The Practice of Anesthesiology

INTRODUCTION

The Greek philosopher Dioscorides is said to have first used the term
anesthesia in the first century AD to describe the narcotic-like effects of the plant
mandragora. The term subsequently was defined in Baileys An Universal
Etymological English Dictionary (1721) as a defect of sensation and again in
the Encyclopedia Britannica (1771) as privation of the senses. The present use
of the term to denote the sleep like state that makes possible painless surgery is
credited to Oliver Wendell Holmes in 1846. In the United States, use of the term
anesthesiology to denote the practice of anesthesia was first proposed in the
second decade of this century to emphasize the growing scientific basis of the
specialty. Although the specialty now rests on scientific foundation that rivals any
other, anesthesia remains very much a mixture of both science and art.
Moreover, the practice of anesthesiology has expanded beyond rendering
patients insensible to pain during surgery or obstetric delivery. Causing the
American Board Of Anesthesiology to revise its definition in 1989 (Table 1-1). The
specialty is unique in that it requires a working familiarity with most other
specialties, including surgery and its sub-specialties, internal medicine,
pediatrics, and obstetrics as well as clinical pharmacology, applied physiology,
and biomedical technology. The application of recent advances in biomedical
technology in clinical anesthesia continues to make anesthesia an exciting and
rapidly evolving specialty. A significant number of physicians applying for
residency positions in anesthesiology already have training and certification in
other specialties.
This chapter reviews the history of anesthesia, its British and American roots,
and the current scope of the specialty and present the general approach to the
preoperative evaluation of patients and documentation of the patient's
anesthetic experience, the Case Discussion at the end of the chapter considers
medicolegal aspects of the specialty.

THE HISTORY OF ANESTHESIA

Anesthetic practices date from ancient times, yet the evolution of the
specialty began only in the mid nineteenth century and only became firmly
established less than six decades ago. Ancient civilizations had used opium
poppy, coca leaves, mandrake root, alcohol, and even phlebotomy (to the point
of unconsciousness) to allow surgeons to operate. It is interesting that the
ancient Egyptians used the combination of opium poppy (morphine) and
hyoscyamus (hyoscyamine and scopolamine); a similar combination, morphine

and scopolamine, is still used parenterally for premedication. Regional

anesthesia in ancients times consisted of compression of nerve trunks (nerve
ischemia) or the application of cold (cryoanalgedia) The Incas may have
practiced local anesthesia as their surgeon chewed coca leaves and spat saliva
(presume ably containing cocaine) into the operative wound. Surgical procedures
were for the most part limited to caring for fractures, traumatic wounds,
amputation, ans the removal of bladder calculi. Amazingly, some civilizations
were also able to perform trephination of the skull,. A major qualification for a
successful surgeon was speed.
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.
INHALATION ANESTHESIA
The first general anesthetics were inhalation agents; ether, nitrous oxide,
and chloroform. Ether (really diethyl ether) was originally prepared by Valerius

Table 1-1. definition of the practice of anesthesiology.*

Assessing. Consulting and preparing patients for anesthesia.
Rendering patients insensible to pain during surgical obstetric. Therapeutic, and
diagnostic procedures
Monitoring and restoring homeostasis in perioperative and
Critically ill patients
Diagnosing and treating painful syndromes
Managing and teaching of cardiac and pulmonary resuscitation
Evaluating respiratory function and applying and pulmonary respiratory
Therapy
Teaching, supervising, and evaluating the performance of
Medical and paramedical personnel involved in anesthesia,
respiratory care, and critical care
Conducing research at the basic and clinical science
levels to explain and improve the care of patients in the terms
of physiologic function and drug response

Involvement in the administration of hospitals, medical

Schools, and outpatient facilities as necessary to implement these
responsibilities

*Adapted from the revised definition of the American Board

Of Anesthesiology, 1989.

