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Editors: Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.

;
Stock, M. Christine
Title: Clinical Anesthesia, 6th Edition
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1.AnesthesIology.2.AnesthesIa..8arash,PaulC.
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10987654J21
Editors: Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.;
Stock, M. Christine
Title: Clinical Anesthesia, 6th Edition
CopyrIght2009LIppIncottWIllIamsEWIlkIns
Frontof8ookEdItors
Edited By
Paul G. Barash MD
Professor
0epartmentofAnesthesIology,YaleUnIversItySchoolof|edIcIne;AttendIng
AnesthesIologIst,YaleNewHavenHospItal,NewHaven,ConnectIcut
Bruce F. Cullen MD
EmerItusProfessor
0epartmentofAnesthesIology,UnIversItyofWashIngton,Seattle,WashIngton
Robert K. Stoelting MD
EmerItusProfessorandPastChaIr
0epartmentofAnesthesIa,ndIanaUnIversItySchoolof|edIcIne,ndIanapolIs,ndIana
Michael K. Cahalan MD
ProfessorandChaIr
0epartmentofAnesthesIology,TheUnIversItyofUtahSchoolof|edIcIne,SaltLakeCIty,
Utah
M. Christine Stock MD
ProfessorandChaIr
0epartmentofAnesthesIology,NorthwesternUnIversItyFeInbergSchoolof|edIcIne,
ChIcago,llInoIs
Contributing Authors
J. Jeffrey Andrews MD
ProfessorandChaIr
0epartmentofAnesthesIology,UnIversItyofTexasHealthScIenceCenter,SanAntonIo,San
AntonIo,Texas
Shamsuddin Akhtar MBBS
AssocIateProfessor
0epartmentofAnesthesIology,YaleUnIversItySchoolof|edIcIne,AttendIngPhysIcIan,
YaleNewHavenHospItal,NewHaven,ConnectIcut
Michael L. Ault MD, FCCP, FCCM
AssIstantProfessor
0epartmentofAnesthesIology,NorthwesternUnIversItyFeInbergSchoolof|edIcIne;
AssocIateChIef,SectIonofCrItIcalCare|edIcIne,Northwestern|emorIalHospItal,
ChIcago,llInoIs
Douglas R. Bacon MD
Professor
0epartmentofAnesthesIology,|ayoClInIc,Fochester,|Innesota
Paul G. Barash MD
Professor
0epartmentofAnesthesIology,YaleUnIversItySchoolof|edIcIne;AttendIng
AnesthesIologIst,YaleNewHavenHospItal,NewHaven,ConnectIcut
Honorio T. Benzon MD
Professor
0epartmentofAnesthesIology,NorthwesternUnIversIty,FeInbergSchoolof|edIcIne;
ChIef,0IvIsIonofPaIn|edIcIne,Northwestern|emorIalHospItal,ChIcago,llInoIs
Christopher M. Bernards MD
AnesthesIologyFaculty
0epartmentofAnesthesIology,7IrgInIa|ason|edIcal,Seattle,WashIngton
Arnold J. Berry MD, MPH
Professor
0epartmentofAnesthesIology,EmoryUnIverIstySchoolof|edIcIne,EmoryUnIversIty
HospItal,0epartmentofAnesthesIology,Atlanta,CeorgIa
David R. Bevan MB
Professor
0epartmentofAnesthesIology,UnIversItyofToronto,UnIversItyHealthNetwork,Toronto,
DntarIo,Canada
Barbara W. Brandom MD
Professor
