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Anaesthesiology
Autonomic Nervous System Anatomy and Physiology
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
10 sections · 191 slides
Overview
- Scope of this topic
Anaesthesia and the Autonomic Nervous System
- Autonomic nervous system: definition and relevance to anaesthesia
- Functions of the system and its visceral afferent limb
Functional Anatomy
- Division into two parts, and central organisation
- Hypothalamus, medulla and the nucleus tractus solitarius
- Hypothalamic-neurohypophyseal connection
- Medulla oblongata and pons in acute autonomic control
- Spinal reflexes and peripheral organisation
- Reading the adrenergic-cholinergic balance table
- Homeostatic balance between adrenergic and cholinergic effects
- Homeostatic balance between adrenergic and cholinergic effects (continued)
- Homeostatic balance between adrenergic and cholinergic effects (continued)
- Homeostatic balance between adrenergic and cholinergic effects (continued)
- Craniosacral and thoracolumbar distribution
- Somatic versus autonomic motor pathways
- Efferent autonomic nervous system pathways
- The two-neuron autonomic motor chain
- Fibre conduction speeds and the sympathetic outflow
- Classification of nerve fibres by size and speed
- Three courses of a sympathetic preganglionic fibre
- Somatic reflex arc compared with sympathetic neuron arrangements
- The adrenal medulla and sympathetic postganglionic cell bodies
- Grey rami and the cervical sympathetic ganglia
- Origin and vagal distribution of the parasympathetic system
- Sacral outflow and sympathetic divergence
- Convergence in the parasympathetic system
- Sympathetic and parasympathetic wiring compared
Autonomic Innervation of Organs
- Cardiac pump function and the vagal effect
- Parasympathetic inotropy and the sympathetic cardiac supply
- Effects of right and left stellate ganglion stimulation
- Sympathetic tone and myocardial contractility
- Autonomic control of the coronary circulation
- Sympathetic control of the peripheral circulation
- Regional density of sympathetic vascular innervation
- Basal vasomotor tone and venous capacitance
- Autonomic innervation and vasomotor control of the lungs
- Hypoxic pulmonary vasoconstriction and bronchomotor control
Autonomic Nervous System Transmission
- Chemical transmission and the transmitter at each site
- Terminal effector plexus and the junctional cleft
- Terminal postganglionic nerve fibre and its varicosities
- Synthesis and quantal release of acetylcholine
- Metabolism of acetylcholine
- Synthesis and metabolism of acetylcholine
- Sympathetic transmission and the adrenal medullary surge
- Metabolic effects of adrenaline and the blood-brain barrier
- Definition and sources of catecholamines
- Catecholamine content of the adrenal medulla
- Chemical structures of endogenous and synthetic catecholamines
- Sympathomimetics and the synthesis of noradrenaline
- Direct-acting and indirect-acting sympathomimetics
- Catecholamine synthesis cascade
- Enzymes of the final synthetic steps
- Synthesis pathway of the catecholamines
- Regulation of catecholamine synthesis and release
- Inactivation of catecholamines and drugs that block reuptake
- Metabolism, excretion and clearance of catecholamines
- Synthesis, release and disposition of noradrenaline
Receptors
- Agonists, antagonists and the three cholinergic receptor classes
- Muscarinic receptor naming and the features of muscarinic stimulation
- Presynaptic adrenergic muscarinic receptors and atropine
- Physiological role of the prejunctional muscarinic receptor
- Nicotinic receptors and the nicotinic effect
- Cholinergic receptor subtypes and their locations
- Origin of the alpha and beta classification and its subtypes
- Dopamine receptors as a separate class
- Synaptic location of adrenergic receptors
- Presynaptic receptors on the adrenergic terminal
- Locations of known adrenergic receptors
- Order of potency of adrenergic agonists and antagonists
- Adrenergic receptor types, sites and actions
- Basis of the alpha subdivision and where alpha-1 receptors sit
- Cardiac alpha-1 receptors and the synaptic location of alpha receptors
- Actions of postsynaptic alpha-2 receptors
- Alpha-2 receptors in cholinergic pathways
- Effects of presynaptic and postsynaptic alpha-2 stimulation
- Alpha receptors in the coronary arteries
- Alpha-1 receptors and contractility in the normal and failing heart
- Alpha-1 activity in ischaemia and reperfusion
- Alpha receptors in peripheral vessels, preload and afterload
- Alpha receptors in the central nervous system and dexmedetomidine
- Alpha receptors in the kidney
- Beta receptor subtypes, second messenger and presynaptic beta-2
- Distribution of beta-1 and beta-2 receptors
- Postsynaptic beta responsiveness and beta receptors in the myocardium
- Beta receptor effects in heart, vessels and kidney
