Lecture 1/18/22 Flashcards
what is the definition of Anesthesia?
Lack of feeling or sensation
Artificially induced loss of the ability to feel pain
To permit the performance of surgery or painful procedures
What is General Anesthesia
A drug-induced loss of consciousness
Patients are not arousable; even by painful stimulation.
Intubation is not required
A ventilator is not essential.
Volatile anesthesia is not necessary but can be induced from prop or Roc
Independent ventilatory function is often impaired
Maintain patent airway, ie jaw thrust, O2 supplementation
Positive pressure ventilation
Cardiovascular support
What is Regional Anesthesia
Insensibility is caused by interrupting the sensory nerve conduction of a particular region of the body
-Peripheral
-Spinal
-Epidural
Level of consciousness is unchanged (unless sedatives are used)
Ventilatory/airway protection is maintained
What are the qualities of minimal sedation?
Responsiveness: To verbal commands
Airway: Unaffected
Spontaneous ventilation: Unaffected
Cardiovascular function: Unaffected
What are the qualities of Moderate Sedation?
Responsiveness: To verbal/touch
Airway: No assistance is needed
Spontaneous ventilation: Adequate
Cardiovascular function: Usually maintained
What are the characteristics of Deep Sedation?
Responsiveness: After repeated or painful stimulation
Airway: Assistance might be required
Spontaneous ventilation: Possibly inadequate
Cardiovascular function: is Usually maintained
What are some anesthetic techniques used from 4000 BC-400 BC
Plants…poppy, coca leaves
Acupuncture
Ethylene fumes from geologic fault lines beneath Apollo’s temple
Cannabis vapor
Carotid compression
Hippocrates
Accommodate the operator
Avoid sinking down and turning away
Dioscorides 40-90 AD
(a surgeon in Nero’s army)
Wrote Materia Medica (pharmacology)
- Authoritative for 15 centuries
- 5 volumes; plants, animal and mineral products
- 360 medical properties (antiseptic, anti-inflammatory)
What is a Soporific?
Soporific was something on a sponge that was smelt to illicit some response
Soporifics….sponges
½ ounce opium
Juice of mandrake leaves
Juice of hemlock
3 ounces of hyposcyamus (L-isomer of atropine)
Sufficient water
Reversal: vinegar
Who is accredited with making Diethyl Ether?
Valerius Cordus 1515-1544
German botanist, physician
What made Diethyl Ether popular
Made from sulfuric acid and ethyl alcohol
Named ether: greek for ignite (Explosive)
Tested on chickens
Recreational d/t whiskey tax
People who would experiment on themselves would get addicted to the high. Liquor was expensive so diethyl ether was a substitute
Why was early anesthetics inhalation agents and not IV?
IV equipment was not invented yet or not easily avaliable
Who is Sir Christopher Wren and who was his partner
His partner was Robert Boyle
Created IV therapy using a goose quill
Administered alcohol into a dog’s vein
Royal Society of London members
“I have injected wine and ale in a living dog into the mass of blood by a veine, in good quantities, till I have made him extremely drunk, but soon after he pisseth it out.”
Hint: “Wren” is a type of bird, A goose is a bird
Hint: if you put in an iv wrong you may get a “BOYLE” under the skin
Joseph Priestly
1773
English chemist
Discovers oxygen and nitrous oxide
Discovered photosynthesis
Hint: Priests are supposed to be religiously “pure”. what is a pure element? Oxygen
Humphry Davy
1800 British chemist
- Suggested its (Nitrous Oxide) use for surgical pain control
- Suggestion not appreciated… instead, its use became recreational and entertainment
- Surgeons wanted pt to hold still not so much did they care about the pain
- He also discovered potassium, sodium, calcium, magnesium….
Who was Horace Wells?
1815-1848
Dentist
- Nitrous experimentation
- Noticed that a man under the influence of N2O had no recall of pain/injury
- Self-administered for tooth extraction and uses on several dental patients
- 1845 at Mass General….Arranged administration for amputation
“humbug” Use of Nitrous disregarded by surgeons because pt. was still moving
Hint: after the demonstration, the surgeons said “WELLs” it’s ”NO”t good enough if they are still moving!
Who pioneered the combination of Nitrous and Oxygen? Why was this important?
Andrews
Chicago surgeon….Nitrous/oxygen anesthesia without cyanosis
Some thought that the anesthetic effect was brought about by anoxia and not actually Nitrous
Who invented the 1st anesthesia machine with nitrous/oxygen together
Hewitt
Hint: Nitrous makes you laugh so you have to have a good sense of “Witt”
Crawford Long
Revisited Ether in 1842
delivered either for a patient with 2 vascular neck tumors
Continued use of whiskey
Hint: “Long” after the discovery of ether it was used for a pt with a Long neck who had tumors
William Morton
Revisited Ether
1819-1868
Dentist
Needed anesthesia for denture fitting
Who Developed the process for pure Ether?
