Introduction to

Anesthesiolgy and CCM

By : dr. kirubel tinsae (MD, assistant professor of
anaesthesiology and critical care)

07/02/2024 1
Outlines

• Introduction • Scope of anesthesia

• Definition
• Options of sub specialties
• History of anesthesia
• Inhalational
• Intravenous
• Local & regional
• Opioids
• NMBS
07/02/2024 2
Objectives

At the end of this session we will be able to understand

History of anesthesia
Scope of anesthesiology practice
Fellowship programs

07/02/2024 3
 Before discovery of anesthetics
07/02/2024 I) 4
Introduction

• Anesthesia is essential for the practice of surgery

• Since its beginning in 1842 it has evolved in to a recognized specialty

providing continuous improvement in patient care

• It’s a duty to administer the safest anesthetic possible, to protect the

patient and to give full attention for the anesthetized patient.

07/02/2024 5
Definition
• Anesthesia:- is a medical procedure which is deliberately produced to
make a patient insensible to pain either in part or in the whole of the
body by which diagnostic and surgical procedure are done while the
patient safety and comfort are maintained.
• Anesthetist – a qualified HCP who administer anesthetics to produce
total or partial loss of sensation in patients during surgical or
diagnostic procedures.
• Nurse anesthetist-a nurse who specialize in administration of
anesthesia.

07/02/2024 6
• Anesthesiologist –are a physician with specialized training and
certification in anesthesia perioperative medicine, pain management
and often additional subspecialties like
• Sleep medicine

• Intensive care medicine

• Critical care medicine

07/02/2024 7
Cont int….
• Definition of the practice of anesthesiology within the practice of
medicine.
1. Assessment and preparation of patients for surgery and anesthesia.
2. Prevention, diagnosis, and treatment of pain during and following surgical,
obstetric, therapeutic, and diagnostic procedures.
3. Acute care of patients during the perioperative period.
4. Diagnosis and treatment of critical illness.
5. Diagnosis and treatment of acute, chronic, and cancer related pain.
6. Cardiac, pulmonary, and trauma resuscitation.

07/02/2024 8
Cont…

7. Evaluation of respiratory function and application of treatments in

respiratory therapy.

8. Instruction, evaluation of the performance, and supervision of both medical

and paramedical personnel involved in perioperative care.

9. Administration in health care facilities, organizations, and medical schools

necessary to implement these responsibilities.

10. Conduct of clinical, translational, and basic science research

07/02/2024 9
• Moreover, the practice has expanded well beyond rendering patients
insensible to pain during surgery or obstetric delivary.
• The specialty uniquely requires a working familiarity with a long list
of other specialties, including
• surgery and its subspecialties,
• internal medicine,
• pediatrics, and
• obstetrics
• clinical pharmacology,
• applied physiology, and
• biomedical technology
07/02/2024 10
• Components of anesthesia
• Analgesia

• Hypnosis(amnesia)

• Muscle relaxation

• Drugs used in anesthesia have varying effect on these three areas and
to be combined to optimize the whole process of anesthesia

07/02/2024 11
• Hypnosis- a state of sleep or unconsciousness which enable the
patient unaware any events
• Analgesia – suppression of pain
• Amnesia – refers to the lack of memory of the intraoperative and
perioperative experience.
• Muscle relaxation ; aided by drugs which affect skeletal muscle
function and decrease the muscle tone by which immobility and
relaxation of the skeletal muscle produced ….surgery will be
proceeded at ease.
07/02/2024 12
 History

• 1846 - Oliver Wendell Holmes coined the

term Anaesthesia.
• It originates from the Greek word an-
“without” and “aisthesis” refers to the
inhibition of sensation.
• The term Anesthesia to denote the state
that incorporates amnesia, analgesia, and
narcosis to make painless surgery possible
07/02/2024 13
 CONT……..
• The Greek philosopher Dioscorides first used the term anesthesia in the first century AD to

describe the anticholinergic and narcotic-like effects of the plant mandragora.

• Its used in wine and can make patients insensible to incision and cauterization.

