Introduction to

anaesthesia
University of Hawassa
 Course objective
At the end of this session, the student will be
able to describe
History of anaesthesia - inhalational agents

- IV anaesthetics
- Regional anaesthesia
Muscle relaxants

History of anesthetic & monitoring

equipment's
Basic Physics in anaesthesia

Application of basic monitoring equipment's

Anesthetic equipment's
History and scope of
anaesthesia
 History of
anaesthesia
What is anaesthesia ?
 Oliver Wendell Holmes in 1846 was
the first to propose use of the term
anesthesia to announce the state
that incorporates
amnesia,analgesia ,and narcosis to
make painless surgery possible.
 Anaesthesia- Partial or complete
loss of sensation with or without loss
of consciousness as a result of
disease, injury or administration of
an anaesthetic agent usually by
injection or inhalation.
 Before the discovery of inhalational
agents pain was considered or
believed to be an inevitable out
come of surgery.
 At that time pitilessness was
considered to be an important
characteristic of the surgeon.
 Surgery was considered as payment
for sinful action.
 In those dark days many patient
approach surgery as though facing
execution
Attempts used to relive pain during
surgery before discovery of
anaesthesia
 Hypnosis

 Ingestion of herbs

 Alcohol

 Local application of ice

 Early records indicate that mandragora
and indian hemp ( hashish) were the
first to be used as a pain reliving
methods.
 The Egyptians believed that
mandragora is the special gift from
their god Ra, their sun god.
 The mandragora (mandrake) plant has a
long tap-root split into two parts so that
it roughly resembles a human figure
 Mandrake was very popular anaesthetic
in the middle ages as indicated by the
following lines from Shakespeare
“give me to drink mandragora…
that I might sleep out this great gap
of time
my Antony is away”
Antony and Cleopatra, William
Shakespeare
 Opium is also a very ancient narcotic
drug and it was introduced by Chinese
 Apuleius in about A.D. 200 wrote “if any
one is to have a member mutilated,
burned… let him drink half an ounce
with wine and let him sleep till the
member is cut away without any pain or
sensation” K. Walker The story of
medicine
 For some reason the practice of drugging
people before operating on them was
discontinued during the middle ages
 In modern anaesthesia inhalational was
evolved first, followed by local & regional
anaesthesia, finally IV anaesthesia
 Early use of
Ether & Nitrous
oxide
Just the beginning !!!…
 Diethyl ether
 Is the first inhalational agent used in
practice of anaesthesia
 A man called Dr William T. Gram
Morton, Boston dentist and former
partner of Dr Horace Wells, was the first
person who showed the world the
anaesthtic effect of ether in 1846.
 But before this it was produced by two
individuals, named Valerius Chordus &
Paracelsus)
 At that time ether was not used as
anaesthetic agent, they used it as a
therapeutic agent for different clinical
conditions.
=> Valarius Chordus recommended
ether to be taken in wine for relief of
whooping cough & other respiratory
diseases(1540)
=> Paracelsus observed its analgesic
effect & recommended for use in painfull
illnesses
 For three centuries it remained as a
therapeutic agent to be used
occasionally.
 It was also used routinely as a
recreational drug by poor Britain &
Ireland people.
 In America group of medical
students socked ether with towel
and apply to their face to experience
its effect
 Nitrous oxide (N2O)
 N2O was first discovered by Joseph
Priestley(1733-1840)
 He prepared N2O by heating Ammonium
nitrate(1773)
 This man is also remembered for his
recognition of the pure gas oxygen
 Joseph Priestley’s research on N2O &
other gases was discontinued when his
scientific apparatus & laboratory was
burned during French revolution.
Joseph Priestley
 But his work drew attention of other
chemist Humphrey Davy(1778-1829)
of England.
 Davy continued his study on N2O &
identified analgesic effect of N2O.
 He commented that N2O transiently
relived a sever headache & briefly
quench an aggravating toothache.
 Davy & his associates inhaled N2O
from a cylinder by a tight face mask.
 Following Davy’s research the only
application of N2O for the next 4
decades was limited to producing
hilarity & social entertainment.
 But its application was not easy as that
of Diethyl ether
 Horace Wells(1815-1848)- the first man
to use N2O in practice of surgery
=> the 1st person to recognize the
anaesthetic quality of N2O
=> he made a self experiment &
declared an experiment of great success
 Chloroform
 Although ether was safe to be administered
even by untrained person, it has some
adverse effects such as irritability to upper
respiratory tract, nausea, vomiting,
unpleasant odor & flammability.
 This adverse effects initiate different
researchers to find other agents which lack
the above effects
 Chloroform was independently prepared by
Samuel Gutter.
 Dr. James Simpson (1811-70), “a well
known gynecologist of Scotland was the
first to use ether in his obstetric
practice, but was too unstable.
 After much experimentation, Simpson

