ANESTHESIA
AND
INTENSIVE
CARE
[email protected]
069105713
Critical State
Criteria:
• Conditions of auto-regulatory mechanisms
• The need for correction or/and replacement of a function(s)
Healthy Ill Critically Ill
Critical State
Critical state – as an extreme degree of any pathology including
iatrogenic one, which requires support or replacement of vital
functions
General & Local/Regional
Anesthesia
Pain Management
General Anesthesia Components :
• Analgesia (33)
• Consciousness control (hypnosis, induced)
• Muscle relaxation
• Stability of the autonomic nervous system
1;2;4
Complications of Acute Pain
Pulmonary
- respiratory muscle spasm
- immobility
- suppression of cough
- abdominal distension from decreased GI motility
- atelectasis from impaired ventilation
- mucus plugging from suppression of clearing
mechanisms
- V/Q mismatching and hypoxemia
- Pulmonary infections
Complications of Acute Pain
Hematologic
- increase thrombus formation by increasing blood
viscosity
- increasing activity of clotting factors
- increasing platelet aggregation
Complications of Acute Pain
Cardiovascular
Acute rise in HR, BP, Cardiac Output =
increased cardiac work and oxygen
consumption.
This could be disastrous for patients with
ischemic heart diseases and may lead to
myocardial infarction and /or CHF
Complications of Acute Pain
Gastrointestinal
- Ileus
- Nausea
- Vomiting
- Decreased bowel motility
Urinary
- hypomotility of the urethra and bladder
- difficulty with urination
Complications of Acute Pain
Neuroendocrine and Metabolic
- increased sympathetic tone & hypothalamic
stimulation
- increased catecholamine and catabolic hormone
secretion
- increased metabolism and O2 consumption
Complications of Acute Pain
Psychological
- fear
- anxiety
- depression
- frustration
Pain evaluation Scales/Scores
No pain Maximal pain
0 |||||||||||||||||||||||||||||||||||||||| |||||||||||||||||||||||||||||||||||||||| |||||||||||||||||||||||||||||||||||||||| |||||||||||||||||||||||||||||||||||||||| ||||||||| 100mm
0 1 2 3 4 5 6 7 8 9 10
WHO Analgesic Ladder
Pain Management
WHO Ladder
NRS ≥7
NRS 5-6
NRS 4
ANESTHESIA
Neurobiological aspects of wakefulness and sleeping states
ANESTHESIA
Sleep and anesthesia: similarities and differences
ANESTHESIA
Sleep and anesthesia: similarities and differences
Slow waves in all
unconscious
atates
Similar frequency
and distribution
Origin - anterior,
propagation -
posterior
ANESTHESIA - Partial or complete loss of
sensation with or with out loss of
consciousness as result of disease,
injury, or administration of an
anesthetic agent, usually by injection
or inhalation.
Anesthesia
The main goal is control of the vital
functions of the human body in the
framework of the surgery in order to protect
the patient from the operative stress
HISTORY OF ANESTHESIA
PRIMITIVE TECHNIQUES
Club Cerebral concussion achieved by placing a wooden bowl over the
head of the patient, and striking this until the patient became
unconscious
Strangulation Practiced in Italy as late as the seventeenth century
Alcohol Popular in the eighteenth and nineteenth centuries.
Mesmerism In 1779 Friedrich A. Mesmer of Vienna demonstrated a
capacity to bring certain subjects under hypnotic influence. First surgical procedure
under mesmerism was performed by J. Cloquet, a French surgeon
in 1829. Mesmerism failed because it was less efficient than ether.
Plants Opium, Mandragora (Romans)
HISTORY OF ANESTHESIA
INHALATION AGENTS
• Nitrous Oxide • Modern Agents
1799 Davy • Halothane 1956
1824 Hickman
• Enflurane 1972
1844 Wells
• Isoflurane 1981
• Ether • Sevoflurane and
1842 Long
Desflurane
1847 Snow
• Xenon
Components of Anesthesia (detailed)
1st Line: Measures designed to diminish body reaction to
surgical trauma
- Systemic Analgesia
- Local Anesthesia
- Control of consciousness
- Control of Neuro-vegetative Response (Atar-analgesia (15) &
Neurolept-analgesia (16) +46)
- Muscle Relaxation
- Artificial/Deliberate Hypotencion
- Artificial/Controlled Hypothermia
2nd Line : Measures to control vital functions of the body
(respiration, circulation, metabolism)
Anesthesia Management
I. Evaluation of the Patient and Preoprative Preparation
- Preoperative Assessment
- Preoperative Medication
II. Equipment Preparation
III. Patient Positioning
IV. Immediate Preinduction Period and Induction
V. Anesthesia Course and Monitoring
VI. Ending Anesthesia and Weaning the Patient
Preoperative Assessment
I. Anesthesia Management Plan
a. Previous anesthetic experience (malignant hypepyrexia and
adverse r.)