Dr. Robinson Squibb
Founded Squibb pharmaceuticals….leading manufacturer
Hint: A “Squibb” (HP reference) is a “PURE” blood wizard with no powers. But some people thought you are “Ether” a wizard or basically a muggle.
What was the disadvantages of ether?
Prolonged induction: Slow onset and slow offset.
Flammable
An unpleasant persistent odor that everyone was breathing in the room
High incidence of nausea/vomiting
Who used Chloroform in obstetric surgerys?
Sir James Simpson 1847
Obstetrician in Scotland
Experimented following dinner parties
Defined pain: “actual or potential tissue damage”
Religious opposition: though biblically women deserved to have pain during childbirth since they gave man the apple.
Genesis 2:21 was Simpsons defense
- “and the Lord God caused a deep sleep to fall upon Adam, and he slept; and he took one of his ribs and closed up the flesh instead thereof”.
Hint: Think of Pregnant Marge Simpson
Who is Dr John Snow?
Full-time anesthetist
Queen Victoria was given Chloroform for the birth of prince Leopold and Princess Beatrice
“discovered” epidemiology when he traced the London Cholera Outbreak to the water source
Hint: John Snow from GOT turned out to be “royalty”.
What was the Controversial aspect of Chloroform? what were the Commissions called to question its use?
Many deaths of healthy individuals
Hyderabad Commissions
1888 and 1891… safe with “their methods”
Respiratory arrest vs cardiac paralysis
430 cases without “recording devices” + 157 cases with “recording devices”
Guthrie, 1894, delayed chloroform hepatotoxicity in children
Levy, 1900, Light chloroform anesthesia and adrenaline….fatal vfib in animals
Dr Koller
Dr. Koller 1857-1944
Viennese ophthalmologist (a colleague of Sigmund Freud)
Used Cocaine for Anesthetic for eye surgery
Hint: Some “SEE” it as”Kool”ler to use Cocaine than other drugs
Dr. Halsted
1852-1922
1st regional (mandibular) nerve block with cocaine
Dr. August Bier
1861-1949
1st spinal anesthetic with cocaine
Developed Bier block still used today
Turnaquate on arm used
Dude hold my “Bier” said the guy before he did something stupid and broke his spine
Sister Mary Bernard
1877
Low pay
Intelligent
Focused on the pt and not the surgery
Alice Magaw
1928
“mother of anesthesia”
14,000 open drop ether cases without death
Agatha Hodgins
1877-1945
Worked for Dr Crile
Opened one of 1st nurse anesthesia schools
Taught in France
Developed nitrous/oxygen techniques
Founded AANA
What volatile Anesthetic caused violent explosions?
Cyclopropane (1934)
Hint: propane explodes so…
What Volatile Anesthetic was associated with Hepatitis and had a very slow onset?
Halothane (1956)
used until the early 90’s
Isoflurane
1981
Relatively safe
Less nausea and vomiting
Quicker onset than halothane
Not a great outpt. Surgery med because of the slow onset and slow offset
Used for pts that you know will not get extubated and that will probably get transferred to the ICU
Desflurane
1992
Rapid uptake and distribution! (most rapid onset and offset)
Great for outpt. surgery
High vapor pressure. Almost the same as atmospheric air
Large quantities to achieve anesthesia
Because of the high vapor pressure is “Des”appears when spilt
Edmund Egar
1960’s-1990’s
Know for doing all the experimentation and data on Desflorane
End-tidal concentration correlated to movement….MAC
Mac (Minimal Alveolar Concentration) is the dose of volatile anesthetic needed to get desired effects
How much concentration to get into the brain….ect
Hint: Edmund Egar was eager to teach what he researched
Sevoflurane
1995 in US
Intermediate action between isoflurane and desflurane
Unstable or toxic in soda lime (CO2 absorber); toxic. Only in low flow 2L per min. degradation product concerns
Better Co2 absorbers nowadays
great for asthmatics and kids
No new inhaled anesthetics since
What was the emphasis on the development of new volatile anesthetics in the 1990’s?
Early discharge and Outpatient Surgery
What was the emphasis on the development of new volatile anesthetics in the 1990’s?
Early discharge and Outpatient Surgery
who proved that children got liver failure from chloroform?
Guthrie
Acetylcholine and Amnesia
Stimulate inhibitory transmissions
Gaba and Amnesia
Inhibit stimulatory transmissions
What modality is encouraged today to achieve analgesia
The multimodal approach is helping with decreasing dependence on Narcotics and addiction
Morphine: From opium in 1805: initially higher death rates
Today’s analgesics
Narcotics (opioids)
Cyclooxygenase inhibitors
Gabapentin (pregabalin)
Acetaminophen
Peripheral nerve blocks
What medication was introduced to decrease the number of anesthetics used and decreased mortality?
