Autonomic Nervous System Basic anatomical difference between the motor pathways of

Rashelle Lopez-Salvatierra, MD the voluntary somatic nervous system (to skeletal muscles)
Pre test and those of the autonomic nervous system
1. Two branches of ANS Somatic division:
2. The preganglionic neurons of SNS originate from  Cell bodies of motor neurons reside in CNS (brain
________ regions of spinal cord? or spinal cord)
3. Neurotransmitter of SNS (example)  Their axons (sheathed in spinal nerves) extend all
the way to their skeletal muscles
4. Effect of SNS in the heart?
Autonomic system: chains of two motor neurons
5. Example of endogenous catecholamine
 1st = preganglionic neuron (in brain or cord)
6. Neurotransmitter of PNS?  2nd = gangionic neuron (cell body in ganglion
7. Receptor for PNS? outside CNS)
8. Beta-blocker (example)  Slower because lightly or unmyelinated

9. Give a sympathomimetic drug? (see next diagram)

10. Effect of PNS in the sweat gland? Axon of 1st (preganglionic) neuron leaves CNS to
synapse with the 2nd (ganglionic) neuron
ANESTHESIOLOGY Axon of 2nd (ganglionic) neuron extends to the
 Practice of autonomic nervous system organ it serves
 Pre-op: bedside evaluation of ANS fxn.
- record BP and HR when pt. Changes from
supine to upright posture
 ANS dysfxn is suggested by orthostatic
hypotension (SBP decrease more than 30mmhg)
and absence of an increase HR on assuming the
upright position
ANS
 ANS is the subdivision of the peripheral nervous
system that regulates body activities that are
*autonomic (upper) / somatic (lower)
generally not under conscious control
 Visceral motor innervates non-skeletal (non-
somatic) muscles Comparison of Somatic and Autonomic Systems
 Composed of a special group of neurons serving:
 Cardiac muscle (the heart)
 Smooth muscle (walls of viscera and blood vessels)
 Internal organs
 Skin
ANS in the Nervous System

Divisions of the autonomic nervous system

 Parasympathetic division
 Sympathetic division
 Serve most of the same organs but cause Parasympathetic Division
opposing or antagonistic effects  Preganglionic fibers
 Parasysmpathetic: routine maintenance originate in the brain
“rest &digest” stem and the sacral
segments of the spinal
 Sympathetic: mobilization & increased metabolism cord
“fight, flight or fright” or “fight, flight or freeze”  Synapse in ganglia
Where they come from very close to, or
within, the target
organ.
Sympathetic:
 Preganglionic fibers
thoracolumbar are long and
Parasympathetic
craniosacral
postganglionic fibers are short
Cranial outflow
III - pupils constrict
VII - tears, nasal mucus, saliva
IX – parotid salivary gland
X (Vagus n) – visceral organs of thorax & abdomen:
 Stimulates digestive glands
 Increases motility of smooth muscle of digestive
tract
 Decreases heart rate
 Causes bronchial constriction
Sacral outflow (S2-4): form pelvic splanchnic nerves
Role of the Parasympathetic Division
 Supply 2nd half of large intestine
 Concerned with keeping body energy use low  Supply all the pelvic (genitourinary) organs
 Involves the D activities – digestion, defecation,
Parasympathetic Division Outflow
and diuresis (urination)
 Its activity is illustrated in a person who relaxes
after a meal
 Blood pressure, heart rate, and respiratory rates
are low
 Gastrointestinal tract activity is high
 The skin is warm and the pupils are constricted
Parasympathetic Functions - Memory Device
SLUDD
S = salivation
L = lacrimation
U = urination
D = digestion
D = defecation
Parasympathetic nervous system
“rest & digest”
 Also called the craniosacral system because all its
preganglionic neurons are in the brain stem or
sacral levels of the spinal cord
 Cranial nerves III,VII, IX and X
 In lateral horn of gray matter from S2-S4
 Only innervate internal organs (not skin)
 Acetylcholine is neurotransmitter at end organ as
well as at preganglionic synapse: “cholinergic”
PNS transmission
 Ach – main NT
 Ach acts on Muscarine or Nicotine receptors