decided to use chloroform as a better

anaesthesia
 Many in Scotland protested that the use

of
chloroform in child-labor was contrary to
biblical teaching, for didn’t God say to
Eve,
“in sorrow thou shalt bring forth
children”?
 John Snow- the first physician
anaesthetist gave chloroform to Queen
Victoria for the birth of Prince Leopold
in 1853.
 Halothane was discovered by Charles
Suckling in 1953.
=> Volatile agents with non-flammable
property & high potency were
discovered recently.
=> Enflurane – 1963
=> Isoflurane- 1965
=> Sevoflurane- 1963
=> Desflurane - 1993
 Intravenous anaesthetics
 The development of IV anaesthetics has
been an important component of
anaesthetic management
 Induction with IV agents avoids the
unpleasant odor of inhalational agents
 The 1st successful IV anaesthetic (opium)
administration to a patient was done by
Sigmund Elsholtz
 In 1909 Luding Burkardt gave
combination of volatile agents & IV and
produced anaesthesia
 Seven years later in 1916, Elizabeth
Bredenfeld of Switzerland reported the use
of IV morphine & scopalamine
=> these attempts failed to show significant
improvements over inhalational agents
 The 1st barbiturate (barbituric acid) was
discovered in 1864, but it had no sedative
effect
 The 1st sedative barbiturate was discovered
in 1903 by Emil Fischer of Berlin
=> but short acting barbiturates such as
Hexobarbital were introduced 30 years later
in 1932.
 Thiopental was introduced in 1934.
=> use of thiopental introduced the
concept of balanced anaesthesia
 Several attempts were made to replace
thiopental with other agents which
have less CVS depressant effect.
 Etomidate which has minimal CVS
effect was introduced in 1973
 Benzodiazepines which are important
anxiolytic agents were began to be
studied since 1933
 Ketamine was introduced in to
clinical use in 1966
=> it can be given IV or IM and can
produce complete anaesthesia.
=> but its post operative
hallucinations necessitate
combination with other sedatives
 Propofol was introduced clinically in 1977
=> it has some advantages over
thiopental
=> has high hepatic extraction ratio, so
that it has fast onset & recovery
=> it has anti-emetic property
 When propofol is combined with analgesic
agents such as opioids, propofol produce
satisfactory components of general
anaesthesia; the term called total
intravenous anaesthesia
 Muscle relaxants
 Introduction of curare played the most
important role in advancement of
anaesthesia
 Endotracheal intubation was a practice
left for experts only before introduction of
muscle relaxants
 Before it was used as muscle relaxants in
clinical area, curare was used by jungle
tribes on separate continents (Asia, Africa
& South America for hunting purpose)
 Curare entered clinical medicine through
the action of psychiatrist.
 It was used as shock absorber
 Harold Griffith gave curare for a patient
to whom appendectomy was done in 1942
 The successful use of curare prompted
several pharmacologic studies that led to
the introduction of other neuromuscular
blockers.
 Gallamine & Decamethonium were
prepared in 1948.
 Suxamethonium was synthesized in 1949
 Regional anaesthesia
 Several surgeons of 19th century tried to
relieve pain by applying drugs locally
 In 1953 Alexander Wood tried to apply
morphine locally in to a painful area, but
with no success, since the drug only acts
systemically
 Cocaine, an extract of coca leaf, was the
first effective local anaesthetic.
 Peru surgeons chewed coca leaf and
allowed their saliva to fall on to the surface
of the wound; by this technique both the
surgeon & the patient shared the action of
the drug
 Carl Koller in 1884 was the 1st person who
recognized the anaesthetic effect of cocaine
on the eyes
 While he had been a medical student Koller
had worked in a Vienna laboratory in a
search for a topical anaesthetic that would
overcome the limitations of general
anaesthesia
 The use of ether for ophthalmic surgery had
several limitations
=> poor cooperation of anaesthetized
patient
=> poor access to surgical site, because of
anaesthetic apparatus
=> high incidence of vomiting increase IOP
 In 1884 Koller appreciated accidentally
the local anaesthetic effect of cocaine,
finally he realized that he had found the
object of his search
 He observed the anaesthetic effect of
cocaine on the eyes of frogs, but
because of its addictive potential it was
replaced by lignocaine & bupivacaine
 In October 1884 two American surgeons
reported its efficiency in anaesthetizing
the nose, mouth, larynx, trachea, rectum
& urethra.
 The next month its subcutaneous
injection was reported
 The two surgeons did self
experimentation which was finally
resulted in addiction to cocaine

