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
 3
Living Made Easy: Prescription for Scolding Wives [1830]
 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 4
.Harvard Medical School in Boston.
5
6
 Ether Monument, Boston Public Garden
Photographs from the Detroit Publishing Company, 1880-1920
7
aLibrary of Congress American Memory Collection
 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
nitrous oxide, which, when inhaled, served to suppress the
sensation of pain.
8
9
Year 1846

The Ether Dome, Boston, Massachussets, USA 10

 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
H. Bigelow
11
 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 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
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

13
Ether :
- good narcosis
a cos s
- good analgesia
- good muscle relaxation

14
 Tran
nsfusi

Antib
biotika
Kemajuan
Ilmu Bedah

Nutrisi
Anestesia
15
 and .…..
TODAY

Anesthesia
A h i isi 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
increasing number of patients …...... M.Dobson 16
 Endoscopic
surgery

Trauma surgery
g y

17
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
essential for all doctors. 18
 Working together
S
Surgery &A
Anesthesiology
th i l
|
extends the boundaries of life and death

Massive Crush Injury - Hb

19 2
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Pengembangan
Intensive Care / ICU
1975 Anestesiologi RSCM
1977 Anestesiologi RSDS

21
Prolonged Life Support
di ICU
|
adalah bagian dari
Resusitasi

22
Magill
Guedel
MacIntosh
E t i
Epstein

Archie Brain
LMA

23
Resusitasi Jantung Paru
ACLS
ATLS
semua perlu intubasi trachea
24
25
Sekolahnya 4 tahun, 120 SKS
+ MKDU

26
 Anestesia

• Keadaan yang ditandai hilangnya kesadaran

dan / atau p
persepsi
p nyeri
y ((bersama atau terpisah)
p )

27
 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
• Menghilangkan nyeri
y khronis (ischemia
( dll))
• Menghilangkan rasa cemas pada anak

29
 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
offices—who hurt and even fatallyy injure
j patients
p
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
32
 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 1:10,000
– Class II 3:10,000
– Clas III 28:10,000
– Class IV 230:10,000

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 Anestesia
menghambat hantaran impulse nyeri atau
menghilangkan persepsi nyeri

• Suntikan im atau iv • Anestesia umum

• Inhalasi (dihisap nafas)

• Dengan suntikan syaraf • Anestesia regional /

conduction block

• Dengan suntikan di • Anestesia (infiltrasi) lokal

tempat
p operasi
p
35
 Anestesia umum
blok otak = syaraf pusat
36
 Anestesi umum
Morfin pada reseptor
Ketamin pada jalur thalamus-cortex

37
Anestesia regional
blok serat syaraf

38
 Ketamine
OA IInhalasi
h l i

S i l block
Spinal bl k

Plexus & Nerve

Block

39
 Anestesia regional

• P
Pada
d ujung
j syaraff di lokasi
l k i
(local infiltration block)
• Pada serabut syaraf
(nerve block)
y
• Pada berkas syaraf dekat medula spinalis
p
(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 Subarachnoid block
41
Peridural block
Subarachnoid
block

42
 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

44
 Obat anestesia umum

• Ether • Bau (+) menyengat, terbakar,

murah
• Halothane • Harum, gg liver, aritmia
• Enflurane • Harum <, gg ginjal, convulsi
• Isoflurane • Harum <, sadar cepat, mahal
• Sevoflurane • Harum>,, sadar cepat,
p , mahal >>
• Desflurane • Harum<<, sadar cepat, mahal >>

45
 Sistem anestesia

breathing tubes
vaporizer P

canister sodalime
(CO2 absorber)
Flowmeter
oksigen

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 Vaporizer ether
Sumber ggas O2,, N2O
Flowmeter pengatur gas

Vaporizer halothane

Vaporizer enflurane 50
 otak

Uap obat inhalasi

Alveoli Art.carotis int..

