katedraanest.cm-uj.krakow.pl

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

2. Anesthesia as a specialty Past, present and future

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. 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: 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)

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. 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 1857-1944, cocaine in ophthalmology • Sir Magill (1888-1986) • Arthur Guedel (1883-1956) • 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 1/250 000 • 2010 ?

14. 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

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

16. 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. 10 causes of Cardiac Arrest related to anaesthesia A.R. Aitkenhead. Injurys associated with anesthesia. A global perspective. British Journal of Anesthesia 2005; 95(1), s. 95-109

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

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

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. 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. 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

27. General anaesthesia and Preoperative evaluation

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

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

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

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

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. 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) • www.apsf.org

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

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. 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. Airway management

39. Airway management

40. Airway management

41. Airway management

42. Airway management

43. Airway management

44. Mask ventilation

45. Mask ventilation