Cordus I 1540 but was not used as an anesthetic agent in humans until 1842,
when Crawford W. long and William F. Clark used it independently on patients.
Four years later, in Boston, on October 16, 1856, William T.G. Morton conducted
on the first publicized demonstration of general anesthesia using ether. Nitrous
oxide was produced by Joseph Priestley in 1772, but its analgesic properties were
first noted by Humphry Davy in 1800. Gardner Colton and Horace wells are
credited for having first used nitrous oxide as an anesthetic in humans in 1844.
Cloroform was independently in 1831. Although it was first used clinically as an
general anesthetic by Holmes Coote in 1847, chloroform was introduced into
clinical practice by the obstetrician James Simpson, who administered it ti his
patients to relieve the pain of labor.
Nitrous oxide was the leasts popular of the three early inhalation
anesthetics because of its relatively low potency and its tendency to cause
asphyxia when used alone (see Chapter 7). Interest in nitrous oxide was not
revived until Edmund Andrews administrated it in 20% oxygen in 1868, it was,
whoever, overshadowed by the popularity of ether and chloroform. it is ironic
that nitrous oxide is the only one of these agents still in common use today.
Chloroform initially superseded ether in popularity in many areas, but reports of
chloroform related cardiac arrhythmias and hepatotoxicity eventually cause more
and more practitioners to abandon it in favor of ether. Even with introduction of
other inhalation anesthetics (ethyl chloride, ethylene, divinyl ether,
cyclopropane, trichloroethylene, and fluroxene), ether remained the standard
general anesthetic until the early 1960S. The only inhalational agents that
rivaled ether's safety and popularity was cyclopropane. Unfortunately, both are
highly combustible and have since been replaced by the nonflammable potent
fluorinated hydrocarbon; halothane (developed in 1951; released 1956),
methoxyflurane (developed in 1963;released, 1958; released 1960), enflurane
(developed in 1963; released 1973) and isoflurane (developed in 1965; released
1981). New agents continue to be developed. One such agent. Desflurane
(released 1992), has many of the desirable properties of isoflurane characteristic
of nitrous oxide, sevoflurane also has a low blood solubility, but concern about
potentially toxic degradation product delayed its lease in the United State until
1955 (see Chapter 7).

LOCAL & REGIONAL ANESTHESIA

The origin or modern local anesthesia is credited to Carl Koller, an
ophthalmologist, who demonstrated the use of topical cocaine for surgical
anesthesia of the eye in 1884. Cocaine had been isolated from the coca plant in
1855 by Gaedicke and later purified in 1860 by Albert Neimann. The surgeon
William Halsted demonstrated in 1844 the use of cocaine for intradermal
infiltration and nerve blocks (including the facial nerves, the brachial plexus, and
the pudendal and posterior tibial nerves). August Bier is credited with
administering the first spinal anesthetic in 1898; he used 3 ml of 0,5 % cocaine
intrathecally,. He was also the first to describe intravenous regional anesthesia
(Bier block) in 1908. Procaine was synthesized in 1904 by Alfred Einhorn, and
within a year found clinical use as a local anesthetic by Heinrich Braun. Braun
was also the first to add epinephrine to prolong the action of local anesthetics.
Caudal epidural anesthesia was introduced in 1901 by Ferdinant Cahtelin and
Jean Sicard. Lumbar epidural anesthesia was described first in 1921 by Fidel
Pages and again 1931 by Achille Dogliotti. Additionally local anesthetics
subsequently introduced clinically include dibucaine (1930), tetracaine (1932),
lidocaine (1947), chloroprocaine (1955), mepivacaine(1957), prilocaine (1960),
bupivacaine(1963), and etidocaine(1972). Ropivacaine, a new agent with the
same duration of action as bupivacaine but perhaps less toxicity, may soon be
available for clinical use (see Chapter 14)

