1.introduction to anaesthesia wubieeeee copy

HISTORY OF
ANAESTHESIA
1WUBIE B11/2/2018

Presentation outline
 Objectives
 Introduction
 History of IV anaesthesia
 History of inhalational anaesthetics
 History of regional anaesthesia and muscle relaxants
 History of air way equipments
 History of anaesthesia machine and monitoring
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Objectives
After completion of this course students will be able to
• Describe the Hx of inhalational anaesthetic agents, IVA,
muscle relaxants, regional anaesthesia, anaesthesia
machine, airway and monitoring equipments
• understanding anaesthesia machine, airway equipments,
monitoring equipments, techniques of BP measurement,
measurements of temperature
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What is anaesthesia??
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Introduction
• Greek an- without and aesthesia – sensation
refers to the inhibition of sensation.
• Origin of anesthesia :
– Oliver Wendell Holmes Sr 1846
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Oxford dictionary definition
• Insensitivity to pain , especially as artificially induced
by the administration of gases or the injection of
drugs before surgical operation.
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What are the triads of
anaesthesia??
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The three components…..
1. Analgesia
2. Hypnosis (amnesia) and
3. Muscle relaxation.
• Drugs used in anesthesia have varying effect on these
three areas and to be combined to optimize the whole
process of anesthesia.
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• Hypnosis (amnesia): a state of sleep or unconsciousness
which enable the patient unaware any events
• Analgesia: Insensitivity to pain + loss of consciousness.
• Muscle relaxation: aided by drugs which affect skeletal
muscle function and decrease the muscle tone by which
immobility and relaxation of the skeletal muscle
produced ….surgery will be proceeded at ease.
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What are Features of
a good anaesthetic?
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Features of a good anaesthetic?
An anesthetic procedure should:
• Abolish pain
• Provide good operating conditions.
• E.g. good relaxation for abdominal surgery.
• Be Completely reversible.
• Be acceptable to the patient
• Be safe
 Comfortable - important
 Safety - essential and must come first.
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Types of Anaesthesia??
 General Anesthesia : Reversible, unconscious state
is characterised by Amnesia(sleep, hypnosis or
basal narcosis) , analgesia, depression of reflexes
and muscle relaxation.
• GA with ETT
• GA with face mask
• GA with LMA
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Types of Anaesthesia??
• Regional Anesthesia:A reversible loss of sensation in
a specific area of the body.
 Spinal anesthesia
 Epidural anesthesia
 Peripheral Nerve Blocks
 IV Regional Blocks(Bier’s block)
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General Anaesthetics might be….
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Inhalation Anesthetics
• Gasses or Vapors
• Usually Halogenated
• Halothane, isoflurane,
sevoflurane etc.
IntravenousAnesthetics
– Intravenous
– Anesthetics or induction agents.
– Barbiturates ( thiopentone )
– Ketamine, Propofol, Etomidate
etc.

What are the phases of
anaesthesia care?
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 Anesthesiologists/anaesthetists care for the surgical patient in
the preoperative, Intraoperative & postoperative period .
1. Preanesthetic care
• Routine pre-anesthesia evaluation
1. History
2. physical examination
3. laboratory evaluation
4. ASA classification
• Preanesthetic preparation
• Premedication
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2. anesthetic care
- preinduction phase
- induction phase
- maintenance phase
- emergence phase
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3. Postanesthesia care
3.1 Immediate : RR or PACU
3.2 late postanesthesia care
- pain control
-complication mgt
-monitoring
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WHY USE ANESTHESIA??
 Advantages of anesthesia
1. good operating condition
2. no suffer to pain
3. decrease stress response to surgery
4. maintain physiologic balance
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History of Anaesthesia??
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• Pre-1846 - the foundations of anaesthesia
• 1846 - 1900 - establishment of anaesthesia
• 20th Century - consolidation and growth
• 21st Century - the future

Why study history of Anaesthesia?
1. Understanding of our past guides and our future
2. We are all part of it
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Pre 1846 - The Foundations of Anaesthesia
A. Drug methods and
B. Non drug methods
Drug methods
• Alcohol
• Opium (poppy)
• Hyoscine (Mandrake)
• Cannabis (Hemp)
• Coca leaves11/2/2018 WUBIE B 25

