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#1.Introduction to Anesthesiology III.

A “Blessing” to Obstetrics
SHERWIN F. REVIBES, M.D.
James Young Simpson- successful obstetrician of Scotland
among the first to use ether for the relief of pain in Obstetrics
History of Anesthesiology - later encouraged the use of Chloroform

I. The Prehistory of Anesthesiology IV. John Snow-first anesthesiologist and regarded as the
 Celsius encouraged “pitilessness” as an essential “Father of Anesthesiology”
characteristic of a surgeon. - achieved fame as an Obstetric Anesthetist by
 Surgeons became injured to their patient’s agony. relieving Queen Victoria of her labor pains
 Prior to introduction of anesthesia with diethyl ether, - developed a face mask and introduced a chloroform
pain was an inevitable consequence of surgery. inhaler

Agents used to achieve anesthesia: VI. 19th Century British Anesthesia After John Snow
 Mandragora, black nightshade, poppies, herbs, hypnosis,
ingestion of alcohol, ice and cold water
Joseph Clover-became the leading anesthetist of London after
 Diethyl ether- therapeutic agent with only occasional use.
the death of John Snow
 Nitrous oxide- coined by Humphry Davy as the “laughing
- first anesthetist to administer chloroform in known
gas”
concentrations and advocate palpating the patient’s
- capable of destroying physical pain
pulse during its administration
- first prepared by Joseph Priestly in 1773 and called
Frederick Hewitt-superb and inventive clinician
dephlogisticated nitrous air (dephlogisticated-
- designed the first anesthetic apparatus to deliver
support combustion)
oxygen and N2O in variable proportions
- wrote the first true textbook of anesthesia entitled
Henry Hill Hickmann- 1st physician who demonstrated in 1824
“Anesthetics and their Administration”
that inhalation of carbon dioxide could produced an
analgesia in animals.
Gardner Q. Colton- dominant figure in the eventual VII. Discovery of Regional Anesthesia in the 19th
introduction of inhalational anesthesia Century
- designed an exhibit that included a demonstration of
the effects of nitrous oxide inhalation. Cocaine-an extract of the coca leaf was the first effective local
anesthetic in 1856
II. Almost Discovery Carl Kollar-introduced cocaine as a topical anesthetic for
ophthalmic surgery in 1884
 William E. Clarke-given the first ether anesthetic in New Wiliam Halsted and Richard Hall-American surgeons who
York in 1842 described the use of cocaine in multiple sites and to produce
- administered ether from a towel for dental nerve blocks
extraction Leonard Corning- a neurologist
 Crawford Williamsow Lone-administered ether for -coined the term spinal anesthesia in 1885
surgical anesthesia on March 10, 1842 but remained August Bier-introduced the first true spinal anesthetic based
silent about his historic work on an understanding of injections into the CSF in his classic
 Horace Wells- discovered the analgesic effect of experimental studies in 1898
nitrous oxide
- attempted public demonstration at the Harvard VIII. Spinal Anesthesia – into the 20th Century
Medical School but judged a failure
Heinrich Quinke-described a technique of lumbar puncture for
III. William T.G. Morton spinal anesthesia
- his technique was used for the first deliberate
October 16, 1846- viewed as the day “Anesthesia was cocainization of the spinal cord in 1899 by a surgical
discovered” colleague, August Bier
William Thomas Green Morton-one of the founders of Heinrich Braun-introduced epinephrine to prolong the action
anesthesia of local anesthetics with great success
- use ether to produce anesthesia for excision of neck - father of conduction anesthesia
mass - first person to use procaine
- successful public demonstration of ether anesthesia
at the amphitheater of Massachusetts General IX. Epidural Anesthesia
Hospital
Edward Tuohy- introduced Tuohy neddle to facilitate the use
Oliver Wendell Holmes- suggested the term “Anesthesia”- of continuous spinal technique
state of temporary insensibility
Caudal Anesthesia- introduced in 1901, used by Cathelin XII. Fluorinated Anesthetics
Lumbar and Thoracic Epidural anesthesia- described in 1921
by Fidel Pages Fluorine-lightest and most reactive halogen, forms
exceptionally stable bonds
Achillo F. Dogliotti- perfected the loss of resistance method to
identify the epidural space Charles Suckling- chemist, synthesized Halothane which
became available in 1956
Martinez Curbelo- used Tuohy’s needle and ureteral catheter
to perform the first continuous epidural anesthesia Methoxyflurane-popular only in 1970 due to dose related
nephrotoxicity
X. The Quest for Safety in Anesthesiology Enflurane-has convulsant properties
Isoflurane- nearly abandoned
Introduction of monitoring and advances in technology such as Sevoflurane
machines capable of delivering calibrated amount of gas and Desflurane-newest
volatile anesthetics, CO2 absorbance, vaporizers, ventilators-
were critical to improve patient safety. XIII. Intravenous Anesthetics
George W. Crile and Harvey Cushing-advocated systemic Intravenous chloroform and ether
blood pressure monitoring during anesthesia Intravenous Morphine and Scopolamine
Barbital-first barbiturate
Severinghaus-stated that pulse oximetry is arguably the most Thiopental-synthesized in 1932
important technological advance made in monitoring the well - its successful introduction into clinical practice was
being and safety of patients during anesthesia, recovery, and due to John S. Lundy in 1934.
critical care
XIV. Muscle Relaxants
XI. Tracheal Intubation in Anesthesia
Curare-the 1st known neuromuscular blocking agent
The development of techniques and instruments for - earliest clinical used in humans was to ameliorate
intubation ranks among the major advances in the history of the tortuous muscle spasms of infectious tetanus
anesthesiology - first applied by Harold Griffith in anesthesia

