7/30/2019 Anestezja

1/66

1

Anesthesia as a specialty

Past, present and future

7/30/2019 Anestezja

2/66

2

Reference book

Clinical Anesthesiology,

G. Edward Morgan, Jr., Maged S.Mikhail, Michael J. Murray

Fourt Edition by the McGraw-HillCompanies 2006 a LANGEMedical Book

7/30/2019 Anestezja

3/66

3

www.katedraanest.cm-uj.krakow.pl

Prof. Janusz Andres (Head of the Chair andDepartment)

email: msandres@cyf-kr.edu.pl Agnieszka Frczek (Secretary)

email: agafrk@cm-uj.krakow.pl

Katarzyna Lepszy-Muszyska (Coordinator,email:muszynscy.brzozowka@neostrada.pl

mailto:msandres@cyf-kr.edu.plmailto:agafrk@cm-uj.krakow.plmailto:agafrk@cm-uj.krakow.plmailto:agafrk@cm-uj.krakow.plmailto:agafrk@cm-uj.krakow.plmailto:msandres@cyf-kr.edu.plmailto:msandres@cyf-kr.edu.plmailto:msandres@cyf-kr.edu.pl

7/30/2019 Anestezja

4/66

4

Pain as a part of surgery

Hypnosis

Alkohol

Botanical preparation

Superficial surgery

Galenic concept: body humors: blood,phlegm, yellow and black bile

7/30/2019 Anestezja

5/66

5

Inhalation Anesthesia

1540 Paracelsus: oil of vitriol (prepared by

Valerius Cordus and named Aether byFrobenius): used to feed fowl: it was taken

even by chickens and they fall asleep from

it for a while but awaken later without

harm

7/30/2019 Anestezja

6/66

6

Local anesthesia

Ancient Incas: coca leaf as a gift to the

Incas from the sun of God:

destruction of Incas culture

slaves payment

7/30/2019 Anestezja

7/66

7

Important names in history of

anesthesia Humphry Davy: 1778 - 1829 (laughing

gas, N20)

Horace Wells: January 1845, HarvardMedical School, clinical use of N20

William Morton: October 16,1846 ether for

the excision of the vascular lesion from theneck (John Collin Warren: gentlemen this isnot a humbug)

7/30/2019 Anestezja

8/66

8

Important names in the history of

anesthesia Prof. Ludwik Bierkowski: February 1847

KRAKW ether in Poland

anesthesia = temporary insensibility James Simpson: November 1847,

chloroform

John Snow : 1813-1858, firstanesthesiologist, face mask, vaporizer,clinical study

Joseph T. Clover follows John Snow

7/30/2019 Anestezja

9/66

9

American and British Origin

Mayo Clinic and Cleveland Clinic Students and nurses as anaesthetists

Long Island Society of Anesthetist 1905 New York Society of Anaesthetist 1911 became in

1936 ASA (Anaesthetists) in 1945 ASA(Anaesthesiologists)

England: Sir Robert Macintosh in 1937 first Chair,Faculty of Anaesthetists of the Royal College ofSurgeons was established in 1947

7/30/2019 Anestezja

10/66

10

Important names in the history of

anesthesia Carl Koller 1857-1944, cocaine in

ophthalmology

Sir Magill (1888-1986) Arthur Guedel (1883-1956)

Harold Griffith 1942 : curara

Paul Janssen: intravenous anesthesia

7/30/2019 Anestezja

11/66

11

Important steps in development

of anesthesia Ether (Morton)

Regional (spinal, epidural) end of XIX

century Thiopental 1934

Curara 1942

Halotane 1956

7/30/2019 Anestezja

12/66

12

Anesthesia

analgesia

reversible anesthetic effect

amnesia

areflexia

sleep supression of the vegetative response

7/30/2019 Anestezja

13/66

13

Is anesthesia safe?

Like airplane?

Anesthesia related deaths:

1940 1/1000

1970 1/10 000

1995 1/250 000 2005 ?

