Recent advances in anesthesia and painless surgeries.pptx

Dr Nayana Kulkarni.
Chief Consultant Anesthesiologist.
Hcg Manavata Cancer Center Nasik

 More than 150 years ago William Morton
successfully used diethyl ether as general
anaesthesia.
 Newer advances made even the most
difficult surgical and diagnostic procedures
possible to undertake, which were
considered impossible earlier.
 There was an era when bark of mandrake
plant was used to administer anaesthesia,
and for analgesia, ice, topical pressure, or
even hypnosis was used.
 In 1846, the first public demonstration of
ether was held and it paved the way for a
new branch of medicine that came to evolve
into a speciality and even superspeciality.
 Ether, after reigning the kingdom of
anaesthesiology for more than a century,
came to be superseded by newer and newer
agents. Even nitrous oxide is all set to be
replaced by xenon in developed countries.
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NIMA NASIK 2

 Advances in anaesthesia have
made many new surgical
techniques possible, and
mortality directly attributable
to anaesthesia is now rare.
 Most recent advances have
contributed to an important
decrease in morbidity from
anaesthesia and to an
increase in quality of
perioperative management.
 In the last 150 years,
anaesthesiology has
developed into a major
speciality, its rate of advance
has surpassed most other
branches of medicine.
Old work
station?/boyles
machine
New workstation with
inbuilt ventilator,
monitor,close circuit with
low flow technology,
anesthesia gas monitoring
with scavenging system to
prevent OT pollution
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 As airway adjuncts, the jump is from ether mask to endotracheal
tube to double lumen bronchial tube to microlaryngeal tube to
supraglottic airways and so on.
 Regarding other :
 labour analgesia,
 patient-controlled analgesia, from syringe pump to elastomeric
pump to microprocessor driven CADD pump for PCA.[CADD stands
for Computerised Ambulatory Delivery Device]
 fibreoptics, - for INTUBATION, BRONCHOSCOPIES
 Bispectral Index (BIS) monitors, FOR MONITORING DEPTH OF
ANESTHESIA
 workstations, FOR CONDUCTING DIFFICULT EXTRA MAJOR
CASES WITH SMOOTHNESS AND FINE CONTROL.
 simulators and robotic surgeries, FOR BEST PATIENT CARE.
 Anaesthesia for robotic surgery received much impetus and is still a
dream to come true in many countries.
 But in Nasik we are doing robotic surgeries and giving anesthesia
since 2019 sept. at HCG.
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supraglottic airway devices in this study. Note: From left to right: lMa ®
Supreme™ (Teleflex, Athlone, Ireland), AuraGain™ (Ambu, Kopenhagen,
Denmark), i-gel ® (intersurgical, Wokingham, UK), KOO™-sga prototype
(KOO Medical equipment, Tsuen Wan, China), lTs-D™ (VBM gmbh, sulz
a.n. germany) and cuff pressure gauge (Covidien, Plymouth, Mn, Usa).
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 Any form of anesthesia
is never MINOR- all
anesthesia is major as
complications can
occur in local injections
like drug anaphylaxis!!
 So always tell patients,
anesthesiologist will
see what can be given
for operations.
 Testing local
anesthesia- skin test is
an important
preoperative necessity.
 Any drug can result in
allergy, so history of
allergy to food
products/dust/etc
/rhinitis/ or URI
repeatedly SHOULD
TRIGGER QUESTION
OF ALLERGY.
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NIMA NASIK 6

