History of Anesthesia Flashcards
1
Q
Anesthesia
A
- Lack of feeling or sensation
- Artificially induced loss of the ability to feel pain; To permit the performance of surgery or painful procedures
2
Q
General Anesthesia
A
- A drug-induced loss of consciousness
- Patients are not arousabale; even by painful stimulation.
- Not necessarily intubated, ventilated, or receiving volatile anesthetic.
- Independent ventilatory function often impaired (we need to maintain their airway (eg., ETT or LMA), might need to provide positive pressure ventilation and cardiovascular support).
3
Q
Regional Anesthesia
A
- Insensibility caused by interrupting the sensory nerve conduction of a particular region of the body.
- Level of consciousness is unchanged (unless sedatives are used).
- Ventilatory/airway protection is maintained (unaffected). – good for COPD pts
4
Q
Three types of regional anesthesia
A
Peripheral
Spinal
Epidural
5
Q
Sedation
A
A spectrum of consciousness between “awake” and “unconscious”.
6
Q
Three categories of Sedation
A
Minimal (anxiolysis)
Moderate
Deep
7
Q
Minimal (anxiolytics) sedation
A
- Responsive to verbal commands
- Airway unaffected
- Spontaneous ventilation unaffected
- CV function unaffected
8
Q
Moderate Sedation
A
- Responsive to verbal/touch
- Airway – no assistance needed
- Spontaneous ventilation adequate
- CV function usually maintained
9
Q
Deep Sedation
A
- Responsive after repeated or painful stimulation
- Airway – assistance might be required
- Spontaneous ventilation possibly inadequate
- CV function usually maintained
10
Q
Historic anesthetics (4000 BC-400 BC
A
- Plants – poppy, coco leaves
Acupuncture - Ethylene fumes from geologic fault lines beneath Apollo’s temple
- Cannabis vapor
- Carotid compression
11
Q
Hippocrates
A
More in favor in worrying about the surgeon. “If you were a good patient, your job is to make it easy on the surgeon.”
- Accommodate the operator
- Avoid sinking down and turning away
12
Q
Dioscorides
A
- Surgeon in Nero’s army
- Materia Medica (Pharmacology)
- Used Mandragora with wine as a hallucinogenic
13
Q
Materia Medica
A
- First pharmacology book written by Dioscorides
- Authoritative for 15 centuries (1500 years)
- 5 volumes: plants, animal, and mineral products
- 360 medical properties (antiseptic, anti-inflammatory)
14
Q
What did they use a lot in the Middle Ages?
A
Soporifics… sponges (used as an inhalation-type approach)
- 1/2 oz opium
- juice of mandrake leaves
- juice of hemlock
- 3 oz of hyposcyamus (L-isomer of atropine)
- sufficient water
Reversal: vinegar
15
Q
What was the first true inhalation anesthetic?
A
Diethyl ether (aka ether)
16
Q
Who was the first person credited for the creation of ether?
A
Valerius Cordus (German botanist and physician)
17
Q
How did Valerius Cordus make diethyl ether?
A
- Made from sulfuric acid and ethyl alcohol
18
Q
Where does the name ether originate?
A
Named ether which is greek for ignite
19
Q
What was ether tested on?
A
chickens
20
Q
Whaat is one of the common chemical properties of ether?
A
Extremely flammable
21
Q
Diethyl was used ________ instead of ___________ due to ____________.
A
recreationally; alcohol or other drugs available; no tax
22
Q
Why did volatile anesthetics take off first before IV anesthetics?
A
There was no IV technology at the time
23
Q
When was IV technology created and by whom?
A
1650s
Sir Christopher Wren and Robert Boyle
- Created the IV needle itself from a goose quill.
- Used the goose bladder as the IV bag.
- Administered alcohol into a dog’s vein
- Members of the Royal Society of London.
24
Q
Second volatile anesthetic to come on the scene?
A
Nitrous oxide
25
Who first discovered nitrous oxide?
- Joseph Priestly 1773; English Chemist
- Also discovered oxygen and photosynthesis
26
Discovered potassium, sodium, calcium, magnesium
Humphry Davy 1800; British Chemist
27
Suggested nitrous oxide for its use for surgical pain control
Humphry Davy 1800; British Chemist
- at the time, most people didn't appreciate this suggestion and thought of it more for recreational and entertainment purposes.
28
Horace Wells
- Dentist
- Noticed a man under the influence of N2O had no recall of pain/injury
- Self administered for tooth extraction and uses on several dental pts
- 1845 at Mass General... arranged administration of nitrous oxide for amputation but the pt moved a lot
- "humbug" because pt moved
29
Common problem with nitrous?
- Hypoxia; Cyanosis
- Is it the nitrous or lack of O2?