Non-drug methods
• Cold
• Concussion
• Carotid compression
• Nerve compression
• Hypnosis
• Acupuncture
• Blood letting
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CONSOLIDATION AND GROWTH- 20th Century
• Intubation and airway advance
• Anesthetic equipment
• Monitoring
• Drug advance
• Pain management
• Intensive care
• Local anesthesia
• Organization of specialty11/2/2018 WUBIE B 27

Historical perspective
 Anaesthetic practices date from ancient times.
 Ancient civilizations had used opium poppy ,coca
leaves, mandrake root ,alcohol and even phlebotomy to
allow surgeons to operate.
 The ancient Egyptians used the combination of opium
poppy(morphine) and hyoscyams (hyoscyamine and
scopolamine .
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• A physician from the first century A.D. commented
upon mandragora.
• He stated that the plant substance could be boiled in
wine and strained, and used “ in the case of persons…
about to be cut or cauterized, when they wish to
produce anesthesia.”
• Mandragora was still being used to anesthetize patients
as late as the 17th century.
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Opium poppy(papaver somniferum)
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Carotid compression
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Acupancture
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Mandrake leaves
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• From the 9th to the 13th centuries The
soporific sponge was a dominant mode of
providing pain relief during surgery.
• Mandrake leaves, along with black nightshade,
poppies, and other herbs, were boiled together
and cooked onto a sponge.
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 The sponge was then reconstituted in hot water,
and placed under the patient's nose prior to
surgery.
 Prepared as indicated by published reports of the
time, the sponge generally contained morphine
and scopolamine in varying amounts—drugs
used in modern anesthesia.
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• In addition to using the “sleeping sponge,” Europeans
attempted to relieve pain:
 by hypnosis, by the ingestion of alcohol, herbs, and
extracts of botanical preparations and by the topical
application of pressure or ice.
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• Regional Anesthesia: in ancient times consisted of
– Compression of nerve trunks(nerve ischemia) or
– The application of cold( cryoanalgesia).
• The Incas may have practiced local anaesthesia as their
surgeons chewed coca leaves and spat saliva
(presumably containing cocaine ) into the operative
wound.
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Leg amputation prior to introduction of general anesthesia. Artist
unknown. Council of the Royal College of Surgeons of England.)
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It was the custom then, as for centuries afterward, to bind the patient
to the table with ropes or straps. His screams were disregarded, but
if he struggled too Violently, assistants grasped his arms and legs.

 The evolution of modern surgery was hampered not
only by a poor understanding of disease processes,
anatomy, and surgical asepsis but also by the lack of
reliable and safe anasthetic techniques .
 These techniques evolved first with inhalational
anesthesia, followed by local & RA, and finally IV
anesthesia .
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• The development of surgical anesthesia is considered
one of the most important discoveries in human
history.
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Inhalational anaesthesia?
• Inhaled anesthetics: Prior to the hypodermic syringe
&needle (1855) and routine venous access, ingestion
and inhalation were the only known routes of
administering medicines to gain systemic effects.
• The discovery of surgical anaesthetics, in the modern
era, remains linked to inhaled anaesthetics.
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• The discovery of surgical anesthetics is the story of
inhaled anesthetics.
• From the ‘dark ages’ where diethyl ether was first
synthesized to the modern operating room; inhalational
anesthetics have played a tremendous role in
anesthesia.
• These compounds are the ‘backbone’ of modern
anesthetic practice.
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• The history of inhalational agents is also the quest for
safety as many different agents have been tried.
• The search for the perfect agent, one that rapidly
induces anesthesia, smells pleasant and is free of
side effects continues.
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List some
Inhalational anaesthetic agents?
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 Diethyl ether
 Nitrous oxide
 Chloroform
 Ethyl chloride & ethylene
 Cyclopropene
 Halogenated anaesthetics / florinated
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Ether, Chloroform and Nitrous oxide, were the first
universally accepted general anesthetics.
Ethyl chloride, Ethylene and Cyclopropane were also
used , but the toxicity and flammability led to their
withdrawal from the market.
 Mainly 5 inhalation anesthetic agents are used in
clinical practice these days: Nitrous oxide, Halothane,
Isoflurane, Desflurane and Sevoflurane.
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Diethyl ether
• Paracelsus (1493–1541) observed that diethyl ether
caused chickens to fall asleep and awaken unharmed.
– He must have been aware of its analgesic qualities,
because he reported that it could be recommended for
use in painful illnesses.
– An inexpensive recreational drug among the poor of
Britain and Ireland.
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• An American variation of this practice was
conducted by groups of students who held ether-
soaked towels to their faces at nocturnal “ether
frolics.”
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1. 1540 Ether was prepared by Valerius Cordus and
called "sweet oil of vitriol".
2. Ether used as anesthetic in 1842 by Dr. Crawford
W. Long.
3. In Boston, on october, 1846 William T.G. Morton
conducted the first publicized demonstration of
general anaesthesia using Ether.
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October 16, 1846 first successful surgical procedure
with ether as anesthetic William T.G. Morton
Excision of tumor under jaw

