1. Anesthesia as a specialty
Past, present and future

2. 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

3.
Prof. Janusz Andres (Head of the Chair and Department)
Agnieszka Frączek (Secretary)
Katarzyna Lepszy-Muszyńska (Coordinator,

4. Pain as a part of surgery
Hypnosis
Alkohol
Botanical preparation
Superficial surgery
Galenic concept: body humors: blood, phlegm, yellow and black bile

5. 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”

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. Important names in history of anesthesia
Humphry Davy: (“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)

8. 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 : , first anesthesiologist, face mask, vaporizer, clinical study
Joseph T. Clover follows John Snow

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 of Surgeons was established in 1947

10. Important names in the history of anesthesia
Carl Koller , cocaine in ophthalmology
Sir Magill ( )
Arthur Guedel ( )
Harold Griffith 1942 : curara
Paul Janssen: intravenous anesthesia

11. Important steps in development of anesthesia
Ether (Morton)
Regional (spinal, epidural) end of XIX century
Thiopental 1934
Curara 1942
Halotane 1956

12. Anesthesia analgesia reversible anesthetic effect amnesia areflexia
sleep
supression of the vegetative response

13. Is anesthesia safe? Like airplane? Anesthesia related deaths:
1940 1/1000
1970 1/10 000
1995 1/
2005 ?

14. Safety of anesthesia
deaths during 108 hours of anesthesia
deaths during 108 hours of anesthesia
Airplane risk (very low) - 5 deaths during 108 hours of flight
Risk of anaesthesia: 100 x higher

15. 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

16. Present status of anesthesiology
Anesthesia
Pain management
Intensive Care Medicine
Emergency Medicine
Operative Medicine
Education
Research

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 perioperative period
Management of critical ill patients
Clinical management and teaching of the CPR
Teaching, Research, Administration, Transdisciplinary approach

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

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

21. General anaesthesia and Preoperative evaluation

22. ASA scale 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

23. An anaesthetic plan
Patient’s baseline condition with medical record and previous anaesthesia and surgery
Planned procedure
Drug sensitivities
Psychological makeup

24. The anesthetic plan ASA physical status scale General versus regional
Airway
Induction
Monitoring
Intraoperative management
Postoperative management

25. ASA and perioperative mortality rate% % % % %

26. Documentation Informed consent Preoperative note
Intraoperative anesthesia record
patient status
review of anesthesia and surgery
laboratory
drugs dosage and time of administration

27. Documentation 2
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

28. Safety of working place
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)

29. Ventilation management
Breathing systems
Open drop anesthesia
Mapleson circuits
Anesthesia machines

30. Breathing Systems 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,

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

32. Airway management

33. Airway management

34. Airway management

35. Airway management

36. Airway management

37. Airway management

38. Mask ventilation

39. Mask ventilation

50. Edotracheal intubation
Most common and safe protection of aiways during anaesthesia and intensive care
But
Need skills and permament training

51. AIRWAY Difficulty in managing the airway Difficult intubation
Traumatic intubation
Esophageal intubation
Bronchial intubation
Laryngospasm
Bronchospasm

52. Special airway techniques
Fiberoptic intubation
Retrograde (wire) intubation
Transtracheal jet ventilation
Lighted stylets
Laryngeal mask
Combitube
Surgical airway

53. Patient monitors Arterial blood pressure ECG CVP, PAC Capnometry
Pulsoxymetry
EEG, BIS
Temperature
Nerve stimulation

54. Inhalation anesthetic agents
Nitrous oxide
Halothane (Fluothane)
Methoxyflurane (Penthrane)
Enflurane (Ethrane)
Isoflurane (Forane)
Desflurane (Suprane)
Sevoflurane (Ultane)
MAC concept

55. Pharmacokinetics and pharmacodymanics
Pharmacokinetics: how the body affects the drug
Pharmacodymanics: how the drugs affects the body

56. Factors affecting anesthetic uptake
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

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

58. Minimum alveolar concentration
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)

59. Inhalation anesthetic agents
Nitrous oxide
Halothane (Fluothane)
Methoxyflurane (Penthrane)
Enflurane (Ethrane)
Isoflurane (Forane)
Desflurane (Suprane)
Sevoflurane (Ultane)

60. Intravenous induction and anesthestic agents
Thiopental
Metohexital
Benzodiazepins (Midazolam)
Propofol
Etomidate
Ketamine
Opioids
Droperidol

61. Intravenous anaesthesia
Changes in plasma concentration
Absorption
Distribution (Vd= Dose/Concentration)
Biotransformation
Excretion
Compartment model of distribution and elimination

62. Muscle relaxants Neuromuscular transmission
Depolarizing agents (Ach rec. agonists)
Nondepolarizing agents (Ach rec. antagonists)
Cholinesterase inhibitors (edrofonium, neostigmine, pyridostigmine)

63. Anticholinergic drugs
Antimuscarinic effect
Atropine
Scopolamine
Glycopyrrolate

64. Anesthesia complications
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

65. Anesthetic complications
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

66. Anesthesia and perioperative complications
Airway
Circulation
Central and peripheral nervous system
Pain therapy
Drugs used in anesthesia
Equipment failure