Joseph Clover- first Englishman who introduced the practice of Succinylcholine-introduced as a depolarizing muscle relaxant
thrusting the patient’s jaw forward to overcome obstruction in 1949 by Hunt and Traveaux
of the upper airway by tongue
1994- Rocuronium was introduced
William Macewan- undertaken the first use of elective oral
intubation for anesthesia Balanced anesthesia-introduced by John S. Lundy in 1926
- this emphasized the use of multiple drugs to
Joseph O’ Dwyer-remembered for his extraordinary dedication produce unconsciousness and anti nociception ,
to the advancement of tracheal intubation provide skeletal muscle relaxation, and obliterate
reflex responses
Albert Kirstein- devised the first direct vision laryngoscope
(1895) XV. Evolution of Professional Anesthesiology
Robert Miller-introduced a slender, straight laryngoscope
Long Island Society of Anesthetists- America’s first specialty
blade (1941)
anesthesia
Robert Macintosh- introduced a curved laryngoscope blade
Francis Hoffer McMehan- editor of the first journal devoted to
(1943)
anesthesia, current researches in anesthesia and analgesia
Ivan Magill- developed a wide bore tube that would resist
Ralph M. Waters- first chair of an academic anesthesia
kinking but conformable to the contours of the upper airway
department at the University of Wisconsin in 1927
(Magill Tubes)
American Society of Anesthesiologists- reflected physician
Arthur Guedel- introduced cuffed tubes
training in contrast to non physician technicians
Emery Rovenstine- introduced double cuffed, single lumen
tube
Frank Robertshaw- designed the currently most popular
double lumen tube in both right and left sided version.
Archie Brain- 1st recognized the principle of Laryngeal Mask
Airway
Scope of Anesthesiology #3.Basic Pharmacologic Principles
SHERWIN F. REVIBES, M.D. Dr. Erwin Taguinod