INTRAVENOUS ANESTHESIA
Induction Agents
Intravenous anesthesia followed 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 Ore in 1872), chloroform and
ether (Burkhardt in 1909), and the combination of morphine and scopolamine
(Bredenfelt in 1916). Barbiturates were synthesized in 1903 by Fischer and von
Mering. The first barbiturate used for induction of anesthesia was diethyl
barbituric acid (barbital), but it was not until in introduction of hexobarbital in
1927 that barbiturate induction became a popular technique. Thiopental,
synthesized in 1932 by Volwiler and Tabern, was first used clinically by john
Lundy and Ralph Waters in 1934 and remains the most common induction agents
for anesthesia. Methothexital was first used clinically in 1957 by V.K. Stoelting
and is the only other barbiturate currently used for induction. Since the synthesis
of chlorodiazepoxide in 1957 the benzodiazepines-diazepam (1959), lorazepam
(1971), and midazolam (1976)- have been extensively used premedication,
Induction, Supplementation of anesthesia, and intravenous sedation. Ketamine
was synthesized in 1962 by Stevens and first used clinically in 1965 by Corssen
and Domino; it was released in 1970. Ketamine was the first intravenous agent
associated with minimal cardiac and respiratory depression. Etomidate was
synthesized in 1964 and released in 1972; enthusiasm over its relative lack of
circulatory and respiratory effects has been tempered by reports of adrenal

suppression after even a single dose. The release of propofol, diisopropylphenol,

in 1989 was a major advance in outpatient anesthesia because of its short
duration of action (see Chapters 8 and 46).
Muscle Relaxants
The use of curate by Harold griffith and Enid Johnson in 1942 was a
milestone in anesthesia. Curare greatly facilitates endotracheal intubation and
provided excellent abdominal relaxation for surgery. For the first time, surgery
could be performed on patients without having to administer relatively large
doses of anesthetic to produce muscle relaxation. These large doses often
resulted in excessive circulatory and respiratory depression as well prolonged
emergence; moreover, they were often not tolerated by frail patients.
Other muscle relaxants -gallamine, decamethonium, metocurine,
alcuronium, and pancuranium- were soon introduced clinically. Because these
agents were often associated with significant side effects (Chapter 9), the search
for the ideal muscle relaxant continued. Recently introduced agents that come
close to this goal include vecuronium, atracurium, pipecuronium, and
doxacurium. Succinyicholine was synthesized by Bovet in 1949 and released in
1951 ; it has become at standard agent for facilitating endotracheal intubation.
Although it remains unparalleled in its rapid onset of profound muscle
relaxation, its occasional side effects have continued to fuel the search for a
comparable substitute. Mivacurium, a new short-acting nondepolarizing muscle
relaxant. Has minimal side effects, but it still has a slower onset and longer
duration of action that succinylcholine. Rocuronium is a new intermediate- acting
relaxant with a rapid onset approaching that of succinylcholine.

Opioids
Morphine was isolated from opium in 1805 by Sertuner and subsequently
tried as an intravenous anesthetic (see above) the morbidity and mortality
initially associated with high doses of opioids in early report caused many
anesthetists to avoid opioids and favor pure inhalation anesthesia. Interest in
opioids in anesthesia returned following the synthesis of meperidine in 1939. The
concept of Balanced anesthesia was introduced by Lundy and others and evolved
to consist of thiopental for induction, nitrous oxide for amnesia, meperidine (or
any nacrotic) for analgesia, and curate for muscle relaxation. In 1969,
Lowenstein rekindled interest in opioid anesthesia by reintroducing the concept
of high doses of narcotics as complete anesthetics . morphine was initially
employed , but fentanyl, sufentanil, and alfetantanil were all subsequently used
as sole agents. As experience grew with this technique, its limitations in reliably
preventing patient awareness and suppressing autonomic responses during
surgery were realized. Remifentanil is a new rapidly-metabolized opioid that is
broken down by nonspecific plasma and tissue esterases.

