INTRODUCTION OF ANESTHESIA
Departement of Anestesiology and Reanimation , School of Medicine, S Sumatera t Ut Utara U University i it 1
History off Anesthesia 2
Living 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 Garden Photographs from the Detroit Publishing Company, 1880-1920 aLibrary of Congress American Memory Collection
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History of Anesthesia A history of anesthesia or "pain pain killing killing" techniques throughout history Anesthesia, historical background and the word's origin Pain, however useful as a warning signal designed to keep living organisms from damaging themselves too badly, badly becomes useless agony when operations must be performed. Attempts to control pain were many. The use of alcohol or some f form off what h t came to t be b called ll d hypnotism h ti was old. ld Acupuncture A t was used in the Orient. The new chemistry also contributed pp the nitrous oxide, which, when inhaled, served to suppress sensation of pain. 8
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Year 1846
The Ether Dome, Boston, Massachussets, USA
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1846, Boston Massachussetts
The first clinical use of ether as anesthetic
W ll William TG Morton M
Inventor and revealer of anesthetic inhalation Before whom in all time surgery was agony By whom pain in surgery was averted and annuled Since whom science has control of pain 11 H. Bigelow
Dr. William Morton, Dr Morton a Boston dentist and former partner of Dr. Horace Wells was one of the first to use ether as an anesthesia. I 1846, In 1846 jjustt ttwo years after ft Horace H Wells’ W ll ’ anesthetic th ti success with nitrous oxide, Dr. William Morton (1819-68), constructed the first anesthetic machine. Morton’s simple device was a glass globe housing an ethersoaked 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 twenty-year-old 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. 12
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 a cos s - good analgesia - good muscle relaxation
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Anestesia
Antib biotika
Tran nsfusi Kemajuan Ilmu Bedah
Nutrisi 15
and .….. TODAY Anesthesia A h i is i now muchh safer f andd more pleasant l for f the h 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 M.Dobson increasing number of patients …......
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Endoscopic surgery
Trauma surgery g y
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Many techniques originally developed for use during anesthesia are now widely recognized as applicable to the care of a variety of critically ill patients, for example those with severe head injuries, asthma tetanus or neonatal asphyxia asthma, asphyxia. Skills such as the rapid assessment and management of unconscious patients, control of airway, endotrachel intubation,…. cardioplumonary resuscitation h have their h i origins i i in i anesthesia, h i but are now recognized as 18 essential for all doctors.
Working together S Surgery &A Anesthesiology th i l |
extends the boundaries of life and death
19 Massive Crush Injury - Hb 2
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Pengembangan Intensive Care / ICU 1975 Anestesiologi RSCM 1977 Anestesiologi RSDS
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Prolonged Life Support di ICU | adalah bagian dari Resusitasi
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Magill Guedel MacIntosh E t i Epstein Archie Brain LMA
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Resusitasi Jantung Paru ACLS ATLS semua perlu intubasi trachea 24
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Sekolahnya 4 tahun, 120 SKS + MKDU
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Anestesia • Keadaan yang ditandai hilangnya kesadaran dan / atau p persepsi p nyeri y ((bersama atau terpisah) p )
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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 28
