Anesthesia - Wikipedia, the free encyclopedia http://en.wikipedia.

org/wiki/Anesthesia

Anesthesia
From Wikipedia, the free encyclopedia

Anesthesia, or anaesthesia (from Greek -, an-, "without"; and , aisthsis, "sensation"),[1]

traditionally meant the condition of having sensation (including the feeling of pain) blocked or temporarily taken
away. It is a pharmacologically induced and reversible state of amnesia, analgesia, loss of responsiveness, loss of
skeletal muscle reflexes, decreased stress response, or all of these simultaneously. These effects can be obtained
from a single drug which alone provides the correct combination of effects, or occasionally a combination of
drugs (such as hypnotics, sedatives, paralytics and analgesics) to achieve very specific combinations of results.
This allows patients to undergo surgery and other procedures without the distress and pain they would otherwise
experience. An alternative definition is a "reversible lack of awareness," including a total lack of awareness (e.g.
a general anesthetic) or a lack of awareness of a part of the body such as a spinal anesthetic. The pre-existing
word anesthesia was suggested by Oliver Wendell Holmes, Sr. in 1846 as a word to use to describe this state.[2]

Types of anesthesia include local anesthesia, regional anesthesia, general anesthesia, and dissociative anesthesia.
Local anesthesia inhibits sensory perception within a specific location on the body, such as a tooth or the urinary
bladder. Regional anesthesia renders a larger area of the body insensate by blocking transmission of nerve
impulses between a part of the body and the spinal cord. Two frequently used types of regional anesthesia are
spinal anesthesia and epidural anesthesia. General anesthesia refers to inhibition of sensory, motor and
sympathetic nerve transmission at the level of the brain, resulting in unconsciousness and lack of sensation.
Dissociative anesthesia uses agents that inhibit transmission of nerve impulses between higher centers of the
brain (such as the cerebral cortex) and the lower centers, such as those found within the limbic system.

Contents
1 Anesthesia
1.1 Physicians
1.2 Nurse anesthetists
1.3 Anesthesiologist assistants
1.4 Operating department practitioners
1.5 Veterinary anesthetists
2 Other personnel
3 Agents
4 Equipment
5 Monitoring
6 Record
7 History
7.1 Plant derivatives
7.2 Early inhalational anesthetics
8 See also
9 References
10 Further reading
11 External links

Anesthesia

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Further information: Anesthesia provision in the United States

Doctors specializing in perioperative care, development of an anesthetic plan, and the administration of
anesthetics are known in the US as anesthesiologists and in the UK, Canada, Australia, and NZ as anaesthetists
or anaesthesiologists. All anesthetics in the UK, Australia, New Zealand, Hong Kong and Japan are
administered by doctors. Nurse anesthetists also administer anesthesia in 109 nations.[3] In the US, 35% of
anesthetics are provided by physicians in solo practice, about 55% are provided by anesthesia care teams
(ACTs) with anesthesiologists medically directing anesthesiologist assistants or certified registered nurse
anesthetists (CRNAs), and about 10% are provided by CRNAs in solo practice.[4][5][3]

Physicians

Main article: Anesthesiologist

In the strict sense, the term anesthetist refers to any individual who
administers anesthesia. In the US, however, the term is most commonly
employed to refer to registered nurses who have completed specialized
education and training in anesthesia to become certified registered nurse
anesthetists (CRNAs). In the US and Canada, medical physicians who
specialize in anesthesiology are called anesthesiologists. Such physicians
in the United Kingdom (UK), Australia and New Zealand are called
anaesthetists.
Anesthesiology residents training with
In the US, a physician specializing in anesthesiology typically completes a patient simulator
four years of college, four years of medical school, and four years of
postgraduate medical training or residency[6] According to the American
Society of Anesthesiologists, anesthesiologists provide or participate in more than ninety percent of the forty
million anesthetics delivered annually.[7] In the UK, this training lasts a minimum of seven years after the
awarding of a medical degree and two years of basic residency, and takes place under the supervision of the
Royal College of Anaesthetists.[citation needed] In Australia and New Zealand, it lasts five years after the
awarding of a medical degree and two years of basic residency, under the supervision of the Australian and New
Zealand College of Anaesthetists.[8] Other countries have similar systems, including Ireland (the Faculty of
Anaesthetists of the Royal College of Surgeons in Ireland), Canada and South Africa (the College of
Anaesthetists of South Africa).

