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Practical Treatment Recommendations for the Safe Use of Anaesthetics

  • Practical Therapeutics
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Summary

General anaesthesia is the reversible depression of central nervous system function. There is still no agreement over what constitutes depth of anaesthesia, and the clinical anaesthetist must thus titrate drug input according to clinical signs (heart rate, blood pressure, somatic movement, autonomic responses).

The potency of inhalational agents may be expressed in terms of the MAC (minimum alveolar concentration); comparable end-points (including blood concentrations) have been proposed for the intravenous agents. Kinetic infusion regimens can be constructed for the intravenous agents to achieve the ED95 concentrations required to provide clinically adequate anaesthesia. However, because of individual differences in drug kinetics and: dynamics, as well as the influences of disease states and intercurrent therapy, the clinician will titrate the dose according to response. Administration of volatile or intravenous anaesthetics by fixed regimens may result in either overdosage or the risk of patient awareness.

The choice of anaesthetic drug is usually based on the nonhypnotic side effects of the different agents — including their central and regional cardiovascular effects, the speed and completeness of recovery, and the need to provide intraoperative analgesia. In addition, special techniques and drugs are often needed for neurosurgical, cardiothoracic and obstetric anaesthesia.

All anaesthetic agents (inhalation and intravenous) have other side effects (such as cardio-respiratory depression and organ toxicity related to the liver or kidney). Both halothane and enflurane may be responsible for postoperative hepatic dysfunction, while the metabolism of enflurane can also result in nephrotoxicity in patients with pre-existing renal dysfunction. Isoflurane has been reported to cause ‘coronary steal’ in patients with ischaemic heart disease through its coronary vasodilator properties.

Of the intravenous agents available for maintenance anaesthesia, large doses of thiopental result in prolonged recovery time, while ketamine may cause hallucinations. Benzodiazepines obtund these effects of ketamine, but are also accompanied by delayed recovery. At present, the combination of propofol and alfentanil offers the best pharmacological properties for maintenance of anaesthesia; however, caution is needed in the patient with ischaemic heart disease, hypertension or hypovolaemia.

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  1. Nuffield Department of Anaesthetics, The John Radcliffe Hospital, Headington, Oxford, OX3 9DV, England

    J. W. Sear

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Sear, J.W. Practical Treatment Recommendations for the Safe Use of Anaesthetics. Drugs 43, 54–68 (1992). https://doi.org/10.2165/00003495-199243010-00006

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