History of anesthesia pharmacology Flashcards
1
Q
Anesthesia
A
- The lack of feeling or sensation.
- The 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 arousable, even with painful stimulation.
- Independent ventilatory function is often impaired; the patient may need cardiovascular support and positive pressure ventilation to maintain a ptaent airway.
3
Q
Regional anesthesia
A
- insensibility caused by interupting the sensory nerve conduction of a particular region of the body.
- EX: Spinal, epidural, and peripheral.
- Level of consciousness is unchanged unless sedatives are used.
- ventilatory/airway protection is maintained. (these are not affected by regional anesthetics)
4
Q
Sedation
A
- a spectrum of consciousness between awake and unconscious
5
Q
Minimal sedation
A
- Responsive to verbal commands
- airway unaffected
- spontaneous ventilation unaffected
- cardiovascular function unaffected
- Also called anxioloysis
- Used to decrease anxiety. EX: 2mg of versed in preop
6
Q
Moderate sedation
A
- responsive to verbal/touch
- airway, no assistance needed
- spontaneous ventilation adeqaute.
- cardiovascular function usually maintained
7
Q
Deep sedation
A
- responsive after repeated or painful stimulation
- airway, assistance might be required. EX: nasal airway, readjusting of head, or chin thrust
- spontaneous ventilation, possibly inadequate
- Cardiovascular function usually maintained.
8
Q
4000 BC - 400BC anesthesia
A
- plants such as poppy and coca leaves.
- acupuncture
- Ethylene fumes from geologic fault lines beneath apollos temple.
- Cannabis vapor
- Carotid compression
9
Q
Hippocrates 460-377BC
A
- Wanted the patient to accomodate the operator/surgeon by just being still and laying there.
- Wanted the patient to avoid sinking down or pulling away.
10
Q
Dioscorides 40-90AD
A
- Was a surgeon in Nero’s army
- Wrote the first pharmacology book called the materia medica.
- He also used Mandragora and wine as a hallucinogenic. The plant itself has a human shape to its roots and it was thought to have some magical properties.
11
Q
Materia medica
A
- The first pharmacology book written by Dioscorides.
- Had 5 volumes of plant, animal, and mineral products and 360 medical properties from antiseptic to anti-inflammatory.
- Peoplec used this book for 15c centuries/ 1500 years.
12
Q
Middle ages anesthesia
A
- They used sponges soaked in all sorts of substances such as 1/2 ounce opium, juice of mandrake leaves, juice of hemlock, 3 ounces of hyposcyamis (L-isomer of atropine), and water.
- The sponge was held over the nose to be used is an inhalation anesthetic.
- The reversal was vinegar to be inhaled.
- Vinegar/ammonia is still used today to wake people up when they have been knocked out in a sport.
13
Q
What was the first true inhalation anesthetic?
A
- Diethyl ether
14
Q
Diethyl ether
A
- Discovered by a physician that was also a botonist named Valerius Cordus 1515-1544.
- Made from sulfuric acid and ethyl alcohol.
- Named ether which is greek for ignite. Ether is very flammable.
- Initially tested on chickens and dogs.
- People used ether recreationally at parties because there was no alcohol or whiskey tax on them.
15
Q
Why were volitile anesthetics discovered and used first?
A
- Because at the time, we didn’t have IV technology, needles, tubing, or a way to make the medications for IV use.
16
Q
IV access
A
- Christoher Wren and Robert Boyle created the technology for IV access in the 1650’s by using a goose quill as the IV catheter, and the goose bladder as the IV bag, and administering alcohol into a dogs vein.
- Christopher Wren stated “I have injected wine and ale into a living dog into the mass of blood by a vein, in good quantities, till I have made him extremely drunk, and he pisseth it out.”
- From this they learned that these drugs could infuse into the venous system via the vein of the animal, and that there are effects to the animal but the effects don’t last forever. They started learning about metabolism. They think it is a urinary elimination. They don’t know yet that it is metabolized by the liver, and by first pass.
- Understand that they can give a medication, it has an effect for a certain period of time, and then it is eliminated.
