Marko Jukić, Mladen Carev, Nenad Karanović &Mihajlo Lojpur Anesthesiology and intensive medicine for students For internal use (Scripta ad usum privatum) Department of Anesthesiology and Intensive Care Medicine Split, 2015. Authors* Mladen Carev, MD, PhD Associate Professor and Chair of the Department of Anesthesiology and Intensive Medicine, University of Split School of Medicine Nataša Dropulić, MD, PhD Staff Anesthesiologyst, Department of Anesthesiology and Critical Care, University Hospital Split Marko Jukić, MD, PhD Associate Professor, Department of Anesthesiology and Critical Care, University Hospital Split Nenad Karanović, MD, PhD Associate Professor, Head of the Department of Anesthesiology and Critical Care University Hospital Split Mihajlo Lojpur, MD, PhD Associate Professor Department of Anesthesiology and Critical Care, University Hospital Split Igor Vuković, MD Resident in Anesthesiology, Department of Anesthesiology and Critical Care, University Hospital Split Translation/translators ** Ivan Agnic, MD, PhD Staff Anesthesiologyst, Department of Anesthesiology and Critical Care, University Hospital Split Ines Bilokapić, MD Resident in Anesthesiology, Department of Anesthesiology and Critical Care, University Hospital Split Antonela Bunoza, MD Resident in Anesthesiology, Department of Anesthesiology and Critical Care, University Hospital Split Duje Erceg, MD Resident in Anesthesiology, Department of Anesthesiology and Critical Care, University Hospital Split Božena Ivančev, MD, PhD Staff Anesthesiologyst, Department of Anesthesiology and Critical Care, University Hospital Split Mila Kavelj, MD Resident in Anesthesiology, Department of Anesthesiology and Critical Care, University Hospital Split Josip Krnić, MD Resident in Anesthesiology, Department of Anesthesiology and Critical Care, University Hospital Split Toni Lozančić, MD Resident in Anesthesiology, Department of Anesthesiology and Critical Care, University Hospital Split Ivana Prkić, MD, PhD Resident in Anesthesiology, Department of Anesthesiology and Critical Care, University Hospital Split Sanda Stojanović Stipić, MD Staff Anesthesiologist, Department of Anesthesiology and Critical Care, University Hospital Split Ana Šarić, MD Resident in Anesthesiology, Department of Anesthesiology and Critical Care Universiti hospital Split Lenko Šarić, MD Resident in Anesthesiology, Department of Anesthesiology and Critical Care, University Hospital Split Note: It is not proof-read because it is not the final version of the script. Marko Jukić, Mladen Carev, Nenad Karanović &Mihajlo Lojpur Anesthesiology and intensive medicine for students For internal use (Scripta ad usum privatum) Department of Anesthesiology and Intensive Care Medicine Split, 2015. Literature 1. Miller’s Anesthesia, seventh edition 2. Morgan and Mikhail’s Clinical Anesthesiology, fifth edition 3. Barash Clinical Anesthesia, sixth edition 4. Jukić i sur. Klinička anesteziologija, second edition 5. Nolan JP, Hazinski MF, Billi JE i sur. 2010 International Consensus on Cardiopulmonary Resuscita- ti-on and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscita- tion. 2010. 6. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors, Student Course Manual, 8th ed, American College of Surgeons, Chicago 2008. 7. Newgard CD, Schmicker RH, Hedges JR, et al. Emergency medical services intervals and survival in trauma: assessment of the »golden hour« in a North American prospective cohort. Ann Emerg Med 2010; 55:235. CONTENTS 1. ANESTHESIA, MEDICAL, LEGAL AND ETHICAL ISSUES .....................................1 1.1. Introduction . 1 1.2. Choosing type of anesthesia .........................................................1 1.3. Legal aspect of anesthesia...........................................................1 1.4. Informed consent . .2 2. HISTORY OF ANESTHESIOLOGY . 4 2.1 Discovery of anesthetics, analgesics and other drugs used in anesthesia . .4 2.2. History of anesthesiology in Croatia ...................................................5 3. PREANESTHESIA EVALUATION . .7 3.1. Introduction . 7 3.2. Data on medications taken (drug, dosage, for how long, drug reactions). .....................7 3.3. Preoperative interview and physical examination . 8 3.5. Use of pharmacologic agents prior anesthesia . 9 4. LOCAL ANESTHETICS . 15 4.1. Local anesthetics .................................................................15 4.2. Types of local anesthetics . 