General anesthetics, administered by inhalation or intravenous injection, cause unconsciousness as well as insensibility to pain, and are used for major surgical procedures. In the past, ether was the most commonly used general anesthetic. Today, safer anesthetics include Halothane and Isoflurane, both of which are administered through inhalation. Short-acting anesthetic agents, such as pentothal, Diprivan, and Midazolam, are generally given through intravenous or intramuscular routes. Inhaled nitrous oxide is used for light anesthesia in minor surgical procedures and in dentistry. Ultra-short-acting analgesics can also be given intranasally for pre-medication prior to the induction of general anesthesia. Anesthetics such as Brevital may be administered rectally, primarily among children.
Local anesthetics affect sensation only in the region where they are injected, and are used regularly in dentistry and minor surgery. Spinal and epidural anesthesia involves the injection of an anesthetic agent into a space adjacent to the spinal cord, a technique frequently employed for surgical procedures below the waist (e.g., obstetrics) where total unconsciousness is not necessary. Such anesthetics are known as regional blocks. Muscle relaxants may be used in conjunction with general anesthetics, particularly to reduce the amount of anesthetic required. Body temperatures are generally lowered in conjunction with the use of anesthetics in heart and brain surgery, reducing the body's metabolic rate so that cells are not damaged by the lack of circulating blood and reduced oxygenation. Several forms of anesthesia may be used in combination. Safer and more efficient anesthetics are constantly researched, in the hopes of perfecting new ways of combining and administering them.
See J. Rupreht et al., ed., Anesthesia: Essays on Its History (1985); J. Tolmie and A. Birch, Anesthesia for the Uninterested (2d ed. 1986); J. M. Fenster, Ether Day: The Strange Tale of America's Greatest Medical Discovery and the Haunted Men Who Made It (2001).
Anesthesia, or anaesthesia (see spelling differences; from Greek αν-, an-, "without"; and αἲσθησις, aisthēsis, "sensation"), has traditionally meant the condition of having sensation (including the feeling of pain) blocked. This allows patients to undergo surgery and other procedures without the distress and pain they would otherwise experience. The word was coined by Oliver Wendell Holmes, Sr. in 1846. Another definition is a "reversible lack of awareness", whether this is a total lack of awareness (e.g. a general anaesthestic) or a lack of awareness of a part of a the body such as a spinal anaesthetic or another nerve block would cause. Anesthesia differs from analgesia in blocking all sensation, not only pain.
Today, the term general anesthesia in its most general form can include:
Patients undergoing surgery usually undergo preoperative evaluation. It includes gathering history of previous anesthetics, and any other medical problems, physical examination, ordering required blood work and consultations prior to surgery.
There are several forms of anesthesia. The following forms refer to states achieved by anesthetics working on the brain:
The level of anesthesia achieved ranges on a continuum of depth of consciousness from minimal sedation to general anesthesia. The depth of consciousness of a patient may change from one minute to the next.
The following refer to the states achieved by anesthetics working outside of the brain:
In Central Asia, in the 10th century work of Shahnameh, the author, Ferdowsi, describes a caesarean section performed on Rudaba when giving birth, in which a special wine agent was prepared as an anesthetic by a Zoroastrian priest, and used to produce unconsciousness for the operation. Although largely mythical in content, the passage does at least illustrate knowledge of anesthesia in ancient Persia.
The use of herbal anaesthesia had a crucial drawback compared to modern practice — as lamented by Fallopus, "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 famous locations (such as opium from the fields of Thebes in ancient Egypt). Anaesthetics 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. Despite these refinements, the discovery of morphine, a purified alkaloid that soon afterward could be injected by hypodermic for a consistent dosage, was enthusiastically received and led to the foundation of the modern pharmaceutical industry.
Another factor affecting ancient anaesthesia is that drugs used systemically in modern times were often administered locally, reducing the risk to the patient. Opium used directly in a wound acts on peripheral opioid receptors to serve as an analgesic, and a medicine containing willow leaves (salicylate, the predecessor of aspirin) would then be applied directly to the source of inflammation.