0epartmentofAnesthesIology,UnIversItyofPIttsburgh|edIcalCenter;AttendIng
AnesthesIologIst,ChIldren'sHospItalofPIttsburgh,PIttsburgh,PennsylvanIa
Ferne R. Braveman MD, CM
Professor
0epartmentofAnesthesIology,YaleUnIversItySchoolof|edIcIne;ChIef,SectIonof
DbstetrIcalAnesthesIology;AttendIngPhysIcIan,YaleNewHavenHospItal,NewHaven,
ConnectIcut
Russell C. Brockwell MD
AnesthesIaAssocIatesofNaples
Naples,FlorIda
Sorin J. Brull MD
Professor
0epartmentofAnesthesIology,|ayoClInIcCollegeof|edIcIne,|ayoClInIcHospItal,
JacksonvIlle,FlorIda
Michael K. Cahalan MD
ProfessorandChaIr
0epartmentofAnesthesIology,TheUnIversItyofUtahSchoolof|edIcIne,SaltLakeCIty,
Utah
Levon M. Capan MD
ProfessorofAnesthesIology;7IceChaIrforPromotIon
NewYorkUnIversItySchoolof|edIcIne;AssocIate0IrectorofAnesthesIaServIce,8ellevue
HopItalCenter,NewYork,NewYork
C. Richard Chapman PhD
0Irector
PaInFesearchCenter,0epartmentofAnesthesIology,UnIverIstyofUtahSchool,SaltLake
CIty,Utah
Amalia Cochran MD
AssIstantProfessor;AdjunctAssIstantProfessorofPedIatrIcs
0epartmentofSurgery,UnIversItyofUtah,SaltLakeCIty,Utah
Barbara A. Coda MD
StaffAnesthesIologIst
ThreeFIversAnesthesIa,DregonUrologynstItute,SprIngfIeld,Dregon
Edmond Cohen MD
ProfessorofAnesthesIology
The|ountSInaISchoolof|edIcIne;0IrectorofThoracIcAnesthesIa,The|ountSInaI
|edIcalCenter,NewYork,NewYork
Joseph P. Cravero MD
AssocIateProfessorofAnesthesIology
0artmouthHItchcock|edIcalCenter,Lebanon,NewHampshIre
C. Michael Crowder MD, PhD
AssocaIateProfessorofAnesthesIologyand|olecular8Iology/Pharmacology
WashIngtonUnIversItySchoolof|edIcIne,8arnesJewIshHospItal,St.LouIs,|IssourI
Marie Csete MD, PhD
AssocIateProfessor
0epartmentofAnesthesIology,EmoryUnIversIty,Atlanta,CeorgIa
Bruce F. Cullen MD
EmerItusProfessor
0epartmentofAnesthesIology,UnIversItyofWashIngton,Seattle,WashIngton
Steven Deem MD
AssocIateProfessor
0epartmentofAnesthesIologyand|edIcIne,UnIversItyofWashIngton;AssocIate0Irector,
NeurocrItIcalCareServIce,HarborvIew|edIcalCenter,Seattle,WashIngton
Timothy R. Deer MD
ClInIcalProfessor
0epartmentofAnesthesIology,West7IrgInIaUnIversItySchoolof|edIcIne,TheCenterfor
PaInFelIef,nc.,Charleston,West7IrgInIa
Stephen F. Dierdorf MD
Professorand7IceChaIr
0epartmentofAnesthesIa,ndIanaUnIversItySchoolof|edIcIne,ndIanapolIs,ndIana
Karen B. Domino MD, MPH
Professor
0epartmentofAnesthesIology,UnIversItyofWashIngtonSchoolof|edIcIne,Seattle,
WashIngton
Francois Donati MD, PhD, FRCPC
Professor
0epartmentofAnesthesIology,UnIversItyof|ontreal,HospItal|aIsonneuveFosemont,
|ontreal,Quebec,Canada
Michael B. Dorrough MD