b. Allergies (analgesics, antibiotics, radiographic dyes, latex)
c. Review patients medical status (extent of the disease)
d. Medications (can adversely interact with anesthetics)
e. Fasting (to prevent aspiration pneumonitis)
f. Physical Examination
g. Laboratory tests (hemoglobin and ECG) (+8)
h. The surgical procedure (choosing anesthesia and monitoring
techniques)
I. The anesthesia management plan
Preoperative Assessment
II. Risk and Anesthesia
ASA Classification of Physical Status
ASA Category Description
I. Healthy patient
II. Mild systemic disease – no functional limitation
III. Severe s. disease – definite functional limitation
(25)
IV. Severe s. disease that is a constant threat to life
V. Monitored patient not expected to survive 24
(+ VI) hours with or without an operation
E Emergency procedure
Preoperative Medication
Goals for Preoperative Medication
– Anxiety relief
– Sedation
– Amnesia
– Analgesia
– Drying of airway secretions
– Prevention of autonomic nervous system responses
– Reduction of gastric fluid volume and increased pH
– Antiemetic effects
– Reduction of anesthetic requirements
– Facilitate induction of anesthesia
– Prophylaxis against allergic reactions
Anesthesia Equipment
Anesthesia Equipment (36;38+39)
Immediate Preinduction Period and Induction
Airway Management
Airway Management
Airway Management
Airway Management
Anesthesia Course and Monitoring
Inhalation Anesthesia (50)
Blood/Gas Partitition Coefficient & MAC
Halothane 2.4 0.75%
Enflurane 1.9 1.7 %
Isoflurane(50) 1.4 1.2
%
Nitrous Oxide (27+39+49) 0.47
105%
Intravenous Anesthesia
A. General Anesthetics
Barbiturates (Thiopental (42) , Thiamylal, Methohexital) (9;17;18)
Benzodiazepines (Diazepam (23) , Midazolam (24) ) (15)
Ketamine (7;20+48)
Propofol (50)
Mechanism of action
Mechanism of action
Mechanism of action
Mechanism of action
Mechanism of action
Intravenous Anesthesia
B. Opioid Analgetics
Morphine (10;11) , Fentanyl (12;13;14)+45 , Alfentanyl,
Remifentanyl, Sufentanyl, Meperidine)
Mechanismul of action
Mechanism of action
Mechanism of action
Mechanism of action
Muscle Relaxants Classification
Depolarizing (19)
- Succinylcholine (43) (5-10 min)
Nondepolarizing
Long – acting (60 – 90 min)
- d- Tubocurarine
- Metocurine
- Pancuronium
- Doxacurium
Intermediate – acting (20 - 30 min)
- Atracurium (44)
- Vecuronium
Short – acting (10 – 20 min)
- Mivacurium
Anesthesia
Monitoring Requirements & Standards
I. Routine Monitoring
– Presence of an Anesthetist
– Heart Rate (q 5 min)
– Blood Pressure (non-invasive vs invasive)
– ECG (continuous) (30)
– Ventilation (observing the r. bag; auscultation; ET CO2 (5) )
– Disconnect Monitors (pressure alarms)
– Oxygen analyzer (inspired oxygen concentration)
– Pulse Oxymeter
– Temperature
– Diuresis
II. Advanced Hemodynamic Monitoring (CVP,
PCWP, CO, etc.)
3
Local / Regional Anesthesia
(34)
A. Peripheral Nerve Blockade (21;22;28;29)
B. Spinal and Epidural (35)
Local anesthetics
Mechanism of action
Spinal and Epidural Anesthesia
Spinal Cord Anatomy (6;31;32)
Spinal and Epidural Anesthesia
Patient positioning
Spinal and Epidural Anesthesia
Patient positioning
Epidural Anesthesia(41)
Lumbar and Thoracic Techniques
Spinal-Epidural Anesthesia
‘Readings’ on Anesthesia:
https://www.dropbox.com/s/
xpnng8tw5upvuqg/
Anesthesia_readings_final.pdf?dl=0
Practical class for gr. 1665
Today, February 15, 2020
11:00
https://meet.google.com/rum-fxom-rhj
Monitoring is the serial evaluation of time-stamped data, and the volume of such
data in an intensive care unit is huge…. All these data, together with large
amounts of clinical data, lead to information overload…
McIntosh N.
Intensive care monitoring: past, present and future.
Clin Med. 2002 Jul-Aug;2(4):349-55.
The medical community is presently in a state of transition from a situation
dominated by the paper medical record to a future situation where all patient
data will be available on-line by an electronic clinical information system. In
data-intensive clinical environments, such as intensive care units (ICUs),
clinical patient data are already fully managed by such systems in a number of
hospitals.
Lucas P.J. et al.
A probabilistic and decision-theoretic approach to
themanagement of infectious disease at the ICU
Artif Intell Med. 2000 Jul;19(3):251-79.
MEDICAL INFORMATION GENERATION RATE
“…doubling every
three years
currently
and projected to be
doubling every
73 DAYS
by 2020…”