Acetyl Co A + Choline acetyl

Acetylcholine
Choline transferase

Choline +
Ach Cholinesterase
Acetic acid Options of preganglionic axons in sympathetic trunk
1. Synapse on postganglionic neuron in chain
ganglion then return to spinal nerve and follow its
Role of the Sympathetic branch to the skin
(Thoracolumbar) Division 2. Ascend or descend within sympathetic trunk,
 The sympathetic division is the fight-or-flight synapse with a posganglionic neuron within a chain
system ganglion, and return to spinal nerve at that level
 Involves E activities – exercise, excitement, and follow branches to skin
emergency, and embarrassment 3. Enter sympathetic chain, pass through without
Role of the Sympathetic (Thoracolumbar) Division synapsing, form a splanchnic nerve that passes
toward thoracic or abdominal organs
 Promotes adjustments during exercise – blood
flow to organs is reduced, flow to muscles  These synapse in prevertebral ganglion in front of
 Its activity is illustrated by a person who is aorta
threatened  Postganglionic axons follow arteries to organs
 Heart rate increases, and breathing is rapid and Synapse in chain ganglia at same level or different level
deep
 The skin is cold (reduced blood flow) and sweaty,
and the pupils dilate
 Increased blood glucose
 Decreased GI peristalsis
Sympathetic nervous system
“fight, flight or fright”
 Also called thoracolumbar system: all its neurons
are in lateral horn of gray matter from T1-L2
 Lead to every part of the body (unlike parasymp.)
 Easy to remember that when nervous, you sweat;
when afraid, hair stands on end; when excited
blood pressure rises (vasoconstriction): these Pass through ganglia and synapse in prevertebral ganglion
sympathetic only
 Also causes: dry mouth, pupils to dilate, increased
heart & respiratory rates to increase O2 to skeletal
muscles, and liver to release glucose
 Norepinephrine (aka noradrenaline) is
neurotransmitter released by most postganglionic
fibers (acetylcholine in preganglionic): “adrenergic”
 Regardless of target, all begin same
 Preganglionic axons exit spinal cord through
ventral root and enter spinal nerve
 Exit spinal nerve via communicating ramus
 Enter sympathetic trunk/chain where
postganglionic neurons are
 Has three options…
Sympathetic The Organization of the Sympathetic Division

SNS Transmission
 Catecholamine - compound with catechol nucleus
+ amine containing side chain
 Endogenous
Adrenal gland is  Dopamine
exception  NE
On top of kidneys  EPI
 Synthetic
 Isoproterenol
 Dobutamine
4 types of adrenergic receptor organ cells:
Adrenal medulla 1. Alpha-1
(inside part) is a
2. Alpha-2
major organ of
the sympathetic 3. Beta-1
nervous system 4. Beta-2
Dopaminergic
Inactivation of Catecholamine
 Reuptake into the presynaptic terminal
 Extraneuronal uptake (MAO, COMT)
 Diffusion into circulation
 VMA – final metabolic end product
Adrenal gland is
exception
 Synapse in gland
 Can cause body-
wide release of
epinephrine aka
adrenaline and
norepinephrine
in an extreme
emergency
 (adrenaline
“rush” or surge)
Parasympathetic NS Sympathetic NS  Stimulation of these nonadrenergic receptors
- 1:1/1:2 -1:8000/1:20 (specifically, DA1 receptors) vasodilates the renal
vasculature and promotes diuresis
-Localized,discrete -Diffuse  At moderate doses (2–10 g/kg/min)
Conservation of body fxns - Beta1-stimulation increases myocardial
-Nicotinic and muscarinic -Alpha and Beta receptors contractility, heart rate, and cardiac output
receptor  Myocardial oxygen demand typically increases
more than supply.
-Cholinergic -Adrenergic  Alpha1-Effects - at higher doses (10–20g/kg/min)
Fibers: Fibers: - Increase in peripheral vascular resistance and
preganglionic –Long a fall in renal blood flow
Preganglionic –short  Indirect effects of DA are due to release of
postganglionic –short Postganglionic- long norepinephrine: At doses above 20 g/kg/min
 near the organ it  treatment of shock
supplies - improve cardiac output, support blood
pressure, and maintain renal function
 Used in combination with a vasodilator (eg,
SUMMARY nitroglycerin or nitroprusside)
- reduces afterload and further improves
cardiac output
NE
 Predominate on alpha1 receptor
 Increase PVR and inc. diastolic, systolic, MAP
 Vasoconstriction caused can decrease blood flow
to pulmonary, renal and mesenteric circulation
 Can cause ischemia of fingers bec of marked
peripheral vasoconstriction
EPI
 Binds to alpha and beta receptors
 Exogenous epi is given IV to treat cardiac arrest,
circulatory collapse, and anaphylaxis
 Beta1 – positive inotropy, chronotropy, and
enhanced conduction
 Beta2- s.m. relaxation in vasculature and bronchial
tree
 Alpha 1 - vasoconstriction
Dobutamine
 Stimulates beta1 without significant effect on
beta2, alpha, or DA
 Useful in CHF or MI complicated by low CO
 Lower doses than 20ug/kg/min do not cause
tachycardia
Isoprotenerol
CATECHOLAMINES
 Pure beta–agonist
 Pharmacologic effects produced by catecholamines  Beta1- predominates
reflect the ability of these substances to stimulate - Increase heart rate, contractility, and cardiac
adrenergic receptors output.
Dopamine  associated with marked tachycardia and
 nonselective direct and indirect adrenergic agonist arrythmias -> removed from ACLS resuscitation
 vary markedly with the dose protocols
 Small doses ( 2 g/kg/min) -minimal adrenergic 4 types of adrenergic receptor organ cells:
effects but activate dopaminergic receptors 1. Alpha-1 = vasoconstriction of blood vessels
- inc. blood return to heart, inc. circulation, inc. BP
2. Alpha-2 = inhibits release of norepinephrine
- dec. in vasoconstriction, dec. BP
3. Beta-1 = inc. in heart rate & force on contraction
4. Beta-2 = relaxation of smooth muscle in bronchi, uterus,
peripheral blood vessels
Dopaminergic = dilate vessels, inc. in blood flow - only
dopamine activates this receptor