FesIdentPhysIcIan
0epartmentofAnesthesIology,UnIversItyofUtahSchoolof|edIcIne,UnIversItyHealth
Care,SaltLakeCIty,Utah
John C. Drummond MD, FRCPC
ProfessorofAnesthesIology
TheUnIversItyofCalIfornIa,San0Iego;StaffAnesthesIologIst,7A|edIcalCenter,San
0Iego,San0Iego,CalIfornIa
Randal O. Dull MD, PhD
AssocIateProfessor
0epartmentofAnesthesIology,UnIversItyofUtah,SaltLakeCIty,Utah
Thomas J. Ebert MD, PhD
ProfessorofAnesthesIology;Program0Irector
|edIcalCollegeofWIsconsIn,7A|edIcalCenter,112A,|Ilwaukee,WIsconsIn
Jan Ehrenwerth MD
Professor
0epartmentofAnesthesIology,YaleUnIversItySchoolof|edIcIne,YaleNewHaven
HospItal,NewHaven,ConnectIcut
John H. Eichhorn MD
Professor
0epartmentofAnesthesIology,UnIversItyofKentuckyCollegeof|edIcIne,UnIverIstyof
Kentucky|edIcalCenter,LexIngton,Kentucky
James B. Eisenkraft MD
Professor
0epartmentofAnesthesIology,The|ountSInaISchoolof|edIcIne;AttendIng
AnesthesIologIst,The|ountSInaIHospItal,NewYork,NewYork
John E. Ellis MD
AdjunctProfessor
0epartmentofAnesthesIologyandCrItIcalCare,UnIversItyofPennsylvanIaSchoolof
|edIcIne,PhIladelphIa,PennsylvanIa
Matthew Eng MD
0epartmentofAnesthesIology
UnIversItyofTexasSouthwestern,0allas,Texas0epartmentofAnesthesIology,Cedars
SInaI|edIcalCenter,LosAngeles,CalIfornIa
Alex S. Evers MD
HenryE.|allInckrodtProfessorandChaIr
0epartmentofAnesthesIology,WashIngtonUnIversItySchoolof|edIcIne,AnesthesIologIst
InChIef,8arnesJewIshHospItal,St.LouIs,|IssourI
Lynne R. Ferrari MD
AssocIateProfessorofAnesthesIology
0epartmentofAnesthesIology,Harvard|edIcalSchool;ChIef,PerIoperatIveAnesthesIa,
TheChIldren'sHospItal,8oston,|assachusetts
Scott M. Fishman MD
ChIef,0IvIsIonofPaIn|edIcIne;ProfessorofClInIcalAnesthesIology
0epartmentofAnesthesIologyandPaIn|edIcIne,UnIversItyofCalIfornIa,0avIs,EllIson
AmbulatoryCareCenter,Sacramento,CalIfornIa
Michael A. Fowler MD, MBA
AssocIateProfessor
0epartmentofAnesthesIology,7IrgInIaCommonwealthUnIversIty;0Irector,Post
AnesthesIaCareUnIt,7IrgInIaCommonwealth|edIcalCenter,FIchmond,7IrgInIa
J. Sean Funston MD
AssIstantProfessor
0epartmentofAnesthesIology,UnIversItyofTexas|edIcal8ranch,Calveston,Texas
Steven I. Gayer MD, MBA
AssocIateProfessor
0epartmentsofAnesthesIologyandDphthalmology,UnIversItyof|IamI|IllerSchoolof
|edIcIne,8ascomPalmerEyenstItute,|IamI,FlorIda
Ronald George MD, FRCP
0epartmentofAnesthesIology
0ukeUnIversIty|edIcalCenter,0urham,NorthCarolIna
Kathryn Glas MD, FASE, MBA
AssocIateProfessor
0epartmentofAnesthesIology,EmoryUnIversItySchoolof|edIcIne;Co0Irector,
CardIothoracIcAnesthesIology,CrawfordLongHospItal,Atlanta,CeorgIa
Alexander W. Gotta MD
