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Chapter 3 T&L Chapter 3 Anesthetic Agents and Adjuncts 1 Chapter 3 Anesthetic Agents and Adjuncts Anesthetic agents and adjuncts may be classified a number of ways. First, they may be classified based on the route of administration. Inhalant agents are administered from an anesthetic machine into the lower respiratory tree via an endotracheal tube or mask. Injectable agents are injected intravenously, intramuscularly, subcutaneously, intraperitoneally, intralesionally, or into a number of other locations. Oral agents are given by mouth, and topical agents are applied to a body surface such as the skin or mucous membranes. Another way these agents may be classified is based on the time period at which they are given during the course of an anesthetic procedure. Drugs given before general anesthesia are referred to as preanesthetic medications. Drugs used to induce general anesthesia are referred to as induction agents, and those used to maintain general anesthesia are referred to as maintenance agents. A third way anesthetic agents and adjuncts may be classified is according to the principal effect. Local anesthetics induce a loss of sensation in a localized area of the body. In contrast, general anesthetics induce a loss of sensation over the entire body, accompanied by unconsciousness. Sedatives and tranquilizers are agents that cause sedation and tranquilization, respectively. Analgesics prevent and control pain. Muscle relaxants decrease muscle tone. Chapter 3 Anesthetic Agents and Adjuncts Neuromuscular blockers, although infrequently used in general practice, are used to relax or paralyze skeletal muscles during ophthalmic, orthopedic, or other surgeries. Anticholinergic agents are used to decrease effects of parasympathetic nervous system (PNS) stimulation such as bradycardia and excessive salivation. Finally, reversal agents lessen or abolish the effects of other anesthetic agents and are therefore used to “wake” the patient after sedation or anesthesia. Many of the agents used in anesthesia cause two or more of these effects, depending on the dose and the circumstances under which they are used. For instance, morphine causes sedation and is an excellent analgesic. The injectable drug dexmedetomidine causes moderate to profound sedation, analgesia, and good muscle relaxation when given alone but can be used in combination with other agents to induce general anesthesia. The intravenous (IV) anesthetic propofol induces general anesthesia at higher doses but can be used as a sedative when given as a low-dose constant rate infusion (CRI). As a consequence, classification of these agents based on the principal effect is somewhat arbitrary. The final way anesthetic agents and adjuncts may be classified is based on their chemistry. For the student, this is perhaps the most useful method of classification because the agents within a given class tend to have similar properties and effects. For this reason, the anesthetic agents and adjuncts Chapter 3 Anesthetic Agents and Adjuncts discussed herein will be presented this way. Tables 3-1 to 3-4 summarize the principal effects and adverse effects of the anesthetic agents and adjuncts. 3 Chapter 3 Anesthetic Agents and Adjuncts Before embarking on a study of anesthetic agents and adjuncts, a general knowledge of pharmacokinetics (the effect the body has on a drug) and pharmacodynamics (the effects a drug has on the body) is necessary. 4 Chapter 3 Anesthetic Agents and Adjuncts Anesthetic agents and adjuncts differ according to the degree to which they stimulate target tissue receptors. Agonists bind to and stimulate tissue receptors. Most anesthetics and adjuncts are classified as agonists. 5 Chapter 3 Anesthetic Agents and Adjuncts Some drug classes such as the alpha2-adrenergics and opioids include drugs that are classified as antagonists. Antagonists bind to but do not stimulate receptors. Antagonists competitively bind to target tissues preventing the corresponding agonist from causing more stimulation. Must use the proper antagonist when “waking” a patient from anesthesia. Chapter 3 Anesthetic Agents and Adjuncts The opioid class also includes some partial agonists and agonist-antagonists. Partial agonists bind to and partially stimulate receptors. Agonist-antagonists bind to more than one receptor type and simultaneously stimulate at least one and block at least one. Both partial agonists and agonist-antagonists are sometimes used to partially block the effects of pure agonists. 