Unit 4 - Inhaled Anesthetics Flashcards
3 groups of inhaled anesthetics
ethers alkanes gases
inhaled anesthetics - ethers
Desflurane
Isoflurane
Sevoflurane
Enflurane
Methoxyflurane
Ether
inhaled anesthetics - alkanes
Halothane
Chloroform
inhaled anesthetics - gases
Nitrous oxide
Cyclopropane
Xenon
relationship between fluorination and potency
tends to reduce potency
type & number of halogens in isoflurane
5 fluorine atoms
1 chlorine atom
type & number of halogens in desflurane
6 fluorine atoms (fully fluorinated)
type & number of halogens in sevoflurane
7 fluorine atoms
inhaled anesthetics that have a chiral carbon
desflurane
isoflurane
what is vapor pressure
pressure exerted by a vapor in equilibrium with its liquid or solid phase inside a closed container
relationship between vapor pressure and temperature
directly proportional
what is boiling point
vapor pressure = atmospheric pressure
what is evaporation
process where compound transitions from liquid to gas at temp below its boiling point
vapor pressure < atmospheric pressure
relationship between atmospheric pressure and boiling point
- ↑ atmospheric pressure = ↑ boiling point (ex. Hyperbaric O2 chamber)
- ↓ atmospheric pressure = ↓ boiling point (high altitude)
what is partial pressure
fractional amount of pressure a single gas exerts within a gas mixture
what is Dalton’s law of partial pressures
total gas pressure in a container is equal to the sum of the partial pressures exerted by each gas
what determines the depth of anesthesia
partial pressure of anesthetic agent in the brain
NOT the volumes percent (set on vaporizer dial)
partial pressure of 6% Desflurane at sea level vs. in Denver (1 mile above sea level)
sea level = 45.6 mmHg
Denver = 37.2 mmHg
inhaled anesthetics that can become unstable in dessicated soda lime
what can they produce
desflurane
isoflurane
can produce carbon monoxide (des > iso)
vapor pressure of sevo
157 mmHg
vapor pressure of des
669 mmHg
vapor pressure of iso
238 mmHg
vapor pressure of N2O
38,770 mmHg
boiling point of des
22 dec C
molecular weight of sevo
200 g
molecular weight of des
168 g
molecular weight of iso
184 g
molecular weight of N2O
44 g
inhaled anesthetic that is unstable in hydrated CO2 absorbent
sevo
inhaled anesthetic that is stable in dehydrated CO2 absorber
N2O
what is solubility of an anesthetic agent
ability of anesthetic agent to dissolve in blood & tissues
which is more soluble in a hydrophilic solvent - polar or nonpolar solute?
polar
what describes the relative solubility of a solute in 2 different solvents
partition coefficient
describes relative solubility of an inhalation anesthetic in blood vs. in alveolar gas when partial pressures between compartments are equal
blood:gas partition coefficient
how is b:g partition coefficient calculated
anesthetic dissolved in blood / anesthetic inside alveolus
anesthetic implications of a low b:g
faster onset, faster speed of emergence
anesthetic implications of a higher b:g
slower onset, slower speed of emergence,
b:g of sevo
0.65
b:g of des
0.42
b:g of iso
1.46
b:g of N2O
0.46
what is FA/FI
- Concentration of agent inside alveoli is proportional to concentration inside blood, which is proportional to anesthetic inside brain
- Alveolar partial pressure ~ blood partial pressure ~ brain partial pressure
what is FA?
partial pressure of anesthetic inside the alveoli (surrogate for measurement of anesthetic inside the brain)
Anesthetic washes into alveoli & establishes a partial pressure
what is FI
concentration of anesthetic exiting vaporizer
how are anesthesia gases transferred from machine to the patient’s brain (4 steps)
- machine to fresh gas
- fresh gas to alveoli
- alveoli to arterial blood
- arterial blood to brain
what is speed of induction a function of?
solubility
opposes buildup of anesthetic partial pressure in alveoli
continuous uptake of agent into blood
3 factors that have the most significant impact on anesthetic uptake into the blood (determinants of removal from alveoli)
- b:g
- CO
- partial pressure difference between alveolar gas and mixed venous gas
how does low solubilty affect speed of induction
↓ uptake into blood = ↑ rate of rise = faster equilibration of FA/FI = faster onset
how does high solubility affect speed of induction
↑ uptake in blood = ↓ rate of rise = slower equilibration of FA/FI = slower onset
what does the FA/FI curve show us?
