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INTRODUCTION OF

ANESTHESIA

Departement of Anestesiology and Reanimation , School of Medicine,

Sumatera Utara University2

History of

Anesthesia

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

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

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

The Hinkley painting today hangs in the Francis A. Countway Library of Medicine at

Harvard Medical School in Boston. .

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Ether Monument, Boston Public GardenPhotographs from the Detroit Publishing Company, 1880-1920

American Memory Collection aLibrary of Congress 8

History of Anesthesia History of Anesthesia History of Anesthesia History of Anesthesia

A history of anesthesia or "pain killing" techniques A history of anesthesia or "pain killing" techniques A history of anesthesia or "pain killing" techniques A history of anesthesia or "pain killing" techniques throughout historythroughout historythroughout historythroughout history

Anesthesia, historical background and the word's originPainPainPainPain, however useful as a warning signal designed to keep living organisms from damaging themselves too badly, becomes useless

agony when operations must be performed.Attempts to control pain were many. The use of alcohol or some form of what came to be called hypnotism was old. Acupuncture

was used in the Orient. The new chemistry also contributed nitrous oxide,nitrous oxide,nitrous oxide,nitrous oxide, which, when inhaled, served to suppress the

sensation of pain.

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9 10The Ether Dome, Boston, Massachussets, USA

Year 1846

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William TG Morton

Inventor and revealer of anesthetic inhalationBefore whom in all time surgery was agony

By whom pain in surgery was averted and annuled Since whom science has control of pain

H. Bigelow

1846, Boston MassachussettsThe first clinical useof ether as anesthetic

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Dr. William Morton, a Boston dentist and former partner of Dr. Horace Wells was one of the first to use ether as an

anesthesia. In 1846, just two years after Horace Wells’ anesthetic success with nitrous oxide, Dr. William Morton (1819-68), constructed

the first anesthetic machine. Morton’s simple device was a glass globe housing an ether-

soaked sponge so all the patient had to do was merely to inhale the vapor through one of two outlets.

Morton’s invention was put to the test on October 16, 1846, in the surgical amphitheater of the Massachusetts General Hospital

in Boston when a twenty-year-old man was successfully anesthetized so a tumor could be painlessly removed from what one source said was his neck and another indicated was from his

jaw.

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Anesthesiology is a blessed profession

• When God created Eva from Adam’s rib ………. first, He put Adam into a deep sleep…………….

• The beginning of mankind started with anesthesia

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Ether :- good narcosis- good analgesia- good muscle relaxation

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KemajuanIlmu Bedah

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Ant

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A n

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t e

s i

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N u t r i s i

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Anesthesia is now much safer and more pleasant for the patient than it was 50 years ago.Factors contributing to the improvements include a fuller understanding of physiology and pharmacology, better preoperative assessment and preparation of patients …… Improvements in anesthesia have allowed surgeons to attempt more complicated operations on increasing number of patients…......

and .…..TODAY

M.Dobson

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Trauma surgery

Endoscopic surgery

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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, asthma, tetanus or neonatal asphyxia. Skills such as the rapid assessment and management of unconscious patients, control ofairway, endotrachel intubation,…. cardioplumonary resuscitation have their origins in anesthesia, but are now recognized as essential for all doctors.

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Working togetherSurgery & Anesthesiology

|extends the boundaries of life and death

Massive Crush Injury - Hb 2 20

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PengembanganIntensive Care / ICU1975 Anestesiologi RSCM1977 Anestesiologi RSDS

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Prolonged Life Supportdi ICU

|adalah bagian dari

Resusitasi

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MagillGuedelMacIntoshEpstein

Archie Brain

L M A

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Resusitasi Jantung ParuACLSATLSsemua perlu intubasi trachea

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Sekolahnya 4 tahun, 120 SKS + MKDU

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Anestesia

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

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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

– akupunktur

– hipnosis

– stimulasi listrik

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Kapan anestesia diperlukan?

• Menghilangkan nyeri pembedahan & trauma

• Menghilangkan nyeri akut lain:

– proses persalinan

– proses diagnostik medik tertentu

• Menghilangkan nyeri kanker

• Menghilangkan nyeri khronis (ischemia dll)

• Menghilangkan rasa cemas pada anak

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Apakah anestesia berbahaya?

• Ya– menyebabkan depresi nafas, jantung, sirkulasi,

fungsi otak, hati, usus, ginjal dan sistim imun

• Tidak– jika semua perubahan diawasi dan dikendalikan

maka bahaya dapat di-minimal-kan

• Dengan anestesia yang baik � risiko mati adalah 1: 10,000

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Throughout America there are thousands of doctors—working in hospitals, clinics and private offices—who hurt and even fatally injure patients through incompetence or carelessness yet remain

in active practice.

