introduction of anesthesia

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Departement of Anestesiology andReanimation , School of Medicine,

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uma era ara n vers


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3Living Made Easy: Prescription for Scolding Wives [1830]


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Hinkley, an American portrait painter who studiedat the Paris Ecole des Beaux Arts, in 1882 began his

painting of the ether demonstration as aspeculative work and took 11 years to complete it.

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The Hinkley painting today hangs in the

Francis A. Countway Library of Medicine atHarvard Medical School in Boston..


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History of Anesthesiaistory of AnesthesiaA history of anesthesia or "pain killing" techniqueshistory of anesthesia or pain killing techniquesthroughout historyAnesthesia, historical background and the word's origin

Pain, however useful as a warning signal designed to keep living,agonywhen operations must be performed.

Attempts to control pain were many. The use of alcohol or some

orm o w a came o e ca e ypno sm was o . cupunc urewas used in the Orient. The new chemistry also contributednitrous oxide, which, when inhaled, served to su ress the8

sensation of pain.


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Year 1846

10The Ether Dome, Boston, Massachussets, USA


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1846, Boston Massachussetts

of ether as anesthetic

i iam orton

Inventor and revealer of anesthetic inhalation

Before whom in all time surgery was agonyBy whom pain in surgery was averted and annuled

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H. Bigelow


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. ,Dr. Horace Wells was one of the first to use ether as an

anesthesia.

n , us wo years a er orace e s anes e c success

with nitrous oxide, Dr. William Morton (1819-68), constructedthe first anesthetic machine.

Mortons simple device was aglass globe housinganether-soaked spongeso all the patient had to do was merely to inhale

the vapor through one of two outlets.Mortons invention was put to the test on October 16, 1846, in

the surgical amphitheater of the Massachusetts General HospitalinBostonwhenatwent - ea -oldmanwassuccessfull

anesthetized so a tumor could be painlessly removed from whatone source said was his neck and another indicated was from his

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Anesthesiology is a blessed profession

When God created Eva from Adams rib .

first, He put Adam into a deep sleep.

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Ether :

- ood narcosis- good analgesia- good muscle relaxation

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KemajuanIlmu Bedah

a

sfusi

io

tika

t

esi

Tra

Anti

A

ne

N u t r i s i

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...TODAY

nest esa s now muc sa er an more peasant or t epatient than it was 50 years ago.Factors contributing to the

pharmacology, better preoperative assessment and preparation of

patients Improvements in anesthesia have allowed

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surgeons to attempt more complicated operations on

increasing number of patients...... M.Dobson


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surgery

Trauma surger

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Many techniques originally developed for use during anesthesiaare now widely recognized as applicable to the care of a variety ofcritically ill patients, for example those with severe head injuries,

, .assessment and management of unconscious patients, control ofairway, endotrachel intubation,. cardioplumonary resuscitation

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ave t er or gns n anest esa,but are now recognized as

essential for all doctors.


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Working together

urgery nes eso ogy|

extends the boundaries of life and death

19Massive Crush Injury - Hb 2


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Pengembangan

1975 Anestesiologi RSCM1977 Anestesiologi RSDS

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Prolon edLifeSu ordi ICU|

adalah bagian dariResusitasi

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MagillGuedelMacIntoshpsen

Archie Brain

L M A

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Resusitasi Jantung Paru

ATLS

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Sekolahnya 4 tahun, 120 SKS+ MKDU

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Anestesia

Keadaan yang ditandai hilangnya kesadarandan / atau erse si n eri bersama atau ter isah

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Anestesia

Keadaan yang ditandai hilangnya kesadaran dan /atau persepsi nyeri (bersama atau terpisah)

Dapat dilakukan secara temporer dengan

obat anestesia umum obat anestesia lokal / regional

hipnosis

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Apakah anestesia berbahaya?

