Typical American Hospital

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(No Transcript)
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2010
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Typical American Hospital
Typical American Hospital
1985 - 25 years ago
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Therapeutic Armamentarium

• Thiopental
• Isoflurane
• Morphine, Fentanyl
• Succinylcholine, Curare, Pancuronium, Metocurine

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Routine Monitors

• Electrocardiogram
• Inspired oxygen
• Blood pressure cuff
• Temperature
• Finger on the pulse

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Special Monitors

• In selected patients

• Pulmonary Artery Catheters

• Capnography

• Capnography

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Airway Control

• Endotracheal Intubation

• Mask Ventilation

• Mask Ventilation

• Mask Ventilation

• Mask Ventilation

• Mask Ventilation

• Mask Ventilation

• Mask Ventilation

• Mask Ventilation

• Mask Ventilation

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MAC
Monitored Anesthesia Care
Mostly Apneic and Cyanotic
Mostly Apneic and Cyanotic
Mostly Apneic and Cyanotic
Mostly Apneic and Cyanotic
Mostly Apneic and Cyanotic
Mostly Apneic and Cyanotic
Mostly Apneic and Cyanotic
Mostly Apneic and Cyanotic
Mostly Apneic and Cyanotic
Mostly Apneic and Cyanotic
Mostly Apneic and Cyanotic
Mostly Apneic and Cyanotic
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Patient Care

• Admission before surgery
• Highly invasive surgical technique
• Intramuscular pethidine for postoperative
  analgesia
• Discharge in days to weeks

surgical technique
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Patient Care Issues

• Poor post-operative pain control
• Slow recovery
• Nausea and Vomiting

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Anesthesia1998
12 years ago
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Basics of Anesthesia

• Delivery of oxygen

• Support of intravascular volume and tissue
  perfusion

• Patient Comfort

Patient Comfort
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Therapeutic Armamentarium

• Thiopental
• Isoflurane
• Morphine, fentanyl, alfentanil, sufentanil,
  remifentanil
• Succinylcholine, pancuronium

• Thiopental, propofol
• Isoflurane, sevoflurane, desflurane
• Morphine, fentanyl, alfentanil, sufentanil,
  remifentanil
• Succinylcholine, pancuronium, vecuronium,
  rocuronium, atracurium, mivacurium, doxacurium,
  and pipecuronium

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TIVA
TIVAE
Total IntraVenous Anesthesia
Total IntraVenous Awareness
Total IntraVenous Anesthesia
with Ephedrine
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Propofol
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Desflurane, Sevoflurane
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Fentanyl Family Tree
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Remifentanil
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Routine Monitors

• Pulse Oximetry
• Capnography
• Electrocardiogram
• Inspired oxygen
• Blood pressure cuff
• Temperature

? Finger on the pulse
? Finger on the pulse
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Special Monitors

• In selected patients

• Esophageal echocardiography
• Pulmonary artery catheterization
• Continuous arterial blood gas
• Continuos mixed-venous saturation
• Sophisticated ventilator monitoring

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Bispectral Index

• Based on EEG spectral analysis
• Good predictor of mental status of patient during
  anesthesia with
• Inhalational anesthesia
• Inhalational anesthesia with opioids
• Propofol anesthesia with opioids

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Airway Control

• Endotracheal Intubation
• Mask Ventilation
• LMA

Laryngeal Mask Airway
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MAC
Monitored Anesthesia Care
Midazolam, Alfentanil, and Conversation
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Patient Care

• Admission on day of surgery
• Discharge in 3 - 24 hours
• Fast tracking of patients
• Laparoscopic surgery
• Improved post-operative pain management
• Epidural opioids
• PCA

Patient Controlled Analgesia
Patient Controlled Apnea
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2010
Today
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New Therapeutics

• Duzitol

• Hypnotic
• Analgesic
• Amnestic
• Muscle Relaxant
• Aphrodisiac

Anesthesiology 76327-330, 1992
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New Therapeutics

• Cycloflurane
• Chemical stability of isoflurane
• Rapid induction of sevoflurane
• Rapid emergence of desflurane
• Pleasant smell of Mr. Propre

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New Therapeutics

• Dexmedetomidine
• Central ?2 adrenergic agonist
• Profound postoperative analgesia in the ICU
• Profound anti-ischemic properties
• Modest sedation
• Rapid offset
• Reversible
• Demonstrated improved outcome after major surgery

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New Therapeutics

• Hyptiva
• Pharmacodynamics of propofol
• Pleasant induction and emergence
• Modest cardiovascular effects
• Modest respiratory effects
• Pharmacokinetics of remifentanil
• Extraordinarily rapid emergence
• Predictable
• Minimal change with disease or age

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New Therapeutics

• Central nicotinic analgesics
• Derived from amphibian skin
• Prototype is epibatidine
• Efficacy equal to morphine
• No ventilatory effects
• No physical dependence
• No kidding
• Science 1998 Jan 2279(5347)77-81

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New Therapeutics

• Muscle Relaxants
• Suxuronium
• MadamCurium
• Rockandrolium

Suxuronium
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MAC
Monitored Anesthesia Care
Madam, Are you Comfortable?
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New Therapeutic Modes

• RemifentanilPCA

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New Monitoring

• Intraoperative EEG
• BIS now standard-of-care
• EEG Guided Anesthesia Delivery System

EGADS
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EGADS
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Patient Care

• Nearly all operations done on outpatients
• Most operations are laparoscopic/endoscopic
• Intelligent intra-operative and post-operative
  drug delivery systems
• ICU care rarely needed

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Anesthesia in 2020?
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Plausible vs. Implausible

• Plausible
• Remifentanil PCA
• Dexmedetomidine
• Nicotinic agonists
• New generation of hypnotics
• EGADS system

• Implausible
• Duzitol
• Cycloflurane
• Suxuronium, madamcurium, rockandrolium