Total knee replacement (TKR) is one of the most commonly done surgical procedures, with over 150,000 total knee replacements and THR performed annually in England and Wales in the National Health Service (NHS). In India although clear-cut data is not available but the incidence is increasing. In the US, 431,000 TKRs are performed yearly and the utilization of TKR has increased over the last two decades, especially among younger patients .TKR may be associated with severe post-operative pain. The International Association for the Study of Pain (IASP) has defined pain as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has made adequate pain management a priority and has deemed monitoring pain as the “fifth” vital sign.
Pain Physicians should consider nerve blocks when systemic analgesics are failing. (Adjuvant therapy)
Careful selection of patients
Benefits should outweigh the risks
Thorough knowledge of the limitations and side effects
Need for randomized controlled clinical trials.
Total knee replacement (TKR) is one of the most commonly done surgical procedures, with over 150,000 total knee replacements and THR performed annually in England and Wales in the National Health Service (NHS). In India although clear-cut data is not available but the incidence is increasing. In the US, 431,000 TKRs are performed yearly and the utilization of TKR has increased over the last two decades, especially among younger patients .TKR may be associated with severe post-operative pain. The International Association for the Study of Pain (IASP) has defined pain as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has made adequate pain management a priority and has deemed monitoring pain as the “fifth” vital sign.
Pain Physicians should consider nerve blocks when systemic analgesics are failing. (Adjuvant therapy)
Careful selection of patients
Benefits should outweigh the risks
Thorough knowledge of the limitations and side effects
Need for randomized controlled clinical trials.
Knee replacement is one of the most commonly performed operations in the United States with over 700,000 procedures performed annually. In 2012, the American Society of Anesthesiologists (ASA) published its guidelines for acute pain management in the perioperative setting. This document recommends “multimodal analgesia” which means that two or more classes of pain medications or therapies, working with different mechanisms of action, should be used in the treatment of acute pain. The ASA also strongly recommends the use of regional analgesic techniques as part of the multimodal analgesic protocol when indicated.
The key to a successful Acute Pain Service is not so much the use of sophisticated drugs and high technology equipment, but an excellent organisational structure and well trained medical and nursing personnel.
Transcranial Magnetic Stimulation ( TMS) for Chronic PainDr. Rafael Higashi
Aula sobre avanço no tratamento da dor crônica com o uso de Estimulação Magnética Transcraniana (EMT) ministrada por Dr. Rafael Higashi, médico neurologista, no departamento de tratamento da dor do Centro Médico da Universidade de Nova York, NYU, EUA.
www.estimulacaoneurologica.com.br
Get Rid of Your Traditional Acute Pain Service and Broaden Your Vision!Edward R. Mariano, MD
Our biggest challenge (and also opportunity) is to demonstrate our value as anesthesiologists and pain medicine specialists in the evolving healthcare landscape. Going forward, physician anesthesiologists need to take on leadership roles in coordinating patient care, including by not limited to pain medicine, by collaborating with primary care, surgery, nursing, physical therapy, pharmacy, social work, and other hospital-based services.
Management of the patient with suspected perioperative nerve injuryEdward R. Mariano, MD
At the conclusion of the activity participants should be able to: discuss potential risks for perioperative nerve injury; estimate occurrence rates of various regional anesthesia complications; evaluate the patient with suspected nerve injury and recommend appropriate testing.
Peran Fentanyl pada balance anestesia -> telah banyak diteliti hasilnya adanya potensiasi fentanyl dengan obat anestesia baik inhalasi maupun intravena. Berikut ini kami mencoba menelaah beberapa penelitian dari luar maupun penelitian yang kami lakukan sendiri.
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION THERAPY IN TEMPOROMANDIBULAR DISO...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Knee replacement is one of the most commonly performed operations in the United States with over 700,000 procedures performed annually. In 2012, the American Society of Anesthesiologists (ASA) published its guidelines for acute pain management in the perioperative setting. This document recommends “multimodal analgesia” which means that two or more classes of pain medications or therapies, working with different mechanisms of action, should be used in the treatment of acute pain. The ASA also strongly recommends the use of regional analgesic techniques as part of the multimodal analgesic protocol when indicated.
