Anesthesia In The Future

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Anesthesia In The Future

  1. 1. Anesthesia in the Future Steven L. Shafer Palo Alto VA Health Care System Stanford
  2. 2. 2010
  3. 3. Typical American Hospital 1985 - 25 years ago Typical American Hospital
  4. 4. Therapeutic Armamentarium <ul><li>Thiopental </li></ul><ul><li>Isoflurane </li></ul><ul><li>Morphine, Fentanyl </li></ul><ul><li>Succinylcholine, Curare, Pancuronium, Metocurine </li></ul>
  5. 5. Routine Monitors <ul><li>Electrocardiogram </li></ul><ul><li>Inspired oxygen </li></ul><ul><li>Blood pressure cuff </li></ul><ul><li>Temperature </li></ul><ul><li>Finger on the pulse </li></ul>
  6. 6. Special Monitors <ul><li>In selected patients: </li></ul><ul><ul><ul><li>Capnography </li></ul></ul></ul><ul><ul><ul><li>Capnography </li></ul></ul></ul><ul><ul><ul><li>Pulmonary Artery Catheters </li></ul></ul></ul>
  7. 7. Airway Control <ul><li>Endotracheal Intubation </li></ul><ul><li>Mask Ventilation </li></ul><ul><li>Mask Ventilation </li></ul><ul><li>Mask Ventilation </li></ul><ul><li>Mask Ventilation </li></ul><ul><li>Mask Ventilation </li></ul><ul><li>Mask Ventilation </li></ul><ul><li>Mask Ventilation </li></ul><ul><li>Mask Ventilation </li></ul><ul><li>Mask Ventilation </li></ul>
  8. 8. MAC M onitored A nesthesia C are M ostly A pneic and C yanotic M ostly A pneic and C yanotic M ostly A pneic and C yanotic M ostly A pneic and C yanotic M ostly A pneic and C yanotic M ostly A pneic and C yanotic M ostly A pneic and C yanotic M ostly A pneic and C yanotic M ostly A pneic and C yanotic M ostly A pneic and C yanotic M ostly A pneic and C yanotic M ostly A pneic and C yanotic
  9. 9. Patient Care <ul><li>Admission before surgery </li></ul><ul><li>Highly invasive surgical technique </li></ul><ul><li>Intramuscular pethidine for postoperative analgesia </li></ul><ul><li>Discharge in days to weeks </li></ul>        surgical technique
  10. 10. Patient Care Issues <ul><li>Poor post-operative pain control </li></ul><ul><li>Slow recovery </li></ul><ul><li>Nausea and Vomiting </li></ul>
  11. 11. Anesthesia 1998 12 years ago
  12. 12. Basics of Anesthesia <ul><li>Delivery of oxygen </li></ul>Patient Comfort <ul><li>Support of intravascular volume and tissue perfusion </li></ul><ul><li>Patient Comfort </li></ul>
  13. 13. Therapeutic Armamentarium <ul><li>Thiopental </li></ul><ul><li>Isoflurane </li></ul><ul><li>Morphine, fentanyl , alfentanil, sufentanil, remifentanil </li></ul><ul><li>Succinylcholine, pancuronium </li></ul><ul><li>Thiopental, propofol </li></ul><ul><li>Isoflurane, sevoflurane, desflurane </li></ul><ul><li>Morphine, fentanyl, alfentanil, sufentanil, remifentanil </li></ul><ul><li>Succinylcholine, pancuronium, vecuronium, rocuronium, atracurium, mivacurium, doxacurium, and pipecuronium </li></ul>
  14. 14. TIVA Total IntraVenous Anesthesia Total IntraVenous Awareness TIVAE Total IntraVenous Anesthesia with Ephedrine
  15. 15. Propofol
  16. 16. Desflurane, Sevoflurane
  17. 17. Fentanyl Family Tree
  18. 18. Remifentanil
  19. 19. Routine Monitors <ul><li>Pulse Oximetry </li></ul><ul><li>Capnography </li></ul><ul><li>Electrocardiogram </li></ul><ul><li>Inspired oxygen </li></ul><ul><li>Blood pressure cuff </li></ul><ul><li>Temperature </li></ul> Finger on the pulse  Finger on the pulse
  20. 20. Special Monitors <ul><li>In selected patients: </li></ul><ul><ul><ul><li>Esophageal echocardiography </li></ul></ul></ul><ul><ul><ul><li>Pulmonary artery catheterization </li></ul></ul></ul><ul><ul><ul><li>Continuous arterial blood gas </li></ul></ul></ul><ul><ul><ul><li>Continuos mixed-venous saturation </li></ul></ul></ul><ul><ul><ul><li>Sophisticated ventilator monitoring </li></ul></ul></ul>
  21. 21. Bispectral Index <ul><li>Based on EEG spectral analysis </li></ul><ul><li>Good predictor of mental status of patient during anesthesia with: </li></ul><ul><ul><ul><li>Inhalational anesthesia </li></ul></ul></ul><ul><ul><ul><li>Inhalational anesthesia with opioids </li></ul></ul></ul><ul><ul><ul><li>Propofol anesthesia with opioids </li></ul></ul></ul>
  22. 22. Airway Control <ul><li>Endotracheal Intubation </li></ul><ul><li>Mask Ventilation </li></ul><ul><li>LMA </li></ul>Laryngeal Mask Airway