Ya men ebabkande resi nafas antun sirkulasi

fungsi otak, hati, usus, ginjal dan sistim imun

jika semua perubahan diawasi dan dikendalikan

maka baha a da at di-minimal-kan

Dengan anestesia yang baik risiko mati

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,


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Mortality associated w/ anesthesia

- ,

Forrest (1990)-7 days 1:10,000 -

MHA (Maryland Hosp Assoc 1999)-

National Aggregate Data

Class I 1:10,000

Class II 3:10,000

Clas III 28:10,000 Class IV 230:10,000

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Anestesiamenghambat hantaran impulse nyeri ataumenghilangkan persepsi nyeri

Suntikan im atau iv Anestesia umum

Inhalasi (dihisap nafas)

Dengan suntikan syaraf Anestesia regional /conductionbloc

Dengan suntikan ditem at o erasi

Anestesia (infiltrasi) lokal

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blok otak = syaraf pusat


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Anestesi umum

Ketamin pada jalur thalamus-cortex

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Anestesia regional

blok serat syaraf

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Ketaminen aas

pna oc

Plexus & NerveBlock

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a a uung syara o as

(local infiltration block)

(nerve block)

Pada berkas s araf dekat medula s inalis(plexus block)

Pada medula spinalis

per ep ura oc an su arac no oc= spinal anesthesia

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Nerve block

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exus oc

Epidural block Subarachnoid block


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Peridural block

block

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Obat anestesia = obat berbahayadosis kecil = anestesia

dosis besar = fatal

Pentothal, lidocain, N2O, halothan, sevoflurane,es urane aam oss t ngg semuamemat an

coma yang dalam

tekanan darah turun hebat

henti jantung

Pavulon, Esmeron, Tracrium, Succinylcholine =obat pelumpuh otot

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henti nafas (apnea) perlu nafas buatan

P t th l


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Pentothal PavulonKCl

Obat anestesia

=

Obat eksekusi mati

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Obat anestesia umum

Ether Bau (+) menyengat, terbakar,murah

Halothane

Enflurane

Harum, gg liver, aritmia

Harum >

Desflurane Harum

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Sistem anestesia

Pvaporizerbreathing tubes

canister sodalime

Flowmeteroksigen

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Sumber as O2 N2OVaporizer ether

Flowmeter pengatur gas

Vaporizer halothane

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Vaporizer enflurane


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otak

Uap obat inhalasi

Alveoliaru

Art.carotis int..

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Kapiler paru

Obat intravena


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TAHAP RECOVERY

turun OA dalam darah pindah ke

aveo ar a ar aam ara turun

OA dalam sel otak pindah ke darah

kadar OA dalam otak turun pasien sadarkembali

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TAHAP INDUKSI & MAINTENANCE

lalu ke jantung kiri sirkulasi oleh jantung

jaringan otakmasuk sel-sel otak

menjadi tidak sadar

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Urutan proses anestesia umum

Puasa: mengosongkan lambung ,

Induksi: memberi loading dose obat anestesia

antenance: memelihara kadar obat anestesi

Recovery: menunggu siuman kembali

Post-op care: menunggu normal kembali

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A t i b bk d i f i it l


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Anestesia menyebabkan depresi fungsi vital

Nafas:

sumbatan alannafas

mengurangi nafas (hipoventilasi) henti nafas

Sirkulasi:

tekanan darah turun nadi tak teratur

henti jantung

Kesadaran: menurun sampai coma

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PerubahanpCO2akibatanestesia


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Perubahan pCO2 akibat anestesia

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(hipoventilasi)pCO2 arteria

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Enflurane

Isoflurane

50Halothane

20

30

0

10

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0 MAC 1.0 MAC 1.5 MAC

Perubahancardiacoutputakibatanestesia


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Perubahan cardiac output akibat anestesia

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(depresi sirkulasi)% awake value

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Isoflurane

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Enflurane

Halothane

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0

20

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1.0 MAC 1.5 MAC 2.0 MAC

Perfusi nadidantekanandarah


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Perfusi, nadi dan tekanan darah

harus di monitor selama anestesia

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Waktu induksi

Jari raba Mata lihat nafas

Waktu maintenanceTelinga dengarjantung

Monitoring selama anestesi

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Edmond I Eger 1985


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Pasien trauma kepala dengan tekanan intra-kranial tinggi