In the US, satisfactory completion of the written and oral Board examinations allows an anesthesiologist to be
called a "Diplomate" of the American Board of Anesthesiology or of the American Osteopathic Board of
Anesthesiology. This is often referred to colloquially as being "Board Certified". In the UK, Fellowship of the
Royal College of Anaesthetists (FRCA) is conferred upon medical doctors following satisfactory completion of
the written and oral parts of the Royal College's examination.

The role of the anesthesiologist is no longer limited to the operation itself. Many anesthesiologists function as
perioperative physicians, ensuring optimal analgesia and maintenance of physiologic homeostasis throughout the
preoperative, intraoperative, and postoperative periods. Anesthesiologists may elect to subspecialize in
anesthesia for particular types of surgery (cardiothoracic, obstetrical, neurosurgical, pediatric), regional
anesthesia, acute or chronic pain medicine, or Intensive Care Medicine.

Anesthesia providers are often trained using full scale human simulators. The field was an early adopter of this
technology and has used it to train students and practitioners at all levels for the past several decades. Notable

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centers in the United States can be found at the Johns Hopkins Medicine Simulation Center,[9] Harvard's Center
for Medical Simulation,[10] Stanford,[11] The Mount Sinai School of Medicine HELPS Center in New York,[12]
Duke University,[13]and the University of Utah. [14]

Nurse anesthetists

Main article: Nurse anesthetist

In the United States, advanced practice nurses specializing in the provision of anesthesia care are known as
certified registered nurse anesthetists (CRNAs). According to the American Association of Nurse Anesthetists,
the 39,000 CRNAs in the US administer approximately 30 million anesthetics each year, roughly two thirds of
the US total. 34% of nurse anesthetists practice in communities of less than 50,000. CRNAs start school with a
bachelors degree in nursing and at least 1 year of acute care nursing experience, and gain a masters degree in
nurse anesthesia before passing the mandatory Certification Exam. Masters-level CRNA training programs
range in length from 24 to 36 months.

CRNAs may work with podiatrists, dentists, anesthesiologists, surgeons, obstetricians and other professionals
requiring their services. CRNAs administer anesthesia in all types of surgical cases, and are able to apply all the
accepted anesthetic techniquesgeneral, regional, local, or sedation. 34 states require physician supervision of
a CRNA's practice, and hospitals can regulate what CRNAs can or can not do based on local laws.

In the United States, the Centers for Medicare and Medicaid Services (CMS), a federal agency within the United
States Department of Health and Human Services, determines the conditions for payment for all anesthesia
services provided under the Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP)
programs. For the purposes of payment for anesthesiology services, CMS defines an anesthesia practitioner as a
physician who performs the anesthesia service alone, a CRNA who is not medically directed, or a CRNA or AA
who is medically directed.[15] Under the QZ Anesthesia Claims Modifier, CMS allows payment to a CRNA for
anesthesiology services provided under these programs without medical direction by a physician.[15]
Furthermore, under CMS regulations, anesthesia must be administered only by:

a qualified doctor of medicine or osteopathic medicine, dentist, oral surgeon, or podiatrist;

a CRNA who, unless exempted, is under the supervision of the operating practitioner or of an
anesthesiologist;
an anesthesiologist's assistant who is under the supervision of an anesthesiologist.[16]

The aforementioned exemption for CRNAs is the State exemption (also referred to as an "opt-out"). Under the
State exemption, if the State in which the hospital is located submits a letter to CMS requesting exemption from
physician supervision of CRNAs, and that letter has been signed by the Governor of that State, then hospitals
within that State may be exempted from the requirement for physician supervision of CRNAs.[16] In 2001, CMS
established this exemption for CRNAs from the physician supervision requirement by recognizing a Governor's
written request to CMS attesting that it is in the best interests of the State's citizens to exercise this
exemption.[17] As of September 2010, sixteen states (California, Iowa, Nebraska, Idaho, Minnesota, New
Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, South Dakota, Wisconsin,
Montana and Colorado) have chosen to opt-out of the CRNA physician supervision regulation.[17]