On october 16,1846, a Boston dentist by the name of William T.
G. Morton demonstrate the use of ether during surgery. Using an
ether-soaked sponge, Morton anesthetized a Boston printer
named Gilbert Abbott. Once Mr. Abbott was unconscious,
surgeon John Collins Warren removed a tumor from under his
Jaw.
After the surgery, the patient replied, “I did not experience pain at
any time, though I knew that the operation was proceeding.”
Dr. Warren turned to the audience in attendance and said the
famous word” Gentlemen , this is no humbug” .
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• Mass general hospital of Boston, massachettes has
since observed october 16 as “Ether day”, often
marking it with pageantry, celebration , or just a
nice photograph of the residents in the finest
surgical whites.
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• It is an inhaled anesthetic
• No longer used as an anesthetic agent currently
• Classic stages and planes of anesthesia
described using ether.
• Desirable characteristics
– Stable cardiac output, rhythm and blood
pressure
– Stable respirations
– Good muscle relaxation
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 PHYSICAL PROPERTIES:
– Pungent smelling liquid, decomposes in presence of
light, air, heat.
– Highly inflammable and explosive.
– Highly irritant vapour.
– Very Cheap.
– Also called as Complete Anesthetic agents.
– Can be used by less experience hands.
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• Undesirable characteristics
– Tracheal and bronchial mucosal irritation
– Prolonged induction and recovery
– Postoperative nausea and vomiting
– Flammable and explosive
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What are the stages of
ether anaesthesia??
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Stages of ether Anesthesia
The Four main stages are recognized based upon
• Patient’s body movements,
• Respiratory rhythm,
• Oculomotor reflexes, and
• Muscle tone.
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Stages of ether Anesthesia
In 1920 Arthur E Guedel described the signs and stages of
anaesthesia.
Stage I: Analgesia
Stage II : Disinhibition / excitement
 (stimulation of CNS; ↑ Resp, ↑ BP, ↑ HR).
Stage III: Surgical anesthesia (normal vital functions).
Stage IV: Medullary depression (↓ Resp, ↓ CVS →
coma → death).
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STAGES OF ETHER ANESTHESIA
 STAGE I: Stage of analgesia : From analgesia to loss of
consciousness
• Respiration is regular with small tidal volume.
• Pupil is normal in size.
 STAGE II : (Stage of Excitement):
• From loss of consciousness to rhythmic respiration
• Respiration is irregular.
• Pupil is Mid dilated.
• Eyelashes reflex absent.
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 STAGE III : Stage of surgical Anesthesia
 Plane I: From rhythmic resp to cessation of eye movement
• Respiration is regular with large volume. Pupil is normal in
size. Eyelashes reflex absent, Pharyngeal and vomiting reflex
lost.
 Plane II: From cessation of eye movement to resp paresis
• Respiration is regular with large volume , Pupil is mid dilated
with corneal reflexes lost.
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 Plane III: Resp paresis to Paralysis
• From Respiration is regular with small volume, Pupil is
moderate dilated with laryngeal reflexes absent.
 Plane IV: Diaphragmatic Paralysis
• Respiration is irregular with small volume, Pupil dilated
and centrally placed.
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 Stage IV: Medullary Paralysis
– Stage of overdose
– Apnea
– Pupil dilated and non reacting to light.
• NOTE: Withdrawal of anesthetic agents and administration of
100% oxygen lightens anesthesia with recovery.
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Stage IV: Medullary Paralysis
 The patient may exhibit the following signs:
o Cessation of spontaneous respiration
o Severe bradycardia and hypotension
o Cardiac arrest
o Absence of all reflexes
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Chloroform??
Day 2