Perlu obat anestesia yang tidak meningkatkan TIKlebih tin i la i

63selama Dr Bedah Syaraf tidak dapat dekompresi

Perubahan hormonal


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Resusitator


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- tekanan darah- ECG- suhu

- saturasi O2- kedalamanstadium anestesia

- resusitator- defibrilator

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- resprator


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ether halothan sevofluran desfluran

Induksi sukar mudah sangamudah

sukar

Titikdidih

36.2 50.2 58.5 22.8

oo gaspart.coeff 12.1 2.3 0.68 0.42

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e .uappada 20C


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VOLATILE ANESTHETICS

ETHERHALOTHAN

ISOFLURAN

SEVOFLURAN

67DESFLURAN


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Induksi inhalasi dengan ether perlu waktu 20-30 menit

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-


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Induksi inhalasi halothane3-5 menit dan dapat dipercepat

Induksi inhalasi desfluranebisa cepat tetapi > 25% pasien

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dengan suntikan pentothal iv au an spasme arynxharus dibantu propofol iv


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muntah tidak masuk paru(aspirasi)

MASA RECOVERY

aga agar

waktu gelisah tidak jatuhNafas dibantu oksigen

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Tekanan darah dipantau


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Anestesiologi & Reanimasisangat kompleks

dimana multiple variables bekerja cepat dalamhitungan menit dan detik

dan dalam range mati-hidupnya seorang pasien

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Penyulit buruk adalah


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- karena penyakitnya sendiri- karena pembedahannya- karena anestesianya

Penyulit terburukadalahMALIGNANT

obat cuma satu (dantrolene)

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efeknya belum tentuDipicu succinyl - halothan


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Goodgeneral anesthesia

n

cosis

l

gesia

relaxati

Na

An

uscle

Stress Free

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Narcosis dan analgesia


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Anestesi umumKetamin padajalur thalamus-cortex

Morfin pada

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Analgesia


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Nerve block

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exus oc

Epidural blockSubarachnoid block


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Muscle relaxation

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Anestesia

1. Pemahaman fisiologi, farmakologi, pato-

fisiologi serta pato-farmakologi . apor zer yang a urat

3. Pelumpuh otot dan antagonisnya

4. Narkotik sintetik dan antagonisny

5. Obat inhalasi inert desflurane, xenon

6. Respirator canggih dan analisa gas darah 7. Sarana monitoring fungsi vital yang teliti

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8. Dll masih banyak lagi


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Operasi mikroskopik|

Perfectly still

79Vaporizer yang akurat

Pengembanganblok re ional an andal


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- Jarum spinal #29- Celiac plexus block,- Cervical peridural

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,bahkan untuk janin


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w y y

Reversibility Anesthesia is a physiological trespassing

Awake - Coma - Awake A ain Breathing - Apnea - Breathing Again

made reversible

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Is ta un pengem angan nestesa

Anestesiologi & Reanimasi

Melahirkan disiplin ilmu baru :

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Pen etahuanberdasar reversibilit

Apakah nafas berhenti itu reversible?

Apakah coma itu reversible?

Prevent a premature death mendasari upaya

resustas

reanimasi

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reversing the dying process


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Resusitasi primitif|

|Patophysiology of

Dying and Reanimation(Peter Safar et al)

87Public Access Defibrillation


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Basic Life Support

A-B-C 1968 Safar etal

Advanced Life Support

Artificial Ventilation

oc rugs

Prolonged Life Support

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Intensive Care (G-H-I)

D fi iti Di i


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Definitive Diagnosis

of surgical pathology

LIFE SUPPORTSpesialis

Bedahrway, Breat ngCirculation, Brain

(BLS-ALS-PLS) Spesialis Anestesiologi

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Anestesiologi& Reanimasi Bedah PROFESSIONAL

BedahAnestesiologi& Reanimasi

90Selalu bekerja sama


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1.Sedation

N2O(Ether, Halothane, Ethrane, Isoflurane,

, ,iv-anesthesia

, , , ,

etomidate, etc)

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Narcotic-analgetic(morphin, petidin, fentanyl,