17
Q
The Royal society of london
A
- Christohper Wren and Robert Boyle were members.
- It was a society of men that would get together and do science experiments.
- Had famous scientific men.
18
Q
Nitrous Oxide
A
- In 1773, English Chemist Joseph Preistly discovered oxygen and nitrous oxide as well as photosynthesis.
- This drug has come in and out of favor and is currently used a lot.
19
Q
Humphry Davy 1800
A
- a British chemist who discovered potassium, sodium, calcium, magnesium, and a lot of the important elements in the body.
- He suggested that nitrous oxxide be used for surgical pain control, but at the time no one appreciated this opinion enough, there wasn’t a lot of belief in it, and it was more so used for parties and entertainment.
20
Q
Horace Wells 1815-1848
A
- A dentists that noticed that a man under the influence of nitrous oxide had no recall of pain or injury.
- He. self administerd nitrous oxide to remove some of his own teeth.
- He experimented with it on his dental patients for tooth extraction.
- He tried to present it at Mass General in 1845 to amputate a patient, but he noticed the patient moved alot because nitrous oxide doesn’t prevent movement. Because of this, it was thought that nitrous oxide didn’t work because the patient was moving. They didn’t realize that it was giving the pain relief side effect.
21
Q
Nitrous in 1868
A
- administered with air at this time and not oxygen which created problems with the use of nitrous and hypoxia.
- They didn’t understand if the hypoxia was from the anesthetic or was it the lack of oxygen that was the problem.
22
Q
Who was the first person to give nitrous with oxygen anesthesia without cyanosis?
A
- Dr. Andrews, a Chicago surgeon.
23
Q
Crawford Long 1842
A
- Delivered ether for a patient with 2 vascular neck tumors.
- he still also used whiskey mixed with the ether for these patients so they werent sure if the results were due to the ether alone or with whiskey added.
24
Q
William Morton 1819-1868
A
- Was a Dentist that used ether anesthesia for denture fittings because it was so painful.
25
Q
When was the first public display of ether
A
- 1846
- This was the first successful public demonstration of ether and it was done at Mass General in Boston.
- Complications of ether use during this time were poor fitting inhalers, no IV access, prolonged emergence, and variable quality of the ether. It was hard to know how much or how little ether to give a patient. There wasn’t a good way to measure.
- It was so popular that within 60 days, the use of ether traveled to England where it was widely used.
26
Q
Who developed the first process for pure ether in 1856?
A
- Dr. Robinson Squibb
- He also founded Squibb pharmaceuticals which was the leading manufacturer of different kinds of drugs in the U.S.
- Squibb developed pure ether so that it was consistant and the patient was getting the same dose every single time.
27
Q
What are the disadvantages of ether?
A
- Its flammable
- Has a prolonged induction point.
- Has an unpleasant persistant odor, very sweet smell.
- Has a high incedence of nausea and vomitting.
28
Q
Chloroform
A
- This was the nect volitile anesthetic that came on the scene after ether and nitrous oxide.
- It was discovered all over the world around the same time by many different people around 1831.
- Was discovered by many different chemists, botonists, and dentists at this time.
29
Q
Sir James Simpson 1847
A
- Was an obstetrician in Scotland that experimented with chloroform following a dinner party.
- There was a lot of religious opposition to using chloroform in Scotland and great Britain at this time for women in child birth to have an anesthetic.
- The religious opposition to the pain of childbirth was thought to be a consequence of eve given adam the apple.
- James Simpson was not of this mindset and believed that pain could cause actual or potential tissue damage.
30
Q
Dr. John Snow
A
- Was a full time anesthetist for obstetrician care.
- One of his first patients was Queen Victoria. She had children prince leopold and princess beatrice who were birthed using chloroform by Dr. Snow.
- He is also famous for discovering epidemiology when he traced the London cholera outbreak to a water source.
31
Q
What were the contraversies with chloroform?
A
- There were a lot of deaths in healthy people due to chloroform. This caused people to be afraid of anesthetics.