Chloroform
 1831: Chloroform synthesized
 1833: Cynthia Guthrie accidentally anaesthetized
herself
 1847: Anaesthetic properties recognized
 1847: First clinical use, St Barts, London
 1847:James Young Simpson used chloroform for
obstetric anaesthesia
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James Young Simpson (1811-1870)
• Professor of Midwifery in
Edinburgh from 1840
• Tried chloroform on himself and
friends at suggestion of David
Waldie, a chemist
• Secured and popularized
chloroform as clinical
anaesthetic, esp. in Obstetrics
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James Young Simpson
• Many objections to analgesia for childbirth
• Religious and moral
• Genesis 3:16 - “…..The Lord God said to the woman, I will
greatly increase your pain when you give birth. You will be in
pain when you have children. You will long for your husband.
And he will rule over you……..”
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James Young Simpson
• Less than a year after administering the first
anesthesia during childbirth, Simpson addressed these
concerns in a pamphlet entitled “Answers to the
Religious Objections Advanced Against the
Employment of Anaesthetic Agents in Midwifery and
Surgery and Obstetrics.”
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Chloroform
 1847: John Snow’s regulating inhaler
 1847/48: Chloroform eclipses ether
 1848: Hannah Greener - first anaesthetic death
 1858: John Snow “On Chloroform and other
anaesthetics”
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John Snow (1813-1858)
• Became interested in
anaesthesia via work in
toxicology
• Acknowledged as “first full-
time” anaesthetist developing
ways to improve methods of
ether and chloroform
administration
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John Snow
– “Chloroform a la Reine”
• Prince Leopold
– born 7th April 1853
• Princess Beatrice
– born 14th April 1857
• helped to overcome religious
and moral objections to
analgesia for childbirth
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• Between 1864 and 1910 numerous commissions in UK
studied chloroform, but failed to come to any clear
conclusions.
• It was only in 1911 that Levy proved in experiments with
animals that chloroform can cause cardiac fibrillation.
• Chloroform-related cardiac arrhythmias, respiratory
depression, and hepatotoxicty eventually caused
practitioners to abandon it in favor of ether, particularly
in North America.
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Nitrous Oxide
 Joseph Priestley produced nitrous oxide in 1772.
 Humphry Davy first noted its analgesic properties
in 1799.
 Horace Wells used nitrous oxide as an anesthetic
for dental extractions in humans in 1844 for the
first time.
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Nitrous Oxide
Physical properties:
It is only inorganic anesthetic gas in clinical use.
inert nature with minimal metabolism
Colorless and odorless, tasteless, and does not
burn.
Non Explosive and Non Inflammable
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Nitrous Oxide
Gas at room temperature and can be kept as a
liquid under pressure.
It is relatively inexpensive.
Simple linear compound and Only anesthetic
agent that is inorganic.
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Nitrous Oxide
• N2O lack of potency
– MAC value is 80% results in analgesia & 105% in
surgical anesthesia.( Weak anesthetic, powerful
analgesic)
• was the least popular of the three early inhalation
anesthetics because of its
– Low potency
– tendency to cause Asphyxia when used alone
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Nitrous Oxide
 in 1868 when Edmund Andrews
administered it in 20% oxygen; its use was,
however, overshadowed by the popularity of
ether and chloroform.
• N2O is the only one of these three agents still
in widespread use today.
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• The introduction of other inhalation anesthetics are
continued (ethyl chloride, ethylene, divinyl ether,
cyclopropane, trichloroethylene & fluroxene),but
ether remained the standard inhaled anesthetic until
the early 1960s.
• The only inhalation agent that rivaled ether’s safety
and popularity was cyclopropane (introduced in
1934). However, both are highly combustible
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Ethyl chloride
 Ethyl chloride & ethylene were first formulated in the
18th century, and had been examined as anesthetics in
Germany soon after the discovery of ether's action; but
they were ignored for decades.
• Ethyl chloride retained some use as a topical anesthetic
and counter irritant. It was so volatile that the skin
transiently “froze” after ethyl chloride was sprayed
upon it.
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Ethyl chloride
• Its rediscovery as an anesthetic came in 1894,
when a Swedish dentist sprayed ethyl chloride
into a patient's mouth to “freeze” a dental abscess.
Carlson was surprised to discover that his patient
suddenly lost consciousness.
• Ethyl chloride became a commonly employed
inhaled anesthetic in several countries.
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History of inhalational anesthetics
• From the 1840s- 1950s
– The inhalational anesthetics introduced were either
Very flammable or toxic to liver, or both.
– In the 1903s ,research of inhalational agents become
based on a structure- activity relationship.
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 Nonflammable potent fluorinated hydrocarbons:
 Halothane , 1951
Methoxyflurane , 1958
Enflurane, 1963
Isoflurane , 1965
 Desflurane, 1992
 Sevoflurane in 1994.
 Desflurane and sevoflurane are now the most popular
in developed countries.
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Halothane
1. First synthesized in 1951
2. Used clinically in 1956
3. Represented a significant advancement with its
• Sweet odor
• Nonflammable and high potency
• There were concerned over hepatotoxicty and
arrhythmogenicity
• So the search continued for safer agent….
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Methoxyflurane
• 1960 introduced
• A very soluble agent
• Making for prolonged induction and emergence
• Extensively metabolized by liver
• Resulting in high plasma concentration of
fluoride ions causing nephrotoxics
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How to deliver inhalational anesthetics
• Early time
• Developments in how to deliver the inhalational agents was
taking place also.
– Mid 1800s
 A face mask and an ether inhaler was developed
 Chloroform was delivered in known concentration via a”
clover bag :” invented by Joseph clover
 He also made it a standard to monitor the patient’s pulse.
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Joseph Clover
• Joseph Clover (1825–1882) became the leading anesthetist
of London after the death of John Snow in 1858.
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Joseph Clover anesthetizing a patient with chloroform and
air passing through a flexible tube from a Clover bag.