EmerItusProfessorofAnesthesIology
StateUnIversItyofNewYork,0ownstate|edIcalCenter,8rooklyn,NewYork
Loreta Grecu MD
AssIstantProfessor
0epartmentofAnesthesIology,YaleUnIversIty;AttendIngPhysIcIan,YaleNewHaven
HospItal,NewHaven,ConnectIcut
Steven B. Greenberg MD
AssIstantProfessor
0epartmentofAnesthesIology,NorthShoreUnIversItyHealthSystem,Evanston,llInoIs
Dhanesh K. Gupta MD
AssocIateProfessor
0epartmentofAnesthesIologyandNeurologIcalSurgery,NorthwesternUnIversItyFeInberg
Schoolof|edIcIne,Northwestern|emorIalHospItal,ChIcago,llInoIs
Steven C. Hall MD
ArthurC.KIngProfessorofPedIatrIcAnesthesIa
0epartmentofAnesthesIology,NorthwesternUnIversItyFeInbergSchoolof|edIcIne;
AnesthesIologIstInChIef,0epartmentofPedIatrIcAnesthesIa,ChIldren's|emorIal
HospItal,ChIcago,llInoIs
Tara M. Hata MD
ClInIcalAssocIateProfessor
0epartmentofAnesthesIa,CarverCollegeof|edIcIne,UnIversItyofowa,UnIversItyof
owaHospItalsandClInIcs,owaCIty,owa
Laurence M. Hausman MD
AssocIateProfessor
0epartmentofAnesthesIology,|ountSInaISchoolof|edIcIne,|ountSInaI|edIcalCenter,
NewYork,NewYork
Thomas K. Henthorn MD
ProfessorandChaIr
0epartmentofAnesthesIology,UnIversItyofColorado,0enver,UnIversItyofColorado
HospItal,Aurora,Colorado
Simon C. Hillier MB, ChB
0epartmentofAnesthesIa
SectIonofPedIatrIcAnesthesIaandCrItIcalCare,ndIanaUnIversItySchoolof|edIcIne,
ndIanapolIs,ndIana
Harriet W. Hopf MD
Professor
0epartmentofAnesthesIology,UnIversItyofUtahSchoolof|edIcIne,UnIversItyHealth
Care,SaltLakeCIty,Utah
Terese T. Horlocker MD
Professor
0epartmentsofAnesthesIologyandDrthopedIcs,|ayoClInIcCollegeof|edIcIne,
Fochester,|Innesota
Robert W. Hurley MD, PhD
AssIstantProfessor
0epartmentofAnesthesIologyandCrItIcalCare,JohnsHopkInsUnIversIty,|edIcal
0Irector,PaInClInIc,JohnsHopkIns|edIcalnstItutIons,8altImore,|aryland
Adam K. Jacob MD, MS
Fellow
0epartmentofAnesthesIology,|ayoClInIc,Fochester,|Innesota
Joel O. Johnson MD, PhD
Fussell0.SheldonProfessorandChaIr
0epartmentofAnesthesIologyandPerIoperatIve|edIcIne,UnIversItyof|IssourI,|IssourI
UnIverIstyHealth,ColumbIa,|IssourI
Zeev N. Kain MD, MBA
ProfessorandChaIr
0epartmentofAnesthesIology,UnIversItyofCalIfornIa,rvIne,rvIne,CalIfornIa
John P. Kampine MD, PhD
ProfessorEmerItus
0epartmentofAnesthesIology,|edIcalCollegeofWIsconsIn,|Ilwaukee,WIsconsIn
Jonathan C. Katz MD
StaffAnesthesIologIst;PrIvatePractIce
PlantatIon,FlorIda
Jonathan D. Katz MD
ClInIcalProfessor
0epartmentofAnesthesIology,YaleUnIversItySchoolof|edIcIne,NewHaven,
ConnectIcut;AttendIngAnesthesIologIst,0epartmentofAnesthesIology,St.7Incent's