In 1804, the Japanese surgeon Seishū Hanaoka performed general anaesthesia for the operation of a breast cancer (mastectomy), by combining Chinese herbal medicine know-how and Western surgery techniques learned through "Rangaku", or "Dutch studies". His patient was a 60-year-old woman named Kan Aiya. He used a compound he called Tsusensan, based on the plants Datura metel, Aconitum and others.
In modern anesthetic practice, these techniques are seldom employed.
In the West, the development of effective anesthetics in the 19th century was, with Listerian techniques, one of the keys to successful surgery. Henry Hill Hickman experimented with carbon dioxide in the 1820s. The anesthetic qualities of nitrous oxide (isolated in 1773 by Joseph Priestley) were discovered by the British chemist Humphry Davy about 1799 when he was an assistant to Thomas Beddoes, and reported in a paper in 1800. But initially the medical uses of this so-called "laughing gas" were limited — its main role was in entertainment. It was used on 30 September 1846 for painless tooth extraction upon patient Eben Frost by American dentist William Thomas Green Morton. Horace Wells of Connecticut, a traveling dentist, had demonstrated it the previous year 1845 at Massachusetts General Hospital. Wells made a mistake in choosing a particularly sturdy male volunteer, and the patient suffered considerable pain. This lost the colorful Wells any support. Later the patient told Wells he screamed in shock and not in pain. A subsequently drunk Wells died in jail, by cutting his femoral artery, after allegedly assaulting a prostitute with sulfuric acid.
Another dentist, William E. Clarke, performed an extraction in January 1842 using a different chemical, diethyl ether (discovered by Valerius Cordus in 1540). In March 1842 in Danielsville, Georgia, Dr. Crawford Long was the first to use anaesthesia during an operation, giving it to his friend, who was also a school teacher (James M. Venable) before excising a cyst from his neck. Long got the idea to do this from his observations at ether frolics. He noted that participants experienced bumps and bruises but afterward had no recall of what had happened. He did not publicize this information until 1849.
On October 16, 1846, dentist William Thomas Green Morton, invited to the Massachusetts General Hospital, performed the first public demonstration of diethyl ether (then called sulfuric ether) as an anesthetic agent, for a patient (Edward Gilbert Abbott) undergoing an excision of a vascular tumor from his neck. In a letter to Morton shortly thereafter, Oliver Wendell Holmes, Sr. proposed naming the procedure anæsthesia.
Despite Morton's efforts to keep "his" compound a secret, which he named "Letheon" and for which he received a US patent, the news of the discovery and the nature of the compound spread very quickly to Europe in late 1846. Here, respected surgeons—including Liston, Dieffenbach, Pirogoff, and Syme—undertook numerous operations with ether. An American-born physician, Boott—who had traveled to London—encouraged a leading dentist, Mr 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. The first use of anesthesia in the Southern Hemisphere took place in Launceston, Tasmania, that same year. Ether has a number of drawbacks, such as its tendency to induce vomiting and its flammability. In England it was quickly replaced with chloroform.
Discovered in 1831, the use of chloroform in anesthesia is usually 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 (Hannah Greener) was recorded on 28 January 1848.
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 inhalational anesthesia.
The surgical amphitheatre at Massachusetts General Hospital, or "ether dome" still exists today, although it is used for lectures and not surgery. The public can visit the amphitheater on weekdays when it is not in use.
Opioids were first used by Racoviceanu-Piteşti, who reported his work in 1901.
Physicians specialising in peri-operative care, development of an anesthetic plan, and the administration of anesthetics are known in the United States as anesthesiologists and in the UK and Canada as anaesthetists or anaesthesiologists. All anaesthetics in the UK, Australia, New Zealand and Japan are administered by physicians. Nurse anesthetists also administer anesthesia in 109 nations. In the US, 35% of anesthetics are provided by physicians in solo practice, about 55% are provided by ACTs with anesthesiologists medically directing Anesthesiologist Assistants or CRNAs, and about 10% are provided by CRNAs in solo practice. - -
In the US, medical doctors who specialize in anesthesiology are called anesthesiologists, and dentists who specialize in anesthesiology are called dental anesthesiologists. Such physicians in the UK, Canada and Australia are called anaesthetists or anaesthesiologists.
In the US, a physician specializing in anesthesiology completes 4 years of college, 4 years of medical school, 1 year of internship, and 3 years of residency. According to the American Society of Anesthesiologists, anesthesiologists provide or participate in more than 90 percent of the 40 million anesthetics delivered annually.