In Denver, Richard Corbett Leonard, 8, died during a routine ear operation because the

anesthesiologist allegedly fell asleep.

From an article, “Why Some Doctors May Be Hazardous to Your Health”, by Bernard Gavzer, in the April 14, 1996, issue of Parade Magazine

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Mortality associated w/ anesthesia

• Lund & Mushin (1982)-6 days 1:10,000• Forrest (1990)-7 days 1:10,000• Pedersen (1994)-30 days 1: 2,500• 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 atau

menghilangkan persepsi nyeri

• Suntikan im atau iv

• Inhalasi (dihisap nafas)

• Dengan suntikan syaraf

• Dengan suntikan di tempat operasi

• Anestesia umum

• Anestesia regional / conduction block

• Anestesia (infiltrasi) lokal

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Anestesia umumblok otak = syaraf pusat

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Anestesi umumMorfin pada reseptor

Ketamin pada jalur thalamus-cortex

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Anestesia regionalblok serat syaraf

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OA InhalasiKetamine

Spinal block

Plexus & NerveBlock

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Anestesia regional

• Pada ujung syaraf di lokasi (local infiltration block)

• Pada serabut syaraf (nerve block)

• Pada berkas syaraf dekat medula spinalis (plexus block)

• Pada medula spinalis (peri/epidural block dan subarachnoid block) = spinal anesthesia

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Nerve block

Plexus block

Epidural block Subarachnoid block 42

Peridural block

Subarachnoidblock

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Obat anestesia = obat berbahayadosis kecil = anestesia

dosis besar = fatal

• Pentothal, lidocain, N2O, halothan, sevoflurane, desflurane dalam dosis tinggi semuamematikan

– coma yang dalam

– tekanan darah turun hebat

– henti jantung

• Pavulon, Esmeron, Tracrium, Succinylcholine = obat pelumpuh otot

– henti nafas (apnea) � perlu nafas buatan44

Pentothal PavulonKCl

Obat anestesia

=

Obat eksekusi mati

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Obat anestesia umum

• Ether

• Halothane

• Enflurane

• Isoflurane

• Sevoflurane

• Desflurane

• Bau (+) menyengat, terbakar, murah

• Harum, gg liver, aritmia

• Harum <, gg ginjal, convulsi

• Harum <, sadar cepat, mahal

• Harum>, sadar cepat, mahal >>

• Harum<<, sadar cepat, mahal >>

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Sistem anestesia

Pvaporizer

Flowmeteroksigen

canister sodalime(CO2 absorber)

breathing tubes

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Sumber gas O2, N2O Vaporizer ether

Vaporizer halothane

Vaporizer enflurane

Flowmeter pengatur gas

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Uap obat inhalasi

Alveoliparu

Kapiler paru

otak

Art.carotis int..

Obat intravena 52

Mekanisme anestesia umum inhalasi

• TAHAP INDUKSI & MAINTENANCE

• Uap OA kadar tinggi dihisap masuk alveoli paru → kadar OA alveolair tinggi → menembus membran alveoli-kapiler → masuk darah kapiler → kadar OA dalam kapiler tinggi→ sirkulasi oleh jantung kiri ke otak → menembus kapiler di jaringan otak → masuk sel-sel otak → kadar OA dalam sel otak tinggi → pasien menjadi tidak sadar

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Mekanisme anestesia umum inhalasi

• TAHAP RECOVERY

• Bila uap OA dihentikan → kadar alveolair turun → OA dalam darah pindah ke alveolair→ kadar OA dalam darah turun→OA dalam sel otak pindah ke darah→kadar OA dalam otak turun→ pasien sadar kembali

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Mekanisme anestesia umum parenteral

• TAHAP INDUKSI & MAINTENANCE

• Injeksi obat masuk vena ke jantung kanan lalu ke jantung kiri → sirkulasi oleh jantung kiri ke otak → menembus kapiler di jaringan otak → masuk sel-sel otak →kadar OA dalam sel otak tinggi → pasien menjadi tidak sadar

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Mekanisme anestesia umum parenteral

• TAHAP RECOVERY

• Bila suntikan OA dihentikan → redistribusi, metabolisme dan ekskresi OA → kadar OA intravena turun → OA dalam sel otak pindah ke darah→ kadar OA dalam otak turun→ pasien sadar kembali

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Urutan proses anestesia umum

• Puasa: mengosongkan lambung

• Premedikasi: memberi sedatif, analgesia � tenang

• Induksi: memberi loading dose obat anestesia

• Maintenance: memelihara kadar obat anestesia

• Recovery: menunggu siuman kembali

• Post-op care: menunggu normal kembali

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Anestesia menyebabkan depresi fungsi vital