Joseph Clover
• Clinicians now accept Clover's monitoring of the pulse as
a simple routine of prudent practice, but in Clover's time
this was a contentious issue.
• Clover was the first anaesthetist to administer chloroform
in known concentrations through the Clover bag.
• After 1870, Clover favored a nitrous oxide–ether
sequence. The portable anesthesia machines that he
designed were in popular use for decades after his death.
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• He was the first Englishman to urge the now universal
practice of thrusting the patient's jaw forward to
overcome obstruction of the upper airway by the tongue
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• Late 1800s ; a
device to deliver
oxygen and N2O
was invented
• Because pure N20
or N20 and air
was hypoxic .
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• Late 19th century: free standing anesthesia
machine was invented
• 1906 : Co2 absorber
• 1910 : flowmeters
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A. The bomb-ether
c. heid brink
B. forgcopket

HISTORY OF REGIONAL
ANESTHESIA
The Discovery of Regional Anesthesia in the 19 Century
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Historical perspective
• Anesthesia by compression was a common in the
antiquity
• Cold as an anesthetic was widely used until the 1800s.
• The native Indians of Peru chewed coca leaves and know
about their cerebral stimulating effects and possibly
about their local anesthetic properties ( there are some
reports of natives using an emulsion of chewed coca
leaves and saliva on wounds ).
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• Cocaine, an extract of the coca leaf, was the first
effective local anesthetic.
• Cocaine was isolated from coca leaves in 1855 by
Gaedicke and was purified in 1860 by Albert Niemann.
• Carl Koller, is credited with introduction of cocaine as a
topical ophthalmic local anesthetics in Australia in1884 .
• In 1888 Koller came to the United states and established
a successful ophthalmology practice.
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• 1884 William Halsted used cocaine for
intradermal infiltration and nerve blocks (including
blocks of the facial nerve, brachial plexus,
pudendal nerve, and posterior tibial nerve).
• Recognition of cocaine’s cardiovascular side effects
, as well as its potential for dependency and abuse
,led to search for better local anesthetic drugs.
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• Cocaine :
– A good topical local anesthetic
– vasoconstriction
– reuptake of catecholamines from nerve endings
– The term spinal anesthesia was coined in 1885 by
Leonard Corning, a neurologist
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• August Bier
– administered the first spinal anesthetic in 1898.
– the first to describe intravenous regional anesthesia (Bier
block) in 1908.
• Procaine was synthesized in 1904 by Alfred Einhorn and within a
year was used clinically as a local anesthetic by Heinrich Braun.
• Braun was also the first to add epinephrine to prolong the duration
of local anesthetics.
• FerdinandCathelin and Jean Sicard introduced caudal epidural
anesthesia in 1901.
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• Lumbar epidural anesthesia was described first in 1921 by Fidel
Pages.
• Additional local anesthetics subsequently introduced include
– Dibucaine (1930), Tetracaine (1932), Lidocaine (1947),
– Chloroprocaine (1955), Mepivacaine (1957), Prilocaine (1960),
Bupivacaine (1963), and Etidocaine (1972).
• The most recent additions, Ropivacaine and Levobupivacaine,
have durations of action similar to bupivacaine but less cardiac
toxicity
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INTRAVENOUS ANESTHESIA