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. 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. 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 UK, Fellowship of the Royal College of Anaesthetists (FRCA), is conferred upon medical doctors following completion of the written and oral parts of the Royal College's examination. In the US, completion of the written and oral Board examinations by a physician anesthesiologist allows one to be called "Board Certified" or a "Diplomate" of the American Board of Anesthesiology (or of the American Osteopathic Board of Anesthesiology, for osteopathic physicians).
Other specialties within medicine are closely affiliated to anaesthetics. These include intensive care medicine and pain medicine. Specialists in these disciplines have usually done some training in anaesthetics. The role of the anaesthetist is changing. It is no longer limited to the operation itself. Many anaesthetists perform well as peri-operative physicians, and will involve themselves in optimizing the patient's health before surgery (colloquially called "work-up"), performing the anaesthetic,including specialized intraoperative monitoring (like transesophageal echocardiography), following up the patient in the post anesthesia care unit and post-operative wards, and ensuring optimal analgesia throughout.
It is important to note that the term anesthetist in the United States usually refers to registered nurses who have completed specialized education and training in nurse anesthesia to become certified registered nurse anesthetists (CRNAs). As noted above, the term anaesthetist in the UK and Canada refers to medical doctors who specialize in anesthesiology.
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 techniques -- general, regional, local, or sedation. CRNAs do not require Anesthesiologist supervision in any state and only require surgeon/dentist/podiatrists to sign the chart for medicare billing in all but 16 states.
In the US, 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 through licensing, certification or physician delegation.
In the UK, a similar group of assistants are currently being evaluated. They are named Physician's Assistant (Anaesthesia). Their background can be nursing, operating department professional or another profession allied to medicine or a science graduate. Training is in the form of a post-graduate diploma and takes 27 months to complete. Once finished, a masters degree can be undertaken.
Anesthesiology assistants should be distinguished from anesthesia technicians.
In New Zealand, anaesthetic technicians complete a course of study recognized by the New Zealand Association of Anaesthetic Technicians and Nurses.
In the United Kingdom, personnel known as ODPs (operating department practitioners) or anaesthetic nurses provide support to the physician anaesthetist (anaesthesiologist).
Local anesthetics are agents which prevent transmission of nerve impulses without causing unconsciousness. They act by binding to fast sodium channels from within (in an open state). Local anesthetics can be either ester or amide based.
Ester local anesthetics (e.g., procaine, amethocaine, cocaine) are generally unstable in solution and fast-acting, and allergic reactions are common.
Amide local anesthetics (e.g., lidocaine, prilocaine, bupivicaine, levobupivacaine, ropivacaine and dibucaine) are generally heat-stable, with a long shelf life (around 2 years). They have a slower onset and longer half-life than ester anaesthetics, and are usually racemic mixtures, with the exception of levobupivacaine (which is S(-) -bupivacaine) and ropivacaine (S(-)-ropivacaine). These agents are generally used within regional and epidural or spinal techniques, due to their longer duration of action, which provides adequate analgesia for surgery, labor, and symptomatic relief.
Effects may be localized or systemic.
Examples of systemic effects of local anesthesia:
Local anesthetic drugs are toxic to the heart (where they cause arrhythmia) and brain (where they may cause unconsciousness and seizures). Arrhythmias may be resistant to defibrillation and other standard treatments, and may lead to loss of heart function and death.
The first evidence of local anesthetic toxicity involves the nervous system, including agitation, confusion, dizziness, blurred vision, tinnitus, a metallic taste in the mouth, and nausea that can quickly progress to seizures and cardiovascular collapse.
Toxicity can occur with any local anesthetic as an individual reaction by that patient. Possible toxicity can be tested with pre-operative procedures to avoid toxic reactions during surgery.
An example of localized effect of local anesthesia:
Direct infiltration of local anesthetic into skeletal muscle will cause temporary paralysis of the muscle.
Volatile agents are specially formulated organic liquids that evaporate readily into vapors, and are given by inhalation for induction and/or maintenance of general anesthesia. Nitrous oxide and xenon are gases at room temperature rather than liquids, so they are not considered volatile agents. The ideal anesthetic vapor or gas should be non-flammable, non-explosive, lipid-soluble, and should possess low blood gas solubility, have no end organ (heart, liver, kidney) toxicity or side-effects, should not be metabolized, and should be non-irritant when inhaled by patients.
