vs 0.42.

Answer 15

Least soluble agents

Question 16

N2O has a B/G of 0.47, yet there is a more rapid rate of rise with N2O than with desflurane which is 0.42. Why?

Answer 16

Concentration effect

Question 17

N2O has a higher solubility than desflurance but this is because we can deliver N2O in a very high concentration (up to ?) also due to the second gas effect. Desflurane can only be delivered up to ?

Answer 17

80%

6%

Question 18

The lower the solubility, the more rapid rate of rise. This makes sense since a higher solubility will go into the blood aka the inactive reservoir. The ___ is what makes the difference and the ___ is what determines what goes into this region.

___ is what you set as the concentration on the dial.

Answer 18

• alveolar region
• solubility
• FI

Question 19

• Uptake = Influence on FA/FI:
• Uptake opposes the effect of ___ (which increases the ___).
• If FA removes 1/2 of anesthetic in lung - FA would be ___ of FI.
• If FA removes 2/3 of anesthetic in lung - FA would be ___ of FI.

Answer 19

ventilation (FA)

• 1/2
• 1/3

Question 20

Tissue uptake of the agent will decrease the ___ and therefore it will decrease relative to the ___.
The degree to which the ___ is decreased depends on percentage of uptake into the blood and tissues.

*Tissue solubility coefficients determines this uptake.

Answer 20

alveolar concentration
inspired concentration
alveolar concentration

Question 21

Washout of Anesthetic - Effect of Solubility on FA/FI:
-The higher the solubility the ___ the increase in alveolar concentration rise toward inspired concentration.

• Reason: soluble anesthetics require that a large amount of anesthetic be dissolved in the ___ before the Pa and PA partial pressures equilibrate.
• Greater solubility = greater uptake = less of a ___ buildup in the alveoli.

Answer 21

Slower

• blood (inactive reservoir)
• pressure

Question 22

Determines how the anesthetic will partition itself btw the blood phase and air phase when equilibrium is reached?

Answer 22

Solubility

Question 23

Goal = ???

To accomplish this desire high percentage of ___ in the ___.
Alveoli are the windows to the brain!
-Thus with a 0.5 solubility = faster induction compared to 2.0.

Answer 23

Fast Induction

• Gas
• lungs

Question 24

Impact of High Solubility on Induction:

• Since ___ mirrors brain concentration and the more soluble agent has a ___ - induction is slower with more soluble agents.
• Likewise a low solubility agent demonstrates a fast induction because very little anesthetic must dissolve in the blood reservoir before partial pressures equilibrate.

Answer 24

FA

lower FA

Question 25

___ solubility coefficient = quicker induction and fasterrrr emergence!

Answer 25

LOW

Question 26

In theory use of a moderately soluble agent Halothane B/G 2.4 would result in slow rise of ___ and slow induction. In practice, this effect is compensated for by increasing the ___ used for ___. Use of high delivered concentrations is known as = ___. Use a much higher concentration at induction than during maintenance phase.

Answer 26

FA concentration induction Overpressure

Question 27

Impact of Solubility on Emergence: The ___ the B/G solubility coefficient - the shorter time emergence will take. ~Clinical application - turn off the agents sooner. Also begin to decrease the concentration delivered earlier with a ___ agent compared to one with ___.

Answer 27

lower very soluble agent lower solubility (Halothane - 2.4 off sooner than Desflurane - 0.42)