What is spinal
anaesthesia?
 Spinal anaesthesia
 Spinal anaesthesia was 1st discovered
by neurologist called Leonard Corning.
 He gave cocaine not for surgery, but
as a treatment for specific neurological
problems.
 He 1st tried to observe the action of
cocaine on dogs.
 For the following 14 years spinal
anaesthesia remained only for
therapeutic purpose in 1899.
 Quincke a man from Germany described
a lumbar puncture and he proposed that
the safest site to perform a lumbar
puncture is between L3 &L4.
 In 1899 six patients received cocaine
intrathecally by Professor Bier
 Some of patients cried out during
surgery and others have post operative
vomiting and headache
 Because of this Professor Bier declined
to conduct a clinical experiment on the
spinal anaesthesia
 Nerve block
 At 1st nerve block was done by combining
with general anaesthesia
 It was done on legs and brachial plexus
under direct vision
 In 1902, Harvey Cushing coined the
phrase regional anaesthesia for this
technique of blocking either the brachial
or sciatic plexus under direct vision for
anaesthetized patients with GA
 In 1908 an intravenous regional
anaesthesia was introduced by Professor
Bier, which is called now biers block.
Anaesthesia
equipments
 Anaesthesia machine
 Gram Morton used a specially constructed
glass bottle with an attached mouth piece.
 In England, John Snow developed a new
type of ether inhaler
 During the past few decades the
anaesthesia machine has grown to
become one of the most important objects
in the OR
 In the 19th century medical service were
often provided in patients home, but
modern medical practice demands that
the patient be attended in a well equipped
surgical suit.
 At that time patients monitoring was
limited to the observation of physical
signs.
 The 1st free standing anaesthesia machine
was developed in 1900 by American
dentist Charles Teter.
=> he developed a continuous flow
N2O /O2 & ether machine
=> This lack a flow meters
 Jay Heidbrink modified and Walter
Booth of Harvard university added a
water bubble flow meters.
 The 1st use of CO2 absorber
(canister) in anaesthesia machine
developed in 1906 by Frank Kuhn.
Anaesthesia mac hine
and breathing system
ventilator
Flow
meter

vaporizer

Corrugated APL valve

tube

Scavenging
Soda lime system

1
Introduction to
understanding
the anaesthesia
machine
1. Frame
Supports the components
of the anesthetic machine
 2. Pressure
regulator
 Placed on O2 tanks
to decrease pressure
from the tanks
 Protects the machine

from being damaged

with high pressure
 3.Flow meter
 Controls the amount
of air released in to the
anaesthetic circuit
4. Oxygen flush
 High flow oxygen straight from
oxygen supply
 Use to flush anaesthetic gases
from circuits and minimize
exposure
 5. Vaporizer
• A device which
Changes a liquid
anaesthetic agent in
to its vapor and adds
a controlled amount
of that vapor to the
fresh gas flow or the breathing system
6. Breathing system
• Breathing circuits
 Rebreathing circuit
- Exhaled air is cleaned
and reused with the patient
 Non-rebreathing circuit
- Exhaled air is taken by
scavenging system
 7. Scavenging system
 Waste gas is contained until it is
released to the outside environment
 Anaesthesia machine
now… Computerized!!!!
Introduction to
understanding
airway
equipment's
 History of intubation
 The 1st endotracheal tubes were
developed for the resuscitation of the
new born and victims of drowning
 They were not used for practice of
anaesthesia until 1878
Endotracheal tube
 The 1st use of elective endotracheal
intubation was undertaken by a scotish
surgeon called William Macewan.
 He had practiced on cadaver before
attempting on patient with oral tumor
 At that time he didn’t anaesthetize the
airway and the patient coughed after
tube was placed, but stopped coughing
after chloroform was given via the tube.
 Macewan lost interest in intubation,
because it was resulted in sever
morbidity & mortality
 Joseph O’dwyer – is an American
surgeon who was remembered for
his extra ordinary dedication to the
advancement of tracheal intubation
 He designed a series of metal
laryngeal tubes, which he inserted
between the vocal cords of children
during diphtheric attacks
 Frank Kuhn- was the outstanding pioneer
of tracheal intubation after death of
O’dwyer
 He described techniques of oral & nasal
intubation
 He used flexible metal tubes
 The tubes were introduced over a curved
metal stylet & directed toward the larynx
with his index finger.
 He was the 1st man who suggested that
suctioning of tracheal secretions & blood
could be possible using flexible catheter.
 He also suggested nasal intubation for
long term intubation.
Preoxygnation