EVOLUTION OF THE SPECIALITY

British Origins
Following its first public demonstration in the United States, the use of
ether quickly spread to England. Jhon Snow, generally considered the father of
anesthesia, became the first physician to take a full time interest in this new
anesthetic, for which he invented an inhaler. He was the first to scientifically
invented an inhaler. he was the first to scientifically investigation ether and
physiology of general anesthesia. (Snow was also a pioneer in epidemiology who
helped stop a cholera epidemic in London by proving that the causative agent
was transmitted by ingestion rather than inhalation). In 1847, snow published
the first book on general anesthesia, on the inhalation of ether. When the
anesthetic properties of chloroform were made known (see above), he quickly
investigated and developed an inhaler should be used in administering these
agents in order to control the dose of the anesthetic. his second book, on
chloroform and other Anesthetics, was published posthumously in 1858.
After Snow's death, Joseph T. Clover took his place as England's leading
physician anesthetist. Cover emphasized continuously monitoring the patient's
pulse during anesthesia, a practice that was not widely accepted at the time. He
was the first to use the jaw-thrust maneuver for airway obstruction, first to have
resuscitation equipment always available during anesthesia, and first to use a
cricothyroid cannula (to save a patient with an oral tumor who developed
complete airway obstruction). sir Frederick Hewitt became England's foremost
anesthetist at the turn of the century. He was responsible for many inventions.
Including the oral airways. Hewitt also wrote what many consider to be the first
true textbook of anesthesia, which went through five editions. Snow. Clover, and
Hewitt established a tradition of physician anesthetists that still exists in England
in 1893, the first organization of physician specialist in anesthesia, the Society of
Anesthetists, was formed in England by J.F.Silk.

American Origins
In the United States, Few Physicians had specialized in anesthesia by the
turn of the century. The task of giving anesthesia was usually delegated to junior
surgical house officer or medical students, who tended to be more interested in
the surgical procedure then in monitoring the patient. Because of the shortage of
physicians interested in the specialty in the United states, surgeons at both the
Mayo Clinic and Cleveland Clinic trained and employed nurses as anesthetists.
The first organization of physician anesthetists in the United States was the long
Island Society of Anesthesia in 1911. That society was eventually renamed the
American Society of Anesthetists and become nation in 1936. it was
subsequently renamed the American Society of Anesthetists and later, in 1945,
the American Society of Anesthesiologists (ASA).

Three physicians stand out in the early development of anesthesia in the

United States after the turn of century: Arthur E. Guedel, Ralph M. Waters and
John S. Lundy . Guedel was the first to elaborate on the signs of general
anesthesia after Snow's original description. He advocated cuffed endotracheal
tubes and introduced artificial ventilation during ether anesthesia (later called
controlled respiration by waters). The first elective endoracheal intubation during
anesthesia were performed in the late nineteenth century by surgeon: Sir William
Mac Ewen in Scotland, Joseph ODwyer in the United States, and Franz Kuhn in
Germany. Endotracheal intubation during anesthesia was popularized in england
by Sir Ivan Magill and Stanley Rowbotham in the 1920s. Ralph Waters added a
long list of contributions to the specialty in the United Stated; the most important
of these was insistence on the proper training of Specialists in anesthesia.

Official Recognition
Widespread specialization in anesthesia did not take place until just before
World War II. Ralph Waters was appointed the first professor of anesthesia in
United States in 1933 AT THE University of Wisconsin;the American Board of
Anesthesiology was established in 1937. In England. The first examination for the
Diploma in Anesthetics took place in 1935, and the first Chair in Anesthetics was
awarded to Sir Robert Macintosh in 1937 at Oxford University, Anesthesia
became an officially recognized specialty in England only in 1947, when the
Faculty of Anesthetists of the royal College of Surgeons was established
Pengakuan resmi
anestesia yang memiliki spesialisasi dalam meluas tidak berlangsung hingga
sebelum Perang Dunia II. Ralph air telah dilantik yang pertama profesor
anestesia pada Amerika Serikat pada tahun 1933 di Universitas
Wisconsin;American Board Anestesiologi didirikan pada 1937. Di England.
Pemeriksaan pertama untuk Diploma in anestetik lokal mengambil tempat di
tahun 1935, dan Kursi pertama dalam anestetik lokal telah diberikan kepada Sir
Robert Macintosh di 1937 di Oxford University, anestesia menjadi sebuah secara
resmi diakui di Inggris hanya specialty pada tahun 1947, ketika Fakultas
Anesthetists dari Royal College Ahli Bedah didirikan.