• Ancient civilizations had used

• alcohol, and
• opium poppy,
• even phlebotomy (to the point of
• coca leaves, unconsciousness) to allow surgeons to

operate.
• mandrake root,
07/02/2024 14
 Before 1846
• Few drugs/plant product used to  Other method /non-drugs
remove pain- method used to remove pain-
Alcohol  Cold
Opium  Concussion
Hyoscine
 Carotid compression
Cannabis
 Nerve compression
Cocaine
 Hypnosis

07/02/2024 ) 15
Cont….

• To conduct anesthesia , a sound knowledge of physiology and

pharmacology is essential ,together with an understanding of changes
brought by illness or injury.

• Anesthesiology – the ART and SCIENCE of rendering a patient

insensible to pain by the administration of anesthetic agents and
related drugs and procedure

07/02/2024 16
The History of Anesthesia
• Pre 1846---the foundation of anesthesia
• 1846---1900----establishment of anesthesia
• 20th century----consolidation and growth
• 21st century –the future
• …..so the lord God caused him to fall in to a deep sleep.while the man was
sleeping, the Lord God took out one of his ribs. He closed up the opening that
was in his side……(Genesis2:21)

07/02/2024 17
• The history of anesthesiology is the history of those who have devoted
their career to the administration of anesthetics.
• Without physicians interested in the anesthetic state and the ability to
adapt to new conditions demanded of anesthesiologists by surgeons,
there would be neither modern surgery nor the specialty of
anesthesiology
• The specialty of anesthesia began in the mid nineteenth century and
became firmly established less than six decades ago.

07/02/2024 18
• Egyptians used the combination of opium poppy (containing

morphine) and hyoscyamus (containing scopolamine);

• A similar combination, morphine and scopolamine, has been used parenterally

for premedication.
• The Incas may have practiced local anesthesia as their surgeons
chewed coca leaves and applied them to operative wounds,
particularly prior to trephining for headache
07/02/2024 19
• The evolution of modern surgery was hampered not only by a poor
understanding of disease processes, anatomy, and surgical asepsis but
also by the lack of reliable and safe anesthetic techniques.
• These techniques evolved first with inhalation anesthesia, followed by
local and regional anesthesia, and finally intravenous anesthesia.
• Although anesthesia now rests on scientific foundations comparable to
those of other specialties, the practice of anesthesia remains very much
a mixture of science and art.

07/02/2024 20
 Nitrous oxide
1772 - first anaesthetic, nitrous oxide gas (laughing gas) was
discovered by Priestly.

07/02/2024
PriestlyIntroduction to anesthesia by dr Adinik(ACCPM R-I) 21
 Nitrous oxide Anaesthesia
• 1844- Nitrous oxide was first used as an
anaesthetic by Gardner Colton &
dentist Horace Wells (Hartford, USA)
for removal (his own tooth) of a tooth
in a human.

• 1800-Sir Humphry Davy (British

chemist) suggested its use in painless
Sir Humphry Davy
surgery.
07/02/2024 22
Ether anesthesia
• 1540 - Synthesized and named “sweet oil of vitriol” by
Valerius Cordus. Frobenius renamed it “ether”.
• 1818- Anaesthetic effect of ether was discovered by
Crawford W Long. But not as an anesthetic agent in
humans until 1842.
William T G Morton
• Both C.W. Long & Williams.E.clark independently used
it on pt for surgery and dental extraction respectively.
• 1846-- Ether anaesthesia was first publicly
demonstrated for surgical operation in by William T G
Morton in “Ether Dome” at Massachusetts General
Hospital (Boston, USA). The Ether Dome, Boston,
07/02/2024 ) Massachusetts 23
John Snow : 1st Anaesthesiologist
• 1st anesthetist: Used ether and Chloroform as
surgical anesthetics.
• He designed an apparatus to safe administration of
ether anaesthesia to the patients and also designed a
mask to administer chloroform anaesthesia.

• Chloroform anaesthesia became famous, when He

administered chloroform to Queen Victoria when she
gave birth to the child. John Snow

07/02/2024 24
 Chloroform Anaesthesia
• 1847- Chloroform anaesthesia was introduced by James
Young Simpson (Scottish obstetrician) and became very
popular due to its pleasant odour.