The key to a successful Acute Pain Service is not so much the use of sophisticated drugs and high technology equipment, but an excellent organisational structure and well trained medical and nursing personnel.
Transcranial Magnetic Stimulation ( TMS) for Chronic PainDr. Rafael Higashi
Aula sobre avanço no tratamento da dor crônica com o uso de Estimulação Magnética Transcraniana (EMT) ministrada por Dr. Rafael Higashi, médico neurologista, no departamento de tratamento da dor do Centro Médico da Universidade de Nova York, NYU, EUA.
www.estimulacaoneurologica.com.br
Get Rid of Your Traditional Acute Pain Service and Broaden Your Vision!Edward R. Mariano, MD
Our biggest challenge (and also opportunity) is to demonstrate our value as anesthesiologists and pain medicine specialists in the evolving healthcare landscape. Going forward, physician anesthesiologists need to take on leadership roles in coordinating patient care, including by not limited to pain medicine, by collaborating with primary care, surgery, nursing, physical therapy, pharmacy, social work, and other hospital-based services.
Management of the patient with suspected perioperative nerve injuryEdward R. Mariano, MD
At the conclusion of the activity participants should be able to: discuss potential risks for perioperative nerve injury; estimate occurrence rates of various regional anesthesia complications; evaluate the patient with suspected nerve injury and recommend appropriate testing.
Peran Fentanyl pada balance anestesia -> telah banyak diteliti hasilnya adanya potensiasi fentanyl dengan obat anestesia baik inhalasi maupun intravena. Berikut ini kami mencoba menelaah beberapa penelitian dari luar maupun penelitian yang kami lakukan sendiri.
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION THERAPY IN TEMPOROMANDIBULAR DISO...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Nora e reversal colorato slideshare; NaPoli i SIA 2016Claudio Melloni
Non operating room anesthesia and reversal of muscle relaxation.Respiratory complications due to residual paralysis.Mechanism of action of residual paralysis .Sugammadex.Calabadion New discoveries.
Valut az rischio anest sia napoli dic 2008;italian + bibliografyClaudio Melloni
evaluation of operative risk for non cardiac surgery ;for anesthesia and surgery.Cardiac conditions,including heart failure ,use of betablockers,stains.Diabetes risk,including difficult intubation.Thromboembolic risk,
lowest heart rate
lowest mean arterial pressure
estimated blood loss
A score built from these 3 predictors has proved strongly predictive of the risk of major postoperative complications and death in general and vascular surgery
A new dantrolene formulation for the treatment of Malignant hyperthermia(MH).Receptors,pharmacokinetics,dosages,preparation of dantrolene,practical tips,advantages.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Pharynx and Clinical Correlations BY Dr.Rabia Inam Gandapore.pptx
Are there limits for general anesthesia
1. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Ci sono limiti alla Anestesia
generale?
Claudio Melloni
Servizio di Anestesia e Rianimazione
Ospedale degli Infermi
Faenza(RA)
2. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
I limiti della anestesia generale
Claudio Melloni
Servizio di Anestesia e Rianimazione
Ospedale degli Infermi di Faenza
Faenza(RA)
3. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Lecture outline
What is GA?
GA and awareness;skipped!
Inhalations vs tiva:experience vs mathematics
PK-PD and tiva trainer:from theory to practice
From practice to theory and back to
practice-……………….
We cannot became what we need to
be by remaining what we are(Maxwell De
Pree,Author and Chairman Emeritus,Hermann Miller Inc,Zeeland
.Michigan)
4. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Definitions of anaesthesiaDefinitions of anaesthesia
Rees & Gray 1950,Gray 1960Rees & Gray 1950,Gray 1960
Drug induced uncosciousness:the patient does not perceive nor recall noxious stimulationDrug induced uncosciousness:the patient does not perceive nor recall noxious stimulation
Prys-Roberts C. Anaesthesia: a practical or impractical construct? [editorial]. Br J Anaesth 1987; 59:1341-5.Prys-Roberts C. Anaesthesia: a practical or impractical construct? [editorial]. Br J Anaesth 1987; 59:1341-5.
Paralysis uncosciousness & attenuation of the stress responseParalysis uncosciousness & attenuation of the stress response
Pinsker MC. Anesthesia: a pragmatic construct. Anesth Analg 1986; 65:819-20.Pinsker MC. Anesthesia: a pragmatic construct. Anesth Analg 1986; 65:819-20.
Sensory block,motor block,block of reflexes,mental blockSensory block,motor block,block of reflexes,mental block
WoodbrigeWoodbrige
All separate effects useful to protect the patient from the stress of surgeryAll separate effects useful to protect the patient from the stress of surgery
Kissin I, Gelman S. Components of anaesthesia. Br J Anaesth 1988; 61:237-42.Kissin I, Gelman S. Components of anaesthesia. Br J Anaesth 1988; 61:237-42.
Reversible oblivion and immobilityReversible oblivion and immobility
Eger EI II. What is general anesthetic action? [editorial]. Anesth Analg 1993; 77:408.Eger EI II. What is general anesthetic action? [editorial]. Anesth Analg 1993; 77:408.
5. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Modern balanced anesthesiaModern balanced anesthesia
Do they fir together?Do they fir together?
HypnosisHypnosis AmnesiaAmnesia AnalgesiaAnalgesia Muscle relaxationMuscle relaxation
Stress protectionStress protection Reflexes protectionReflexes protection Absence of movementAbsence of movement
6. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
MuscleMuscle
relaxationrelaxation
Control ofControl of
stressstress
responseresponse
UnconsciousnessUnconsciousness
Hypnotics + inhalation agentsHypnotics + inhalation agents
Muscle relaxantsMuscle relaxants
AnalgesicAnalgesic
drugsdrugs
Modern balanced anesthesiaModern balanced anesthesia
7. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Assessing anesthetic depthAssessing anesthetic depth
Autonomic signsAutonomic signs HR,BP,sweat,tears(PRST score...)HR,BP,sweat,tears(PRST score...)
Somatic signsSomatic signs moving,coughing.breathing...moving,coughing.breathing...
Response to stimulationResponse to stimulation
voice,eyelash
reflex,pinprick,incision,intubation,visceral
traction
voice,eyelash
reflex,pinprick,incision,intubation,visceral
traction
Anesthetic concentrationAnesthetic concentration
MAC,plasma conc,effect site conc....MAC,plasma conc,effect site conc....
8. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
MACMAC
Mac
awake50-95
Mac
awake50-95
Anesthetic
alveolar
concentration
preventing
awareness in 50%
or 95% of
subjects…(Stoelting
1970);
Anesthetic
alveolar
concentration
preventing
awareness in 50%
or 95% of
subjects…(Stoelting
1970);
MACMAC
Minimum alveolar
concentration of
anesthetic
preventing movement
in response to
incision in 50-95% of
subjects..
Minimum alveolar
concentration of
anesthetic
preventing movement
in response to
incision in 50-95% of
subjects..
MAC bar50-95MAC bar50-95
Minimum alveolar
concentration of
anesthetic preventing
stress response to
surgical stimulation in
50-95% of patients
Minimum alveolar
concentration of
anesthetic preventing
stress response to
surgical stimulation in
50-95% of patients
9. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
MAC TablesMAC Tables
Mac
awake
Mac
awake
MAC in
O2
MAC in
O2
MAC in
N2O 60%
MAC in
N2O 60%
MAC
bar
MAC
bar
halothanehalothane 0.410.41 0.70.7 0.30.3 1.3Mac1.3Mac
isofluraneisoflurane 0.380.38 1.141.14 0.500.50 1.3 Mac1.3 Mac
sevofluranesevoflurane 0.620.62 22 0.600.60 1.5 Mac1.5 Mac
desfluranedesflurane 2.422.42 66 2.832.83 1.5 Mac1.5 Mac
10. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
MAC PyramidMAC Pyramid
Stress
response
control
Stress
response
control
MAC barMAC bar
MovementMovement
MACMAC
UncosciousnessUncosciousness
Mac awakeMac awake
fraction of MAC
0.