Anesthesiologist assistants
Main article: Anesthesiologist assistant

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In the United States, anesthesiologist assistants (AAs) are graduate-level trained specialists who have
undertaken specialized education and training to provide anesthesia care under the direction of an
anesthesiologist. AAs typically hold a masters degree and practice under anesthesiologist supervision in 18 states
and the District of Columbia through licensing, certification or physician delegation.[18]

In the UK, a similar group of assistants are currently being evaluated. They are referred to as "physician
assistant (anaesthesia)" (PAA). Their background can be nursing, operating department practice, another of the
allied medical professions, or even one of the natural sciences.[19] Training is in the form of a postgraduate
diploma and takes 27 months to complete.[19]

Operating department practitioners

Main article: Operating Department Practitioners

In the United Kingdom, operating department practitioners provide assistance and support to the anesthetist or
anesthesiologist. They can also assist the surgeon with surgical procedures and provide postoperative care to
patients emerging from anesthesia. ODPs can be found in the operating department, accident and emergency
department, intensive care unit, high dependency unit and in radiology, cardiology and endoscopy suites which
require anesthesia support. They may also work with organ transplantation teams, as well as provide pre-hospital
care to trauma victims. They are state-registered in the UK. The ODP is a mid-level practitioner of perioperative
medicine. ODPs also function as lecturers and trainers in cardiopulmonary resuscitation, and work in
management positions in operating departments.

Veterinary anesthetists
Main article: Veterinary anesthesia

Much of the equipment and drugs utilized by veterinary anesthetists is similar or identical to that used in
anesthesia for human patients. There are vast differences in the physiology of different animal species, which
may influence the choice of anesthetic agents and delivery systems in organisms ranging in diversity from (for
example) annelids to elephants. For many wild animals, anesthetic drugs must often be delivered from a distance
by means of remote projector systems ("dart guns") before the animal can even be approached. Large domestic
livestock can often be anesthetized for certain types of surgery in the standing position using only local
anesthetics and sedative drugs. While most clinical veterinarians and veterinary technicians routinely function as
anesthetists in the course of their professional duties, veterinary anesthesiologists in the U.S. are veterinarians
who have completed a three year residency in anesthesia and have qualified for certification by the American
College of Veterinary Anesthesiologists.

Other personnel
Further information: Anaesthetic technician, Biomedical Equipment Technician, and Surgical technologist

Anesthesia technicians are specially trained Anaesthetic Assistants,equivalent to Operating Department

Practitioners in Great Britain. They do not administer anesthesia, but rather they assist anesthesia providers
similar to the way in which scrub technicians assist surgeons. Commonly these services are collectively called
perioperative services, and thus the term perioperative service technician (PST) is used interchangeably with
anesthesia technician. In the United States, an anesthesia technician can become a Certified Anesthesia
Technician (Cer.A.T.), followed by becoming a Certified Anesthesia Technologist (Cer.A.T.T.) through American
Society of Anesthesia Technologists & Technicians (ASATT).[20] In New Zealand, an anesthetic technician

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completes a course of study recognized by the New Zealand Anaesthetic Technicians Society.[21]

Agents
Further information: Anesthetic, General anesthetic, Inhalational anesthetic, and Local anesthetic

An anesthetic agent is a drug that brings about a state of anesthesia. A wide variety of drugs are used in modern
anesthetic practice. Many are rarely used outside of anesthesia, although others are used commonly by all
disciplines. Anesthetics are categorized into two categories: general anesthetics cause a reversible loss of
consciousness (general anesthesia), while local anesthetics cause reversible local anesthesia and a loss of
nociception.

Equipment
Further information: Instruments used in anesthesiology and Anaesthetic machine

In modern anesthesia, a wide variety of medical equipment is desirable depending on the necessity for portable
field use, surgical operations or intensive care support, and the type(s) of anesthetic(s) to be administered.
Anesthesia practitioners must possess a comprehensive and intricate knowledge of the production and use of
various medical gases, anesthetic agents and vapors, medical breathing circuits and the variety of anesthetic
machines (including vaporizers, ventilators and pressure gauges) and their corresponding safety features,
hazards and limitations of each piece of equipment, for the safe, clinical competence and practical application
for day to day practice.