 Anesthesia for-
 CT / MRI/ ANGIOGRAPHY/ ANGIOPLASTY
 PET SCAN
 CT GUIDED PROCEDURES LIKE ADRENAL
/LUNG/ SPINE BIOPSY/ LIVER BIOPSY
 INTERVENTIONAL RADIOLOGICAL
PROCEDURES LIKE DSA/ ANEURYSMAL
CLIPPING
 SICK PATIENTS LIKE OBSTRUCTIVE
JAUNDICE FOR PTBD/ CRF PATIENTS FRO
PCN
 PEDIATRIC PATIENTS FOR BONE MARROW
BIOPSIES/ CENTRAL CATHETER
INSERTIONS
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 New inhalational anaesthetics allow rapid, pleasant
gaseous induction of anaesthesia and rapid
recovery with a minimal “hangover” effect
 Target controlled infusion techniques have
improved the accuracy of total intravenous
anaesthesia and pave the way for “closed loop”
automatic anaesthesia.
 A unique opioid, remifentanil, allows fine control of
intraoperative analgesia but its effects wear off
within minutes of stopping infusion
 Separation of stereoisomers has allowed the
development of improved safer local anaesthetics
 Mobile epidurals are rapidly gaining popularity in
labor wards because they allow normal mobility
with high quality pain relief
 Recent developments in equipment have helped to
minimise the problems of anaesthetising patients
with “difficult” airways.
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 STARTED WITH HALOTHANE IN GOLDMANS VAPORISER
 THEN ISOFLURANE SEVOFLURANE DESFLURANE IN TEC 7
VAPORISERS.
 NEWEST IS
 Xenon:
 Xenon is an inert gas with anaesthetic properties but until recently its cost has
been prohibitive.
 It is extremely insoluble in plasma and thus exhibits an even faster onset of action
and recovery than any volatile agent.
 It is not sufficiently potent to be used alone in most patients, however, but may
replace nitrous oxide as a supplement to general anaesthesia in the future; it has
analgesic properties, is less soluble, and is not a greenhouse gas (unlike nitrous
oxide).
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 Bupivacaine overdose:
 Sometimes anaesthesiologists encounter
complications due to local anaesthetic
overdose such as high spinal.
 At present, there is little to do in such
cases as there are no antidotes and one
has to wait for the drug to metabolise.
 With nanotechnology, an antidote to
bupivacaine overdose is possible.
 There is a formation of pi–pi complexes
between bupivacaine and a pi-electron–
rich injectable nanoparticle
 This complex would be devoid of the
clinical effects of bupivacaine and would
thus render toxic bupivacaine harmless.
 So, it could be possible in the future to
counteract high spinal as soon as it is
realised.
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 If any case is posted for local anesthesia via block/spinal/epidural and bupivacaine or
lignocaine used, beware of LAST toxicity.
 Atleast emergency 20% intralipid emulsion must be kept as antidote for LAST toxicity.
 Keeping emergency cart with defibrillator is important as medico legal complications will
occur as these are minimum monitoring standards necessary for conducting any
operations minor or major in hospital set up.
 Newer airways – LMA/ AMBU AUROGAIN/LMA supreme, nasal airway/ mask with
reservoir bag available (in nearby pharmacy)
 Minimum drugs- with 1ml/2ml/5ml/10ml/20ml syringes and DW. And voluven as colloid
aminophylline esmolol Lasix / dytor
adrenaline Betaloc/metolar midazolam
atropine amiodarone Levera/ eptoin
dopamine lobet mannitol
Xylocard 2% 25% dextrose dilzem
glycopyrolate reglan avil
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 recent advance in obstetric anaesthesia has
been the introduction of mobile epidurals.
 To produce adequate analgesia, traditional
epidurals require the use of local anaesthetics
in concentrations that may produce significant
motor neuronal blockade and consequent
immobility.
 In contrast, mobile techniques usually depend
on the epidural administration of a mixture of
very low concentration local anaesthetic
together with an opioid such as fentanyl.
 The lower concentration of local anaesthetic
minimises motor block, whereas the opioid acts
at opiate receptors in the central nervous
system to enhance analgesia.
 The preserved mobility is often sufficient to
allow walking, free of pain, which is popular
with women in labour.
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 McCoy laryngoscope
 The McCoy laryngoscope is a recent aid for difficult intubations.40 It is shaped like a
standard Macintosh laryngoscope but has a hinged tip to its blade, which can be activated
by a lever on the handle. Use of this hinged tip has been shown to improve the view of the
larynx.
mccoy
macintosh
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 Target controlled infusion :
 Target controlled infusion systems allow the
anaesthetist to set a desired plasma
concentration, which the software inside the
pump produces rapidly but safely by
controlling the infusion rate according to
complex but standard pharmacokinetic
equations.
 Changes may still be required according to
clinical signs, but the technique enables
changes in rate to reflect factors such as
patient characteristics, previous
administration of Propofol / duration of
infusion.
 Remifentanil :
 Remifentanil is a new potent synthetic opioid
ideally suited for infusion (often with a target
controlled infusion system) during
anaesthesia.
 Ropivacaine :
 allowing good analgesia with less intense
motor block than bupivacaine.
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 Nanotechnology has been a boon in the medical field by delivering drugs to
specific cells using nanoparticles.
 The principle exploited is that overall drug consumption and side effects can be