- A small country called Hyderabad created a commision in 1888 and 1891 that took a look at what was going on with chloroform. These commities determined that it was perfectly safe and that the heart will never stop as long as you ventilate patients appropriately.
- These committies looked at 157 cases with a recording device aftert hey had looked at 430 cases with no recording data or monitoring devices. What they found was that chloroform was relatively safe as long as you ventilted the patient appropriately.
- However today we know there are instances where the heart does stop first even if you have been ventilating.
32
Q
Guthrie 1894
A
- Determined that chloroform was very hepatotoxic in children.
33
Q
Levy 1900
A
- Discovered that light chloroform anesthesia stimulated adrenaline which caused fatal v-fib in animals.
- Chloroform went out of favor after this because o the extreme side effects they were seeing.
34
Q
Cocaine
A
- Not used inhaled for anesthesia.
- It is used topically and also used to be used in spinals.
35
Q
Dr. Kollar 1857-1944
A
- Was a Vienesse opthalmologist and collegue of Sigmund freud who used cocaine as an anesthetic for eye surgery.
36
Q
Dr. Halstead 1852-1922
A
- Used cocaine as the first regional mandibular nerve block
37
Q
Dr. August Beir 1861-1949
A
- Was the first to use cocaine as a spinal anesthetic.
- Also developed the Beir block. This is a regional anesthetic where you put a turnequit on the arm, exanguinate the arm flow up the turnequit and then inject through an IV on the hand some 1/2% lidocaine with or without other medications which makes the arm numb. It is a great anesthetic for procedures like carpal tunnel and pinned fingers.
38
Q
Who was the first nurse anesthetist?
A
- Sister Mary Bernard in 1877.
- we saw nurses in america as the first nurse anesthetists because they were low paying, intellegent, and focused.
39
Q
Who is considered the mother of anesthesia?
A
- Alice Magaw 1860-1928
- She did 14,000 drop ether cases without any deaths.
40
Q
Who opened one of the first nurse anesthesia schools?
A
- Agatha Hodgins 1877-1945.
- Taught in France during WWI
- Developed nitrous/oxygen techniques
- Founded the AANA.
41
Q
Cyclopropane
A
- Developed in 1944
- Came on and off the market very quickly because it was violently explosive and not any more effective than ether.
42
Q
Halothane
A
- Developed in 1956
- Used up intil the late 90’s.
- Caused hepatitis and had a slow onset of action.
43
Q
Isoflurane
A
- Developed 1981.
- Is relatively safe.
- Has less instances of nausea and vomitting
- Has a quicker onset than halothane.
- We still use Isoflurane but it has a much longer onset and emergence than sevoflurane and desflurane.
- Our goal now is to have faster anesthetics with a faster onset and offset.
44
Q
Desflurane
A
- Developed in 1992
- Has the most rapid uptake and ditribution of the volitile anesthetics.
- Has the most rapid onset and offset.
- Has a high vapor pressure, almost that of the atmosphere.
- Requires a large quantity to get desired effect. You use a lot of volume and can be expensive because of that.
45
Q
Edmund Edgar 1960-1990
A
- Was an anesthesiologist that did experimentation into deslfuarne and how it worked.
- Developed the acronym MAC, end tidal concentration correlated to movement.
- Everything we know about desflurane is due to Edmund Edgar.
46
Q
Sevoflurane
A
- Developed in 1995 in the U.S.
- has an intermediate action between isoflurane and desflurane.
- Is unstable in soda lime and there is concern for toxic degredation product.
- There have been no new inhaled anesthetics since.
- It doesn’t irritate the airway like some of the other volitile anesthetics do. This makes it the perfect drug for inhalation induction.
- Used almost extensively in children.
47
Q
What is the triad of anesthesia?
A
- Amnesia
- Analgesia
- Muscle relaxation
- The goal is to have a balance of all 3.
48
Q
Amnesia
A
- Stimulate inhibitory transmissions.
- Inhibit stimulatiry transmissions
- Neurotransmitters for these 2 events are ACh and GABA.
49
Q
Analgesia
A
- Morphine from opium was discovered in 1805.