Cakupan
anestesia amalan anestesia telah berubah secara dramatis sejak zaman Yohanes
salju. Anesthesiologist modern sekarang kedua, konsultan dan penyedia layanan
utama. Peran konsultan yang sesuai karena tujuan utama dari anesthetist - untuk
melihat pasien secara aman dan nyaman melalui pembedahan- umumnya hanya
memerlukan waktu pendek (menit untuk jam). Namun, karena of
Anaesthesiologists mengelola semua "non-pemotongan" aspek-aspek perawatan
pasien dalam periode ekstubasi segera, mereka juga penyedia layanan utama.
"Kapten kapal", yang memegang doktrin ahli bedah bertanggung jawab atas

setiap aspek ekstubasi pasien care (termasuk), anestesia tidak lagi sah. Seorang
ahli bedah dan anesthesiologist harus berfungsi bersama secara efektif, tetapi
kedua-duanya akhirnya dipertanggungjawabkan oleh pasien daripada untuk satu
sama lain. Pasien dapat memilih of Anaesthesiologists, tetapi mereka sendiri
pilihan mereka biasanya dibatasi oleh yang pada staf medis di rumah sakit
tertentu, dokter spesialis bedah yang preferensi (jika ada), atau pada jadwal
panggilan-untuk of Anaesthesiologists pada hari yang diberikan.
Amalan anestesia dari tidak lagi terbatas ke ruang operasi ataupun terbatas
untuk pasien render untuk rasa sakit (Tabel pingsan 1-1). Anesthesiologist
sekarang secara rutin diminta untuk memantau, Denmark tampak tenang, dan
menyediakan atau umum anestesia regional di luar ruang operasi-untuk
lithotripsy, Magnetic Resonance Imaging, komputerisasi tomography,
fluoroscopy, terapi elektrokonvulsif, dan yaitu kateterisasi jantung. Of
anaesthesiologists secara tradisinya telah menjadi pelopor dalam
cardiopulmonary tim resusitasi. Semakin meningkatnya jumlah praktisi memiliki
sub-spesialis dalam anestesia jantung (Bab 21), perawatan kritis (Bab 50),
neuroanesthesia (Bab 26), anestesia kebidanan (Bab 43), anestesia pediatrik
(Bab 44), dan manajemen nyeri (Bab 18). Persyaratan sertifikasi untuk
kompetensi khusus dalam dan nyeri perawatan kritis sudah ada di Amerika
Serikat . Of anaesthesiologists secara aktif terlibat dalam administrasi dan arah
medis dari banyak ruang operasi, intensive care unit, dan departemen terapi
pernafasan. Mereka juga telah mengambil posisi kepemimpinan dan administratif
pada staf medis dari banyak rumah sakit dan fasilitas perawatan ambulatory.

THE SCOPE OF ANESTHESIA

The practice of anesthesia has changed dramatically since the days of
John Snow. The modern anesthesiologist is now both a consultant and a primary
care provider. The consultant role is appropriate because the primary goal of the
anesthetist - to see the patient safely and comfortably through surgerygenerally takes only a short time (minutes to hours). However, because
anesthesiologists manage all non-cutting aspects of the patient's care in the
immediate perioperative period, they are also primary care providers. 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
valid. The surgeon and anesthesiologist must function together effectively, but
both are ultimately answerable to the patient rather than to each other. Patients
can select their own anesthesiologists, but their choices are usually limited by
who is on the medical staff at a particular hospital, the surgeon's preference (if
any), or the on-call schedule for anesthesiologists on a given day.
The practice of anesthesia is no longer limited to the operating room nor
even confined to rendering patients insensible to pain (Table 1-1).
Anesthesiologist are now routinely asked to monitor, sedate, and provide general
or regional anesthesia outside the operating room-for lithotripsy, magnetic
resonance imaging, computerized tomography, fluoroscopy, electroconvulsive

therapy, and cardiac catheterization. Anesthesiologists have traditionally been

pioneers in cardiopulmonary resuscitation teams. An increasing number of
practitioners have sub-specialized in cardiac anesthesia (Chapter 21), critical
care (Chapter 50), neuroanesthesia (Chapter 26), obstetric anesthesia (Chapter
43), pediatric anesthesia (Chapter 44), and pain management (Chapter 18).
Certification requirements for special competence in critical care and pain
management already exist in the united state . Anesthesiologists are actively
involved in the administration and medical direction of many operating room,
intensive care units, and respiratory therapy departments. They have also
assumed administrative and leadership position on the medical staffs of many
hospitals and ambulatory care facilities.