42
Controlled ventilation

43
Holding a mask

45 44
46
47
48
49
Nasal intubation
 Early laryngoscopes
 Before the invention of laryngoscopes
tracheal intubation had been performed
by palpation
 Intubation by palpation is too difficult &
traumatic
 The 1st vision laryngoscope was designed
by Alfered Kirsten.
 Although the laryngoscope of Kirsten was
not used in anaesthesiology, it was the
forerunner of all modern laryngoscopes
 Sir Ivan Magill – self trained
British anaesthetist
 He contributed three things to
anaesthesia
1) Technique of nasal
intubation
2) Magill forceps
3) Magill tubes
Magill forceps
 Miller & Mackintosh
laryngoscope
 Robert Miller of San Antonio Texas
and Professor Robert Mackintosh of
Oxford university created
laryngoscope blades.
 Miller created a slender
predominantly straight blade with a
slight curve near the tip
 Mackintosh blade was curved
Millerblade Macintoshblade
Laryngoscope (continued)
Introduction to
understanding
monitoring
equipment's
Operating room monitors
 Early clinicians concentrated on
physical signs, such as
=> patient color
=> capillary refill
=> dilatation of the pupil
=> regularity & depth of respiration
=> regularity of pulse
=> urine out put
=> lacrimation, sweating…
 Drawbacks of the above methods
=> difficult to teach
=> subjective
=> they require experience to interpret
 Two American surgeons George W. Circle
& Harvey Cushing developed a strong
interest in measuring blood pressure
during anaesthesia
 Cushing’s contribution is better
remembered because he was the 1st
American to apply the Riva Rocci cuff in
1902
 Nicolas Korotokof- the 1st surgeon in
training who was 1st appreciated the
korotokof’s sound in 1905
 Automated BP device was first appeared
in 1936
 Anaesthetists routinely auscultate heart &
breath sounds with pericordial
stethoscope
 Recently added monitors
=> pulse oximetry
=> capnography
=> ECG
=> ABG analysis
 Clinical measurement
 Modern medical practice depends on
reliable measurement of the physiological
& pharmacological state of the patient
 Sophisticated instruments extend clinical
observations beyond human senses and
they enhance patient care
 Whenever we use sophisticated
instruments for clinical measurements,
before we react to the reading we have to
exclude possible causes of false recordings
 Clinical measurement is limited by four
major constraints
1) Feasibility of measurements
2) Interpretation
3) Value of clinical measurement in patient
care
- the role of measurement in clinical
care
4) The correct interpretation of
measurements & appropriate actions in
the context of the patient care
important issues in anaesthesia
 Process of clinical
measurement
1. Detection of biological signals
2. Transduction
- out put from the sensor is
converted to continuous electrical signal
3. Amplification & signal processing

4. Display & storage

- Mechanical instruments lack the strong

property because they use signal energy
to drive a display with minimal
intermediate processing
 Micro processor revolution
 The development of digital microprocessors
has revolutionized anaesthetic practice
 Advantages of digital signals processing
- Continuous real time detection processing
& recordings of measurements
- Increased range of measurement is possible
- Automated control of the apparatus and the
timing & process of measurement &
integration of alarms
- User easily hears & visualizes the display
while performing other related activities
 Disadvantages
- Dependent on electrical power
- Degradation of clinical skills &
disuse of mechanical instruments
- False readings
 Essential requirement for clinical
measurement
- All clinical measurements system detects a
biological signal and reproduces the input in
the form of a display record
- The degree weather a discreet measurement
is a true reflection of the underlying signal is
defined by accuracy and precision
- Accuracy- the difference between the
measurements and the real biological signal
- Precision- the ability to produce the same
biological signal with repeated measurement
 A single recording is changeable.
 Repeated clinical measurement is
useful, because
- There might be changes in clinical
condition of the patient
- The confounding errors[confusing]
- The anaesthetist must be satisfied with
the accuracy & precision of any
clinical measurement
- Repeated measurement can ensure
precision but not accuracy
 Specific measurements
Measurement of arterial pressure
 Blood pressure can be measured
directly & indirectly
 Value of blood pressure can be affected
by different factors, such as
- Caliber of blood vessel [level]
- Distance from the heart
For example;
if we measure BP on standing position
the pressure varies depending on the
site of cuff applied
e.g. if we apply the cuff at the level of
the heart the MAP = 95mmHg
At the level of the feet > 200mmHg
At the level of head > 55mmHg
 Therefore before we say that the

