2010

Typical American Hospital

1985 - 25 years ago

Typical American Hospital

Therapeutic Armamentarium

• Thiopental

• Isoflurane

• Morphine, Fentanyl

• Succinylcholine, Curare, Pancuronium, Metocurine

Routine Monitors

• Electrocardiogram

• Inspired oxygen

• Blood pressure cuff

• Temperature

• Finger on the pulse

• Capnography

Special Monitors

• In selected patients:

• Capnography• Pulmonary Artery Catheters

Airway Control

• Endotracheal Intubation

• Mask Ventilation• Mask Ventilation• Mask Ventilation• Mask Ventilation• Mask Ventilation• Mask Ventilation• Mask Ventilation• Mask Ventilation• Mask Ventilation

MACMonitored Anesthesia CareMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and CyanoticMostly Apneic and Cyanotic

Patient Care

• Admission before surgery

• Highly invasive surgical technique

• Intramuscular pethidine for postoperative analgesia

• Discharge in days to weeks

surgical technique

Patient Care Issues

• Poor post-operative pain control

• Slow recovery

• Nausea and Vomiting

Anesthesia1998

12 years ago

Basics of Anesthesia

• Delivery of oxygen• Support of intravascular volume and tissue

perfusion• Patient Comfort

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

TIVATotal IntraVenous AnesthesiaTotal IntraVenous AwarenessTIVAETotal IntraVenous Anesthesiawith Ephedrine

Propofol

J

JKLDesflurane, Sevoflurane

Fentanyl Family Tree

A lfen ta n il S u fen ta n il R em ifen ta n il

F e n ta n y l

Remifentanil

Routine Monitors

• Pulse Oximetry

• Capnography

• Electrocardiogram

• Inspired oxygen

• Blood pressure cuff

• Temperature Finger on the pulse

Finger on the pulse

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

Special Monitors

• In selected patients:

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

• Endotracheal Intubation

• Mask Ventilation

• LMA

Airway Control

Laryngeal Mask Airway

MACMonitored Anesthesia CareMidazolam, Alfentanil, and Conversation

• 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 Care

Patient Controlled AnalgesiaPatient Controlled Apnea

2010

Today

New Therapeutics

• Duzitol• Hypnotic• Analgesic• Amnestic• Muscle Relaxant• Aphrodisiac

Anesthesiology 76:327-330, 1992

New Therapeutics

• Cycloflurane• Chemical stability of isoflurane

• Rapid induction of sevoflurane

• Rapid emergence of desflurane

• Pleasant smell of “Mr. Propre”

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

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

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 2;279(5347):77-81

New Therapeutics

• Muscle Relaxants• Suxuronium

• MadamCurium

• Rockandrolium

MACMonitored Anesthesia CareMadam, Are you Comfortable?

New Therapeutic Modes

• RemifentanilPCA

Minutes Since Bolus

0 30 60 90

Rem

ifen

tani

l Eff

ect S

ite

Con

cent

rati

on ( g

/ml)

0.0

0.5

1.0

1.5

2.0

Morphine-like half-life of 1 hour

Remifentanil-like onset

New Monitoring

• Intraoperative EEG• BIS now standard-of-care

• EEG Guided Anesthesia Delivery System

EGADS

EGADS

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

Anesthesia in 2020?

Plausible vs. Implausible

• Plausible:– Remifentanil PCA

– Dexmedetomidine

– Nicotinic agonists

– New generation of hypnotics

– EGADS system

• Implausible– Duzitol

– Cycloflurane

– Suxuronium, madamcurium, rockandrolium