Antihypertensives
 Treatment of essential HPN
 Decrease SBP by selectively impairing SNS fxn at
the heart and/or peripheral vasculature
 During Anesthesia: exaggerated decrease in
systemic BP (associated w/ hemorrhage,positive
air pressure,sudden changes in position) may
reflect an impaired degree of compensatory
peripheral vasoconstriction
 The response to sympathomimetic maybe
modified by prior treatment with anti hypertensive
 Antihypertensives that decrease SNS activity are
associated with sedation and decreased MAC
 These drugs should be continued during
SYMPATHOMIMETICS perioperative period to maintain optimal control of
 Exert effects on the alpha or beta receptor via BP
 Direct acting : mimics effect of NE Antihypertensives drugs
 Indirect acting: evoke release of NE
 Angiotensin-converting enzyme inhibitors
 Vasopressors -Captopril
 Reverse downward trend in BP -Enalapril
 Increase BP by: increase myocardial
contractility – EPHEDRINE peripheral  Central sympatholytics
vasoconstriction -Clonidine
 PHENYLEPHRINE  Calcium blockers
Ephedrine -Verapamil
 Indirect acting but with some direct acting effect -Nifedipine
 Cardiovascular effects resembles epinephrine but
BP elevation is less intense and lasts 10x longer -Diltiazem
 Increase in SBP,DBP,CO,HR  Beta Adrenergic Antagonists
 Treatment of anesthesia-induced hypotension in -Propanolol
pregnant women
-Metoprolol
Phenylephrine
-Nadolol/Atenolol/Timolol
 Direct acting
 Increases venous constriction more the arterial  Alpha and Beta Adrenergic Antagonist
constriction (alpha1 effect) -Labetolol
 Devoid of Beta adrenergic receptor stimulation  Peripheral Vasodilators
 Mimics NE
-Nitroprusside
-Nitroglycerine
BETA ADRENERGIC AGONIST NITRIC OXIDE
 CATECHOLAMINES: beta-1 agonist, used to  Administered by inhalation to produce selective
increase HR and myocardial contractility relaxation of the pulmonary vasculature and
 BETA – 2 AGONIST: produce relaxation of improvement of arterial oxygenation
bronchioles,uterine and vascular smooth muscles  Act as selective pulmonary vasodilator
reflecting selective stimulation of beta-2 receptors ANTICHOLINERGICS
 Drug selective for beta 2 receptors are less likely
than beta 1 agonist to produce adverse cardiac  Prevent the muscarinic effects of acetylcholine by
effects (tachycardia and cardiac dysrythmias) competing for the same receptors as are normally
 Tachyphylaxis is attributed to decrease number occupied by the neurotransmitter
and/or sensitivity of beta receptors that occurs  Low doses maybe sufficeint to inhibit salivation but
with chronic stimulation of these receptors large doses are needed for gastrointestinal effects
 Ex: ALBUTEROL –most often selected for treatment
of bronchospasm in anesthetized patients
-inhalation 2-3 deep breaths (90ug) repeated q 4
to 6 hrs
BETA ADRENERGIC ANTAGONISTS
 Produce selective beta-1 blockade ( decrease HR
and myocardial contractility) or mixed responses ANTICHOLINESTERASES
that reflect drug effects at beta-2 receptors
(bronchial and smooth muscle constriction)  Inhibit the enzyme ACETYLCHOLINESTERASES
 ‘LOL’ which is responsible for the rapid hydrolysis of
 Decrease systemic blood pressure by decreasing acetylcholine after its release from cholinergic
cardiac output nerve endings
 Absence of orthostatic hypotension ANTICHOLINESTERASES
 Do not alter anesthetic requirements Type title here

 Effective in decreasing myocardial oxygen

requirements ( relief of angina pectoris) TERTIARY QUATERNARY
Can cross BBB Does not easily cross BBB
 In patients high risk for developing perioperative effective for treatment for accumulation is predominantly at peripheral sites
myocardial ischemia,administration of beta central anticholinergic syndrome
adrenergic antagonist may decrease the incidence
of post operative cardiovascular complications PHYSOSTIGMINE NEOSTIGMINE PROGTISMINE ENDROPHRONIUM
 Adverse effects: excessive myocardial depression
and bronchoconstriction
 Cardioselective drugs: metoprolol,esmolol
 Abrupt discontinuation of treatment with beta
antagonist can be associated with excessive SNS
activity
 Treatment shld. be maintained throughout the
perioperative period.
PERIPHERAL VASODILATORS
 Treatment for hypertensive crisis
 Nitroprusside and nitroglycerin given as
continuous infusion
 Decrease systemic blood pressure by decreasing
vascular resistance (nitroprusside) or by venous
dilatation (nitroprusside and nitroglycerin)
 Both drugs act by generating nitric oxide
intracellularly which act as an endogenous
vasodilator
 Potential toxic effects: Cyanide toxicity
methemoglobinemia