• Nafas:– sumbatan jalan nafas, – mengurangi nafas (hipoventilasi)– henti nafas

• Sirkulasi:– tekanan darah turun– nadi tak teratur– henti jantung

• Kesadaran:– menurun sampai coma

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0

10

20

30

40

50

60

70

80

90

0 MAC 1.0 MAC 1.5 MAC

Perubahan pCO2 akibat anestesia(hipoventilasi)pCO2 arteria

Enflurane

Isoflurane

Halothane

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0

20

40

60

80

100

120

1.0 MAC 1.5 MAC 2.0 MAC

Perubahan cardiac output akibat anestesia(depresi sirkulasi)

Isoflurane

EnfluraneHalothane

% awake value

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Perfusi, nadi dan tekanan darah harus di monitor selama anestesia

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Monitoring selama anestesia

Jari rabanadi

Mata lihat nafas

Telinga dengar jantung

Waktu induksi

Waktu maintenance

62Edmond I Eger 1985

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Pasien trauma kepala dengan tekanan intra-kranial tinggi|

Perlu obat anestesia yang tidak meningkatkan TIKlebih tinggi lagi

selama Dr Bedah Syaraf tidak dapat dekompresi64

Perubahan hormonal akibat anestesia

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Perlu monitor- tekanan darah- ECG- suhu- saturasi O2- kedalamanstadium anestesia

Resusitator

Perlu alat untuk bertindak- resusitator- defibrilator- respirator

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Perbandingan sifat

ether halothan sevofluran desfluran

Induksi sukar mudah sangatmudah

sukar

Titikdidih

36.2 50.2 58.5 22.8

Blood/gaspart.coeff

12.1 2.3 0.68 0.42

Tek.uappada 20C

460 243 160 669

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VOLATILE ANESTHETICS

ETHER

HALOTHAN

ETHRANE

ISOFLURAN

SEVOFLURANDESFLURAN

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Induksi inhalasi dengan ether perlu waktu 20-30 menit

Induksi dengan sevoflurane sangat cepat (cukup 1-2 nafas saja)

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Induksi inhalasi halothane3-5 menit dan dapat dipercepatdengan suntikan pentothal iv

Induksi inhalasi desfluranebisa cepat tetapi > 25% pasienbatuk dan spasme larynx →harus dibantu propofol iv

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Dijaga agarmuntah tidak masuk paru(aspirasi)

Dijaga agarwaktu gelisah tidak jatuhNafas dibantu oksigenTekanan darah dipantau

MASA RECOVERY

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PengembanganIntensive Care / ICU1975 Anestesiologi RSCM1977 Anestesiologi RSDS

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Anestesiologi & Reanimasisangat kompleks

|dimana multiple variables bekerja cepat dalam

hitungan menit dan detik

dan dalam range mati-hidupnya seorang pasien

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Penyulit buruk adalahCARDIAC ARREST- karena penyakitnya sendiri- karena pembedahannya- karena anestesianya

Penyulit terburukadalahMALIGNANT HYPERTHERMIA

obat cuma satu (dantrolene)efeknya belum tentu

Dipicu succinyl - halothan

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Goodgeneral anesthesia

Nar

cosi

s

Ana

lges

ia

Mus

cle

rela

xatio

n

Stress Free

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Narcosis dan analgesia

Anestesi umum

Morfin pada reseptor

Ketamin pada jalur thalamus-cortex

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Nerve block

Plexus block

Epidural block Subarachnoid block

Analgesia

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Muscle relaxation

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Setelah 161 tahun pengembangan Anestesia

• 1. Pemahaman fisiologi, farmakologi, pato-fisiologi serta pato-farmakologi

• 2. Vaporizer yang akurat

• 3. Pelumpuh otot dan antagonisnya

• 4. Narkotik sintetik dan antagonisnya

• 5. Obat inhalasi “inert” desflurane, xenon

• 6. Respirator canggih dan analisa gas darah

• 7. Sarana monitoring fungsi vital yang teliti

• 8. Dll masih banyak lagi80

PengembanganVaporizer yang akurat

Operasi mikroskopikjangka panjang

| Perfectly still

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Pengembanganblok regional yang andal

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

Depresi minimal,bahkan untuk janin 82

What are we trying to say ?

•Reversibility• Anesthesia is a physiological trespassing

– Awake - Coma - Awake Again

– Breathing - Apnea - Breathing Again

• Every change in Anesthesia is made reversible

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1.584

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Isi 161 tahun pengembangan Anestesia

• Menjadi disiplin ilmu kedokteran yang mandiri : Anestesiologi & Reanimasi

• Melahirkan disiplin ilmu baru : Intensive Care

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Anestesiologi & Reanimasi

• Pengetahuan berdasar reversibility– Apakah nafas berhenti itu reversible?

– Apakah jantung berhenti itu reversible?

– Apakah coma itu reversible?

– Apakah renal failure itu reversible?