• Despite of the high toxicity(arrhythmias, respiratory

depression and hepatotoxicity) and mortality rate the use
of chloroform in surgery remained for nearly 100 years.

• Jon snow gave chloroform to Queen Victoria for the

birth of prince Leopold, making the administration of
analgesia to women in labour a socially acceptable
medical activity
07/02/2024 25
 • Halothane (developed in 1951; released in 1956),

• Methoxyflurane (developed in 1958; released in 1960),

• Enflurane (developed in 1963; released in 1973), and

• Isoflurane (developed in 1965; released in 1981)

• Two newer agents are now the most popular in developed countries. Desflurane
(released in 1992), has many of the desirable properties of isofl urane as well as
more rapid uptake and elimination (nearly as fast as nitrous oxide).

07/02/2024 26
• Sevoflurane, has low blood solubility, but concerns about the
potential toxicity of its degradation products delayed its release in the
United States until 1994.

• These concerns have proved to be largely theoretical, and sevoflurane,

not desflurane, has become the most widely used inhaled anesthetic in
the United States, largely replacing halothane in pediatric practice.

07/02/2024 27
LOCAL & REGIONAL ANESTHESIA in the 19th c

• The original application of modern local anesthesia is credited to

Carl Koller, at the time a house officer in ophthalmology, who
demonstrated topical anesthesia of the eye with cocaine in 1884
• August Bier is credited with administering the first spinal anesthetic
in 1898.
• He was also the first to describe intravenous regional anesthesia (Bier
block) in 1908
• Lumbar epidural anesthesia was described first in 1921 by Fidel
Pages and again (independently) in 1931 by Achille Dogliotti.

07/02/2024 28
Additional local anesthetics subsequently introduced include

• Dibucaine (1930), • Mepivacaine (1957),

• Tetracaine (1932), • Prilocaine (1960),
• Lidocaine (1947), • Bupivacaine (1963), and
• Chloroprocaine (1955), • Etidocaine (1972).
• The most recent additions, ropivacaine
and levobupivacaine, have durations of
action similar to bupivacaine but less
cardiac toxicity.

07/02/2024 29
Intravenous anesthesia

• Required the invention of the hypodermic syringe and needle by

Alexander Wood in 1855

• Early attempts at intravenous anesthesia included the use of

• chloral hydrate (by Oré in 1872),

• chloroform and ether (Burkhardt in 1909), and

• the combination of morphine and scopolamine (Bredenfeld in 1916).

07/02/2024 30
• Barbiturates were first synthesized in 1903 by Fischer and von Mering.

• The first barbiturate used for induction of anesthesia was

diethylbarbituric acid (barbital),

• But it was not until the introduction of hexobarbital in 1927 that

barbiturate induction became popular.

07/02/2024 31
• Thiopental,
synthesized in 1932 by Volwiler and Tabern,

was first used clinically by John Lundy and Ralph Waters in 1934

most common agent for IV induction of anesthesia for many years

• Methohexital
was first used clinically in 1957 by V. K. Stoelting and

The only other barbiturate used for induction of anesthesia in humans

07/02/2024 32
Cont…
• After chlordiazepoxide was discovered in 1955 and released 1960.

• Other benzodiazepines— diazepam, lorazepam, and midazolam—came to be

used extensively for premedication, conscious sedation, and induction of
general anesthesia.

• Ketamine was
• Synthesized in 1962 by stevens

• First used clinically in 1965 by corssen and domino;

• It was released in 1970 and continues to be popular today.

07/02/2024 33
• Etomidate was synthesized in 1964 and released in 1972.
• Initial enthusiasm over its relative lack of circulatory and respiratory effects was
tempered by evidence of adrenal suppression, reported after even a single dose.

• The release of propofol in 1986 (1989 in the United States) was a major
advance in outpatient anesthesia because of its short duration of action.

