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Anesthesia in the Future

Anesthesia in the Future. Steven L. Shafer Palo Alto VA Health Care System Stanford . 2010. Typical American Hospital. Typical American Hospital. 1985 - 25 years ago. Therapeutic Armamentarium. Thiopental Isoflurane Morphine, Fentanyl Succinylcholine, Curare, Pancuronium, Metocurine.

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Anesthesia in the Future

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  1. Anesthesia in the Future Steven L. Shafer Palo Alto VA Health Care System Stanford

  2. 2010

  3. Typical American Hospital Typical American Hospital 1985 - 25 years ago

  4. Therapeutic Armamentarium • Thiopental • Isoflurane • Morphine, Fentanyl • Succinylcholine, Curare, Pancuronium, Metocurine

  5. Routine Monitors • Electrocardiogram • Inspired oxygen • Blood pressure cuff • Temperature • Finger on the pulse

  6. Special Monitors • In selected patients: • Pulmonary Artery Catheters • Capnography • Capnography

  7. Airway Control • Endotracheal Intubation • Mask Ventilation • Mask Ventilation • Mask Ventilation • Mask Ventilation • Mask Ventilation • Mask Ventilation • Mask Ventilation • Mask Ventilation • Mask Ventilation

  8. MostlyApneic and Cyanotic MostlyApneic and Cyanotic MostlyApneic and Cyanotic MostlyApneic and Cyanotic MostlyApneic and Cyanotic MostlyApneic and Cyanotic MostlyApneic and Cyanotic MostlyApneic and Cyanotic MostlyApneic and Cyanotic MostlyApneic and Cyanotic MostlyApneic and Cyanotic MostlyApneic and Cyanotic MAC MonitoredAnesthesia Care

  9. Patient Care • Admission before surgery • Highly invasive surgical technique • Intramuscular pethidine for postoperative analgesia • Discharge in days to weeks surgical technique        

  10. Patient Care Issues • Poor post-operative pain control • Slow recovery • Nausea and Vomiting

  11. Anesthesia1998 12 years ago

  12. Basics of Anesthesia • Delivery of oxygen • Support of intravascular volume and tissue perfusion • Patient Comfort Patient Comfort

  13. Therapeutic Armamentarium • Thiopental • Isoflurane • Morphine, fentanyl, alfentanil, sufentanil, remifentanil • Succinylcholine, pancuronium • Thiopental, propofol • Isoflurane, sevoflurane, desflurane • Morphine, fentanyl, alfentanil, sufentanil, remifentanil • Succinylcholine, pancuronium, vecuronium, rocuronium, atracurium, mivacurium, doxacurium, and pipecuronium

  14. TIVA TIVAE Total IntraVenous Anesthesia Total IntraVenous Awareness Total IntraVenous Anesthesia with Ephedrine

  15. Propofol

  16. Desflurane, Sevoflurane

  17. Fentanyl Family Tree

  18. Remifentanil

  19. Routine Monitors • Pulse Oximetry • Capnography • Electrocardiogram • Inspired oxygen • Blood pressure cuff • Temperature  Finger on the pulse  Finger on the pulse

  20. Special Monitors • In selected patients: • Esophageal echocardiography • Pulmonary artery catheterization • Continuous arterial blood gas • Continuos mixed-venous saturation • Sophisticated ventilator monitoring

  21. Bispectral Index • Based on EEG spectral analysis • Good predictor of mental status of patient during anesthesia with: • Inhalational anesthesia • Inhalational anesthesia with opioids • Propofol anesthesia with opioids

  22. Airway Control • Endotracheal Intubation • Mask Ventilation • LMA Laryngeal Mask Airway

  23. Midazolam, Alfentanil, and Conversation MAC MonitoredAnesthesia Care

  24. Patient Care • Admission on day of surgery • Discharge in 3 - 24 hours • Fast tracking of patients • Laparoscopic surgery • Improved post-operative pain management • Epidural opioids • PCA Patient Controlled Analgesia Patient Controlled Apnea

  25. 2010 Today

  26. New Therapeutics • Duzitol • Hypnotic • Analgesic • Amnestic • Muscle Relaxant • Aphrodisiac Anesthesiology 76:327-330, 1992

  27. New Therapeutics • Cycloflurane • Chemical stability of isoflurane • Rapid induction of sevoflurane • Rapid emergence of desflurane • Pleasant smell of “Mr. Propre”

  28. New Therapeutics • Dexmedetomidine • Central 2 adrenergic agonist • Profound postoperative analgesia in the ICU • Profound anti-ischemic properties • Modest sedation • Rapid offset • Reversible • Demonstrated improved outcome after major surgery

  29. New Therapeutics • Hyptiva • Pharmacodynamics of propofol • Pleasant induction and emergence • Modest cardiovascular effects • Modest respiratory effects • Pharmacokinetics of remifentanil • Extraordinarily rapid emergence • Predictable • Minimal change with disease or age

  30. New Therapeutics • Central nicotinic analgesics • Derived from amphibian skin • Prototype is epibatidine • Efficacy equal to morphine • No ventilatory effects • No physical dependence • No kidding • Science 1998 Jan 2;279(5347):77-81

  31. New Therapeutics • Muscle Relaxants • Suxuronium • MadamCurium • Rockandrolium Suxuronium

  32. Madam, Are you Comfortable? MAC MonitoredAnesthesia Care

  33. New Therapeutic Modes • RemifentanilPCA

  34. New Monitoring • Intraoperative EEG • BIS now standard-of-care • EEG Guided Anesthesia Delivery System EGADS

  35. EGADS

  36. Patient Care • Nearly all operations done on outpatients • Most operations are laparoscopic/endoscopic • Intelligent intra-operative and post-operative drug delivery systems • ICU care rarely needed

  37. Anesthesia in 2020?

  38. Plausible: Remifentanil PCA Dexmedetomidine Nicotinic agonists New generation of hypnotics EGADS system Implausible Duzitol Cycloflurane Suxuronium, madamcurium, rockandrolium Plausible vs. Implausible

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