CASE DISCUSSION :
MEDICAL MALPRACTICE
A healthy 45-year-old man suffers a cardiac arrest during an elective
inguinal hernia repair. Although cardiopulmonary resuscitation is successful, the
patient is left with permanent mental status changes that preclude his return to
work, one year later, the patient files a complaint against the anesthesiologist,
surgeon, and hospital.

What four elements must be Proved by the plaintiff (patient) to Establish

negligence on the part Of the defendant (physician or hospital) ?

1. Duty : Once a physicians establishes a professional relationship with a patient,

the physician owes that patient certain obligations, such as adhering to the
standard of care
2. Breach of duty : if these obligations are not fulfilled, the physician has
breached his duties to the patient
3. Causation : the plaintiff must demonstrate that the breach of duty was
causally related to the injury. This proximate cause does not have to be the most
important or immediate cause of the injury.
4. Damages : an injury must result. The injury may cause general damages (eg,
pain and suffering) or special damages (eg, loss of income)

How is the standard of care

Defined and established
Individual physicians are expected to perform as any prudent and
reasonable physician would in light of the surrounding circumstances. As a
specialist, the anesthesiologist is held to a higher standard of knowledge and
skill with respect to the subject matter of that specialty than would be a general
practitioner or a physician in another specialty. The standard of care is usually
established by an expert witness. While most jurisdictions have extended the
locality rule to encompass a national standard of care, the specific
circumstances pertaining to each individual case are taken into account. The law
recognized that these are differences of opinion and varying schools of thought
within the medical profession.
How is causation determined ?
It is usually the plaintiff who bears the burden of proving that the injury
would not have occurred but for the negligence of the physician, or that the
physician's action was a substantial factor in causing the injury. An exception is
the doctrine of res ipsa loquitur (the thing speaks for itself). Which permits a
finding of negligence based solely on circumstantial evidence. For res ipsa to
apply in the present case summary. The plaintiff would have to establish that
cardiac arrest does not ordinarily occur in the absence of negligence and that it
could not have been due to something outside the control of the
anesthesiologist. An important concept is that causation in civil cases need only
be established by a preponderance of the evidence (more likely than not)- as
opposed to criminal cases, where all elements of a charged offense must be
proved beyond a reasonable doubt.

What factors influence the likelihood of a malpractice suit ?

1. The Physician-Patient Relationship: This is particularly important for the
anesthesiologist. Who usually does not meet the patient until the night before or
on the morning of surgery. Another problem is that the patient is unconscious
while under the anesthesiologist's care. Thus, the preoperative and
postoperative visits with the patient assume vital importance. While
anesthesiologists have less long term contact with patients than other medical
specialists do, It is possible and desirable to make this contact meaningful.
Family members should also be considered during these meetings, particular the
postoperative visit if these has been an intraoperative complication.
2. Adequacy of informed Consent : Rendering care to a competent patient who
does not consent constitutes assault and battery. Consent is not enough,
however. The patient should be informed of the contemplated procedure,
including its reasonably anticipated risks, its possible benefits, and the

therapeutic alternatives. The physician may be liable for a complication-even if it

is not due to the negligent performance of a procedure-if a jury is convinced that
a reasonable person would have refused treatment if properly informed of the
possibility of the complication. This does not mean, of course, that a documented
consent relieves from liability physicians who violate the standard of care.
3. Quality of Documentation : careful documentation of the perioperative visits.
Informed consent, consultation with other specialists, intraoperative events, and
postoperative care is absolutely essential. The viewpoint of many courts and
juries is that if it isn't written, it wasn't done, it goes without saying that
medical records should never be intentionally destroyed or altered.