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Anesthesia as a specialty Past, present and future Reference book Clinical Anesthesiology , G. Edward Morgan, Jr., Maged S. Mikhail, Michael J. Murray Fourt Edition by the McGraw-Hill Companies 2006 a LANGE Medical Book www.katedraanest.cm-uj.krakow.pl

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Anesthesia as a specialty l.jpg

Anesthesia as a specialty

Past, present and future


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Reference book

  • Clinical Anesthesiology,

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

    Fourt Edition by the McGraw-Hill Companies 2006 a LANGE Medical Book


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www.katedraanest.cm-uj.krakow.pl

  • Prof. Janusz Andres (Head of the Chair and Department)

    email: [email protected]

  • Agnieszka Frączek (Secretary)

    email: [email protected]

  • Katarzyna Lepszy-Muszyńska (Coordinator, email:[email protected]


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Pain as a part of surgery

  • Hypnosis

  • Alkohol

  • Botanical preparation

  • Superficial surgery

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


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Inhalation Anesthesia

  • 1540 Paracelsus: oil of vitriol (prepared by Valerius Cordus and named “Aether” by Frobenius): used to feed fowl: “it was taken even by chickens and they fall asleep from it for a while but awaken later without harm”


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Local anesthesia

  • Ancient Incas: coca leaf as a gift to the Incas from the sun of God:

  • destruction of Incas culture

  • slaves payment


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Important names in history of anesthesia

  • Humphry Davy: 1778 - 1829 (“laughing gas”, N20)

  • Horace Wells: January 1845, Harvard Medical School, clinical use of N20

  • William Morton: October 16,1846 ether for the excision of the vascular lesion from the neck (John Collin Warren: gentlemen this is not a humbug)


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Important names in the history of anesthesia

  • Prof. Ludwik Bierkowski: February 1847 KRAKÓW ether in Poland

  • anesthesia = temporary insensibility

  • James Simpson: November 1847, chloroform

  • John Snow : 1813-1858, first anesthesiologist, face mask, vaporizer, clinical study

  • Joseph T. Clover follows John Snow


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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 of Surgeons was established in 1947


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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


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Important steps in development of anesthesia

  • Ether (Morton)

  • Regional (spinal, epidural) end of XIX century

  • Thiopental 1934

  • Curara 1942

  • Halotane 1956


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Anesthesia

  • analgesia

  • reversible anesthetic effect

  • amnesia

  • areflexia

  • sleep

  • supression of the vegetative response


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Is anesthesia safe?

  • Like airplane?

  • Anesthesia related deaths:

  • 1940 1/1000

  • 1970 1/10 000

  • 1995 1/250 000

  • 2005 ?


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Safety of anesthesia

  • 1950 - 25 000 deaths during 108 hours of anesthesia

  • 2000 - 500 deaths during 108 hours of anesthesia

  • Airplane risk (very low) -5 deaths during 108 hours of flight

  • Risk of anaesthesia: 100 x higher


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Receptor theory of anesthesia

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

  • Membrane structure and function: future of the anesthesiology

  • Glutamate: major excitatory neurotransmitter

  • Endorphins: analgesia

  • Unitary hypothesis of the inhalation agents


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Present status of anesthesiology

  • Anesthesia

  • Pain management

  • Intensive Care Medicine

  • Emergency Medicine

  • Operative Medicine

  • Education

  • Research


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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 perioperative period

  • Management of critical ill patients

  • Clinical management and teaching of the CPR

  • Teaching, Research, Administration, Transdisciplinary approach


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Progress in anesthesia (ABA)

  • 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


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Future of anesthesiology (ABA)

  • 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


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General anaesthesia and (ABA)Preoperative evaluation


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ASA scale (ABA)

  • 1 normal healthy patient

  • 2 mild systemic disease (no limitation0

  • 3 moderate to severe systemic disease with limitation of function

  • 4 severe systemic disease (threat to life)

  • 5 moribund patient

  • E emergency case

  • 6 brain death patient


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An anaesthetic plan (ABA)

  • Patient’s baseline condition with medical record and previous anaesthesia and surgery

  • Planned procedure

  • Drug sensitivities

  • Psychological makeup


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The anesthetic plan (ABA)

  • ASA physical status scale

  • General versus regional

  • Airway

  • Induction

  • Monitoring

  • Intraoperative management

  • Postoperative management


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ASA and perioperative mortality rate (ABA)

  • 1 0.07%

  • 2 0.3%

  • 3 2%

  • 4 7-23%

  • 5 9-51%


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Documentation (ABA)

  • Informed consent

  • Preoperative note

  • Intraoperative anesthesia record

    • patient status

    • review of anesthesia and surgery

    • laboratory

    • drugs dosage and time of administration


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Documentation 2 (ABA)