- We want a balance between opioid and non opioid medications.
- Analgesia from opioids was initially not in favor because of the high death rate from overdose.
- There are synthetic derivitives
- Todays analgesics include narcotics (opioids), cyclooxygenase inhibitors, gabapentin (pregabalin), acetaminophen, and peripheral nerve blocks.
50
Q
Muscle relaxation
A
- Curare discovered in 1942 from South american indians. Was used in blowdarts to hunt.
- The addition of a muscle relaxant decreased the amount of anesthesia needed due to relaxation which also decreased mortality rate.
51
Q
What was added to the triad of anesthesia in the late 1990s?
A
- Homeostasis; monitor cardiac ouput, make sure the sympathetic nervous system isn’t overly stimulated, and monitor immunosuppresion.
- Homeostasis along with amnesia, analgesia, and muscle relaxation gives us balanced/ stress free anesthesia.
52
Q
Dr. Liston
A
- Attempted balance in anesthesia
- Was a big proponent in quickness of the surgical case.
- He said that the faster you get in and out of surgery, the better of the patient is.
- he thought that surgeries longer than 20 minutes would result in death.
- Also known for killing 3 people in the same operation because he was so crazy fast. He killed the patient and the 2 assistants from a 1 slice cut for an amputation. Was not careful where his knife was going.
53
Q
Dr. Crile 1864-1943
A
- Was a famous surgeon from the cleveland clinic
- Recognized that local infiltration of procaine (an anesthetic) preemtively inhibited pain reflexes up to the brain was beneficial.
- Many surgical tools named after him.
- Used light nitrous/oxygen anesthesia.
54
Q
Harvey Cushing 1869-1939
A
- Was a big proponent of data collection, anesthesia records, and blood pressure and heart rate measurements.
- Used regional blocks prior to the emergence of ether.
55
Q
Neurolept anesthesia
A
- Used in 1959
- Prodimantly used antipsychotics like droperidol and haldol while also giving nitrous and opioids.
- The good was that it blocked the autonomic and endocrine repsonse to stress.
- The bad was that there was a high incidence of awareness, dysphoria, and extrapyramidal movements.
56
Q
What was a large concern in anesthesia balance in 1981?
A
- The autonomic nervous system.
- Surgical stimulation produced despite lack of movement.
- They were worried about how tachycardia and hypertension affected CAD. A lot of high opioids were used to control that.
- In 1982, anesthesia used up to 100mg of morphine and up to 20mg of versed. This would take forever for the patients to wake up.
57
Q
Anesthesia in the last 20 years.
A
- We started using opioid sparing techniques.
- The beginning of multimodal techniques.
- Using less opioids because of opioid addiction.
- We use more regional anesthesia as well.
58
Q
Phases of anesthesia
A
- Preoperative period: Benzodiazepines, H1 and H2 blockers, and bronchodilators
- Induction of anestheia: Etomidate, ketamine, propofol, and narcotics
- Maintainence of anesthesia: inhalation drugs, neuromuscular blockers, pressors, and blockers.
- Emergence from anesthesia: NMB reversals, and local anesthetics.
- Postoperative period.
59
Q
Stage I of anesthesia
A
- The beginning of induction of general anesthesia to loss of consciousness.
- 1st plane: no amnesia or analgesia.
- 2nd plane: Amnestic but only partial analgesic.
- 3rd plane: complete amnesia and analgesia
60
Q
Stage II of anesthesia
A
- loss of consciousness to onset of automatic breathing.
- eyelash reflex disapears
- coughing vomitting and struggling may occur.
- Irregular respirationswith breath holding
61
Q
Stage III of anesthesia
A
- Onset of automatic respirations to respiratory paralysis (surgical plane)
- 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: beginningto completion of intercostal muscle paralysis. Pupils dilate. This is the desired plane prior to muscle relaxants.
- 4th plane: complete intercostal paralysis to diaphragmatic paralysis (apnea).
62
Q
Stage IV of anesthesia
A
- Stoppage of respiration til death.
- We do not want to be in this stage.
