anesthesia in the future
DESCRIPTION
TRANSCRIPT
2010
Typical American Hospital
1985 - 25 years ago
Typical American Hospital
Therapeutic Armamentarium
• Thiopental
• Isoflurane
• Morphine, Fentanyl
• Succinylcholine, Curare, Pancuronium, Metocurine
Routine Monitors
• Electrocardiogram
• Inspired oxygen
• Blood pressure cuff
• Temperature
• Finger on the pulse
• Capnography
Special Monitors
• In selected patients:
• Capnography• Pulmonary Artery Catheters
Airway Control
• Endotracheal Intubation
• Mask Ventilation• Mask Ventilation• Mask Ventilation• Mask Ventilation• Mask Ventilation• Mask Ventilation• Mask Ventilation• Mask Ventilation• Mask Ventilation
MACMonitored Anesthesia CareMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and Cyanotic
Patient Care
• Admission before surgery
• Highly invasive surgical technique
• Intramuscular pethidine for postoperative analgesia
• Discharge in days to weeks
surgical technique
Patient Care Issues
• Poor post-operative pain control
• Slow recovery
• Nausea and Vomiting
Anesthesia1998
12 years ago
Basics of Anesthesia
• Delivery of oxygen• Support of intravascular volume and tissue
perfusion• Patient Comfort
Therapeutic Armamentarium
• Thiopental
• Isoflurane
• Morphine, fentanyl, alfentanil, sufentanil, remifentanil
• Succinylcholine, pancuronium
• Thiopental, propofol
• Isoflurane, sevoflurane, desflurane
• Morphine, fentanyl, alfentanil, sufentanil, remifentanil
• Succinylcholine, pancuronium, vecuronium, rocuronium, atracurium, mivacurium, doxacurium, and pipecuronium
TIVATotal IntraVenous AnesthesiaTotal IntraVenous AwarenessTIVAETotal IntraVenous Anesthesiawith Ephedrine
Propofol
J
JKLDesflurane, Sevoflurane
Fentanyl Family Tree
A lfen ta n il S u fen ta n il R em ifen ta n il
F e n ta n y l
Remifentanil
Routine Monitors
• Pulse Oximetry
• Capnography
• Electrocardiogram
• Inspired oxygen
• Blood pressure cuff
• Temperature Finger on the pulse
Finger on the pulse
• Esophageal echocardiography• Pulmonary artery catheterization• Continuous arterial blood gas• Continuos mixed-venous saturation• Sophisticated ventilator monitoring
Special Monitors
• In selected patients:
Bispectral Index
• Based on EEG spectral analysis
• Good predictor of mental status of patient during anesthesia with:
• Inhalational anesthesia
• Inhalational anesthesia with opioids
• Propofol anesthesia with opioids
• Endotracheal Intubation
• Mask Ventilation
• LMA
Airway Control
Laryngeal Mask Airway
MACMonitored Anesthesia CareMidazolam, Alfentanil, and Conversation
• Admission on day of surgery
• Discharge in 3 - 24 hours
• Fast tracking of patients
• Laparoscopic surgery
• Improved post-operative pain management• Epidural opioids
• PCA
Patient Care
Patient Controlled AnalgesiaPatient Controlled Apnea
2010
Today
New Therapeutics
• Duzitol• Hypnotic• Analgesic• Amnestic• Muscle Relaxant• Aphrodisiac
Anesthesiology 76:327-330, 1992
New Therapeutics
• Cycloflurane• Chemical stability of isoflurane
• Rapid induction of sevoflurane
• Rapid emergence of desflurane
• Pleasant smell of “Mr. Propre”
New Therapeutics
• Dexmedetomidine• Central 2 adrenergic agonist
• Profound postoperative analgesia in the ICU
• Profound anti-ischemic properties
• Modest sedation
• Rapid offset
• Reversible
• Demonstrated improved outcome after major surgery
New Therapeutics
• Hyptiva• Pharmacodynamics of propofol
» Pleasant induction and emergence
» Modest cardiovascular effects
» Modest respiratory effects
• Pharmacokinetics of remifentanil» Extraordinarily rapid emergence
» Predictable
» Minimal change with disease or age
New Therapeutics
• Central nicotinic analgesics• Derived from amphibian skin
• Prototype is epibatidine
• Efficacy equal to morphine
• No ventilatory effects
• No physical dependence
• No kidding» Science 1998 Jan 2;279(5347):77-81
New Therapeutics
• Muscle Relaxants• Suxuronium
• MadamCurium
• Rockandrolium
MACMonitored Anesthesia CareMadam, Are you Comfortable?
New Therapeutic Modes
• RemifentanilPCA
Minutes Since Bolus
0 30 60 90
Rem
ifen
tani
l Eff
ect S
ite
Con
cent
rati
on ( g
/ml)
0.0
0.5
1.0
1.5
2.0
Morphine-like half-life of 1 hour
Remifentanil-like onset
New Monitoring
• Intraoperative EEG• BIS now standard-of-care
• EEG Guided Anesthesia Delivery System
EGADS
EGADS
Patient Care
• Nearly all operations done on outpatients
• Most operations are laparoscopic/endoscopic
• Intelligent intra-operative and post-operative drug delivery systems
• ICU care rarely needed
Anesthesia in 2020?
Plausible vs. Implausible
• Plausible:– Remifentanil PCA
– Dexmedetomidine
– Nicotinic agonists
– New generation of hypnotics
– EGADS system
• Implausible– Duzitol
– Cycloflurane
– Suxuronium, madamcurium, rockandrolium