lowered significantly by depositing the active agent only in the morbid region and
in no higher dosage than needed.
 This highly selective approach reduces the side effects and cost, at the same time
targeting its goal efficiently.
 Neuroelectronic interfacing, if successful, will allow nano-devices enabled
electronic chips to be joined and linked to the human nervous system.
 This would permit control and detection of nerve impulses to be interpreted by an
external computer.
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Applications for nanotechnology in medicine include imaging, diagnosis, or the delivery of drugs that
will help medical professionals treat various diseases.
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Recently its used in TACE –deb molecule for chemoembolization in hepatic cancers.
Also bupivacaine liposomal formulation is available in US.
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 Region specific surgeries have tailor-made anesthesia now a days.
 Shoulder / upper limb surgeries have regional blocks like supraclavicular/
 inter-scalene /axillary or radial/ or nerve specific as its done under USG
guidance with contiplex needles for continuous blocks like epidural catheter
,a catheter is kept for post op analgesia.
Just for blocks single shot, we use stimuplex needles and nerve locator with
USG machine deep nerve or superficial nerve guidance.
 Adding additives increases duration of blocks like
dexamethasone,fentanyl,tramadol,ketamine,sodabicarb,nalbuphine,butaol,
buprenorphine etc.
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Femoral nerve block
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 Certain difficulties: colon/ prostate/
hysterectomies/ hernia
 Extreme head low position
 Prolonged surgeries
 Obesity
 Inaccessible pulse as hands are tied
down
 Unapproachable airway so good
control is must for good outcome.
 Strapping – causes airway pressures
to rise along with head low position
 Risk of DVT/ pulmonary embolism so
postop DVT prophylaxis like inj
clexane / LMWH must for at least 5
days.
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Spinal needle- pencil tip
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 A system has been unveiled for
regulating anaesthesia via computer.
 This system would be beneficial in
providing computer-controlled GA,
similar to the manual titration of
anaesthetics in response to BIS, as the
anaesthetist does presently. A team of
researchers from the Canary Islands
has developed a technique for
automatically controlling anaesthesia.
 The system detects hypnotic state of
patient continuously and supplies the
most appropriate dose of anaesthetic.
 It senses patient's encephalogram
(EEG) and BIS, measures the hypnotic
state and relates this to the patient's
level of consciousness.
 The data are processed by a computer
software program which controls the
pump that delivers the anaesthetic.
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 The initials RP stand for the two drugs being
titrated: remifentanil and propofol.
 In addition to monitoring the patient’s EEG level
of consciousness (via a BIS monitor device called
NeuroSENSE),
 this new device monitors traditional vital signs
such as blood oxygen levels, heart rate,
respiratory rate, and blood pressure, to determine
how much anesthesia to deliver.
 the iControl-RP allows either remifentanil or
propofol to be operated in any of three modes:
 (1) closed-loop control based on feedback from the
EEG as measured by the NeuroSENSE;
 (2) target-controlled infusion (TCI), based on
previously-described pharmacokinetic and
pharmacodynamic models; and
 (3) conventional manual infusion, which requires
a weight-based dose setting.
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 In the future, closed-loop titration of drugs may lessen an anesthesiologist’s workload and
free him or her for other activities.
 In the distant future, closed-loop titration of drugs may free a solitary anesthesiologist to
initiate and monitor multiple anesthetics simultaneously from a control booth via multiple
video screens and interface displays.
 But the handling of all tasks by an automated robotic device is still the stuff of science
fiction.
 Every patient requires
 (1) preoperative assessment of all medical problems from the history, physical exam, and
laboratory evaluation of each individual patient, so that the anesthesiologist can plan and
prescribe the appropriate anesthesia type
 (2) placement of an intravenous line through which the TIVA drugs may be administered
 (3) mask ventilation of an unconscious patient (in most cases), followed by placement of an
airway tube to control the delivery of oxygen and ventilation in and out of the patient’s
lungs
 (4) observation of all vital monitors during surgery, with the aim of directing the diagnosis
and treatment of any complication that occurs as a result of anesthesia or the surgical
procedure;
 (5) removal of the airway tube at the conclusion of most surgeries, and
 (6) the diagnosis and treatment of any complication in the newly awake patient following
the anesthetic.
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A critical realization is that anesthetizing patients requires
far more skill than merely titrating two drug levels.
 So ANESTHESIOLOGISTIS NOTREPLACABLEYET
 SOMEONEWITHHIGHCRITICALMANAGEMENTSKILLSIS NEEDEDTODECIDE
 WHATTO GIVE,
 SOMEONENEEDEDFORAN INTRAVENOUSACCESS- BEFOREINITIATINGANESTHESIA
 HOWMUCHTOGIVE
 WHENTOGIVE,
 WHENTOSTOP,
 HOWTOWAKEPATIENTFROMANESTHESIA.
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NIMA NASIK 35

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