No anesthetic agent currently in use meets all these requirements. The agents in widespread current use are isoflurane, desflurane, sevoflurane, and nitrous oxide. Nitrous oxide is a common adjuvant gas, making it one of the most long-lived drugs still in current use. Because of its low potency, it cannot produce anesthesia on its own but is frequently combined with other agents. Halothane, an agent introduced in the 1950s, has been almost completely replaced in modern anesthesia practice by newer agents because of its shortcomings. Partly because of its side effects, enflurane never gained widespread popularity.
In theory, any inhaled anesthetic agent can be used for induction of general anesthesia. However, most of the halogenated anesthetics are irritating to the airway, perhaps leading to coughing, laryngospasm and overall difficult inductions. For this reason, the most frequently used agent for inhalational induction is sevoflurane . All of the volatile agents can be used alone or in combination with other medications to maintain anesthesia (nitrous oxide is not potent enough to be used as a sole agent).
Volatile agents are frequently compared in terms of potency, which is inversely proportional to the minimum alveolar concentration. Potency is directly related to lipid solubility. This is known as the Meyer-Overton hypothesis. However, certain pharmacokinetic properties of volatile agents have become another point of comparison. Most important of those properties is known as the blood:gas partition coefficient. This concept refers to the relative solubility of a given agent in blood. Those agents with a lower blood solubility (i.e., a lower blood–gas partition coefficient; e.g., desflurane) give the anesthesia provider greater rapidity in titrating the depth of anesthesia, and permit a more rapid emergence from the anesthetic state upon discontinuing their administration. In fact, newer volatile agents (e.g., sevoflurane, desflurane) have been popular not due to their potency (minimum alveolar concentration), but due to their versatility for a faster emergence from anesthesia, thanks to their lower blood–gas partition coefficient.
The two barbiturates mentioned above, thiopental and methohexital, are ultra-short-acting, and are used to induce and maintain anesthesia. However, though they produce unconsciousness, they provide no analgesia (pain relief) and must be used with other agents. Benzodiazepines can be used for sedation before or after surgery and can be used to induce and maintain general anesthesia. When benzodiazepines are used to induce general anesthesia, midazolam is preferred. Benzodiazepines are also used for sedation during procedures that do not require general anesthesia. Like barbiturates, benzodiazepines have no pain-relieving properties. Propofol is one of the most commonly used intravenous drugs employed to induce and maintain general anesthesia. It can also be used for sedation during procedures or in the ICU. Like the other agents mentioned above, it renders patients unconscious without producing pain relief. Because of its favourable physiological effects, "etomidate has been primarily used in sick patients". Ketamine is infrequently used in anesthesia practice because of the unpleasant experiences which sometimes occur upon emergence from anesthesia, which include "vivid dreaming, extracorporeal experiences, and illusions. However, like etomidate it is frequently used in emergency settings and with sick patients because it produces fewer adverse physiological effects. Unlike the intravenous anesthetic drugs previously mentioned, ketamine produces profound pain relief, even in doses lower than those which induce general anesthesia. Also unlike the other anesthetic agents in this section, patients who receive ketamine alone appear to be in a cataleptic state, unlike other states of anesthesia that resemble normal sleep. Ketamine-anesthetized patients have profound analgesia but keep their eyes open and maintain many reflexes.
The following agents have longer onset and duration of action and are frequently used for post-operative pain relief:
Another potentially disturbing complication where neuromuscular blockade is employed is 'anesthesia awareness'. In this situation, patients paralyzed may awaken during their anesthesia, due to an inappropriate decrease in the level of drugs providing sedation and/or pain relief. If this fact is missed by the anaesthesia provider, the patient may be aware of his surroundings, but be incapable of moving or communicating that fact. Neurological monitors are becoming increasingly available which may help decrease the incidence of awareness. Most of these monitors use proprietary algorithms monitoring brain activity via evoked potentials. Despite the widespread marketing of these devices many case reports exist in which awareness under anesthesia has occurred despite apparently adequate anesthesia as measured by the neurologic monitor.