patient is hypotensive or hypertensive

we have to measure at the level of the
heart on different positions and on
both limbs
 Indirect measurement
of BP
 This is the simplest and doesn’t need
sophisticated invasive technique
 No direct contact between arterial
blood and the system
 It depends on signal generated by the
oscillation or fluctuation of major
artery using Riva Rocci cuff
 Techniques of measuring
 Two methods of measuring
1) Palpation method
2) Auscultation method
 The first man who measured the
patient’s BP was Korotokof.
1. Palpation by this technique we only
detect the systolic BP
 Steps
 Applying appropriate cuff size on the
upper arm of the patient.
 The cuff should cover 2/3 of the arm
- Inflate the cuff till the pressure rises
above 160mmHg
- Slowly deflate the cuff while palpating
the distal radial artery.
- The pressure at which you detect the
pulsation of the artery is the systolic
BP
 Appropriate width of
cuffs
 Adult = 12-14cm
 Children

- neonate = 2-5cm
- 1-4 years = 6cm
- 4-8 years = 9cm
 Using of inappropriate cuff size can

give a false record.

 If we use inappropriately small cuff

size, there will be falsely elevated BP

2. Auscultation method
- Apply appropriate cuff size as above

- Inflate the cuff till the pressure can

occlude the artery
- Place your stethoscope on the
anticubital area and deflate slowly
the cuff.
- The first sound heard is the systolic
BP and the area where the sounds
disapeared is the diastolic BP
 Physiologic bases
 The mechanism is not clearly
understood, but there is a suggested
theory
pressure  jetting of blood  this will
cause turbulent flow  the turbulent
flow will cause vibration of wall of the
vessel  this will produce Korotokof
sound which will be amplified by tissue
resonance
 Direct measurement of
BP
 This method is not routinely used in
clinical practice, but reserved for
selected cases
- Patient with severely compromised
hemodynamic instability
- For cardiovascular surgery

- Brain & spinal cord surgery

- For a patient scheduled for a surgery

from which we anticipate large and
rapid loss of blood.
 Advantages of direct BP
measurement
- It is accurate
- Continuous monitoring of BP is possible
- Since the artery is cannulated, taking arterial
blood sample is possible for ABG analysis
Disadvantages
- Technical difficulty
- Bleeding, hematoma, arterial damage
- Risk of thrombosis, embolism & ischemia of
tissue distal to the artery- if colateral flow is
compromised
- Risk of infection
 Technique of direct
measurement
Needed equipments
Arterial catheter

Pressure tubing

Heparin filled bag

Cannulate the artery

-Radial artery

-Femoral artery

-Dorsalispedis artery can be used

 Before canulating the selected artery,
do weber test  obstruct the artery
and see for adequate of the collateral
artery
e.g. if you select the radial artery,
see weather ulnar supply is adequate
by occluding the radial artery.
- Prevent clot formation by heparin
- Flow rate 1-3ml/hr (1unit of
heparine/1ml of saline is prepared)
 Measurement of
temperature
 Temperature is measured by an
instrument called thermometer
 There are different types of
thermometers
1. Liquid expansion thermometers
2. Dial thermometer
3. bimetallic strip thermometer
4. Chemical thermometer
 1) Liquid expansion
thermometer
 Simple & reliable
 Liquids used can be mercury, alcohol
 Connected to narrow capillary
 The temperature is recorded according
to the height of the fluid ( mercury or
alcohol) in the capillary
 A large bulb & very narrow capillary
increases sensitivity
2. Dial thermometer
3. Bimetallic strip
4. Chemical thermometer