7 Chapter 3 Anesthetic Agents and Adjuncts Most anesthesia protocols use a combination of drugs to provide adequate analgesia and anesthesia. TECHNICIAN NOTE Many commonly used general anesthetics are not analgesics but indirectly provide pain control during the anesthetic period by producing a state of unconsciousness. Therefore when these agents are used, analgesia in the peri- operative period must be provided by the use of true analgesics such as the opioids. Chapter 3 Anesthetic Agents and Adjuncts Two or more anesthetic agents and/or adjuncts are often used in combination. Some drugs can be safely mixed in the same syringe, whereas others cannot. Incompatible mixtures can produce a variety of harmful or even fatal adverse effects because of loss of potency, change in chemistry, precipitation of one or more of the drugs, or other untoward interactions. For this reason, the anesthetist must observe some general guidelines when faced with a decision to mix two or more drugs. TECHNICIAN NOTE With the exception of diazepam, most anesthetic agents and adjuncts are water- soluble. In general, two or more water-soluble drugs can be safely mixed, but a water-soluble drug and a non–water-soluble drug cannot. For this reason, when using two or more drugs in the same patient, do not mix them unless you are sure that it is safe to do so. 9 Chapter 3 Anesthetic Agents and Adjuncts Any use of a controlled substances necessitates compliance with strict handling and storage requirements as well as detailed record-keeping requirements owing to the potential for abuse or theft. Specifically, these agents are subject to diversion by people for illicit purposes, and, when used in this manner, have the potential to induce psychological and/or physical dependency. Theft, illegal use, or diversion of a controlled substance is a criminal act that is punishable by imprisonment and/or fines, and may affect eligibility for professional licensure. In the United States, the Controlled Substances Act assigns each drug to one of five drug schedules (I, II, III, IV, or V) according to its potential for abuse. In a similar way, Canadian legislation has classified each agent as a narcotic, controlled, or prescription drug. Agents classified as narcotics in Canada or as Schedule II substances in the United States cannot be dispensed or drawn into a syringe except under the direct supervision of a licensed veterinarian. 10 Chapter 3 Anesthetic Agents and Adjuncts The inventory must include: • the date the inventory was taken including whether or not it was taken at the beginning or end of the day • the finished form of the drug (e.g. injectable, tablets, oral liquid) • the amount of each drug on hand (e.g. volume for liquid drugs, number of tablets) • the drug concentration (e.g. 10 mg/ml, 100 mg tablets) • the number of containers of each drug (e.g. five 10 ml bottles, two 500 tablet bottles) It should also include the name, address, and DEA registration number of the registrant and the signature of the person that took the inventory 11 Chapter 3 Anesthetic Agents and Adjuncts Schedule II controlled substances may be ordered only by using DEA From 222, which must be filled out in triplicate. Two copies are forwarded to the supplier, and one is retained by the purchaser. No special order form is necessary for Schedule III and IV agents, however the supplier must verify that the purchaser is registered. In June 2010, electronic prescription writing was approved by the DEA, but in order to participate in this program, only software that meets DEA requirements can be used. 12 Chapter 3 Anesthetic Agents and Adjuncts Carfentanil and etorphine hydrochloride (highly potent opioid agonists used to immobilize wild animals) and diprenorphine (a highly potent opioid antagonist used to reverse effects of carfentanil and etorphine in wild animals) must be stored in a safe or steel cabinet. These substances are highly dangerous to humans, and therefore must be used with great caution. 13 Chapter 3 Anesthetic Agents and Adjuncts (See Box 3-1 for DEA prescription writing requirements.) 14 Chapter 3 Anesthetic Agents and Adjuncts These are the principal reasons for giving commonly used preanesthetic medications follow. Table 3-6 summarizes these benefits. TECHNICIAN NOTE Patients given sedatives by the IM or SC route should be left undisturbed until peak action is reached because excitement or stimulation can sometimes cause the patient to override the effects. Drugs given intravenously should be administered slowly and cautiously because potency and the potential for adverse effects are increased when drugs are given by this route. 15 Chapter 3 Anesthetic Agents and Adjuncts 16 Chapter 3 Anesthetic Agents and Adjuncts Give either drug IM 20-30 minutes before anesthetic induction. Chapter 3 Anesthetic Agents and Adjuncts Also known as parasympatholytics, anticholinergics are noncontrolled drugs that are most commonly used to prevent and treat bradycardia and to decrease salivary secretions arising from parasympathetic stimulation. The two anticholinergic
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