, , ,N2O

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ROUTINE PREOPERATIVE LABORATORY EVALUATION OFROUTINE PREOPERATIVE LABORATORY EVALUATION OF

ASYMPTOMATIC APPARENTLY HEALTHY PATIENTSASYMPTOMATIC APPARENTLY HEALTHY PATIENTS


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ASYMPTOMATIC, APPARENTLY HEALTHY PATIENTSASYMPTOMATIC, APPARENTLY HEALTHY PATIENTS

Hematocrit of hemoglobin concentrationAll menstruating womenAll patients over 60 years of ageAll patients who are likely to experience

significant blood loss and

may require transfusionSerum glucose and creatinie ( or blood urea nitrogen )concentration :

All patients over 60 years of age

Chest radiograph : all patients over 60 years of age

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THE ANESTHETIC PLANTHE ANESTHETIC PLAN

Premedication

GeneralAi t


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GeneralAirway managementInduction

Muscle relaxationLocal or regional anesthesia

Technique

Monitored anesthesia careSupplement oxygenSedation

MonitoringPositioningFluid management

Postoperative management

Pain controlIntensive care

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Hemodynamic monitoring

PREOPERATIVE PHYSICAL STATUS CLASSIFICATION ofPATIENTS ACCORDING TO THE AMERICAN SOCIETY OF ANESTHESIOLOGIST


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CLASSIFICATION AND PERIOPERATIVE MORTALITY RATESCLASSIFICATION AND PERIOPERATIVE MORTALITY RATES


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1 0,06 - 0,08 %

2 0,27 - 0,4 %

3 1,8 - 4,3 %

4 7,8 - 23%

5 9,4 - 51 %

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,

Pathwa and Mechanism

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auses.

lower uterine segment and cervix to allowpassage of the fetus.

2. Second stage: greater pressure of the presenting parton pain-sensitive pelvic structures anddistension of surroundin structures.

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Pathways


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Pathways. -

passing in the sympathetic nerves to the

sympathetic chain; referred to the T10L1 dermatomes.

2. Vagina and pelvic outlet: via A-delta and C fibersassin in the aras m athetic bundle in the

pudendal nerves; referred to the S2S4 dermatomes.

. ,

genitofemoral, and perforating branch of the posteriorcutaneous nerve of the thigh; somatic pain experienced

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in the L2S5 dermatomes.

Features.1Over 90% of women experience severe/unbearable labor

i lth h ll ti f d ith ti


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ppain, although recollection fades with time

2. Typically, pain is similar to other types of visceral pain, i.e.,

intermittent, severe, and colicky; it starts in the lowerabdomen and back, spreading to the perineum and thighs

(Lowe 2000).

3. Pain may be influenced by the factors already listed above,in particular by social, societal, and cultural aspects.

,

more stoic ones, leading possibly to differences in painbehavior rather than in the extent of pain felt. Fatigue and

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general debility, common in late pregnancy, may alsocontribute to the experience of labor pain.

A Understandthat labor painmayhaveadverse


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A. Understand that labor pain may have adverse

1. Respiratory: causes hyperventilation, leading tohypocapnia and respiratory acidosis.

2. Cardiovascular: increases cardiac output and bloodpressure via sympathetic activity; this may be

problematic in cardiac disease and pre-eclampsia. Increasedvenous return associated with uterinecontractions ma also contribute.

3. Neuroendocrine: increases maternal catecholaminesecretion with risk of uteroplacental

constriction.

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4 Gastrointestinal:effectof laborongastricemptyingand


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4. Gastrointestinal: effect of labor on gastric emptying and,

increased acid secretion have been suggested.

Opioids are well known to induce gastric stasis

5. Psychological: severe labor pain has been implicated in

- ,potential adverse consequenceson maternal mental health and family relationships.

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B. Understand also that pain during labor may havebenefits:


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p g ybenefits:

1. Indicates to the mother and those assistinglabor/deliver that contractions are occurrin .2. May have positive connotations regardingchildbirth, related to societal/cultural influences.

. ay n cae pro ems e.g. uer ne rupure,placental abruption).

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introduction of anesthesia

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