• Propofol is currently the most popular agent for intravenous induction

worldwide.
07/02/2024 34
• Muscle relaxant
• The use of curare (1942) was a milestone in anesthesia
• Curare greatly facilitated tracheal intubation and muscle relaxation during
surgery.
Succinylcholine was synthesized by Bovet in 1949 and released in 1951;

• It has become a standard agent for facilitating tracheal intubation during

rapid sequence induction

07/02/2024 35
• Until recently, succinylcholine remained unchallenged in its rapid
onset of profound muscle relaxation, but its side effects prompted the
search for a comparable substitute.

• Recently introduced agents that come close to this goal include

vecuronium, atracurium, pipecuronium, doxacurium,rocuronium
and cis-atracurium.

07/02/2024 36
Cont….
• Opioids Morphine, isolated from opium in 1805 by Sertürner, was also tried as an intravenous
anesthetic.

• The concept of balanced anesthesia was introduced in 1926 by Lundy and others and evolved
to include
• Thiopental for induction,

• Nitrous oxide for amnesia,

• An opioid for analgesia, and

• Curare for muscle relaxation.

• Opiods (Morphine,fentanyl and sufentanil ) preventing patient awareness, incompletely

suppressing autonomic responses during surgery,
07/02/2024 ) and prolonged respiratory depression. 37
 Anaesthesia in 21st Century

07/02/2024 38
The Scope of Anesthesia
• The practice of anesthesia has changed dramatically since the days of
John Snow.
• The modern anesthesiologist is now both a perioperative consultant
and a primary deliverer of care to patients.
• In general, anesthesiologists manage nearly all “noncutting” aspects
of the patient’s medical care in the immediate perioperative period.
• The “captain of the ship” doctrine, which held the surgeon responsible
for every aspect of the patient’s perioperative care (including
anesthesia), is no longer a valid notion when an anesthesiologist is
present.
07/02/2024 39
• The surgeon and anesthesiologist must function together as an effective
team, and both are ultimately answerable to the patient rather than to each
other.

• The modern practice of anesthesia is not confined to rendering patients

insensible to pain.

• Anesthesiologists monitor, sedate, and provide general or regional

anesthesia outside the operating room for various imaging procedures,
endoscopy, electroconvulsive therapy, and cardiac catheterization.
07/02/2024 40
• Today, Anesthesiologists must have a detailed understanding of
physiology, pharmacology, anatomy and physics
• Anesthesia care is shifting from the traditional surgical suite to other
• Procedural areas,
• Ambulatory sites,
• Office-based facilities, and
• Home environments.
• As anesthesia care expands, anesthesiologists must focus on
maintaining the safety and quality of care in these diverse

07/02/2024 41
 The scope of modern anesthesia practice
includes
• Perioperative evaluation, preparation, care • Palliative care.

& acute pain management; • Obstetric anaesthesia and pain relief in labour

• Critical care & intensive care medicine • Resuscitation and stabilisation of patients in the

• Resuscitation, and retrieval emergency department (ED) and on the ward

• Prehospital emergency care

• Chronic pain management
• Managerial and organizational roles both inside and
• Transport of acutely ill and injured patients
outside the theatre environment
• The provision of anesthesia or sedation to
• Education, training and simulation
facilitate a wide range of medical, dental
• Anesthesia plays a key role in health service delivery and
and radiological interventions and has a significant impact on population health and the burden
07/02/2024 42
investigations of disease
Cont…
• They have also assumed
• Administrative and leadership positions on the medical staffs of many
hospitals and ambulatory care facilities.
• Deans of medical schools and chief executives of health systems.

07/02/2024 43
Sub specialty (fellowship programs)

1. Adult cardiothoracic 7. Obstetric anesthesiology

anesthesiology fellowship (Mi) 8. Pain medicine fellowship
2. Critical care anesthesiology()
9. Pediatric anesthesiology
3. Neuro-anesthesiology
10. Regional anesthesiology &acute
4. Cancer anesthesia fellowship pain medicine
5. Cardiac anesthesia fellowship 11. Vascular anesthesia
6. Interventional pain fellowship 12. Pediatric cardiac anesthesia
07/02/2024 44
 THANK YOU
H resonate with Make
you?
it easy

Any question
Comment
Suggestion ????

45

07/02/2024