7/30/2019 Anestezja

14/66

14

Safety of anesthesia

1950 - 25 000 deaths during 108 hours ofanesthesia

2000 - 500 deaths during 108 hours ofanesthesia

Airplane risk (very low) -5

deaths during108 hours of flight

Risk of anaesthesia: 100 x higher

7/30/2019 Anestezja

15/66

15

Receptor theory of anesthesia

GABA: major inhibitory neurotransmitter(point of action of anesthetic drugs)

Membrane structure and function: future ofthe anesthesiology Glutamate: major excitatory

neurotransmitter Endorphins: analgesia Unitary hypothesis of the inhalation agents

7/30/2019 Anestezja

16/66

16

Present status of anesthesiology

Anesthesia

Pain management

Intensive Care Medicine

Emergency Medicine

Operative Medicine Education

Research

7/30/2019 Anestezja

17/66

17

Practice of anaesthesiology is the

practice of medicine (ABA) Assesment of, consultation for, and preparation of

patients for anaesthesia

Relief and prevention of pain Monitor and maintenance of the perioperativeperiod

Management of critical ill patients

Clinical management and teaching of the CPR Teaching, Research, Administration,

Transdisciplinary approach

7/30/2019 Anestezja

18/66

18

Progress in anesthesia

New monitoring techniques and standards

New anesthetics (iv and inhalation)

New drugs (inotropic, NO)

New ways of drug delivery

New management techniques Cost - effective

Fast truck

7/30/2019 Anestezja

19/66

19

Future of anesthesiology

CNS and transdermal stimulation

Safe delivery of drugs

More specific drugs (membrane function)

Perfluorocarbons

Genetically focus therapy Noninvasive monitoring

Visible pre- and postsynaptic area

Hibernation

7/30/2019 Anestezja

20/66

20

7/30/2019 Anestezja

21/66

21

General anaesthesia and

Preoperative evaluation

7/30/2019 Anestezja

22/66

22

ASA scale

1 normal healthy patient

2 mild systemic disease (no limitation0

3 moderate to severe systemic disease withlimitation of function

4 severe systemic disease (threat to life)

5 moribund patient

E emergency case

6 brain death patient

7/30/2019 Anestezja

23/66

23

An anaesthetic plan

Patients baseline condition with medical

record and previous anaesthesia and surgery

Planned procedure Drug sensitivities

Psychological makeup

7/30/2019 Anestezja

24/66

24

The anesthetic plan

ASA physical status scale

General versus regional

Airway Induction

Monitoring

Intraoperative management

Postoperative management

7/30/2019 Anestezja

25/66

25

ASA and perioperative mortality

rate 1 0.07%

2 0.3%

3 2% 4 7-23%

5 9-51%

7/30/2019 Anestezja

26/66

26

Documentation

Informed consent

Preoperative note

Intraoperative anesthesia recordpatient status

review of anesthesia and surgery

laboratorydrugs dosage and time of administration

7/30/2019 Anestezja

27/66

27

Documentation 2

Patient monitoring (intraoperative monitor, futurereference for the patient, tool for qualityassurance)

fluid administration procedures (catheters, caniulas, tubes) time of important events

unusual complication end of procedures state of consciousness

7/30/2019 Anestezja

28/66

28

Safety of working place

gas systems (liquid oxygen, air, a pin index systemto avoid failure, Nitrous Oxide critical temperature36,5 oC, different colours of the cylinders)

electrical safety (leakage current on the OR lessthan 10 uA) surgical diathermy (malfunction of the return

electrode may cause burns)

fire and explosion (uncommon), temperature,humidity, ventilation, noise) www.apsf.org

7/30/2019 Anestezja

29/66

29

Ventilation management

Breathing systems

Open drop anesthesia

Mapleson circuits

Anesthesia machines

7/30/2019 Anestezja

30/66

30

Breathing Systems

Patientbreathing systemanaesthesiamachine

Mapleson systems: Beathing tubes, freshgas inlets, adjustable pressure limiting(APL) or pop-off valves, reservoir bags

Carbon Dioxide Absorbent: CO2 + H2O =H2CO3,

7/30/2019 Anestezja

31/66

31

The anesthesia machine

Receive medical gases from gas supply Permits other gases (anaesthetics) only if there is

enough oxygen in the mixture Vaporizers are agent- specific Deliver and control tital volume Waste gas scavenger system