16 5. REGIONAL AND LOCAL ANESTHESIA ...................................................17 5.1. Introduction . .17 5.2. Local anesthetics . .17 5.3. Regional and local anesthesia .......................................................17 5.4. Surface anesthesia ................................................................18 5.5. Infiltration anesthesia ..............................................................19 5.6. Intercostal block ..................................................................19 5.7. Regional anesthesia ...............................................................20 5.8. Intravenous regional anesthesia (Bier’s block) ..........................................21 5.9. Subarachnoid, epidural and caudal anesthesia . .21 6. INHALATIONAL AND INTRAVENOUS ANESTHETICS.......................................26 6.1. Introduction . .26 6.2. Inhalational anesthetics . 26 6.2.1. MAC – The Minimal Alveolar Concentration ...............................................27 6.2.2. Review of individual inhalational anesthetics . 27 6.2.3. Effect of inhalational anestheticon various organ systems ...................................28 6.3. Intravenous anesthetics ............................................................29 6.3.1. Definition and introductory remarks . .29 6.3.2. History - intravenous anesthesia . 29 6.3.3. Intravenous anesthetics and their effect on cardiovascular and respiratory system . .30 6.3.4. Review of specific intravenous anesthetics................................................31 6.3.5. Intravenous analgesics – conclusion .....................................................35 7. NEUROMUSCULAR BLOCKING DRUGS - MUSCLE RELAXANTS .............................36 7.1. Introduction . .36 7.2. Historical context . .36 7.3. Muscle relaxants - Mechanism of action...............................................36 7.3.1. Depolarizing block . .37 7.3.2. Nondepolarizing block . 38 7.3.3. Reversal of neuromuscular blockade . 38 7.4. Review of some relaxants . 38 7.4.1. Succinycholine . 38 7.4.2. Nondepolarizing muscle relaxants.......................................................39 7.5. Clinical use of muscle relaxants . .39 7.5.1. Endotracheal intubation - dosage . .39 7.5.2. Rapid sequence intubation.............................................................39 7.5.3. Autonomic effects of muscle relaxants ...................................................40 7.5.4. Reversal of neuromuscular blockade . 40 7.5.5. Monitoring neuromuscular blockade.....................................................41 8. ANALGESICS . .42 8.1. Non-opioid analgesics .............................................................42 8.2. Non-steroidal anti-inflammatory drugs (NSAID).........................................43 8.3. Narcotics (opiates and opioids)......................................................48 9. GENERAL ANESTHESIA...............................................................60 9.1. Introduction . .60 9.2. General anesthesia - mechanism of action.............................................60 9.3. Ensuring ventilation during general anesthesia . .60 9.4. General anesthesia - indications and complications . .61 9.5. The importance of monitoring during general anesthesia.................................61 10. MONITORING OF VITAL SIGNS . .62 10.1. Introduction . 62 10.2. Monitoring . .62 10.3. Monitoring of the cardiovascular system .............................................62 10.3.1. Electrocardiography .................................................................62 10.3.2. Blood pressure measurement . .63 10.3.3. Measurement of central venous pressure (CVP)...........................................63 10.3.4. Catheterization of the pulmonary artery . .64 10.3.5. Doppler echocardiography............................................................64 10.3.6. Monitoring of tissue perfusion .........................................................64 10.4. Monitoring of the respiratory system ................................................64 10.4.1. Auscultation using a stethoscope . 64 10.4.2. Pulse oximetry . .64 10.4.3. Monitoring of CO2 – capnography ......................................................64 10.4.4. Transcutaneous measurement of blood gases ............................................65 10.4.5. Respiratory mechanics monitoring .....................................................65 10.5. Monitoring of the nervous system ..................................................65 10.5.1. GCS - Glasgow coma score . 65 10.5.2. Neurological status . .65 10.5.3. Intracranial pressure .................................................................65 10.5.4. Electroencephalography..............................................................65 10.5.5. Evoked potentials . 65 10.5.6. Cerebral blood flow .................................................................65 10.5.7. Cerebral oxygenation monitoring . 66 10.6. Laboratory monitoring . .66 10.7. Other monitoring methods ........................................................66 10.7.1. Body temperature...................................................................66