30
One of the first surgeons to give nitrous with oxygen?
- Andrews (Chicago surgeon)
- Gave nitrous/oxygen anesthesia without cyanosis
31
First anesthesia machine with nitrous/oxygen
Hewitt
32
When did oxygen become commonly used with any volatile anesthetic?
~1868
33
Crawford Long
- 1842
- Ether revisited
- Delivered ether for a patient with 2 vascular neck tumors
- Hard to tell if it was the ether in and of itself was the successful element because they were still using whiskey
- data muddy on the topic
34
William Morton
- Denitst
- Used ether for denture fitting
35
First successful public demonstration of ether
- 1846 demonstration at Mass General (Ether Dome)
- called it Letheon ... 60 days after it was being widely used in England in addition to US
- Demonstration was "amazing" but they got lucky (poor inhaler fit, no IV access, prolonged emergence, variable quality).
36
Old method of assessing patient under ether?
- Keeping finger on carotid pulse
- If weak pulse, move ether mask away a bit
- If strong/pt moving, would put ether mask back on
37
Who developed the process for pure ether?
- Dr. Robinson Squibb
- Founded Squibb pharmaceuticals... leading manufacturer
38
Disadvantages of Ether
- Flammable
- Prolonged induction
- Unpleasant, persistent odor (sweet smell)
- High incidence of nausea/vomiting
39
3rd volatile anesthetic to be discovered
- Chloroform
- Discovered independently in 1831... USA, France, Germany, Great Britain
40
Sir James Simpson
- 1847
- Experimented on some of his predecessors at dinner parties
- Defined pain: "actual or potential tissue damage"
- Religious opposition in Scotland/Great Britain surrounding use of anesthetics during child birth.
41
Dr. John Snow
- Full time anesthetist
- Queen Victoria was one of his patients -- prince Leopold and princess Beatrice were born using Chloroform.
- "discovered" epidemiology when he traced London cholera outbreak to water source
42
What were some of the controversies of Chloroform?
- deaths of healthy individuals
- Hyderabad commissions 1888 and 1891 -- 587 cases saying Chloroform was safe (Cardiac death impossible as long as respiration was maintained?)
- Guthrie 1894 -- hepatic toxicity in children
- Levy 1900 -- stimulated release of adrenaline causing fatal vfib in animals
43
Cocaine
An anesthetic used topically or in spinals.
44
Dr. August Bier
- 1st spinal anesthetic with cocaine
- Developed Bier block
45
Describe the Bier block?
- A tourniquet is applied to stop blood flow (exsanguinate) to the limb
- A catheter is inserted into a vein in the limb
- Inject 7.5% Lidocaine with or without other medications --> achieving numbness
- good for carpal tunnel or pinning a finger
46
Dr. Koller
- Viennese ophthalmologist (colleague of Sigmund Freud)
- Anesthetic for eye surgery
47
Dr. Halsted
1st regional (mandibular) nerve block with cocaine
48
1st recognized nurse anesthetist
Sister Mary Bernard in 1877
49
Why nurses as first nurse anesthetists?
- Low pay
- Intelligent
- Focus
50
Who is considered the "mother of anesthesia"?
Alice Magaw
Performed 14k open drop ether cases without death
51
Agatha Hodgins
- Opened one of the first nurse anesthesia schools
- Taught in France
- Developed nitrous/oxygen techniques
- Founded AANA
52
What are some "recent" or "modern day" anesthetics?
- Cyclopropane 1934 (violently explosive)
- Halothane 1956 (used for many years until about the late 1990s; caused hepatitis in some patients and it had slow onset and slow emergence)
- Isoflurane 1981(relatively safe, less N/V than halothane; quicker onset than halothane --> quickly replacing halothane)
- Desflurane 1992
- Sevoflurane 1995
53
What were some problems with halothane?
Hepatitis in some patients; slow onset and slow emergence
54
Isoflurane has less ________ and _________ than halothane
nausea; vomiting
55
Isoflurane has a ____________ than halothane, therefore _________ halothane as the predominant volatile anesthetic
onset; replacing
56
Isoflurane has a __________ onset and emergence than ____________ and _____________
longer; desflurane; sevoflurane
57
Which volatile anesthetic would be ideal if you don't need to wake your patient up immediately after surgery (eg., transporting them to ICU postop)?
Isoflurane
58
Which volatile anesthetic has rapid uptake and distribution (most rapid onset and offset)?
Desfurane
- High vapor pressure (almost that of the atmosphere)
- Requires large quantity to achieve anesthesia (can be expensive for that reason)
59
Who came up with the Minimal Alveolar Concentration (MAC)
Edmund Egar (Anesthesiologist)
60
What is the MAC correlated with?
