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The Application of Local Anesthetics

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The Application of Local Anesthetics Drugs affecting the central nervous system Anesthetic agents 1. General anesthetic agents General anesthesia is used mainly for operative procedures. Anesthesia involves: . narcosis – putting the patient into the state of unconsciousness . analgesia – elimination of pain . autonomic blockade – decreasing the patient’s reaction to stimuli . decreasing the tension of the striate muscles. The following groups of drugs are used as general anesthetic agents . inhalational anesthetics – nitrous oxide, ether and halogenated anesthetics – halothane, enflurane, isoflurane, desflurane, sevoflurane . intravenous anesthetic agents –to prepare the patient for operative procedures or for general anesthesia. Intravenous anesthetic drugs include: General anesthetics – ketamine, propanidid, etomidate and propofol Hypnotic drugs – barbiturates: thiopental and methohexital Opioid analgesic drugs – fentanyl, alfentanil, sufentanil, remifentanil Anxiolytic drugs – eliminating emotional tension: diazepam, flurazepam, midazolam Neuroleptics - mainly droperidol Drugs causing muscle relaxation - mainly pancuronium The ideal anesthetic agent should meet many requirements, such as: . good analgesic and anesthetic properties . slight influence on breathing and circulation . lack of irritative action on the skin . biotransformation without creating harmful metabolites . low toxicity and a high therapeutic index . rapid start and end of action when administration is stopped . appropriate physicochemical properties (stability, non- flammability and non-explosiveness) . environmental safety. General inhalational anesthetics Nitrous oxide. It is a common inhalational anesthetic with weak hypnotic and strong analgesic action. Nitrous oxide is slightly toxic. Depression of the respiratory tract is the main danger during the use of nitrous oxide. This problem may be avoided when nitrous oxide is administered in a mixture with oxygen (70% N2O + 30% oxygen). Nitrous oxide does not act harmfully on the parenchymatous organs, does not irritate the mucous membrane of the upper airways and does not impair intestinal peristalsis. It is most often used with halothane. Nitrous oxide does not induce skeletal muscle relaxation. It is also known as laughing gas because of causing short, very pleasant periods of excitation. Ethyl ether (H3C-CH2-O-CH2-CH3). It is a flammable liquid, susceptible to oxidation producing explosive peroxides. Ether for anesthesia is stabilized by ethanol. Ethyl ether has many advantages: a wide therapeutic range, ease of use, strong hypnotic, analgesic and relaxing action, and a low price. However, it is being withdrawn form therapy because of its explosive properties and unfavourable metabolic action, which is caused by inhibition of lactate dehydrogenase and leads to metabolic acidosis. Halogenated anesthetics are volatile liquids with a distinctive odour. They have dfifferent blood:gas partition coefficients (desflurane – 0.42, sevoflurane – 0.59, isoflurane – 1.40, enflurane – 1.91, halothane – 2.30, methoxyflurane - 12), which is important for their accumulation in the blood and tissues, the onset of general anesthesia and elimination time. The more easily a drug dissolves in the blood, the greater its concentration in the blood and tissues before it reaches the desired partial pressure in the brain and the more slowly it is eliminated from the body. Halothane Cl HALAN, NARCOTAN CF3 Br Isoflurane, FORANE Halogenated anesthetics F Cl F O CF3 F F Desflurane, SUPRANE F O CF3 F Cl F Enflurane, EFRANE O F F F Cl F Methoxyflurane, METOFANE CH3 O Cl F CF3 Sevoflurane, SEVOFRANE F O CF3 The main pathway of elimination of inhalational anesthetics is the lungs. Only a small part is metabolized in the liver and eliminated by the kidneys. The degree of biotransformation is crucial for their toxicity. Isoflurane, in contrast to other inhalational anesthetics, undergoes biotransformation to a small degree. 18-20% of halothane, 2.9% of enflurane and sevoflurane and 0.02% of isoflurane (to fluoride and non-volatile fluoride-organic compounds) undergoes biotransformation in the liver. The nephrotoxic action of methoxyflurane is caused by its biotransformation leading to significant amounts of fluoride and oxalate acid. The halogenated anesthetics differ in their power of action and unwanted effects. The most powerful action is demonstrated by methoxyflurane. Its Cl F CH3 O good solubility in fats results in a longC linduction period of 20-30 min and a long withdrawal from anesthesia.F The anesthetic action of desflurane and sevoflurane is weaker than that of isoflurane. Isoflurane has a higher therapeutic index than halothane. The halogenated anesthetics cause some unwanted