Kapan anestesia diperlukan? • Menghilangkan nyeri pembedahan & trauma • Menghilangkan nyeri akut lain: – proses persalinan – proses diagnostik medik tertentu • Menghilangkan nyeri kanker g g nyeri y khronis (ischemia ( dll)) • Menghilangkan • 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 a a bahaya ba aya dapat di-minimal-kan d a a
• Dengan anestesia yang baik risiko mati adalah 1: 10,000 10 000 30
Throughout America there are thousands of doctors—working in hospitals, clinics and private y injure j patients p offices—who hurt and even fatally 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, Gavzer in the April 14, 14 1996, 1996 issue of Parade Magazine 31
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Mortality associated w/ anesthesia • • • •
Lund & Mushin (1982) (1982)-66 days 1:10 000 1:10,000 Forrest (1990)-7 days 1:10,000 Pedersen (1994) (1994)-30 30 days 1: 2,500 MHA (Maryland Hosp Assoc 1999)National Aggregate Data
– – – –
Class I Class II Clas III Class IV
1:10,000 3:10,000 28:10,000 230:10,000 33
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Anestesia menghambat hantaran impulse nyeri atau menghilangkan persepsi nyeri
• Suntikan im atau iv • Inhalasi (dihisap nafas)
• Anestesia umum
• Dengan suntikan syaraf
• Anestesia regional / conduction block
• Dengan suntikan di tempat p operasi p
• Anestesia (infiltrasi) lokal
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Anestesia umum
blok otak = syaraf pusat 36
Anestesi umum Morfin pada reseptor Ketamin pada jalur thalamus-cortex
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Anestesia regional
blok serat syaraf
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Ketamine
OA IInhalasi h l i
S i l block Spinal bl k Plexus & Nerve Block
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Anestesia regional • P Pada d ujung j syaraff di lokasi l k i (local infiltration block) • Pada serabut syaraf (nerve block) y dekat medula spinalis p • Pada berkas syaraf (plexus block) • Pada medula spinalis ( i/ id l block (peri/epidural bl k dan d subarachnoid b h id block) bl k) = spinal anesthesia 40
Nerve block Pl Plexus block bl k Epidural block
41 Subarachnoid block
Peridural block Subarachnoid block
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Obat anestesia = obat berbahaya dosis kecil = anestesia dosis besar = fatal • Pentothal, lidocain, N2O, halothan, sevoflurane, d fl desflurane dalam d l dosis d i tinggi i i semua mematikan ik – coma yang dalam – tekanan darah turun hebat – henti jantung • Pavulon, Esmeron, Tracrium, Succinylcholine = obat pelumpuh otot – henti nafas (apnea) perlu nafas buatan 43
Pentothal
Pavulon
KCl
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 p , mahal >> • Harum>,, sadar cepat, • Harum<<, sadar cepat, mahal >>
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Sistem anestesia
vaporizer
Flowmeter oksigen
breathing tubes
P
canister sodalime (CO2 absorber)
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Sumber ggas O2,, N2O
Vaporizer ether Flowmeter pengatur gas
Vaporizer halothane
Vaporizer enflurane
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otak
Uap obat inhalasi Alveoli pparu
Art.carotis int..
Kapiler paru Obat intravena
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Mekanisme anestesia umum inhalasi • TAHAP INDUKSI & MAINTENANCE gg dihisapp masuk alveoli paru p • Uapp OA kadar tinggi → kadar OA alveolair tinggi → menembus membran alveoli-kapiler → masuk darah kapiler → kadar k d OA ddalam l kapiler k il tinggi i i → sirkulasi i k l i oleh l h jantung kiri ke otak → menembus kapiler di j i jaringan otak t k → masukk sel-sel l l otak t k → kadar k d OA dalam sel otak tinggi → pasien menjadi tidak sadar 52
Mekanisme anestesia umum inhalasi • TAHAP RECOVERY • Bila uap OA dihentikan → kadar alveolair turun → OA dalam darah pindah ke alveolair l l i → kadar k d OA ddalam l ddarah h turun → OA dalam sel otak pindah ke darah → kadar OA dalam otak turun → pasien sadar kembali 53
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 54
