1. 1 www.katedraanest.cm-uj.krakow.pl Prof. Janusz Andres (Head of the Chair and Department) email: msandres@cyf-kr.edu.plmsandres@cyf-kr.edu.pl Agnieszka Frączek (Secretary) email: agafrk@cm-uj.krakow.plagafrk@cm-uj.krakow.pl Dr Agnieszka Jastrzębska email: aejastrzebska@wp.plaejastrzebska@wp.pl

2. 2 Anesthesia as a specialty Past, present and future

3. 3 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

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

5. 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. 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. 7 Important names in history of anesthesia Humphry Davy: 1778 - 1829 (“laughing gas”, N 2 0) Horace Wells: January 1845, Harvard Medical School, clinical use of N 2 0 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. 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 : 1813-1858, first anesthesiologist, face mask, vaporizer, clinical study Joseph T. Clover follows John Snow

9. 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. 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

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

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

13. 13 Is anesthesia safe? Like airplane? Anesthesia related deaths: 1940 1/1000 1970 1/10 000 1995 1/250 000 2010 ?

14. 14 Safety of anesthesia 1950 - 25 000 deaths during 10 8 hours of anesthesia 2000 - 500 deaths during 10 8 hours of anesthesia Airplane risk (very low) - 5 deaths during 10 8 hours of flight Risk of anaesthesia: 100 x higher

15. 15 Perioperative cardiac arrest Known since 60 years Large investigations USA, Australia, Canada, South Africa, UK Differences depends on methodology and local circumstances

16. 16 AutorRok publikacjiLiczba znieczuleńPierwotna przyczyna Pierwotna i skojarzona przyczyna Lunn and Mushin 63 19821 147 3621:10 0001:700 Tiret et al. 98 1986198 1031:13 207– Buck et al. 13 1987555 2581:185 0861:1354 Holland 50 1987–1:26 000– Chopra et al. 19 1990113 0741:16 250– Pedersen 77 1994200 0001:2500– Tikkanen and Hovi-Viander 96 1995325 5851:66 667– Warden and Horan 100 1996––1:20 000 Arbous et al. 3 2001869 4831:124 2121:7143 Willis et al. 103 200210 336 0001:220 0001:79 509 Kawashima et al. 55 20032 363 0381:47 619– Anesthesia related morbidity 1982 -2003 A.R. Aitkenhead. Injurys associated with anesthesia. A global perspective. British Journal of Anesthesia 2005; 95(1), s. 95-109

17. 17 CauseIncidence % Drug overdosage or adverse reaction 15.3 Rythm disturbances 13.9 MI, perioperative ischaemia 8.8 Airway obstruction 7.9 High spinal anaesthesia 7.4 Lack of vigilance 6.9 Bleeding 5.1 Overdosage of inhalation anesthetics 2.8 Aspiration 2.8 Technical errors (disconnections) in anaesthesia circuit 2.3 A.R. Aitkenhead. Injurys associated with anesthesia. A global perspective. British Journal of Anesthesia 2005; 95(1), s. 95-109 10 causes of Cardiac Arrest related to anaesthesia

18. 18 Newland MC et al.: Anesthestic related Cardiac Arrest and Its Mortality (73000 Anesthetics over 10 years, Anesthesiology 2002, 97, 108-15 ) 144 cases of CA (20 cases per 10 000 operations) Interdisciplinary jury (anesthesist, surgeon, internist) 45 cases needed double assesment 129 CA combined with preop. status, 15 „related” to anaesthesia, only 5 caused by anesthesia (0,7 per 10 000 operations)

19. 19 Patients with CA Advanced age Men ASA III i IV Large and urgent operations

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21. 21 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

22. 22 Present status of anesthesiology Anesthesia Pain management Intensive Care Medicine Emergency Medicine Operative Medicine Education Research

23. 23 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 www.erc.edu

24. 24 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

25. 25 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

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27. 27 General anaesthesia and Preoperative evaluation

28. 28 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

29. 29 An anaesthetic plan Patient’s baseline condition with medical record and previous anaesthesia and surgery Planned procedure Drug sensitivities Psychological makeup

30. 30 The anesthetic plan ASA physical status scale General versus regional Airway Induction Monitoring Intraoperative management Postoperative management

31. 31 ASA and perioperative mortality rate 1 0.07% 2 0.3% 3 2% 4 7-23% 5 9-51%

32. 32 Documentation Informed consent Preoperative note Intraoperative anesthesia record –patient status –review of anesthesia and surgery –laboratory –drugs dosage and time of administration

33. 33 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

34. 34 Safety of working place gas systems (liquid oxygen, air, a pin index system to avoid failure, Nitrous Oxide critical temperature 36,5 o C, 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

35. 35 Ventilation management Breathing systems Open drop anesthesia Mapleson circuits Anesthesia machines

36. 36 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,

37. 37 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

38. 38 Airway management

39. 39 Airway management

40. 40 Airway management

41. 41 Airway management

42. 42 Airway management

43. 43 Airway management

44. 44 Mask ventilation

45. 45 Mask ventilation

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56. 56 Edotracheal intubation Most common and safe protection of aiways during anaesthesia and intensive care But Need skills and permament training

57. 57 AIRWAY Difficulty in managing the airway Difficult intubation Traumatic intubation Esophageal intubation Bronchial intubation Laryngospasm Bronchospasm

58. 58 Special airway techniques Fiberoptic intubation Retrograde (wire) intubation Transtracheal jet ventilation Lighted stylets Laryngeal mask Combitube Surgical airway

59. 59 Patient monitors Arterial blood pressure ECG CVP, PAC Capnometry Pulsoxymetry EEG, BIS Temperature Nerve stimulation

60. 60 Inhalation anesthetic agents Nitrous oxide Halothane (Fluothane) Methoxyflurane (Penthrane) Enflurane (Ethrane) Isoflurane (Forane) Desflurane (Suprane) Sevoflurane (Ultane) MAC concept

61. 61 Pharmacokinetics and pharmacodymanics Pharmacokinetics: how the body affects the drug Pharmacodymanics: how the drugs affects the body

62. 62 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

63. 63 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

64. 64 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)

65. 65 Inhalation anesthetic agents Nitrous oxide Halothane (Fluothane) Methoxyflurane (Penthrane) Enflurane (Ethrane) Isoflurane (Forane) Desflurane (Suprane) Sevoflurane (Ultane)

66. 66 Intravenous induction and anesthestic agents Thiopental Metohexital Benzodiazepins (Midazolam) Propofol Etomidate Ketamine Opioids Droperidol

67. 67 Intravenous anaesthesia Changes in plasma concentration Absorption Distribution (Vd= Dose/Concentration) Biotransformation Excretion Compartment model of distribution and elimination

68. 68 Muscle relaxants Neuromuscular transmission Depolarizing agents (Ach rec. agonists) Nondepolarizing agents (Ach rec. antagonists) Cholinesterase inhibitors (edrofonium, neostigmine, pyridostigmine)

69. 69 Anticholinergic drugs Antimuscarinic effect Atropine Scopolamine Glycopyrrolate

70. 70 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

71. 71 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

72. 72 Anesthesia and perioperative complications Airway Circulation Central and peripheral nervous system Pain therapy Drugs used in anesthesia Equipment failure