Regulary inspections Failure of the machine is a significant percentage

of the mishaps in anaesthesia practice

7/30/2019 Anestezja

32/66

32

Airway management

7/30/2019 Anestezja

33/66

33

Airway management

7/30/2019 Anestezja

34/66

34

Airway management

7/30/2019 Anestezja

35/66

35

Airway management

7/30/2019 Anestezja

36/66

36

Airway management

7/30/2019 Anestezja

37/66

37

Airway management

7/30/2019 Anestezja

38/66

38

Mask ventilation

7/30/2019 Anestezja

39/66

39

Mask ventilation

7/30/2019 Anestezja

40/66

40

7/30/2019 Anestezja

41/66

41

7/30/2019 Anestezja

42/66

42

7/30/2019 Anestezja

43/66

43

7/30/2019 Anestezja

44/66

44

7/30/2019 Anestezja

45/66

45

7/30/2019 Anestezja

46/66

46

7/30/2019 Anestezja

47/66

47

7/30/2019 Anestezja

48/66

48

7/30/2019 Anestezja

49/66

49

7/30/2019 Anestezja

50/66

50

Edotracheal intubation

Most common and safe protectionof aiways during anaesthesia and

intensive care

ButNeed skills and permament training

7/30/2019 Anestezja

51/66

51

AIRWAY

Difficulty in managing the airway

Difficult intubation

Traumatic intubation Esophageal intubation

Bronchial intubation

Laryngospasm

Bronchospasm

7/30/2019 Anestezja

52/66

52

Special airway techniques

Fiberoptic intubation

Retrograde (wire) intubation

Transtracheal jet ventilation Lighted stylets

Laryngeal mask

Combitube

Surgical airway

7/30/2019 Anestezja

53/66

53

Patient monitors

Arterial blood pressure

ECG

CVP, PAC Capnometry

Pulsoxymetry

EEG, BIS Temperature

Nerve stimulation

7/30/2019 Anestezja

54/66

54

Inhalation anesthetic agents

Nitrous oxide

Halothane (Fluothane)

Methoxyflurane (Penthrane) Enflurane (Ethrane)

Isoflurane (Forane)

Desflurane (Suprane)

Sevoflurane (Ultane)

MAC concept

7/30/2019 Anestezja

55/66

55

Pharmacokinetics and

pharmacodymanics Pharmacokinetics: how the body affects the

drug

Pharmacodymanics: how the drugs affectsthe body

7/30/2019 Anestezja

56/66

56

Factors affecting anesthetic uptake

Solubility in blood

Alveolar blood flow

Differences in partial pressure betweenalveolar gas and venous blood

Therefore: low output states predispose

patients to overdosage of the soluble agents

7/30/2019 Anestezja

57/66

57

Factors affecting elimination

Biotransformation: cytochrome P-450(specifically CYP 2EI)

Transcutaneous loss or exhalation Alveolus is the most important in

elimination of the inhalation agents

Diffusion hypoxia and the nitrous oxide

7/30/2019 Anestezja

58/66

58

Minimum alveolar concentration

Is the concentration of inhaledanaesthetics in the alveolar that

prevents movements in 50% of patientsin response to a standardized stimulus

(eg surgical incision)

7/30/2019 Anestezja

59/66

59

Inhalation anesthetic agents

Nitrous oxide

Halothane (Fluothane)

Methoxyflurane (Penthrane) Enflurane (Ethrane)

Isoflurane (Forane)

Desflurane (Suprane)

Sevoflurane (Ultane)

7/30/2019 Anestezja

60/66

60

Intravenous induction and

anesthestic agents Thiopental

Metohexital

Benzodiazepins (Midazolam) Propofol

Etomidate

Ketamine

Opioids

Droperidol

7/30/2019 Anestezja

61/66

61

Intravenous anaesthesia

Changes in plasma concentration

Absorption

Distribution (Vd= Dose/Concentration) Biotransformation

Excretion

Compartment model of distribution andelimination

7/30/2019 Anestezja

62/66

62

Muscle relaxants

Neuromuscular transmission

Depolarizing agents (Ach rec. agonists)

Nondepolarizing agents (Ach rec.antagonists)

Cholinesterase inhibitors (edrofonium,

neostigmine, pyridostigmine)

7/30/2019 Anestezja

63/66

63

Anticholinergic drugs

Antimuscarinic effect

Atropine

Scopolamine

Glycopyrrolate

7/30/2019 Anestezja

64/66

64

Anesthesia complications

Inadequate preoperative planning and errorsin patient preparation are the most commom

causes of anesthestic complications

Anesthesia and elective operations should

not proceed until the patient is in optimalmedical condition

7/30/2019 Anestezja

65/66

65

Anesthetic complications

Human error (technical problems, lack ofcommunication, experience, fatigue,)

Ventilation (breathing circuit, defect ofmonitoring equipment, anesthesia machine)

Position (periferal nerve damage)

Anaphylaxis Latex allergy

7/30/2019 Anestezja

66/66

Anesthesia and perioperative

complications Airway

Circulation

Central and peripheral nervous system

Pain therapy

Drugs used in anesthesia

Equipment failure