effects: . respiratory depression . hepatotoxicity and nephrotoxicity . cardiotoxicity (negative inotropic action, arrhythmogenic action, hypotension) . malignant hyperthermia (uncontrolled increase of body temperature, which may lead to death and is caused by generalized muscle tension, during which excessive heat is produced and a huge amount of oxygen is used). Dantrolene is a drug which prevents malignant hyperthermia. It inhibits the release of calcium ions from sarcoplasmic reticulum and prevents muscular contraction. H O N O N O 2 Dantrolene O N N General intravenous anesthetic agents Ketamine is a structural analog of phencyclidine. There is an asymmetric carbon atom in position C2 of the cyclohexane ring. Although in therapy racemate is used, the potency of S(+)-ketamine is greater than that of racemate and the R(-)-isomer and fewer unwanted effects are observed. Cl O Ketamine, KETANEST N H 2-(2-Chlorophenyl)-2-(methylamino)- CH 3 cyclohexanon Ketamine acts analgetically, anesthetically, locally anesthetically, sympathomimetically (inhibits the reuptake of NA, DA and 5- HT), and parasympathomimetically (increases glandular secretion). S(+)-Ketamine acts by binding with opioid receptors and places which bind the phencyclidine (PCP) of NMDA receptors. The R(-)-isomer shows lower affinity for opioid receptors and places binding the phencyclidine of NMDA receptors. ANALGESY Opioid and NMDA receptors -stimulation NMDA NEURO- BRONCHOLYSIS KETAMINE receptors PROTECTION NMDA receptors ANALGESY Figure The action of ketamine (according to M. Bastgkeit: Pharm. Ztg. 1997, 142 (no 4), p. 40). Ketamine: inhibits the reuptake of NA, DA and 5-HT by neurons, which increases indirectly the stimulation of particular receptors acts parasympathomimetically (increases glandular secretion by influencing nicotinic and muscarinic cholinergic receptors) affects voltage-dependent ion channels (mainly sodium, potassium and calcium channels) affects the GABAA-chlorine channel. The mechanism of all that action remains unexplained. While the affinity of ketamine for -opioid receptors determines its hypnotic action, its affinity for -opioid receptors determines its analgetic action. The analgetic action of ketamine is similar to petidine, an opioid analgetic. The analgetic action of S(+)-ketamine is approx. 70% greater than that of racemate. The depressive action of S(+)-ketamine is weaker than that of racemate. R(-)-Ketamine binds mainly with -opioid receptors, which explains its unwanted cardiologic effects and the patient’s agitation after awakening. S(+)-Ketamine acts as a noncompetitive NMDA receptor agonist and demonstrates neuroprotective and possibly, anesthetic action. The anesthetic action of S(+)-ketamine is twice as strong as that of racemate. It is believed that the neuroprotective action of ketamine is caused by the trapping of free radicals, which act neurotoxically, central sympatholytic action and the increased DA degradation in the nucleus caudatus. S(+)-Ketamine has 4 times greater affinity for places binding PCP (phencyclidine) than the R(-)-isomer. The places binding PCP are located inside the ion channel, which is connected with the NMDA receptor. They are responsible for memory processes. S(+)-Ketamine inhibits the extraneuronal trapping and transport of catecholamines. R(-)-Ketamine inhibits weakly the transport of catecholamines but its inhibition of serotonin transport is twice as strong as that of the S(+)-isomer. The superiority of S(+)-ketamine over R(-)-ketamine consists in: . stronger analgesic and anesthetic action . 2.5 times greater therapeutic index . lower spontaneous response and arrhythmia . shorter phase of awakening . insignificant influence on the patient’s attention . insignificant degree of amnesia. The bioavailability of ketamine after oral or rectal administration is 20% and 93% after IM administration. The action of ketamine is observed: . immediately on IV administration . after 5 minutes on IM administration . after 20 minutes on oral administration . after 10-15 minutes after rectal administration. Ketamine demonstrates the following kinds of action in terms of duration time: anesthetic: 10-15 minutes analgesic: 40 minutes amnesia: 1-2 h. In the presence of barbiturates, benzodiazepines and neuroleptics the duration of action of ketamine is prolonged. In the liver, under the influence of cytochrome P-450 ketamine undergoes N-demethylation to active norketamine. Hydroxyderivatives are the next products of biotransformation. H3C OH CH3 Propofol, DEPRIVAN H C 3 CH3 2,6-Bis(1-methylethyl)phenol Propofol is a short-acting agent with a very fast start of action (~30 s) and a short time needed to recover consciousness after anesthesia. It is metabolized in the liver where it conjugates with glucuronic acid (~50% of a dose) and is hydroxylated. Its
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