pparu

Kapiler paru
Obat intravena 51
 Mekanisme anestesia umum inhalasi

• TAHAP INDUKSI & MAINTENANCE

• Uapp OA kadar tinggi
gg dihisapp masuk alveoli paru
p
→ kadar OA alveolair tinggi → menembus
membran alveoli-kapiler → masuk darah kapiler
→ kadar
k d OA ddalaml kapiler
k il tinggi
i i → sirkulasi
i k l i oleh
l h
jantung kiri ke otak → menembus kapiler di
j i
jaringan t k → masukk sel-sel
otak t k → kadar
l l otak 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
l l i → kadar
alveolair 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

55
 Urutan proses anestesia umum

• Puasa: mengosongkan lambung

• sedatif, analgesia  tenang
Premedikasi: memberi sedatif
• 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
pCO2 arteria
(hipoventilasi)
90
80
Enflurane
70
Isoflurane
60
50
Halothane
40

30
20

10

0
0 MAC 1.0 MAC 1.5 MAC
58
 Perubahan cardiac output akibat anestesia
% awake value
(depresi sirkulasi)
120

100
Isoflurane
80
Halothane
60 Enflurane

40

20

0
1.0 MAC 1.5 MAC 2.0 MAC
59
 Perfusi, nadi dan tekanan darah
harus di monitor selama anestesia

60
 Waktu induksi

Jari raba Mata lihat nafas

Waktu maintenance
nadi
Telinga dengar
jantung

Monitoringg selama anestesia

61
Edmond I Eger 1985
62
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

64
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 sukar

mudah
Titik 36.2 50.2 58.5 22.8
didih
Blood/gas
Bl d/ 12.1 2.3 0.68 0.42
part.coeff
Tek.uap
T k 460 243 160 669
pada 20C 66
VOLATILE ANESTHETICS
ETHER
HALOTHAN
ETHRANE
ISOFLURAN
SEVOFLURAN
DESFLURAN 67
Induksi inhalasi dengan ether perlu waktu 20-30 menit

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

71
 Anestesiologi & Reanimasi
sangat kompleks
|
dimana multiple variables bekerja cepat dalam
hitungan menit dan detik
dan dalam range mati-hidupnya seorang pasien

72
 Penyulit buruk adalah
CARDIAC ARREST
- karena penyakitnya sendiri
- karena pembedahannya
p y
- karena anestesianya

Penyulit terburuk adalah

MALIGNANT
HYPERTHERMIA

obat cuma satu (dantrolene)

efeknya belum tentu
Dipicu succinyl - halothan 73
 Narrcosis

Anaalgesia
Good

Stress Free
general anesthesia

Muscle rrelaxatioon
M
74
 Narcosis dan analgesia
Ketamin pada Anestesi umum
jalur thalamus-cortex

Morfin pada
reseptor

75
Analgesia

Nerve block
Pl
Plexus block
bl k
Epidural block Subarachnoid block
76
Muscle relaxation

77
 Setelah 161 tahun pengembangan
Anestesia
• 1. Pemahaman fisiologi, farmakologi, pato-
fisiologi 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 Againg
– Breathing - Apnea - Breathing Again
• Every change in Anesthesia is
made reversible
81
15
1.5
82
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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

85
 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
87
 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

Spesialis
LIFE SUPPORT Bedah
Airway, Breathing
Ai hi
Circulation, Brain

(BLS-ALS-PLS) Spesialis Anestesiologi

& Reanimasi
89
 Perlu dibedakan antara

KNOWLEDGE

Anestesiologi
& Reanimasi Bedah PROFESSIONAL
COMPETENCE

Anestesiologi Bedah
& Reanimasi

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

92
 Trias Anesthesia
3. Relaxation,
Muscle relaxan
( succinylcholine, pancuronium
bromide, atracurium
bromide atracurium, vecuronium
rocuronium, etc)

93
 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

94
 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

96
 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 %

97
 Labour Pain
Pain,
Pathwayy and Mechanism

98
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100
101
 Causes
1 First stage: uterine contractions and dilatation of the
1.
lower uterine segment and cervix to allow
passage of the fetus.
2. Secondd stage: greater pressure off the
h presenting part
on pain-sensitive pelvic structures and
distension of surrounding g structures.

102
 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.

106
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
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