  • Patient monitoring (intraoperative monitor, future reference for the patient, tool for quality assurance)

  • fluid administration

  • procedures (catheters, caniulas, tubes)

  • time of important events

  • unusual complication

  • end of procedures

  • state of consciousness


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Safety of working place (ABA)

  • gas systems (liquid oxygen, air, a pin index system to avoid failure, Nitrous Oxide critical temperature 36,5 oC, different colours of the cylinders)

  • electrical safety (leakage current on the OR less than 10 uA)

  • surgical diathermy (malfunction of the return electrode may cause burns)

  • fire and explosion (uncommon), temperature, humidity, ventilation, noise)

  • www.apsf.org


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Ventilation management (ABA)

  • Breathing systems

  • Open drop anesthesia

  • Mapleson circuits

  • Anesthesia machines


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Breathing Systems (ABA)

  • Patient – breathing system – anaesthesia machine

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

  • Carbon Dioxide Absorbent: CO2 + H2O = H2CO3,


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The anesthesia machine (ABA)

  • 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










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Edotracheal intubation (ABA)

Most common and safe protection of aiways during anaesthesia and intensive care

But

Need skills and permament training


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AIRWAY (ABA)

  • Difficulty in managing the airway

  • Difficult intubation

  • Traumatic intubation

  • Esophageal intubation

  • Bronchial intubation

  • Laryngospasm

  • Bronchospasm


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Special airway techniques (ABA)

  • Fiberoptic intubation

  • Retrograde (wire) intubation

  • Transtracheal jet ventilation

  • Lighted stylets

  • Laryngeal mask

  • Combitube

  • Surgical airway


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Patient monitors (ABA)

  • Arterial blood pressure

  • ECG

  • CVP, PAC

  • Capnometry

  • Pulsoxymetry

  • EEG, BIS

  • Temperature

  • Nerve stimulation


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Inhalation anesthetic agents (ABA)

  • Nitrous oxide

  • Halothane (Fluothane)

  • Methoxyflurane (Penthrane)

  • Enflurane (Ethrane)

  • Isoflurane (Forane)

  • Desflurane (Suprane)

  • Sevoflurane (Ultane)

  • MAC concept


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Pharmacokinetics and pharmacodymanics (ABA)

  • Pharmacokinetics: how the body affects the drug

  • Pharmacodymanics: how the drugs affects the body


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Factors affecting anesthetic uptake (ABA)

  • Solubility in blood

  • Alveolar blood flow

  • Differences in partial pressure between alveolar gas and venous blood

  • Therefore: low output states predispose patients to overdosage of the soluble agents


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Factors affecting elimination (ABA)

  • 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


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Minimum alveolar concentration (ABA)

  • Is the concentration of inhaled anaesthetics in the alveolar that prevents movements in 50% of patients in response to a standardized stimulus (eg surgical incision)


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Inhalation anesthetic agents (ABA)

  • Nitrous oxide

  • Halothane (Fluothane)

  • Methoxyflurane (Penthrane)

  • Enflurane (Ethrane)

  • Isoflurane (Forane)

  • Desflurane (Suprane)

  • Sevoflurane (Ultane)


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Intravenous induction and anesthestic agents (ABA)

  • Thiopental

  • Metohexital

  • Benzodiazepins (Midazolam)

  • Propofol

  • Etomidate

  • Ketamine

  • Opioids

  • Droperidol


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Intravenous anaesthesia (ABA)

  • Changes in plasma concentration

  • Absorption

  • Distribution (Vd= Dose/Concentration)

  • Biotransformation

  • Excretion

  • Compartment model of distribution and elimination


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Muscle relaxants (ABA)

  • Neuromuscular transmission

  • Depolarizing agents (Ach rec. agonists)

  • Nondepolarizing agents (Ach rec. antagonists)

  • Cholinesterase inhibitors (edrofonium, neostigmine, pyridostigmine)


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Anticholinergic drugs (ABA)

  • Antimuscarinic effect

  • Atropine

  • Scopolamine

  • Glycopyrrolate


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Anesthesia complications (ABA)

  • Inadequate preoperative planning and errors in patient preparation are the most commom causes of anesthestic complications

  • Anesthesia and elective operations should not proceed until the patient is in optimal medical condition


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Anesthetic complications (ABA)

  • Human error (technical problems, lack of communication, experience, fatigue,)

  • Ventilation (breathing circuit, defect of monitoring equipment, anesthesia machine)

  • Position (periferal nerve damage)

  • Anaphylaxis

  • Latex allergy


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Anesthesia and perioperative complications (ABA)

  • Airway

  • Circulation

  • Central and peripheral nervous system

  • Pain therapy

  • Drugs used in anesthesia

  • Equipment failure


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