• Induction Agents
 IV anesthesia required the invention of the hypodermic
syringe and needle by Alexander Wood in 1855.
 Early attempts at IVA included the use of chloral
hydrate (by Oréin 1872), chloroform and ether
(Burkhardt in 1909), and the combination of morphine
and scopolamine (Bredenfeld in 1916).
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 Barbiturates
– were first synthesized in 1903.
– The first barbiturate used for induction of anesthesia was
diethylbarbituric acid (barbital), but it was not until the
introduction of hexobarbital in 1927 that barbiturate induction
became popular.
– Thiopental, synthesized in 1932, used clinically by John
Lundy and Ralph Waters in 1934 and for many years
remained the most common agent for intravenous induction
of anesthesia.
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• Methohexital was first used clinically in 1957 by V. K.
Stoelting.
 Chlordiazepoxide was discovered in 1955 and released
for clinical use in 1960, other benzodiazepines—
diazepam, lorazepam and midazolam—came to be used
extensively for premedication, conscious sedation and
induction of general anesthesia.
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 Ketamine
• Synthesized in 1962 by Stevens
• First used clinically in 1965 by Corssen and Domino; it was
released in 1970 and continues to be popular today, particular
when administered in combination with other agents.
 Etomidate : was synthesized in 1964 and released in 1972. Lack
of circulatory and respiratory effects was tempered by evidence of
adrenal suppression, reported after even a single dose.
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 Propofol
 Released in 1986 , was a major advance in outpatient
anesthesia because of its short duration of action .
 Propofol is currently the most popular agent for intravenous
induction worldwide.
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Neuromuscular Blocking Agents
• History of Muscle Relaxers
 The earliest known use of muscle relaxant drugs dates back
to the 16th century, when European explorers encountered
natives of the Amazon were using poison-tipped arrows
that produced death by skeletal muscle paralysis.
 By 1943, neuromuscular blocking drugs became
established as muscle relaxants in the practice of anesthesia
and surgery.
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Neuromuscular Blocking Agents
• The introduction of curare by Harold Griffith and Enid
Johnson in 1942 was a milestone in anesthesia.
• Curare greatly facilitated tracheal intubation and
muscle relaxation during surgery.
• Succinylcholine/Suxamethonium was synthesized by
Bovet in 1949 and released in 1951; it has become a
standard agent for facilitating tracheal intubation
11/2/2018 WUBIE B 110

• Other neuromuscular blockers such as gallamine,
decamethonium, metocurine, alcuronium, and
pancuronium—were subsequently introduced.
Unfortunately, these agents were often associated with side
effects and the search for the ideal NMB continued.
• Recently Introduced agents that more closely resemble an
ideal NMB include vecuronium, atracurium, rocuronium,
and cis -atracurium.
11/2/2018 WUBIE B 111

Opioids
• Morphine, isolated from opium in 1805 by Sertürner,
was also tried as an intravenous anesthetic.
• The adverse events associated with large doses of
opioids in early reports caused many anesthetists to
avoid opioids and favor pure inhalation anesthesia.
11/2/2018 WUBIE B 112

11/2/2018 WUBIE B 113
Structural formulas of anesthetic drugs.

11/2/2018 WUBIE B 114
Traditional monoanesthesia vs. modern balanced anesthesia

1.introduction to anaesthesia wubieeeee copy

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