- Dopamine receptor types and the actions of DA2
- Dopamine effects on myocardium and peripheral vessels
- Dose-related dopamine effects and central dopamine receptors
- Dopamine in kidney and gut, and dopaminergic decline with age
- Adenosine and serotonin at the adrenergic terminal
- Prostaglandin E2, opioids and the histamine receptors
- Cardiac effects of histamine
- Receptor turnover, upregulation and downregulation
- Beta-1 downregulation in chronic heart failure
- Clinical consequences of receptor regulation and withdrawal syndromes
Autonomic Reflexes and Interactions
- Components of an autonomic reflex and where drugs interrupt it
- The baroreceptor reflex as a control loop
- Marey law and the arterial baroreceptor pathway
- Phases of the Valsalva manoeuvre and its interpretation
- Normal and abnormal blood pressure response to the Valsalva manoeuvre
- Venous baroreceptors
- Arterial and venous baroreceptors compared
- The Bainbridge reflex and bradycardia during spinal anaesthesia
- Autonomic interventions for resistant hypertension
- The denervated transplanted heart and its drug responses
- Reinnervation after cardiac transplantation
- Accentuated antagonism and coronary receptor interactions
- Muscarinic inhibition of noradrenaline release and coronary spasm
- Autonomic modulation of insulin release
- The renin-angiotensin cascade
- Angiotensin II, sympathetic tone and the triggers for renin release
- Interaction of the renin-angiotensin system with sympathetic control
Clinical Autonomic Pharmacology
- Classification of autonomic drugs and their modes of action
- Eight sites of autonomic drug action
- Postjunctional drug actions and determinants of response
- Ganglionic drugs: selectivity and agonists
- Ganglionic blocking agents, tubocurare and anticholinesterases
- Trimethaphan
- Three groups of cholinomimetic drugs
- Acetylcholine and the choline esters as drugs
- Receptor binding sites and structure-activity relations
- Clinical use and cautions with methacholine
- Clinical uses of bethanechol
- Cholinomimetic alkaloids and contraindications to muscarinic agonists
- Structures of direct-acting cholinomimetic esters and alkaloids
- Comparative muscarinic actions of direct cholinomimetic agents
- Indirect cholinomimetics and the effects of accumulated acetylcholine
- Anticholinesterases in reversal of neuromuscular block
- Reversible and irreversible cholinesterase inhibitors
- Competitive inhibitors and physostigmine's central access
- Structures of reversible anticholinesterase drugs
- Organophosphates, echothiophate and succinylcholine
- Organophosphate poisoning, atropine and pralidoxime
- Muscarinic antagonists and the clinical actions of atropine-like drugs
- Tertiary and quaternary antimuscarinic drugs
- Structures of the clinically useful antimuscarinic drugs
- Relative potency of the antimuscarinic drugs
- Glycopyrrolate in spinal anaesthesia, and central effects of scopolamine
- Cardiac and ocular effects of atropine and scopolamine
- Further cautions with the antimuscarinic drugs
- Central anticholinergic syndrome and its clinical features
- Treatment of the central anticholinergic syndrome
- Why physostigmine is used cautiously
- Reading the list of antimuscarinic compounds
- Antimuscarinic compounds associated with central anticholinergic syndrome
- Antimuscarinic compounds associated with central anticholinergic syndrome (continued)
Autonomic Syndromes and Autonomic Regulation
- The autonomic system beyond fight or flight
- Cardiac autonomic dysregulation and autonomic testing
- Autonomic neuromodulation as therapy
- Autonomic impairment as an outcome predictor
- Horner syndrome: the clinical triad
- Miosis and ptosis of the left eye in Horner syndrome
- Comparison of the two pupils and lid positions
- The three-neuron oculosympathetic pathway
- Anatomy and causes of Horner syndrome
- Localising the lesion by neuron order
- Pharmacological confirmation and localisation in Horner syndrome
- Diabetic neuropathy: presentation, prevalence and complications
- Assessment and classification of diabetic neuropathy
- Orthostatic hypotension and its distinction from reflex syncope
- Neurodegenerative, peripheral and autoimmune causes
- Drug causes and symptoms of orthostatic hypotension
- Diagnostic criteria for orthostatic hypotension
- Treatment of orthostatic hypotension
- Monoamine oxidase inhibitors: use and mechanism
- Hypertensive crisis and management of patients on MAOIs
- Tricyclic antidepressants and their anaesthetic implications
- Selective serotonin reuptake inhibitors
- Fluoxetine, bupropion and antidepressants in heart disease
Key Points and References
- Key points: organisation of the autonomic nervous system
- Key points: receptors and pharmacology
- References
- References (continued)
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- References (continued)
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition