Marsudi Rasman, dr.

SpAnKIC
Bag Anestesiologi & Reanimasi
Fakultas Kedokteran Unpad Bandung
INTRODUCTORY
I esteem it the office of physician not
only to restore health but to mitigate
pain and dolours
Francis Bacon (1516-1626)
Modern western civilisations :
Pain should be controlled
pain of surgery should be abolished
Our ancestors :
pain is inevitable and to be accepted as
part of life
Philosophers and theologians stressed :
the benefits of suffering pain with stoicism
and fortitude to strengthen moral character
Physycians and Surgeons have attempted to
relieve pain by herbal extracts and other
means.
Some believed that experience of pain
during surgery was essential for
subsequent healing.
Anesthesia did not develop until humanitarian
attitudes in the 19th century made the
circumstances propitious.
Introduction of general anesthesia

Massachussetts General Hospital 16
Okt. 1846 : The first successful public
demonstration ether anesthesia. (Paracelsus
1493-1541)
After Morton and introduction of antiseptic
and aseptic surgery and development in
anesthetic techniques, every part of the body
become accessible to the surgeon
Introduction of pharmacological local
anesthesia

Before Morton : compression of the nerve
trunks and refrigeration produce insesnsibility
of the limbs and trunk.
Cocain : surface analgesic effects natural drug
known to the natives of Peru
Von Anrep of Wurtzburg 1880
surface anesthetic for urology and
laryngology.
15th Sept 1884 in Heidelberg Joseph
Brettaner (Carl Koller)
cocain for operation on the eye Alexander
Wood of Edinburg 1885 injection cocain
around nerves
Cocain is toxic and addictive drug
Procain is synthetic, alternative techniques as
spinal anesthesia.
Discovery of pharmacological local anesthesia
preceded discovery of pharmacological general
anesthesia.
Spectrum of anaesthetic techniques :
local to general anesthesia via combinations of
local and general anaesthetic
Modern specialty of anesthesia Responsibility of
the modern physician anesthetist :
To keep the patient alive in the face of the assault of
surgery
To keep the patient free from pain
To condition the patient for surgery
resuscitation
Intensive care
Pain management
Anesthetist are called up on to facilitate the work of most
department in the modern general hospital
No other medical discipline so constantly
demands such moment to moment decision in
the management of unconscious or acutely ill
patients.
An anesthetist must always be prepared to
assess a situation rapidly and act quickly
Jargon
Anesthesia : loss of feeling or sensation The
present technical use :
Pain relief for surgery
General anesthesia : reversibly unconscious
by drugs for the execution of a
painful operative procedure
Inhalation, Intravenous,
Intramuscular, and Rectal
anesthesia are subdivision of
general anesthesia.
It define the rout by which the drugs
are introduced into the body and
thence via the blood stream to the
brain.
Local anesthesia :
Anesthesia of only portions of the body
The pain free patient will be conscious
or sedated or combine with general
anesthesia
Regional anesthesia :
Synonym with local anesthesia

Analgesia : freedom from pain
Conscious patient free from pain
Anesthesia to describe local or regional
anesthesia.
Patient is conscious
Suppression of synaps in the CNS of the
unconscious patient.
Preventing somatic withdrawal reflex and
autonomic respons such as tachycardia

Hypnosis and Narcosis
Hypnosis : the state of being asleep :
The state of deprivation of the critical
faculties induced hypnotism
Pharmacological sleep; patient cannot be
aroused to consciousness by physical
stimulus, but he may still react
unconsciously by withdrawal or autonomic
reflex if not sufficient analgesia

Hypnotic : drug which will help the patient to
sleep.
- barbiturate; benzodiazepine
Narcosis : a state of stupor produced by drugs
- morphine
Muscular relaxation : allow access to the
body cavity, produced by :
- central depression of n.s.
- local anesthesia of the p.n.
- blocking the neuromuscular junction

Sedatives, Anxiolytics, Tranquillisers, and
antidepressants
Sedation : allaying anxiety to inducing natural sleep with
drugs.
Anxiolysis : reduction in anxiety without necessarily
producing sedation
Tranquilliser : drug which acts at a lower level of CNS than
the c. cortex.
- benzodiazepine
Antidepressants : alter the mood and mental reaction of
patients.
In large doses will cause loss of consciousness, reps,
depression and abolition of protective reflex.

Anesthesia and anesthetist

The science of anesthesia is called :
Anesthesia, Anesthetics, Anesthesiology
Anesthesia : individual who administered
anesthetic
Perception and prevention of pain
We are more sensible of one little touch of the
Surgeons lancet than of twenty wounds with
a sword in the heat of battle
Michel Wyquiem de Montaigne
(1533-1592)
The perception of pain

Pain; is appreciated by the conscious patient
at the highest critical levels of the cortex, but
peripheral stimulus is not necessarily
interpreted as painful even in the absence of
drugs.
Exp; sportsmen on the playing flied soldiers
in battle, ect.

Fig. 3.1.
The psycholocigal and physical control
of pain in the conscious patient
Sugestion and distraction
Massive sensory input
Acupuncture
Counter stimulation :
rubbing; ice packs,
camphorated oil;
aerosol cold spray;
TNS (Transcutaneous Nerve Stimulation)
The control of pain by drugs
Simple sedative : oral barbiturate
Tranquilizers : benzodiazepine, control emotional,
response to pain
Opioid analgesics : the most useful pain relieve
Phenothiazepine : depress RAS
Local anesthetics : spinal cord, nerve roots,
peripheral nerve
Anti prostaglandin analgesics : act at the source of
pain, aspirin, paracetamol
Inhalation agents : N2O 50%;Trichorethylene
Pain control and the surgical patient
Psychological reduced or eliminate
Physical appreciation of pain
Pharmacological
preoperatively, during surgery and
postoperative period
The action of drugs
Pharmacodynamics : the actions of
drugs used in surgical anesthesia.
Pharmacodinamics is the study of the
effect of drugs on the body.
Pharmacokinetics : what the body
does to drugs.25
How do the drugs used in
general an. Act ?
Drugs acting on CNS (general an;
sedatives; tranquilizers and
analgesics) be introduced into the
body by several routes (intravenous,
IM; Inhalational; Oral, Rectal;
Sublingual and Transdermal)
Drugs blood stream brain
(spesific cells) anaesthetic state.
Probability theory :
Alteration in the permeability of the brain
cell membrane, interference with
oxygenation, interference with oxygenation,
intracellular H
+
concentration/ion exchange.
Reversible distortion of the protein
elements of the membrane and blocking of
the sodium channels.
Centrally acting drugs act on spec. receptors
in the brain.
Opioid analgesics; brain and spinal cord
Anti inflamatory analgesics : aspirin and
paracetamol act locally by inhibiting synthesis
of prostaglandins
Local anesthetics : injected or topically close
to the cell or the axonal nerve.
The greater the protein binding capacity the
longer its action.
Neuromuscular blocking agents
Motor nerve fibre nerve ending (ach)
neuromuscular junction muscle fibre.
Stimulus Ach release depolarisation muscle
contraction.
There are two types of muscle relaxant :
Depolarizers : suxamethonium
Act similarly to Ach
Non depolarisers : competitive blocking agents.
Tubocurarine.
Occupy the endplate without
causing depolarization
Classical and modern concepts
Spectrum of techniquest anesthesia :
1. Local anesthesia alone
2. Local anesthesia with sedation
3. Local anesthesia combine General
Anesthesia
4. General Anesthesia alone, with and
without paralysis by neuromuscular
bl. Agent and controlled ventilation
The classic general anesthesia
Modern polypharmaceutical G.A. : to produce
unconsciousness quickly with IV agents and to
maintenance a depth of anesthesia appropriate for
the surgery.
The classic General Anesthesia : ether anesthesia
Ether anesthesia is safe because :
1. It is sympathomimetic agent preserve cardiac,
output and blood pressure
2. Induction and the depth of anesthesia is gradual
3. Adequate abdominal relaxation

Fig. 5.1
Modern techniques of general anesthesia
Aim : to keep in light surgical anesthesia
recovery is rapid
Abdominal relaxation : local anesthetic or muscle relaxant agents.
1. Balanced anesthesia
Prof.T.Cecil Gray :
Anesthesia : narcosis (sedation)
reflex supression (analgesia)
relaxation
2. Light general anesthesia and breathing spontanously
3. Light general anesthesia with local anesthesia
4. Light general anesthesia with neuromuscular block
5. Total Intravenous Anesthesia (TIVA)
Local anesthesia for consious patients
Minor surgery
Major surgery is better under General
Anesthesia
Advantages of local anesthesia : in
elderly, obstetric.
The Anaesthetist is a man apart, . The
patients life is in his hands. The ease and
perfection of an operation largely depend
upon his skill . The anaesthetist appears as
a sort of prologue to the operation and then
becomes an influence, pervading the whole
action.
The History of St. Bartholomews Hospital, 1918
Norman Moore, M.D.
The safety and comfort of the patient and
the success of the anaesthetic rest
squarely on the anaesthetist. The best
anaesthetic is unnoticed by the surgeon
and patient, and so the anaesthetists
only reward may be the self knowledge
that he has done a good job.
Table 1-1. Definition of the practice of anesthesiology.*
Assessing, consulting and preparing patients for anesthesia.
Rendering patients insensible to pain during surgical
obstetric, therapeutic, and diagnostic procedures.
Monitoring and restoring homeostasis in perioperative and
critically ill patients.
Diagnosing and treating painfull syndromes.
Managing and teaching of cardiac and pulmonary
resuscitation.
Evaluating respiratory function and applying respiratory
therapy.
Teaching, supervising, and evaluating the performance
of medical and paramedical personnel involved in
anesthesia, respiratory care, and critical care.
Conducting research at the basic and clinical science
levels to explain and improve the care of patients in
terms of physiologic function and drug response.
Involvement in the administration of hospitals, medical
schools, and outpatient facilities as necessary to
implement these responsibilities.
*Adapted from the revised definition of the American
Board of Anesthesiology, 1989.