|edIcalCenter,8rIdgeport,ConnectIcut
Brian S. Kaufman MD
AssocIateProfessor
0epartmentsof|edIcIne,AnesthesIologyandNeurosurgery,NewYorkUnIversItySchoolof
|edIcIne;0IrectorofCrItIcalCare,NYULangone|edIcalCenter,NewYork,NewYork
M. Sean Kincaid MD
ClInIcalnstructor
0epartmentofAnesthesIology,UnIversItyofWashIngton;AttendIngPhysIcIan,0epartment
ofAnesthesIology,HarborvIew|edIcalCenter,Seattle,WashIngton
Sandra L. Kopp MD
AssIstantProfessor
0epartmentofAnesthesIology,|ayoClInIc,Fochester,|Innesota
Arthur M. Lam MD, FRCPC
AnesthesIologIstInChIef;0IrectorofCerebrovascularLaboratoryHarborvIew|edIcal
Center;ProfessorofAnesthesIologyandNeurologIcalSurgery
UnIversItyofWashIngton,Seattle,WashIngton
Thomas A. Lane MD
ProfessorofPathology
UnIversItyofCalIfornIa,San0Iego;|edIcal0Irector,UCS0TransfusIonServIcesandStem
CellProcessIngLab,San0Iego,CalIfornIa
Noel W. Lawson MD
Professor
0epartmentofAnesthesIology,UnIversItyof|IssourIColumbIa;StaffAnesthesIologIst,
UnIversItyof|IssourIColumbIaHospItalsandClInIcs,ColumbIa,|IssourI
Wilton C. Levine MD
nstructorInAnesthesIa
Harvard|edIcalSchool;AssIstantInAnesthesIa,0epartmentsofAnesthesIologyand
CrItIcalCare,|assachusettsCeneralHospItal,8oston,|assachusetts
Jerrold H. Levy MD, FAHA
Professorand0eputyChaIrforFesearch
0epartmentofAnesthesIology,EmoryUnIversItySchoolof|edIcIne;0Irectorof
CardIothoracIcAnesthesIologyandCrItIcalCare,EmoryHealthcare,Atlanta,CeorgIa
Adam D. Lichtman MD
AssIstantProfessorofAnesthesIology
0epartmentofAnesthesIology,WeIllCornell|edIcalCenter,NewYorkPresbyterIan
HospItal,NewYork,NewYork
J. Lance Lichtor MD
Professor
0epartmentofAnesthesIology,UnIversItyof|assachusetts|edIcalSchool,Worcester,
|assachusetts
Yi Lin MD, PhD
ClInIcalnstructorofAnesthesIology
0epartmentofAnesthesIology,WeIll|edIcalCollegeofCornellUnIversIty,AssIstant
AttendIngAnesthesIologIst,HospItalforSpecIalSurgery,NewYork,NewYork
Spencer S. Liu MD
ClInIcalProfessor
0epartmentofAnesthesIology,WeIll|edIcalCollegeofCornellUnIversIty,HospItalfor
SpecIalSurgery,NewYork,NewYork
David A. Lubarsky MD, MBA
Emanuel|.PapperProfessorandChaIr
0epartmentofAnesthesIology,PerIoperatIve|edIcIne,andPaIn|anagement,UnIversIty
of|IamI|IllerSchoolof|edIcIne,0epartmentofAnesthesIology,Jackson|emorIal
HospItal,|IamI,FlorIda
Stephen M. Macres PharmD, MD
0Irector,PostoperatIvePaInandFegIonalAnesthesIaServIce
ClInIcalProfessorofAnesthesIology,0epartmentofAnesthesIologyandPaIn|edIcIne,
UnIversItyofCalIfornIa,0avIs,Sacramento,CalIfornIa
Srinivas Mantha MD
ProfessorandSub0ean
0epartmentofAnesthesIologyandntensIveCare,NIzam'snstItuteof|edIcalScIences,