Mekanisme anestesia umum parenteral • TAHAP RECOVERY • Bila suntikan OA dihentikan → redistribusi, redistribusi metabolisme dan ekskresi OA → kadar OA intravena turun → OA dalam sel otak pindah ke darah → kadar OA dalam otak turun → pasien i sadar d kembali k b li
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Urutan proses anestesia umum • • • • • •
Puasa: mengosongkan lambung Premedikasi: memberi sedatif sedatif, analgesia tenang Induksi: memberi loading dose obat anestesia M i Maintenance: memelihara kadar obat anestesia Recovery: menunggu siuman kembali Post-op care: menunggu normal kembali 56
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 57
Perubahan pCO2 akibat anestesia (hipoventilasi) pCO2 arteria 90 80
Enflurane
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Isoflurane
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Halothane
50 40 30 20 10 0 0 MAC
1.0 MAC
1.5 MAC 58
Perubahan cardiac output akibat anestesia (depresi sirkulasi) % awake value 120 100
Isoflurane
80
Halothane Enflurane
60 40 20 0 1.0 MAC
1.5 MAC
2.0 MAC 59
Perfusi, nadi dan tekanan darah harus di monitor selama anestesia
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Waktu induksi Jari raba nadi
Mata lihat nafas
Waktu maintenance
Telinga dengar jantung
Monitoringg selama anestesia 61
62 Edmond I Eger 1985
Pasien trauma kepala dengan tekanan intra-kranial tinggi | Perlu obat anestesia yang tidak meningkatkan TIK lebih tinggi gg lagi g selama Dr Bedah Syaraf tidak dapat dekompresi 63
Perubahan hormonal akibat anestesia
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Resusitator
Perlu monitor - tekanan darah - ECG - suhu - saturasi O2 - kedalaman stadium anestesia
Perlu alat untuk bertindak - resusitator - defibrilator - respirator i 65
Perbandingan sifat ether
halothan sevofluran desfluran
Induksi
sukar
mudah
sangat mudah
sukar
Titik didih
36.2
50.2
58.5
22.8
Blood/gas Bl d/ part.coeff
12.1
2.3
0.68
0.42
Tek.uap T k pada 20C
460
243
160
669 66
VOLATILE ANESTHETICS ETHER HALOTHAN ETHRANE ISOFLURAN SEVOFLURAN DESFLURAN
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Induksi inhalasi dengan ether perlu waktu 20-30 menit Induksi dengan sevoflurane sangat cepat (cukup 1-2 1 2 nafas saja) 68
Induksi inhalasi halothane 3-5 menit dan dapat dipercepat dengan suntikan pentothal iv
Induksi inhalasi desflurane bisa cepat tetapi > 25% pasien b t k dan batuk d spasme larynx l → harus dibantu propofol iv 69
Dijaga agar muntah tidak masuk paru (aspirasi)
MASA RECOVERY
Dij Dijaga agar waktu gelisah tidak jatuh Nafas dibantu oksigen Tekanan darah dipantau 70
Pengembangan Intensive Care / ICU 1975 Anestesiologi RSCM 1977 Anestesiologi RSDS
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Anestesiologi & Reanimasi sangat kompleks | dimana multiple variables bekerja cepat dalam hitungan menit dan detik dan dalam range mati-hidupnya seorang pasien
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Penyulit buruk adalah CARDIAC ARREST - karena penyakitnya sendiri p y - karena pembedahannya - karena anestesianya
Penyulit terburuk adalah MALIGNANT HYPERTHERMIA obat cuma satu (dantrolene) efeknya belum tentu Dipicu succinyl - halothan
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Muscle rrelaxatioon M
Anaalgesia
Narrcosis
Good general anesthesia
Stress Free 74
Narcosis dan analgesia Ketamin pada jalur thalamus-cortex
Anestesi umum
Morfin pada reseptor
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Analgesia
Nerve block Pl Plexus block bl k Epidural block
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Muscle relaxation
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Setelah 161 tahun pengembangan Anestesia • 1. Pemahaman fisiologi, farmakologi, patofisiologi serta pato-farmakologi • 2. 2 Vaporizer V i yang akurat k • 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 lagi 78
Operasi mikroskopik jangka panjang | Perfectly still
Pengembangan Vaporizer yang akurat 79
Pengembangan blok regional g yyang g andal - Jarum spinal # 29 - Celiac plexus block, - Cervical peridural
Depresi minimal minimal, bahkan untuk janin 80
What are wee trying tr ing to say sa ?
