Clinical Anaesthesiology Qiu Wei Fan Associate Professor Department of Anaesthesiology Rui Jin Hospital Shanghai Second Medical University 1

Contents * The history of Anaesthesia * The scope of anaesthesia * Classification of Anaesthesia Methods * Definition of the practice of anaesthesiology * Preoperative assessment and premedication 2

The History of Anaesthesia British Origins John Snow was the first to scientifically investigate ether and the physiology of general anaesthesia. Snow was also a pioneer in epidemiology who helped stop a cholera epidemic in London by proving that the causative agent was transmitted by ingestion rather than inhalation. 3

The History of Anaesthesia British Origins In 1847, Snow published the first book on general anaesthesia, On the Inhalation of Ether. When the anaesthetic properties of chloroform were made known, he also quickly investigated and developed an inhaler for that agent as well. He felt that an inhaler should be used in administering these agents in order to control the dose of the anaesthetic. 4

The History of Anaesthesia British Origins In 1893, then first organization of physician specialists in anaesthesia, the Society of Anaesthetists, was formed by J. F. Silk in England. 5

The History of Anaesthesia American Origins Three physicians stand out in the early development of anaesthesia in the United States after the turn of the century: Arthur E. Guedue, Ralph M. Waters, and John S. Lundy. Guedue was the first to elaborate on the signs of general amaesthesia after Snow ’ s original description. He advocated cuffed endotracheal tubes and introduced artificial ventilation during ether anaesthesia (later called “ controlled respiration ” by Waters). 6

The History of Anaesthesia American Origins The first organization of physician anaesthetists in the United States was the Long Island Society of Anaesthetists in That society was eventually renamed the New York Society of Anaesthetists and become national in It was subsequently renamed the American Society of Anaesthetists and later, in 1945, the American Society of Anaesthesiologists ( ASA ). 7

The History of Anaesthesia Chinese Origins More than 1500 years ago, Chinese physician of traditional medicine already used some herb and alcohol to make patients unconscious and did some minor operations. In our country, the first department of Anaesthesiology was established in 1950 as soon as Professor Jue Wu returned to Shanghai, the People ’ s Republic of China from abroad. 8

The Scope of Anaesthesia * Providing general or regional anaesthesia inside and outside the operating room * Intensive care units * Respiratory therapy departments * Recovery room 9

The Scope of Anaesthesia * Cardiopulmonary resuscitation * Postoperative pain relief * Anaesthetic research, teaching medical students, and assuming administrative and leadership positions on the medical staffs of many hospitals and ambulatory care facilities. 10

Classification of Anaesthesia Methods General anaesthesia * Inhalation anaesthesia * Intravenous anaesthesia\ * Intramuscularly * Rectally * Orally * Balanced anaesthesia 11

Classification of Anaesthesia Methods Regional Anaesthesia * Intrathecal anaesthesia * Subarachnoid block * Epidural anaesthesia * Caudal block * Nerve plexus block * Ganglion block * Nerve block * Field block. 12

Definition of the practice of anaesthesiology 1)Assessing,consulting, and preparing patients for anaesthesia 2)Rendering patients insensible to pain during surgical obstetric, therapeutic, and diagnostic procedures 13

Definition of the practice of anaesthesiology 3)Monitoring and restoring homeostasis in perioperative and critically patients 4)Diagnosing and treating painful syndromes 14

Definition of the practice of anaesthesiology 5)Managing and teaching of cardiac and pulmonary resuscitation 6)Evaluating respiratiry function and applying respiratory therapy 7)Teaching, supervising, and evaluating the performance of medical and paramedical personnel involved in anaesthesia,respiratory care, and critical care 15

Definition of the practice of anaesthesiology 8)Conducting research at the basic and clinical science levels to explain and improve the care of patients in terms of physiologic function and drug response 9)Involvement in the administration of hospitals, medical schools, and outpatient facilities as necessary to implement these responsibilities 16

Preoperative assessment Planning the conduct of ansesthesia starts normally after details concerning the surgical procedure and the medical condition of the patient have been ascertained at the preoperative visit. 17