the speed at which alveolar partial pressure equilibrates with partial pressure leaving the vaporizer
fastest to slowest rate of rise of FA/FI
N2O > des > sevo > iso > halothane
6 determinants of gas delivery to alveoli
- setting on vaporizer
- FGF
- time constant of delivery system
- anatomic dead space
- alveolar ventilation
- FRC
3 determinants of tissue uptake of gas
- tissue:blood solubility
- tissue blood flow
- partial pressure difference between arterial blood and tissue
what must happen for FA/FI to increase
there must be greater wash in or reduced uptake
what must happen for FA/FI to decrease
there must be either a reduced wash in or an increased uptake
5 factors that increase wash in and therefore increase FA/FI
- high FGF
- high alveolar ventilation
- low FRC
- low time constant
- low anatomic dead space
3 factors that decrease uptake and therefore increase FA/FI
- low solubility
- low CO
- low Pa-Pv difference
5 factors that decrease wash in and therefore decrease FA/FI
- low FGF
- low alveolar ventilation
- high FRC
- high time constant
- high anatomic dead space
3 factors that increase uptake and therefore decrease FA/FI
- high solubility
- high CO
- high Pa-Pv difference
body mass for VRG, muscle, fat, and vessel-poor groups
- VRG = 10%
- muscle = 50%
- fat = 20%
- vessel poor = 20%
CO received by VRG, muscle, fat, and vessel-poor groups
- VRG = 75% CO
- muscle = 20%
- fat = 5%
- vessel poor = < 1%
organs in vessel rich group
- brain
- heart
- kidneys
- liver
- endocrine glands
what is contained in the muscle group
skeletal muscle & skin
contained in vessel-poor group
bone, tendon, cartilage
what 3 things is the rate of anesthetic uptake into tissues dependent on?
- tissue blood flow
- solubility coefficient
- arterial blood:tissue partial pressure gradient
first to equilibrate with FA
VRG - These organs receive most of the anesthetic agent during induction,
uptake of N2O by different body compartments
uptake minimal in all groups; partitions the same to all compartments
3 ways inhaled anesthetics are eliminated
- Elimination from alveoli (primary mechanism)
- Hepatic biotransformation (secondary)
- Percutaneous loss (minimal, not clinically significant)
hepatic biotransformation of inhaled anesthetics
- N2O = 0.004%
- des = 0.02
- iso = 0.2
- sevo = 2-5
- halothane = 20
why does desflurane undergo a greater degree of elimination from the lungs than other anesthetics
the greater the hepatic metabolism, the less is eliminated from the lungs
how are halogenated agents metabolized
P450 system
primarily CYP2E1
primary mechanism for immune-mediated hepatic dysfunction
Trifluoroacetic acid (TFA)
metabolites of des & iso
inorganic fluoride ions
TFA
what is concentration effect
the higher the concentration of inhalation anesthetic delivered to alveolus (FA), the faster its onset of action (overpressurizing)
concentration effect is probably only clinically relevant for what inhaled anesthetic
N2O
which is more affected by concentration effect - higher or lower solubility gases
higher
N2O is ____ x more soluble in the blood than nitrogen
~34
why does N2O acheive the fastest rate of rise of FA/FI even though des is less soluble?
concentration effect
- When N2O introduced in lung, volume of N2O going from alveolus to pulmonary blood is much higher than amount of Nitrogen moving in opposite direction - alveolus shrinks - reduction in alveolar volume causes relative increase in FA
what is the augmented gas inflow effect
- Concentrating effect temporarily reduces alveolar volume
- Subsequent breath - concentrating effect causes increased inflow of tracheal gas containing anesthetic agent to replace lost alveolar volume
- Increases alveolar ventilation, augments FA
what is ventilation effect
describes how changes in alveolar ventilation can affect rate of rise of FA/FI
Greater alveolar ventilation = greater rate of rise of FA/FI
how does ventilation effect minimize risk of anesthetic overdose
In spontaneously ventilating patient, as anesthetic deepens alveolar ventilation decreases - reduced anesthetic input to alveolus
what is the 2nd gas effect
consequences of concentration effect when a second gas is co-administered
- When N2O and the second gas are introduced into alveolus, rapid uptake of N2O causes alveolus to temporarily shrink
- Reduction in alveolar volume and augmented tracheal inflow = relative increase in concentration of 2nd gas
- Partial pressure of alveolar O2 also increases when alveolus shrinks (transient)
- End result: alveolar concentration of the other gases is higher vs. admin alone
- More meaningful benefit with agents of higher b:g (iso > seo > des)
how does R-L shunt affect FA/FI
- causes some deoxygenated blood leaving R heart to bypass lungs
- Results in reduced PaO2
- Results in slower rate of rise, reduction in partial pressure of anesthetic in arterial blood
examples of conditions that cause a R-L shunt
ToF, PFO, Eisenmenger’s syndrome, tricuspid atresia, Ebstein’s anomaly
are gases of high or low solubility more affected by R-L shunt
why
lower
Less soluble agents undergo very little uptake by blood (effect of dilution unchecked)
inhaled anesthetic FA/FI curves affected the most and least by R-L shunt
most = des (lowest b:g)
least = iso (highest b:g)
how is IV induction affected by R-L shunt
faster induction (blood bypasses lungs and travels to brain faster)
what is MAC
concentration that prevents nociceptive withdrawal reflex following painful stimulus in 50% of population