Hyderahad,ndIa
Joseph P. Mathew MD, MHSc
Professor
0epartmentofAnesthesIology,0ukeUnIversIty;ChIef,0IvIsIonofCardIothoracIc
AnesthesIology,0ukeUnIversIty|edIcalCenter,0urham,NorthCarolIna
Michael S. Mazurek MD
AssocIateProfessor
0epartmentofAnesthesIology,ndIanaUnIversItySchoolof|edIcIne,FIleyHospItalfor
ChIldren,ndIanapolIs,ndIana
Kathryn E. McGoldrick MD
ProfessorandChaIr
0epartmentofAnesthesIology,NewYork|edIcalCollege,Westchester|edIcalCenter,
7alhalla,NewYork
Sanford M. Miller MD
ClInIcalAssocIateProfessor
NewYorkUnIversItySchoolof|edIcIne;AssIstant0IrectorofAnesthesIology,8ellevue
HospItalCenter,NewYork,NewYork
Peter G. Moore MB, BS, PhD, FANZCA
ProfessorandChaIr
0epartmentofAnesthesIologyandPaIn|edIcIne,UnIversItyofCalIfornIa,0avIs,UnIversIty
ofCalIfornIa,0avIs|edIcalCenter,Sacramento,CalIfornIa
John R. Moyers MD
Professor
0epartmentofAnesthesIa,CarverCollegeof|edIcIne,UnIversItyofowa,UnIversItyof
owaHopsItalsandClInIcs,owaCIty,owa
Holly Muir MD
AssIstantProfessor
0epartmentofAnesthesIology,0ukeUnIversIty|edIcalCenter,0urham,NorthCarolIna
Glenn S. Murphy MD
NorthShoreUnIversItyHealthSystem
Evanston,llInoIs
Michael J. Murray MD, PhD
Professor
0epartmentofAnesthesIology,|ayoClInIcCollegeof|edIcIne,|ayoClInIcHospItal,
JacksonvIlle,FlorIda
Steven M. Neustein MD
AssocIateProfessor
0epartmentofAnesthesIology,The|ountSInaISchoolof|edIcIne,|ountSInaIHospItal,
NewYork,NewYork
E. Andrew Ochroch MD, MSCE
AssocIateProfessorofAnesthesIologyandCrItIcalCare
0IrectorofClInIcalFesearch;0IrectorofThoracIcAnesthesIology,UnIversItyof
PennsylvanIaHealthSystem,PhIladelphIa,PennsylvanIa
Babatunde O. Ogunnaike MD
AssocIateProfessor
0epartmentofAnesthesIologyandPaIn|anagement,UnIversItyofTexasSouthwestern
|edIcalCenter;ChIefofAnesthesIaServIces,ParklandHealthandHospItalSystem,0allas,
Texas
Charles W. Otto MD, FCCM
Professor
0epartmentofAnesthesIology,UnIversItyofArIzonaCollegeof|edIcIne,ArIzonaHealth
ScIencesCenter,Tucson,ArIzona
Nathan Leon Pace MD, Mstat
Professor
0epartmentofAnesthesIology,UnIversItyofUtah,SaltLakeCIty,Utah
Paul S. Pagel MD, PhD
Professor
0epartmentofAnesthesIology,|edIcalCollegeofWIsconsIn;StaffAnesthesIologIst,
0epartmentofAnesthesIaandSpecIalCare,ZablockI7A|edcIalCenter,|Ilwaukee,
WIsconsIn
Albert C. Perrino Jr. MD
Professor
0epartmentofAnesthesIology,YaleUnIversItySchoolof|edIcIne;AttendIngPhysIcIan,
YaleNewHavenHospItal,NewHaven,ConnectIcut
Charise Petrovitch MD
ClInIcalProfessor
0epartmentofAnesthesIaandClInIcalCare|edIcIne,CeorgeWashIngtonUnIversIty
HospItal;ChIef,AnesthesIaSectIon,7A|edIcalCenter,WashIngton,0C