Preoperative assessment Several of the large-scale epidemiological studies have indicated that inadequate preoperative preparation of the patient may be a major contributory factor to the primary anaesthetic causes of peri- operative mortality. 18

Preoperative assessment It is therefore essential that anaesthetist visit every patient in the word before surgery to assess “ fitness for anaesthesia ”, as this function cannot be undertaken by surgical staff. 18

Purposes of the preoperative visit * Estabilish rapport with the patient * Obtain a history and perform a physical examinations * Order a special investigations * Assess the risks of anaesthesia and surgery and if necessary postpone or cancel the date of surgery * Institute preoperative management * Prescribe premedication and the anaesthetic management 19

Preoperative assessment Routine preoperative anaesthetic evaluation * History - Current problem - Other known problems - Medication history 20

Preoperative assessment ( Medication history) * Allergies * Drug intolerances * Present therapy: Prescription, Nonprescription * Nontherapeutic: Alcohol, Tobacco * Illicit 21

Preoperative assessment * Previous anaesthetics, surgery, and obstetric deliverries * Family history * Review of organ systems * Last oral intake 22

Preoperative assessment (Review of organ systems) * General * Respiratory * Cardiovascular * Renal * Gastrointestinal * Hematologic 23

Preoperative assessment (Review of organ systems) * Neurologic * Endocrine * Psychiatric * Orthopedic * Dermatologic 24

Preoperative assessment ( Physical examination) * Vital signs * Airway * Heart * Lungs * Extremities * Neurologic examination 25

Preoperative assessment ( Laboratory evaluation) Hematocrit or hemoglobin concentration All menstruating women All patients over 60 years of age All patients who are likely to experience significant blood loss and may require transfusion Serum glucose and creatinine (or blood urea nitrogen) concentration: all patients over 60 years of age Electrocardiogram: all patients over 40 years of age Chest radiogram: all patients over 60 years of age 26

ASA classification IA normal healthy patient other than surgical pathology- without systemic disease. IIA patient with mild systemic disease – no functional limitations. 27

ASA classification IIIA patient with moderate to severe systemic disturbance due to medical or surgical disease- some functional limitation but not incapacitating. IVA patient with severe systemic disturbance which poses a constant threat to life and is incapacitating. 27

ASA classification VA moribund patient not expected to survive 24 hours with or without surgery. EIf the case is an emergency, the physical status is followed by the letter “ E ” -, “ IIE ”. 27

American Society of Anaesthesiologists classification and perioperative mortality rates Class Mortality Rate I % II % III % IV % V % 28

Documentation * Informed Consent * The preoperative note * The intraoperative anaesthesia record * The postoperative notes 29

The preoperative Note ( The preoperative assessment ) * Medical history * Anaesthesia history * Medication history * Physical history * Physical examination * Laboratory results * ASA classification * Recommendations of any consultants 30

The preoperative Note Anaesthetic plan: Use of specific procedures Informed consent: Plan, alternative plans, their advantage and disadvantages ( risk of complications) 31

The Intraoperative Anaesthesia Record * A preoperative check of the anaesthesia machine and other equipment * A review or reevaluation of the patient immediately prior to induction of anaesthesia * A review of the chart for new laboratory results or consultations * A review of the anaesthesia and surgical consents 32

The Intraoperative Anaesthesia Record * The time of administration, dosage, and route of intraoperative drugs * All intraoperative monitoring( laboratory measurements, blood loss, and urinary output) * Intravenous fluid administration and transfusion * All procedures(intubation, placement of a nasogastric tube or placement of invasive monitors) 33

The Intraoperative Anaesthesia Record * Routine and special techniques such as mechanical ventilation, hypotensive anaesthesia, one-lung ventilation, high-frequency jet ventilation, or cardiopulmonary bypass 34

The Intraoperative Anaesthesia Record * The timing and course of important events such as induction, positioning, surgical incision, and extubation * Unusual events or complications * The condition of the patient at the end of the procedure 34

The postoperative notes * The patient ’ s condition * The patient ’ s recovery from anaesthesia * Any apparent anaesthesia-related complications 35

Questions * How do you take the history from a patient? * What is the meaning of the ASA classification? 36

Any Questions? 37

Thank You! 37