•Reversibility • Anesthesia is a physiological trespassing – Awake - Coma - Awake Again g – Breathing - Apnea - Breathing Again
• Every change in Anesthesia is made reversible 81
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Isii 161 tahun h pengembangan b Anestesia A i
• 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” i i” – “reanimasi” – reversing the dying process 86
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 (A-B-C, B C, 1968, Safar etal)
• Advanced Life Support – Definitive airway – Artificial Ventilation – DC Shock Sh k & Drugs D
• Prolonged Life Support – Intensive Care (G-H-I) 88
Definitive Diagnosis & Definitive Therapy of surgical pathology LIFE SUPPORT Airway, Breathing Ai hi Circulation, Brain
Spesialis Bedah
(BLS-ALS-PLS) Spesialis Anestesiologi & Reanimasi 89
Perlu dibedakan antara KNOWLEDGE
Anestesiologi & Reanimasi
Bedah
PROFESSIONAL COMPETENCE
Anestesiologi & Reanimasi
Bedah
Selalu bekerja sama 90
Trias Anesthesia 1.Sedation N2O Volatile anesthetics (Ether, Halothane, Ethrane, Isoflurane, Sevoflurane Desflurane Sevoflurane, Desflurane, etc)
iv-anesthesia (penthotal, penthotal ketamine, ketamine propofol, propofol midazolam midazolam, etomidate, etc) 91
Trias Anesthesia 2. Analgesia, Narcotic-analgetic (morphin, petidin, fentanyl, sufentanyl alfentanyl sufentanyl, alfentanyl, etc), etc) N2O
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Trias Anesthesia 3. Relaxation, Muscle relaxan ( succinylcholine, pancuronium bromide, atracurium bromide atracurium, vecuronium rocuronium, etc)
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ROUTINE PREOPERATIVE LABORATORY EVALUATION OF ASYMPTOMATIC, APPARENTLY HEALTHY PATIENTS
Hematocrit of hemoglobin concentration All menstruating women All patients over 60 years of age All patients who are likely to experience significant blood loss and may require transfusion Serum glucose and creatinie ( 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 PLAN Premedication Type of anesthesia General Airway management Induction Maintenance Muscle relaxation Local or regional anesthesia Technique Agents Monitored anesthesia care Supplement oxygen Sedation Intraoperative management Monitoring Positioning Fluid management Special techniques Postoperative management Pain control Intensive care Postoperative ventilation Hemodynamic monitoring 95
PREOPERATIVE PHYSICAL STATUS CLASSIFICATION of PATIENTS ACCORDING TO THE AMERICAN SOCIETY OF ANESTHESIOLOGIST
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AMERICAN SOCIETY OF ANESTHESIOLOGIST CLASSIFICATION AND PERIOPERATIVE MORTALITY RATES CLASS
MORTALITY 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 Pain, Pathwayy and Mechanism
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Causes 1 First stage: uterine contractions and dilatation of the 1. lower uterine segment and cervix to allow passage of the fetus. 2. Second d stage: greater pressure off the h presenting part on pain-sensitive pelvic structures and distension of surrounding g structures.
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Pathways 1 Uterus and cervix: mainly via A-delta 1. 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 p g in the p parasympathetic y p bundle in the pudendal nerves; referred to the S2–S4 dermatomes. 33. Other: contributions from the ilioinguinal, ilioinguinal genitofemoral, and perforating branch of the posterior cutaneous nerve of the thigh; somatic pain experienced in the L2–S5 dermatomes. 103
Features
Over 90% of women experience severe/unbearable labor .1 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, 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. 104
Consequences of labor pain A. Understand that labor pain may have adverse physiological and psychological consequences: 1. Respiratory: p y causes hyperventilation, yp leadingg to hypocapnia and respiratory acidosis. 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 uterine contractions mayy also contribute. 3. Neuroendocrine: increases maternal catecholamine secretion with risk of uteroplacental constriction. 105
4. Gastrointestinal: effect of labor on gastric emptying and
acidity is unclear, 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 long term emotional stress, stress with potential adverse consequences on 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/deliveryy that contractions are occurring. g 2. May have positive connotations regarding childbirth, related to societal/cultural influences. 3 May 3. M iindicate di t problems bl (e.g. ( uterine t i rupture, t placental abruption).
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Thank you for listening g 123
