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Anesthesia as a specialty Past, present and future 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 www.katedraanest.cm-uj.krakow.pl
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Anesthesia as a specialty Past, present and future
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
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 • Katarzyna Lepszy-Muszyńska (Coordinator, email:muszynscy.brzozowka@neostrada.pl
Pain as a part of surgery • Hypnosis • Alkohol • Botanical preparation • Superficial surgery • Galenic concept: body humors: blood, phlegm, yellow and black bile
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”
Local anesthesia • Ancient Incas: coca leaf as a gift to the Incas from the sun of God: • destruction of Incas culture • slaves payment
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)
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
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
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
Important steps in development of anesthesia • Ether (Morton) • Regional (spinal, epidural) end of XIX century • Thiopental 1934 • Curara 1942 • Halotane 1956
Anesthesia • analgesia • reversible anesthetic effect • amnesia • areflexia • sleep • supression of the vegetative response
Is anesthesia safe? • Like airplane? • Anesthesia related deaths: • 1940 1/1000 • 1970 1/10 000 • 1995 1/250 000 • 2005 ?
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
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
Present status of anesthesiology • Anesthesia • Pain management • Intensive Care Medicine • Emergency Medicine • Operative Medicine • Education • Research
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
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
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
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
An anaesthetic plan • Patient’s baseline condition with medical record and previous anaesthesia and surgery • Planned procedure • Drug sensitivities • Psychological makeup
The anesthetic plan • ASA physical status scale • General versus regional • Airway • Induction • Monitoring • Intraoperative management • Postoperative management
ASA and perioperative mortality rate • 1 0.07% • 2 0.3% • 3 2% • 4 7-23% • 5 9-51%
Documentation • Informed consent • Preoperative note • Intraoperative anesthesia record • patient status • review of anesthesia and surgery • laboratory • drugs dosage and time of administration
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
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
Ventilation management • Breathing systems • Open drop anesthesia • Mapleson circuits • Anesthesia machines
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,
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
Edotracheal intubation Most common and safe protection of aiways during anaesthesia and intensive care But Need skills and permament training