2010

Typical American Hospital years ago Typical American Hospital

Therapeutic Armamentarium Thiopental Isoflurane Morphine, Fentanyl Succinylcholine, Curare, Pancuronium, Metocurine

Routine Monitors Electrocardiogram Inspired oxygen Blood pressure cuff Temperature Finger on the pulse

Capnography Special Monitors In selected patients: Capnography Pulmonary Artery Catheters

Airway Control Endotracheal Intubation Mask Ventilation

MACM onitored A nesthesia C are M ostly A pneic and C yanotic

Patient Care Admission before surgery Highly invasive surgical technique Intramuscular pethidine for postoperative analgesia Discharge in days to weeks         surgical technique

Patient Care Issues Poor post-operative pain control Slow recovery Nausea and Vomiting

Anesthesia years ago

Basics of Anesthesia Delivery of oxygen Support of intravascular volume and tissue perfusion Patient Comfort

Therapeutic Armamentarium Thiopental Isoflurane Morphine, fentanyl, alfentanil, sufentanil, remifentanil Succinylcholine, pancuronium Thiopental, propofol Isoflurane, sevoflurane, desflurane Morphine, fentanyl, alfentanil, sufentanil, remifentanil Succinylcholine, pancuronium, vecuronium, rocuronium, atracurium, mivacurium, doxacurium, and pipecuronium

TIVA Total IntraVenous AnesthesiaTotal IntraVenous Awareness TIVAE Total IntraVenous Anesthesia with Ephedrine

Propofol

Desflurane, Sevoflurane

Fentanyl Family Tree

Remifentanil

Routine Monitors Pulse Oximetry Capnography Electrocardiogram Inspired oxygen Blood pressure cuff Temperature  Finger on the pulse

Esophageal echocardiography Pulmonary artery catheterization Continuous arterial blood gas Continuos mixed-venous saturation Sophisticated ventilator monitoring Special Monitors In selected patients:

Bispectral Index Based on EEG spectral analysis Good predictor of mental status of patient during anesthesia with: Inhalational anesthesia Inhalational anesthesia with opioids Propofol anesthesia with opioids

Endotracheal Intubation Mask Ventilation LMA Airway Control Laryngeal Mask Airway

MACM onitored A nesthesia C are M idazolam, A lfentanil, and C onversation

Admission on day of surgery Discharge in hours Fast tracking of patients Laparoscopic surgery Improved post-operative pain management Epidural opioids PCA Patient Care Patient Controlled AnalgesiaPatient Controlled Apnea

2010 Today

New Therapeutics Duzitol Hypnotic Analgesic Amnestic Muscle Relaxant Aphrodisiac Anesthesiology 76: , 1992

New Therapeutics Cycloflurane Chemical stability of isoflurane Rapid induction of sevoflurane Rapid emergence of desflurane Pleasant smell of “Mr. Propre”

New Therapeutics Dexmedetomidine Central  2 adrenergic agonist Profound postoperative analgesia in the ICU Profound anti-ischemic properties Modest sedation Rapid offset Reversible Demonstrated improved outcome after major surgery

New Therapeutics Hyptiva Pharmacodynamics of propofol »Pleasant induction and emergence »Modest cardiovascular effects »Modest respiratory effects Pharmacokinetics of remifentanil »Extraordinarily rapid emergence »Predictable »Minimal change with disease or age

New Therapeutics Central nicotinic analgesics Derived from amphibian skin Prototype is epibatidine Efficacy equal to morphine No ventilatory effects No physical dependence No kidding »Science 1998 Jan 2;279(5347):77-81

New Therapeutics Muscle Relaxants Suxuronium MadamCurium Rockandrolium

MACM onitored A nesthesia C are M adam, A re you C omfortable?

New Therapeutic Modes Remifentanil PCA

New Monitoring Intraoperative EEG BIS now standard-of-care EEG Guided Anesthesia Delivery System EGADS

Patient Care Nearly all operations done on outpatients Most operations are laparoscopic/endoscopic Intelligent intra-operative and post- operative drug delivery systems ICU care rarely needed

Anesthesia in 2020?

Plausible vs. Implausible Plausible: –Remifentanil PCA –Dexmedetomidine –Nicotinic agonists –New generation of hypnotics –EGADS system Implausible –Duzitol –Cycloflurane –Suxuronium, madamcurium, rockandrolium