The risk of transmission of infection by anesthetic equipment has been a problem since the beginnings of
anesthesia. Although most equipment that comes into contact with patients is disposable, there is still a risk of
contamination from the anesthetic machine itself[22] or because of bacterial passage through protective
filters.[23]

Monitoring
Patients under general anesthesia must undergo continuous physiological monitoring to ensure safety. In the US,
the American Society of Anesthesiologists (ASA) have established minimum monitoring guidelines for patients
receiving general anesthesia, regional anesthesia, or sedation. This includes electrocardiography (ECG), heart
rate, blood pressure, inspired and expired gases, oxygen saturation of the blood (pulse oximetry), and
temperature.[7] In the UK the Association of Anaesthetists (AAGBI) have set minimum monitoring guidelines
for general and regional anesthesia. For minor surgery, this generally includes monitoring of heart rate, oxygen
saturation, blood pressure, and inspired and expired concentrations for oxygen, carbon dioxide, and inhalational
anesthetic agents. For more invasive surgery, monitoring may also include temperature, urine output, blood
pressure, central venous pressure, pulmonary artery pressure and pulmonary artery occlusion pressure, cardiac
output, cerebral activity, and neuromuscular function. In addition, the operating room environment must be
monitored for ambient temperature and humidity, as well as for accumulation of exhaled inhalational anesthetic
agents, which might be deleterious to the health of operating room personnel.

Effective July 1, 2011 the ASA implemented updated standards for patient monitoring.[24]

Record

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The anesthesia record is the medical and legal documentation of events

while a patient is under anesthesia.[25] It should contain a detailed and
continuous account of all drugs, fluids, and blood products administered
and procedures undertaken, and also includes the observation of
cardiovascular responses, estimated blood loss, urine output and data
from physiologic monitors while a patient is under anesthesia.

Traditionally handwritten on paper, the anesthesia record is increasingly

being replaced by an electronic record as part of an Anesthesia
Information Management System (AIMS), especially since 2007.[26] An
AIMS is any information system that is used as an automated electronic
anesthesia record keeper (i.e., connection to patient physiologic monitors
and/or the anesthetic machine) and which also may allow the collection
and analysis of anesthesia-related perioperative patient data gathered
from monitors and/or the anesthesia machine. These systems typically
run on medical-grade hardware in the operating room. AIMS can be An anesthetic machine with integrated
stand-alone systems or integrated modules of a hospital information systems for monitoring of several vital
system. AIMS have several benefits to the anesthesia departments as parameters.
well to the hospital administration as documented in the scientific
literature:

Reducing anesthesia-related drug costs[27]

Increased anesthesia billing and capture of anesthesia-related charges[28]
Increased hospital reimbursement through improved hospital coding[29][30]
Improved efficiency of the physicians involved in anesthesia and surgery through transfer pricing[31]
Improvement of the data quality of the intraoperative anesthesia record[32][33]
Support training and education of the anesthesia workforce[34]
Support of clinical decision-making[35]
Support of patient care and safety[36]
Enhancement of clinical studies[37]
Enhancement of clinical quality improvement programs[38]
Support of clinical risk management[39]
Monitoring for diversion of controlled substances[40]

History
Main articles: History of general anesthesia and History of neuraxial anesthesia

Plant derivatives

Throughout Europe, Asia, and the Americas a variety of Solanum species containing potent tropane alkaloids
were used, such as mandrake, henbane, Datura metel, and Datura inoxia. Ancient Greek and Roman medical
texts by Hippocrates, Theophrastus, Aulus Cornelius Celsus, Pedanius Dioscorides, and Pliny the Elder
discussed the use of opium and Solanum species. In 13th century Italy, Theodoric Borgognoni used similar
mixtures along with opiates to induce unconsciousness, and treatment with the combined alkaloids proved a
mainstay of anesthesia until the nineteenth century. In the Americas coca was also an important anesthetic used
in trephining operations. Incan shamans chewed coca leaves and performed operations on the skull while

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spitting into the wounds they had inflicted to anesthetize the site.[41] Alcohol was also used, its vasodilatory
properties being unknown. Ancient herbal anesthetics have variously been called soporifics, anodynes, and
narcotics, depending on whether the emphasis is on producing unconsciousness or relieving pain.