I. Introduction
PHARMACOKINETICS
Beginning in 1842, anesthesiology has evolved into a - describes the absorption, distribution, metabolism
recognized medical specialty- affirmed by the American and excretion of inhaled and or injected drugs.
Medical Association and the American Board of Medical
Specialties PHARMACODYNAMICS
- provides continuous improvement in patient care - describes the responsiveness of receptors to drugs
based on the introduction of new drugs and and the mechanism by which these effects occurs.
techniques made possible in large part by research
in the basic and clinical sciences PHARMACOKINETICS
II. Scope DRUG IONIZATION
- extends beyond the operating room to include Ionized
preoperative evaluation clinics, respiratory therapy, Nonionized
treatment of acute postoperative pain, management
of chronic pain problems, care of critically ill patients DRUG ABSORPTION
in intensive care units, and administrative - rate at which a drug leaves its site of administration.
responsibilities in daily management of the - membrane transport
operating rooms.
- Anesthesiologists function as perioperative ROUTE OF ADMINISTRATION
physicians with patient care responsibilities during
the preoperative, intraoperative, and postoperative DRUG DISTRIBUTION
periods. pH of the drug’s environment
degree of ionization
III. Definition of Anesthesiology as a Field of Medicine by ASA dissociation constant (pKa)
protein binding
1. field of medicine that specializes in the medical molecular weight
management of patients who are rendered lipid solubility
unconscious and/or insensible to pain and emotional
stress during surgical, obstetric, and certain other Protein binding
medical procedures; - determines the concentration of the drug in the
2. protection of life functions and vital organs (brain, plasma and various other tissues.
heart, lungs, kidneys, liver) under the stress of - acts as a temporary reservoir for a drug that
anesthetic, surgical, and other medical procedures; prevents large flactuations in the concentration of
3. management of problems in pain relief; the unbound or free drugs.
4. management of cardiopulmonary resuscitation; - Albumin, a1-acid glycoproteins
5. management of problems in pulmonary care; and
6. management of critically ill patients in special care ION TRAPPING
units
REDISTRIBUTION and STORAGE
IV. Anesthesiologist’s Responsibilities to Patients
1. preanesthetic evaluation and treatment, DRUG METABOLISM
2. medical management of patients and their - converts pharmacologically active, lipid soluble drugs
anesthetic procedures, to water soluble and often inactive metabolites.
3. postanesthetic evaluation and treatment, and - may also result in conversion of an inactive form
4. onsite medical direction of any nonphysician who (prodrug) to an active drug
participates in the delivery of anesthesia care to the
patient. Phase I Reaction
oxidation, reduction, hydrolysis
Phase II Reaction
conjugation

DRUG EXCRETION
PHARMACOKINETIC PARAMETERS THERAPEUTIC INDEX
- the ratio between the lethal dose (LD50) in 50% of
Clearance patients and the effective dose (ED50) in 50% of
- volume of plasma cleared of drug (mL/min) by renal patients.
excretion or metabolism, or both in the liver or other - the higher the therapeutic index of a drug, the safer
organs. it is for clinical administration because the LD is far
above the ED.
Volume of Distribution
- Vd is a calculated number (i.e.,dose of drug DRUG TOLERANCE
administered IV, divided by the plasma - present when a large dose of a drug is required to
concentration) that reflects the apparent volumes of elicit an effect that is usually produced by the
the compartments that constitutes the smaller (therapeutic)dose of the drug.
compartmental model for that drug
TACHYPHLAXIS
Elimination Half-Time
- the time necessary for the plasma concentration of DRUG DEPENDENCE
drug to decrease 50% during elimination phase. - a psychic or physical state characterized by
behavioral responses that include a compulsion to
Context-Sensitive Half-Time take the drug on a continuous or periodic basis to
- describes the time necessary for the drug experience its psychic effects and sometimes to
concentration to decrease to a predetermined avoid the discomfort of its absence.
percentage (e.g., 50%, 60%, 80%) after
discontinuation of a continuous IV infusion of a
specific duration.

Effect-Site Equilibration
- the delay between the IV administration of a drug
and the onset of its clinical effect reflects the time
necessary for the circulation to deliver the drug to its
site of action.

Bioavailability
- the amount of active drug that is absorbed and
reaches the systemic circulation.

PHARMACODYNAMICS
RECEPTORS
- are excitable transmembrane proteins that are
responsible for transduction of biologic signals.
- voltage sensitive ion channels
ligand-gated ion channels
transmembrane receptors

RECEPTOR AGONIST and ANTAGONISTS


AGONIST
- a drug that initiates pharmacologic effects after
combining with the receptor.
- when bound to receptor, induce stimulatory or
inhibitory effects that mimic endogenous hormones
and neurotransmitters.

ANTAGONIST
- bind to receptors but are not capable of eliciting a
pharmacologic response.
- prevents receptor mediated agonist effects by
occupying agonist sites

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