End-tidal concentration correlated to movement; determines dose of volatile anesthesia that we give
61
Sevoflurane
- 1995 in US
- Intermediate action between isoflurane and desflulrane
- Unstable in soda lime; toxic degradation product concerns
- No new inhaled anesthetics since
62
Advantage of Sevoflurane?
- Does not irritate the airway like the other volatiles do. Perfect drug for inhalation induction.
- Used almost exclusively in children
63
The "triad" of anesthesia
Amnesia, Analgesia, and Muscle relaxation
64
How is amnesia achieved?
- Stimulate inhibitory transmissions
- Inhibit stimulatory tranmissions
- Acetylcholine and GABA
65
How do we achieve analgesia?
- Morphine (from opium in 1805). Initially not in favor due to high death rates
- Synthetic derivatives
- Today's analgesics
66
Today's analgesics
- Narcotics (opioids)
- Cyclooxygenase inhibitors
- Gabapentin (pregabalin)
- Acetaminophen
- Peripheral nerve blocks
67
Muscle relaxation became more available when _____?
- Curare came out in 1942
68
Who discovered curare?
South American Indians
69
Using muscle relaxants like curare affects what?
The amount of anesthesia needed to relax the patient (lower dose) --> decreased mortality
70
"Balanced anesthesia" or "Stress free"
"Triad" + Homeostasis
71
Dr. Liston was a big proponent of what?
- Surgical cases needing to be no more than 20 minutes. He said >20 mins more likely to die.
- Ironically, he killed 3 people in 1 operation (amputation).
72
George Crile
- Cleveland Clinic
- Light nitrous/oxygen anesthesia
- Local infiltration of procaine (discovered that preemptively inhibiting pain reflexes up to the brain was beneficial)
73
Harvey Cushing
- Regional blocks prior to emergence from ether (preemptively inhibiting pain response)
- Anesthetic records, BP/HR measurements (loved his data!)
74
What kind of drugs were used in neurolept anesthesia?
- 1959
- Used predominantly antipsychotics (Haldol, droperidol), but also opioids and nitrous
75
Pros of neurolept anesthesia?
Blocked autonomic nervous system and endocrine response to stress
76
Cons of neurolept anesthesia?
High incidence of awareness, dysphoria, extrapyramidal movements (people not waking up well)
77
Attempts at balance in the 1980s
- Still worrying about autonomic nervous system, especially in pts with CAD
- Surgical stimulation produced despite lack of movement
- Tachycardia; Hypetension (affecting pts with CAD) --> used high dose opioid technique --> took them forever to wake up
78
Attempts at balance in 2000s
- Opioid sparing techniques
- Regional anesthesia
- "multi modal" techniques (eg., Gabapentin, Tylenol, COX inhibitors)
79
How many Stages of Anesthesia are there?
- 3 stages
- stages are a continuum
80
Phases of Anesthesia
- Preoperative period
- Induction
- Maintenance
- Emergence
- Postoperative period
81
What kind of drugs are given in the preoperative period?
Benzos, H1 and H2 blockers, bronchodilators
82
What are the common induction drugs?
Etomidate, ketamine, propofol, narcotics
83
What are drugs used in maintenance phase?
Inhalation drugs, volatiles, NMBs, pressers, blockers
84
What drugs are used in emergence?
NMB reversal, local anesthetics
85
Stage 1 of Anesthesia
- beginning of induction of general anesthesia to loss of consciousness
- includes 3 planes
86
What are the three planes of Stage 1?
1st plane: no amnesia or analgesia
2nd plane: amnestic but only partially analgesic (eg., administered versed and/or fentanyl)
3rd plane: complete analgesia and amnesia (ie., have given induction drugs -- Lido, fentanyl, Prop) --> LOC
87
Stage 2 of Anesthesia
- loss of consciousness to onset of automatic breathing
- eyelash reflex disappears
- coughing, vomiting, struggling may occur
- irregular respirations with breath-holding
- uncomfortable stage bc pt is at risk for aspirating, bradycardia, laryngospasm
- do not stimulate pt during this stage
88
Stage 3 of Anesthesia
- onset of automatic respiration to respiratory paralysis (surgical plane)
- includes 4 planes
89
What are the 4 planes of Stage 3?
1st plane: automatic respiration to cessation of eyeball movements
2nd plane: cessation of eyeball movements to beginning of intercostal muscle paralysis; secretion of tears increases
3rd plane: beginning to completion of intercostal muscle paralysis; pupils dilate; desired plane prior to muscle relaxants
4th plane: complete intercostal paralysis to diaphragmatic paralysis (apnea)
90
Stage 4 of anesthesia
- stoppage of respiration till death
- "too deep"