The use of herbal anesthesia had a crucial drawback compared to modern practiceas lamented by Fallopius,
"When soporifics are weak, they are useless, and when strong, they kill." To overcome this, production was
typically standardized as much as feasible, with production occurring from specific locations (such as opium
from the fields of Thebes in ancient Egypt). Anesthetics were sometimes administered in the "spongia
somnifera", a sponge into which a large quantity of drug was allowed to dry, from which a saturated solution
could be trickled into the nose of the patient. At least in more recent centuries, trade was often highly
standardized, with the drying and packing of opium in standard chests, for example. In the 19th century, varying
aconitum alkaloids from a variety of species were standardized by testing with guinea pigs. Trumping this
method was the discovery of morphine, a purified alkaloid that could be injected by hypodermic needle for a
consistent dosage. The enthusiastic reception of morphine led to the foundation of the modern pharmaceutical
industry.[42]

The first effective local anesthetic was cocaine. Isolated in 1859, it was first used by Karl Koller, at the
suggestion of Sigmund Freud, in eye surgery in 1884.[43] German surgeon August Bier (18611949) was the first
to use cocaine for intrathecal anesthesia in 1898.[44] Romanian surgeon Nicolae Racoviceanu-Piteti
(18601942) was the first to use opioids for intrathecal analgesia; he presented his experience in Paris in
1901.[45] A number of newer local anesthetic agents, many of them derivatives of cocaine, were synthesized in
the 20th century, including eucaine (1900), amylocaine (1904), procaine (1905), and lidocaine (1943).

Early inhalational anesthetics

Further information: Inhalational anesthetic

Early Arab writings mention anesthesia by inhalation. This idea was the
basis of the "soporific sponge" ("sleep sponge"), introduced by the
Salerno school of medicine in the late twelfth century and by Ugo
Borgognoni (11801258) in the thirteenth century. The sponge was
promoted and described by Ugo's son and fellow surgeon, Theodoric
Borgognoni (12051298). In this anesthetic method, a sponge was
soaked in a dissolved solution of opium, mandragora, hemlock juice, and
other substances. The sponge was then dried and stored; just before
surgery the sponge was moistened and then held under the patient's nose.
When all went well, the fumes rendered the patient unconscious.
Contemporary re-enactment of
Morton's 16 October 1846, ether In 1275, Spanish physician Raymond Lullus, while experimenting with
operation; daguerrotype by Southworth chemicals, made a volatile, flammable liquid he called sweet vitriol.
& Hawes Sweet vitriol, or sweet oil of vitriol, was the first inhalational anesthetic
used for surgical anesthesia. It is no longer used often because of its
flammability. In the 16th century, a Swiss-born physician commonly known as Paracelsus made chickens
breathe sweet vitriol and noted that they not only fell asleep but also felt no pain. Like Lullus before him, he did
not experiment on humans. In 1730, German chemist Frobenius gave this liquid its present name, ether, which is
Greek for heavenly. But 112 more years would pass before ethers anesthetic powers were fully appreciated.

Meanwhile, in 1772, English scientist Joseph Priestley discovered the gas nitrous oxide. Initially, people thought
this gas to be lethal, even in small doses. However, in 1799, British chemist and inventor Humphry Davy

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decided to find out by experimenting on himself. To his astonishment he found that nitrous oxide made him
laugh, so he nicknamed it laughing gas. Davy wrote about the potential anesthetic properties of nitrous oxide,
but nobody at that time pursued the matter any further.