Question 28

``` ___ = parallels induction with respect to solubility concepts. ___ = slower time to awaken, more left in the reservoir (blood) when the gas is turned off. ```

Answer 28

Emergence | Higher Solubility

Question 29

Elimination is more rapid with a ___ agent. Turn off agent - 0% delivered and administer 100% oxygen.

Answer 29

less soluble

Question 30

Quadrupling CO with no change in solubility will ___ FA/FI. ~Clinical example - patient in liver failure and is fluid overloaded will see a ___ in rate of induction. ~If CO decreased and no change in solubility ___ rate of induction as FA/FI ratio ___.

Answer 30

decrease decrease increase increases

Question 31

___ CO slows induction - greater effect with ___ soluble agent.

Answer 31

Increased | highly

Question 32

The a-v difference reflects uptake of anesthetic by the?

Answer 32

tissues

Question 33

This anesthetic has an extremely low uptake in the fat, lowest fat/blood partition coefficient - 2.3 (also lowest with brain to blood - 1.1)? Normal range for lean tissue (brain) - ? Normal range for fat coefficients (usually high) - ?

Answer 33

Nitrous oxide - 1-2 - 27-67

Question 34

0 uptake into the ___ - receives 0% of the CO.

Answer 34

Vessel poor group (VPG)

Question 35

FA/FI Curves - Impact of Tissue Uptake: 1) ___ = a-v difference = 0 as no agent occupies the alveoli - no uptake 2) ___ = uptake by VRG balances input "quasi-equilibrium" 3) ___ = decreased uptake by VRG, MR group uptake 4) ___ = occurs in ___ - uptake by MRG slows

Answer 35

1) Initial steep rise 2) First knee 3) Slower second rise 4) Second knee 4-8 minutes

Question 36

___ - partial pressure, concentration going to the brain ___ - concentration inspired, this is altered by changes in ___ ___ - show the rate at which the alveolar concentrations approaches inspired concentrations

Answer 36

FA FI -Fraction delivered FA/FI curves

Question 37

Represents the partial pressure of anesthetic going to the brain? The alveolar partial pressure = the arterial partial pressure = the brain partial pressure. Based on this assumption PA is used to estimate???

Answer 37

FA depth of anesthetic recovery from anesthesia anesthetic potency or MAC

Question 38

We use a much higher concentration (%) at __ than during __ phase.

Answer 38

induction | maintenance phase

Question 39

The concentration that will produce absence of movement in 50% in response to a noxious stimulus?

Answer 39

Minimum Alveolar Concentration (MAC) (ED50 of inhalation agents)

Question 40

Increase in ventilation (2-4 L/min to 8 L/min) will increase FA/FI more for a ___!!! this will help speed its induction rate

Answer 40

Highly soluble agent * N2O (low solubility) FA rapidly rises to FI even at alveolar ventilation (2L/min). Curve not capable of increasing no matter what the ventilation is. * Ether (high solubility) doubling vent = FA/FI increases 2x

Question 41

Ventilation Perfusion Abnormalities: will have a greater effect with the ??? Ex: Main stem intubation causes a ___ d/t ___.

Answer 41

less soluble agents slower induction dilutional effect

Question 42

Shunting effects are greater with the ??? impact much larger on these.

Answer 42

Lower soluble agents

Question 43

___ agents washout first! | As duration of anesthesia lengthens - washout ___ due to more anesthetic in the reservoirs.

Answer 43

Least soluble | prolonged

Question 44

The higher the B/G solubility coefficient the ___ emergence will take.

Answer 44

Longer

Question 45

___ = is where 50% of the population will respond to a verbal command, still have an anesthetic agent on board but they are still responsive. 50% of people will respond to you.

Answer 45

MAC awake

Question 46

1) ___ solubility = slower increase in alveolar concentration (FA) toward inspired (FI). 2) Elimination (washout) more rapid with ??? 3) Changes in ventilation or CO have less of an impact on depth of anesthetic with ___ agents vs. ___ agents.

Answer 46

1) Higher 2) Low solubility 3) lower solubility vs. higher solubility

Question 47

Want patients breathing at the end, to breathe off the anesthetics. Emergence is a lot tougher than induction. Emergence want to washout the gas and want their physiological drives to kick back in, need to allow CO2 to build up. When trending towards the end of the case need to begin the washout process, start decreasing our agent. Want to reach ___ at the end of the procedure.

Answer 47

MAC awake

Question 48

- If changes in anesthetic depth need to be made to compensate for surgical stimulus - faster with a ___ agent. - Changes in ventilation or CO influence anesthetic depth to a greater degree with ___. - The ___ the solubility the smaller influence of ventilation/perfusion inequalities on arterial anesthetic pressure.

Answer 48

- less soluble agent - soluble agents - greater