5
1.0
1.5
11. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
MuscleMuscle
relaxationrelaxation
Control ofControl of
stressstress
responseresponse
UnconsciousnessUnconsciousness
Inhalation agents
Muscle relaxantsMuscle relaxants Analgesic drugsAnalgesic drugs
NeurolepticsNeuroleptics
Hypnotics and BDZs
Drugs for general anesthesiaDrugs for general anesthesia
12. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
balance of anesthesiabalance of anesthesia
AnesthesiaAnesthesia
respiratory
depression
respiratory
depression
cardiovascular
depression
cardiovascular
depression
13. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Steady state alveolar concentrationSteady state alveolar concentration
what does it meanswhat does it means
PA=kCAPA=kCA
where PA is maintained at a constant value for
at least 10 min
where PA is maintained at a constant value for
at least 10 min
PA=CA=BrainPA=CA=Brain
14. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Rate of rise of alveolar(FA) anesthetic concentration toward
the inspired (Fi) concentration
Min .of administration
15. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Logistic regression curves relating end tidal isoflurane
concentrations and multiple stimulations Zbinden AM, Maggiorini M,
Petersen-Felix S, Lauber R, Thomson DA, Minder CE: Anesthetic depth defined using multiple
noxious stimuli during isoflurane/oxygen anesthesia: I. Motor reactions. ANESTHESIOLOGY
80:253-260, 1994
Tetanic
stimulation
Intubation
Trapezius squeeze
Laringoscopy
Skin incision
16. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
EFFETTO
CONCENTRAZIONE
Concentration/effect curves for iv drugs
Inclinazione margine
terapeutico
EC50 ED50
17. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Probabilityofno-response Cp50 concept
18. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Isobolograms:
A: additive
B: sinergistic
C: infraadditive
19. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Interaction between propofol, midazolam and
alfentanil for LOC
20. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
IOT induzione mantenim. risveglio sedazione
0
2
4
6
8
10
12
concentrazioneematicadi
propofol(µg/ml)
Maitre PO, 1994
?
Propofol: effective Cp50 relative to different
stimulations
21. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
10
8
6
4
2
0
sedazione TIVA: minore: maggiore: TIVA:
Propofol- Propofol- Propofol- solo Propofol
oppioide N2O N2O
Propofol(mg/ml)
Propofol: relationship between plasma
concentration and CNS depression
Shafer SL, Stanski DR, 1991
22. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Loss of consciousnessLoss of consciousness
knowledge ofknowledge of
LOCLOC
time to peak
effect
time to peak
effect
haemodynamic
effects
haemodynamic
effects
impact of
drug
combination
impact of
drug
combination
23. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Loading dose correctedLoading dose corrected
loading doseloading dose
based on Vd
incorporating the
biophase
based on Vd
incorporating the
biophase
drug choice
and timing
drug choice
and timing
based on Keo and
its time to peak
effect
based on Keo and
its time to peak
effect
24. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Vpeak effectVpeak effect
Proportionality constant which,when multiplied by the target concentration,
should produce the desired peak effect in the number of minutes noted.
Proportionality constant which,when multiplied by the target concentration,
should produce the desired peak effect in the number of minutes noted.
V peak
effect(Lt)
V peak
effect(Lt)
Time to peak
effect(min)
Time to peak
effect(min)
fentanylfentanyl 7575 3,63,6
alfentanilalfentanil 5959 1,41,4
sufentanilsufentanil 8989 5,65,6
propofolpropofol 2424 22
Shafer SL,Kern DE,Stanki DR
.The scientific basis of infusion
techniques in anesthesia .
North Reading,Ma.Bard
Medical Division 1990.
25. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Time course of serum concentration
versus EEG spectral edge:Remifentanil
(Anesthesiology 84:821-33,1996)
26. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Fentanyl(150 microgr/kg) and EEG (Anesthesiology
90,566-99,1999)
27. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Ausems ME, Vuyk J, Hug CC Jr, Stanski DR. Comparison of a computer
assisted infusion versus intermittent bolus administration of alfentanil
as a supplement to nitrous oxide for lower abdominal surgery.
Anesthesiology 1988; 68:851-61.
29. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
The interaction between fentanyl and
isoflurane(BJA 1998,81,38-50)
30. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Interaction between remifentanil and isoflurane
Isoflurane concentration reduction by increasing remifentanil whole blood
concentration.Anesthesiology 85:721-8, 1996
31. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Mac reduction of desflurane by fentanyl
Sebel PS., Glass PSA,Fletcher JE,Murphy M,Gallagher C,Quill T.Reduction of rhe Mac of
desflurane with fentanyl. Anesthesiology
76:52-59, 1992
32. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Sevoflurane Mac awake reduction by fentanyl
Katoh T,Iked K. The Effects of Fentanyl on Sevoflurane Requirements for Loss of Consciousness
and Skin Incision ANESTHESIOLOGY 1998; 88:5—6.
33. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
MAC reduction of isoflurane
by sufentanil
+:no movement
-:movement
34. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Plasma alfentanil vs propofol blood concentrations for 95%
probability of no response to surgical stimulation(Vuyk et al.Propofol
Anesthesia and Rational Opioid Selection: Determination of Optimal EC50-EC95 Propofol—Opioid
Concentrations that Assure Adequate Anesthesia and a Rapid Return of Consciousness Anesthesiology
87:1549-62, 1997
35. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
manual opioid infusion schemesmanual opioid infusion schemes
from many sources...from many sources...
drugdrug plasma target
concentation(ngml)
plasma target
concentation(ngml) bolus(microgr/kg)bolus(microgr/kg)
infusion rate
(microgr/kg/min
infusion rate
(microgr/kg/min
fentanylfentanyl 11 33 0.0200.020
fentanylfentanyl 44 1010 0.0700.070
alfentanilalfentanil 4040 2020 0.250.25
alfentanilalfentanil 160160 8080 1.001.00
sufentanilsufentanil 0.150.15 0.150.15 0.0030.003
sufentanilsufentanil 0.500.50 0.500.50 0.0100.010
remifentanilremifentanil 66 11 0.020.02
remifentanilremifentanil 12-2012-20 1-21-2 0.4-1.00.4-1.0
36. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Fiset, P. Practical pharmacokinetics as applied to our daily
anesthesia practice .Can J Anesth 1999 / 46 / R122-R126
37. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Finestra terapeuticaFinestra terapeutica
oppioidioppioidi
fent(ng/ml)fent(ng/ml) alfent(ng/ml)alfent(ng/ml) sufent(ng/ml)sufent(ng/ml)
induz & intub con
tps
induz & intub con
tps
3-53-5 250-400250-400 0,4-0,60,4-0,6
induz & intub con
N2O
induz & intub con
N2O
8-108-10 400-750400-750 0,8-1,20,8-1,2
mant con
N2O+inhalat
mant con
N2O+inhalat
1.5-41.5-4 100-300100-300 0,25-0,50,25-0,5
mant con N2O solomant con N2O solo 1.5-101.5-10 100-750100-750 0,25-10,25-1
mant con O2 solomant con O2 solo 15-60 1000-40001000-4000 00
RS suff all'emergRS suff all'emerg 1,5 125125 0,250,25
38. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
TCI systems
From clinical experience and literature
recommendations to target
concentration ,where the system
calculates the infusion rate necessary
to achieve that concentration over time
39. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Kinetic-dynamic dissociation and the effect
compartment
40. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Pharmacokinetic parameters for PropofolPharmacokinetic parameters for Propofol
Gepts Anesth Analg 66;1256;1987 & Marsh.BJA 67;41:1991 &Gepts Anesth Analg 66;1256;1987 & Marsh.BJA 67;41:1991 &
GeptsGepts MarshMarsh
V1V1 767767 228 ml/kg228 ml/kg
K10K10 0.0350.035 0.119/min0.119/min
KeoKeo 0.630.63 0.26/min0.26/min
K12K12 0.28660.2866 0.114/min0.114/min
K21K21 0.08660.0866 0.055/min0.055/min
K13K13 0.27300.2730 0.0419/min0.0419/min
K31K31 0.0360.036 0.0033/min0.0033/min
41. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
PharmacodynamicsPharmacodynamics
assumptionsassumptions
MEACMEAC
fent:0.6
ng/ml
fent:0.6
ng/ml
Resp
depression
Resp
depression
>2 ng/ml>2 ng/ml
MAC
reduction
MAC
reduction CSHTCSHT
RecoveryRecovery
ED95 intraop for surgery/ED95 for recovery of consciousness & spont.resp.ED95 intraop for surgery/ED95 for recovery of consciousness & spont.resp.
42. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Decrement times of desflurane,sevoflurane,isoflurane and
enflurane as a function of the duration of anesthetic
administration Bailey, J M.Anesth Analg 1997; 85:681-6
50%
80%
90%
43. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Some significant decrement times for the modern
inhalatory agents.
0
10
20
30
40
50
60
70
80
90
100
min
50% decr.times 80% decr times after
60 min
90% decr times after
300 min
desflurane
sevoflurane
isoflurane
enflurane
44. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Context sensitive half times as a
function of infusion duration
remifentanil
45. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Three dimensional
surface
isobolograms
relating drugs A &
B with probability
of no
response;two
dimensional
isobolograms only
produces the line
at 50%
probability….
Minto CF, et al: Anesthesiology 92,1603-15,2000
46. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
The software used in this investigation and other
software useful for modeling dose—response surfaces is
available via the World Wide Web at URL
http://pkpd.icon.palo-alto.med.va.gov in the
directory interaction.dir. The Appendices for this article
and the data set used for the analysis can be found on
the ANESTHESIOLOGY Web site
(www.anesthesiology.org).
Address reprint requests to Dr. Shafer: Pharsight
Corporation, 800 West El Camino Real # 200, Mountain
View, California 94040. Address electronic mail to:
sshafer@pharsight.com
47. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Response
surface for each
of the paired
interactions.Max
effect is failure
to open eyes to
verbal command
Minto CF, et al: Anesthesiology 92,1603-15,2000
48. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
time
Propofol blood concOpioid blood concentration
Three dimensional planes in the
graphs from Vuyk et al.
49. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
time
Propofol blood concOpioid blood concentration
Three dimensional planes in the
graphs from Vuyk et al.
66. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
New definition of
anesthesi..ology
Anesthesiology ..is the
practice of pharmacology
synergism using central
nervous system
depressant..T.D.Egan ,2003 .
67. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
I have made this letter longer than
usual, because I lack the time to
make it short.
I have made this letter longer than
usual, because I lack the time to
make it short.
Blaise PascalBlaise Pascal
(lecture)
Editor's Notes
shows the decrease (from bottom to top) in the effect site concentrations of propofol and alfentanil during the first 40 min after termination of infusions lasting 15, 60, 300, and 600 min, during which constant target propofol and alfentanil concentrations had been maintained at values associated with a 50% probability of no response to surgical stimulation as indicated by the curves in the x—y planes (note that the curve in the x—y plane is identical in all four diagrams in this figure). The bold line over the surface of each of the four diagrams represents the effect site propofol and alfentanil concentrations associated with a 50% probability of awakening and the corresponding times after termination of the infusions. The optimal intraoperative combination of propofol and alfentanil is defined as the combination that, while being associated with a 50% probability of no response to surgical stimuli intraoperatively, results in the fastest possible return of consciousness after termination of the infusion. This combination is represented in each diagram by the lowest point on the bold awakening line. The time to awakening is represented by the distance between this point and the nearest point on the curve in the x—y plane (the bottom of the diagram). The optimal intraoperative effect site EC