American physician Crawford W. Long noticed that his friends felt no pain when they injured themselves while
staggering around under the influence of ether. He immediately thought of its potential in surgery. Conveniently,
a participant in one of those ether frolics, a student named James Venable, had two small tumors he wanted
excised. But fearing the pain of surgery, Venable kept putting the operation off. Hence, Long suggested that he
have his operation while under the influence of ether. Venable agreed, and on 30 March 1842 he underwent a
painless operation. However, Long did not announce his discovery until 1849.[46]

William Thomas Green Morton, a Boston dentist, conducted the first public demonstration of the inhalational
anesthetic. Morton, who was unaware of Long's previous work, was invited to the Massachusetts General
Hospital to demonstrate his new technique for painless surgery. After Morton had induced anesthesia, surgeon
John Collins Warren removed a tumor from the neck of Edward Gilbert Abbott. This occurred in the surgical
amphitheater now called the Ether Dome. The previously skeptical Warren was impressed and stated
"Gentlemen, this is no humbug." In a letter to Morton shortly thereafter, physician and writer Oliver Wendell
Holmes, Sr. proposed naming the state produced "anesthesia", and the procedure an "anesthetic". [47]

Morton at first attempted to hide the actual nature of his anesthetic substance, referring to it as Letheon. He
received a US patent for his substance, but news of the successful anesthetic spread quickly by late 1846.
Respected surgeons in Europe including Liston, Dieffenbach, Pirogov, and Syme, quickly undertook numerous
operations with ether. An American-born physician, Boott, encouraged London dentist James Robinson to
perform a dental procedure on a Miss Lonsdale. This was the first case of an operator-anesthetist. On the same
day, 19 December 1846, in Dumfries Royal Infirmary, Scotland, a Dr. Scott used ether for a surgical procedure.
[citation needed]
The first use of anesthesia in the Southern Hemisphere took place in Launceston, Tasmania, that
same year. Drawbacks with ether such as excessive vomiting and its flammability led to its replacement in
England with chloroform.

Discovered in 1831 by an American physician Samuel Guthrie (1782-1848); and independently a few months
later by Frenchman Eugne Soubeiran (1797-1859) and Justus von Liebig (1803-73) in Germany. Chloroform
was named and chemically characterised in 1834 by Jean-Baptiste Dumas (1800-84). Its anaesthetic properties
were noted early in 1847 by Marie-Jean-Pierre Flourens (1794-1867). The use of chloroform in anesthesia is
linked to James Young Simpson, who, in a wide-ranging study of organic compounds, found chloroform's
efficacy on 4 November 1847. Its use spread quickly and gained royal approval in 1853 when John Snow gave it
to Queen Victoria during the birth of Prince Leopold. Unfortunately, chloroform is not as safe an agent as ether,
especially when administered by an untrained practitioner (medical students, nurses, and occasionally members
of the public were often pressed into giving anesthetics at this time). This led to many deaths from the use of
chloroform that (with hindsight) might have been preventable. The first fatality directly attributed to chloroform
anesthesia was recorded on 28 January 1848 after the death of Hannah Greener.[citation needed]

John Snow of London published articles from May 1848 onwards "On Narcotism by the Inhalation of Vapours"
in the London Medical Gazette. Snow also involved himself in the production of equipment needed for the
administration of inhalational anesthetics.

See also
Main article: Outline of anesthesia

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Allergic reactions during anesthesia

American Board of Anesthesiology
American Osteopathic Board of Anesthesiology
Anesthesia awareness
ASA physical status classification system
Cardiothoracic anesthesiology
Geriatric anesthesia
Intraoperative neurophysiological monitoring
The Helsinki Declaration for Patient Safety in Anaesthesiology
Patient safety
Perioperative mortality
Second gas effect

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Further reading
McGrew, Roderick. Encyclopedia of Medical History (1985), brief history pp 14-18
Wolf, Jacqueline H. Deliver Me from Pain: Anesthesia and Birth in America (Johns Hopkins University
Press, 2009) 277pp; covers 1840s to 21st century; ISBN 978-0-8018-9110-6

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Anesthesia - Wikipedia, the free encyclopedia http://en.wikipedia.org/wiki/Anesthesia

External links
Australian Society Of Anaesthesia Paramedical Officers (http://www.asapo.org.au/)
American Association of Nurse Anesthetists (http://www.AANA.com/)
American Society of Anesthesiologists (http://www.asahq.org/)
American Academy of Anesthesiologist Assistants (http://www.anesthetist.org/)
AnaesthesiaUK (http://www.anaesthesiauk.com/)
Nova Southeastern University (http://www.nova.edu/chcs/healthsciences/anesthesia/index.html/)

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