Muscle relaxants
Curare
1942
What are the 4 aspects of Anesthesia taken into account in Anesthesia?
- Muscle Relaxation
- Homeostasis: was introduced to encourage maintaining steady vitals throughout a procedure “ Railroad Tracks”
- Amnesia
- Analgesia
Dr. Liston
Dr. Liston washed his hands and instruments often.
Said that the faster the surgery, the better the survival rate.
- But in his haste he once killed his Surg tech and another helper.
Hint: Listerine keeps you clean
Hint: There is a “List” of the best times that dr Liston did amputations.
George Crile
1864-1943)
Cleveland Clinic
Light nitrous/oxygen anesthesia
Local infiltration of procaine prior to incision = LOCALS
Hint: when you give lido SQ it sometimes bubbles the skin to look like an Isle (ile) and this way you dont cry (Cri) (Cri-ile)
Harvey Cushing
(1869-1939)
Regional blocks prior to emergence from Ether
Anesthetic records, BP/HR measurements
Hint: Dr Cushing would give a regional block to “CUSHIon” the pain when waking up.
But it was no “Cush” job for anesthesia any more because now they had to document.
What is Neuroleptic Anesthesia?
- Opioids, antipsychotics (Haldol, droperidol), nitrous
- Blocked autonomic and endocrine response to stress
- High incidence of awareness, dysphoria, extrapyramidal movements.
- Pts were not always asleep but so confused they couldn’t understand what was going on or remember
Stage 1 of Anesthesia and the 3 planes
Stage I: the beginning of induction of general anesthesia to loss of consciousness
1st plane: no amnesia or analgesia
2nd plane: amnestic but only partially analgesic
3rd plane: complete analgesia and amnesia
Stage II of Anesthesia
Stage II: loss of consciousness to onset of automatic breathing
eyelash reflex disappears
coughing, vomiting, and struggling may occur
irregular respirations with breath-holding
Stage 2 is more dangerous and uncomfortable stage. Not a great time to extubate. You want to transition through this phase as quickly as possible in induction and waking up.
Stage III of Anesthesia and 4 planes
Stage III: onset of automatic respiration to respiratory paralysis (surgical plane)
- 1st plane: automatic respiration to the cessation of eyeball movements
- 2nd plane: cessation of eyeball movements to the 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)
Stage iV of Anesthesia
Stage IV: stoppage of respiration till death
Levy had a series of studies that showed that light chloroform stimulated what
The autonomic nervous system. slide 18
What are two major adverse effects of chloroform discussed in class?
Hepatotoxicity
Ventricular fibrillation (Light Chloroform)
Slide 18
who identified delayed chloroform hepatotoxicity in children
Guthrie
who stated that Light chloroform anesthesia and adrenaline => active autonomic system
Fatal V-Fib in animals
Levy
What three components made up “the triad”? what was the goal of the triad?
analgesia, amnesia, and muscle relaxation
The goal was to treat the pt more holistically
What was morphine derived from
Opium
In 1981 why were opioids used highly in surgery?
[surgical stimulation produced despite lack of movement]
◦ Tachycardia
◦ Hypertension
◦ Insignificant?
◦ Except with CAD => beta-blockade
◦ High-dose opioid techniques were used
◦ resulting in More N/V
◦ Increased hospital stays
When did we start to realize that maybe giving a top of opioids wasn’t a great idea?
◦ 2000’s
◦ Opioid sparing techniques
◦ “multi modal” techniques
What drugs are used in the Preoperative period
◦ BZD, H1 and H2 blockers, bronchodilators
What drugs are used in the Induction of anesthesia
◦ Etomidate, ketamine, propofol, narcotics
What drugs are used in the Maintenance of anesthesia
◦ Inhalation drugs, neuromuscular blockers, pressors, blockers
what drugs are used in the Emergence from anesthesia
◦ NMB reversal, local anesthetics
According to Guedel’s Reference Chart, when do respiration end?
Stage 3 plane 4 (Diaphragmatic paralyzation)
According to Guedel’s Reference Chart, wehn do ocular movements end?
End of stage 3 plane 1
According to Guedel’s Reference Chart, when are the pupils dilated
Stage 3, phase 4, through stage 4
At what stage is eyelash reflex lost?
End of stage one/ beginning of stage 2
When is the pupillary reflex lost
in stage 3, Plane 3
According to Guedel’s Reference Chart, at what stage do we see increased secretion of tears?
Stage 3 phase 2
According to Guedel’s Reference Chart, when do you have highest muscle tone
Stage 2