  23. 23. MAC M onitored A nesthesia C are M idazolam, A lfentanil, and C onversation
  24. 24. <ul><li>Admission on day of surgery </li></ul><ul><li>Discharge in 3 - 24 hours </li></ul><ul><li>Fast tracking of patients </li></ul><ul><li>Laparoscopic surgery </li></ul><ul><li>Improved post-operative pain management </li></ul><ul><ul><ul><li>Epidural opioids </li></ul></ul></ul><ul><ul><ul><li>PCA </li></ul></ul></ul>Patient Care Patient Controlled Analgesia Patient Controlled Apnea
  25. 25. 2010 Today
  26. 26. New Therapeutics <ul><li>Duzitol </li></ul><ul><ul><ul><li>Hypnotic </li></ul></ul></ul><ul><ul><ul><li>Analgesic </li></ul></ul></ul><ul><ul><ul><li>Amnestic </li></ul></ul></ul><ul><ul><ul><li>Muscle Relaxant </li></ul></ul></ul><ul><ul><ul><li>Aphrodisiac </li></ul></ul></ul>Anesthesiology 76:327-330, 1992
  27. 27. New Therapeutics <ul><li>Cycloflurane </li></ul><ul><ul><ul><li>Chemical stability of isoflurane </li></ul></ul></ul><ul><ul><ul><li>Rapid induction of sevoflurane </li></ul></ul></ul><ul><ul><ul><li>Rapid emergence of desflurane </li></ul></ul></ul><ul><ul><ul><li>Pleasant smell of “Mr. Propre” </li></ul></ul></ul>
  28. 28. New Therapeutics <ul><li>Dexmedetomidine </li></ul><ul><ul><ul><li>Central  2 adrenergic agonist </li></ul></ul></ul><ul><ul><ul><li>Profound postoperative analgesia in the ICU </li></ul></ul></ul><ul><ul><ul><li>Profound anti-ischemic properties </li></ul></ul></ul><ul><ul><ul><li>Modest sedation </li></ul></ul></ul><ul><ul><ul><li>Rapid offset </li></ul></ul></ul><ul><ul><ul><li>Reversible </li></ul></ul></ul><ul><ul><ul><li>Demonstrated improved outcome after major surgery </li></ul></ul></ul>
  29. 29. New Therapeutics <ul><li>Hyptiva </li></ul><ul><ul><ul><li>Pharmacodynamics of propofol </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Pleasant induction and emergence </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Modest cardiovascular effects </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Modest respiratory effects </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Pharmacokinetics of remifentanil </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Extraordinarily rapid emergence </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Predictable </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Minimal change with disease or age </li></ul></ul></ul></ul></ul>
  30. 30. New Therapeutics <ul><li>Central nicotinic analgesics </li></ul><ul><ul><ul><li>Derived from amphibian skin </li></ul></ul></ul><ul><ul><ul><li>Prototype is epibatidine </li></ul></ul></ul><ul><ul><ul><li>Efficacy equal to morphine </li></ul></ul></ul><ul><ul><ul><li>No ventilatory effects </li></ul></ul></ul><ul><ul><ul><li>No physical dependence </li></ul></ul></ul><ul><ul><ul><li>No kidding </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Science 1998 Jan 2;279(5347):77-81 </li></ul></ul></ul></ul></ul>
  31. 31. New Therapeutics <ul><li>Muscle Relaxants </li></ul><ul><ul><ul><li>Suxuronium </li></ul></ul></ul><ul><ul><ul><li>MadamCurium </li></ul></ul></ul><ul><ul><ul><li>Rockandrolium </li></ul></ul></ul>Suxuronium
  32. 32. MAC M onitored A nesthesia C are M adam, A re you C omfortable?
  33. 33. New Therapeutic Modes <ul><li>Remifentanil PCA </li></ul>
  34. 34. New Monitoring <ul><li>Intraoperative EEG </li></ul><ul><ul><ul><li>BIS now standard-of-care </li></ul></ul></ul><ul><li>EEG Guided Anesthesia Delivery System </li></ul>EGADS
  35. 35. EGADS
  36. 36. Patient Care <ul><li>Nearly all operations done on outpatients </li></ul><ul><li>Most operations are laparoscopic/endoscopic </li></ul><ul><li>Intelligent intra-operative and post-operative drug delivery systems </li></ul><ul><li>ICU care rarely needed </li></ul>
  37. 38. Anesthesia in 2020?
  38. 39. Plausible vs. Implausible <ul><li>Plausible: </li></ul><ul><ul><li>Remifentanil PCA </li></ul></ul><ul><ul><li>Dexmedetomidine </li></ul></ul><ul><ul><li>Nicotinic agonists </li></ul></ul><ul><ul><li>New generation of hypnotics </li></ul></ul><ul><ul><li>EGADS system </li></ul></ul><ul><li>Implausible </li></ul><ul><ul><li>Duzitol </li></ul></ul><ul><ul><li>Cycloflurane </li></ul></ul><ul><ul><li>Suxuronium, madamcurium, rockandrolium </li></ul></ul>

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