• Prevent a premature death mendasari upaya – “resusitasi”

– “reanimasi”

– reversing the dying process88

Resusitasi primitif|

Resuscitology|

Patophysiology of Dying and Reanimation

(Peter Safar et al)|

Public Access Defibrillation

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Resuscitation Cycle

• Basic Life Support– (A-B-C, 1968, Safar etal)

• Advanced Life Support– Definitive airway

– Artificial Ventilation

– DC Shock & Drugs

• Prolonged Life Support– Intensive Care (G-H-I)

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LIFE SUPPORTAirway, BreathingCirculation, Brain

(BLS-ALS-PLS)

Definitive Diagnosis& Definitive Therapyof surgical pathology

SpesialisBedah

Spesialis Anestesiologi & Reanimasi

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Perlu dibedakan antara

Anestesiologi& Reanimasi Bedah

BedahAnestesiologi& Reanimasi

KNOWLEDGE

PROFESSIONAL COMPETENCE

Selalu bekerja sama 92

Trias Anesthesia

1.SedationN2O

Volatile anesthetics(Ether, Halothane, Ethrane, Isoflurane,

Sevoflurane, Desflurane, etc)

iv-anesthesia(penthotal, ketamine, propofol, midazolam,

etomidate, etc)

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Trias Anesthesia

2. Analgesia,Narcotic-analgetic

(morphin, petidin, fentanyl, sufentanyl, alfentanyl, etc),

N2O

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Trias Anesthesia

3. Relaxation,Muscle relaxan

( succinylcholine, pancuronium bromide, atracurium, vecuronium

rocuronium, etc)

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ROUTINE PREOPERATIVE LABORATORY EVALUATION OFROUTINE PREOPERATIVE LABORATORY EVALUATION OFASYMPTOMATIC, 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 transfusion

�Serum glucose and creatinine ( or blood urea nitrogen )concentration : All patients over 60 years of age

�Electrocardiogram : all patients over 40 years of age�Chest radiograph : all patients over 60 years of age

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THE ANESTHETIC PLANTHE ANESTHETIC PLAN

PremedicationType of anesthesia

GeneralAirway managementInductionMaintenanceMuscle relaxation

Local or regional anesthesiaTechniqueAgents

Monitored anesthesia careSupplement oxygenSedation

Intraoperative managementMonitoringPositioningFluid managementSpecial techniques

Postoperative managementPain controlIntensive care

Postoperative ventilationHemodynamic monitoring

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

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AMERICAN SOCIETY OF ANESTHESIOLOGISTAMERICAN SOCIETY OF ANESTHESIOLOGISTCLASSIFICATION AND PERIOPERATIVE MORTALITY RATESCLASSIFICATION AND PERIOPERATIVE MORTALITY RATES

CLASSCLASS MORTALITY RATEMORTALITY RATE

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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Labour Pain,Pathway and Mechanism

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Causes1. First stage: uterine contractions and dilatation of the

lower uterine segment and cervix to allowpassage of the fetus.

2. Second stage: greater pressure of the presenting part on pain-sensitive pelvic structures anddistension of surrounding structures.

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Pathways

1. Uterus and cervix: mainly via A-delta and C fibers passing in the sympathetic nerves to the

sympathetic chain; referred to the T10–L1 dermatomes.

2. Vagina and pelvic outlet: via A-delta and C fibers passing in the parasympathetic bundle in the

pudendal nerves; referred to the S2–S4 dermatomes.

3. Other: contributions from the ilioinguinal, genitofemoral, and perforating branch of the posteriorcutaneous nerve of the thigh; somatic pain experienced

in the L2–S5 dermatomes.

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

pain, 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 lower

abdomen 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.

Certain cultures are more emotive and expressive than other, more stoic ones, leading possibly to differences in pain behavior rather than in the extent of pain felt. Fatigue and

general debility, common in late pregnancy, may also contribute to the experience of labor pain. 106

Consequences of labor pain

A. Understand that labor pain may have adverse physiological and psychological consequences:

1. Respiratory: causes hyperventilation, leading to hypocapnia and respiratory aLKALOSIS.

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

problematic in cardiac disease and pre-eclampsia. Increased venous return associated with uterinecontractions may also contribute.

3. Neuroendocrine: increases maternal catecholamine secretion with risk of uteroplacental

constriction.

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4. Gastrointestinal: effect of labor on gastric emptying and acidity is unclear, although delayed 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 contributing to long-term emotional stress, with

potential adverse consequenceson maternal mental health and family relationships.

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B. Understand also that pain during labor may have benefits:

1. Indicates to the mother and those assisting labor/delivery that contractions are occurring.2. May have positive connotations regarding

childbirth, related to societal/cultural influences.3. May indicate problems (e.g. uterine rupture,

placental abruption).

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Thank you for listening