Mihai V. Podgoreanu MD, FASE
AssocIateProfessor
0epartmentofAnesthesIology,0ukeUnIversIty;0Irector,PerIoperatIbeCenomIcsProgram,
0ukeUnIversIty|edIcalCenter,0urham,NorthCarolIna
Wanda M. Popescu MD
AssIstantProfessorofAnesthesIology
0epartmentofAnesthesIology,YaleUnIversItySchoolof|edIcIne;AttendIngPhysIcIan,
YaleNewHavenHospItal,NewHaven,ConnectIcut
Karen L. Posner PhD
FesearchProfessor
0epartmentofAnesthesIology,UnIversItyofWashIngton,Seattle,WashIngton
Donald S. Prough MD
Professor,andChaIr
0epartmentofAnesthesIology,UnIversItyofTexas|edIcal8ranch,Calveston,Texas
Kevin T. Riutort MD
ChIefFesIdent
0epartmentofAnesthesIology,|ayoClInIc,|ayoClInIcHospItal,JacksonvIlle,FlorIda
J. David Roccoforte MD
AssIstantProfessor
0epartmentofAnesthesIology,NewYorkUnIversItySchoolof|edIcIne,NewYork,New
York
Michael F. Roizen MD
Professor
0IvIsIonofAnesthesIology,CrItIcalCare|edIcIneandComprehensIvePaIn|anagement;
ChaIr,WellnessnstItute,ClevelandClInIcalFoundatIon,Cleveland,DhIo
G. Alec Rooke MD, PhD
7IsItIngProfessor
0epartmentofAnesthesIology,8ethsrael0eaconess|edIcalCenter,Harvard|edIcal
School,8oston,|assachusetts;Professor,0epartmentofAnesthesIologyandCrItIcalCare,
UnIversItyofWashIngton,UnIversItyofWashIngton|edIcalCenter,Seattle,WashIngton
Stanley H. Rosenbaum MD
Professor
0epartmentofAnesthesIology,YaleUnIversItySchoolof|edIcIne;AttendIngPhysIcIan,
YaleNewHavenHospItal,NewHaven,ConnectIcut
Henry Rosenberg MD, CPE
0Irector
0epartmentof|edIcalEducatIonandClInIcalFesearch,SaInt8arnabas|edIcalCenter,
LIvIngston,NewJersey
Meg A. Rosenblatt MD
AssocIateProfessor
0epartmentofAnesthesIology,|ountSInaISchoolof|edIcIne,NewYork,NewYork
William H. Rosenblatt MD
Professor
0epartmentofAnesthesIology,YaleUnIversItySchoolof|edIcIne;AttendIngPhysIcIan,
YaleNewHavenHospItal,NewHaven,ConnectIcut
Richard W. Rosenquist MD
Professor
0epartmentofAnesthesIa,UnIversItyofowa;0Irector,PaIn|edIcIne0IvIsIon,UnIversIty
ofowaHospItal,owaCIty,owa
Carl E. Rosow MD, PhD
Professor
0epartmentofAnesthesIaandCrItIcalCare,Harvard|edIcalSchool,|assachusetts
CeneralHospItal,8oston,|assacusetts
Nyamkhishig Sambuughin PhD
AssIstantProfessor
0epartmentofAnesthesIology,UnIformedServIcesUnIversIty,8ethesda,|aryland
Alan C. Santos MD, MPH
ChaIrmanofAnesthesIology
DchsnerClInIcFoundatIon,NewDrleans,LouIsIana
Barbara M. Scavone MD
AssocIateProfessor
0epartmentofAnesthesIology,NorthwesternUnIversItyFeInbergSchoolof|edIcIne,
Northwestern|emorIalHospItal,ChIcago,llInoIs
Philliip G. Schmid MD
0epartmentofAnesthesIology
St.AlphonsusFegIonal|edIcalCenter,8oIse,daho
Jeffrey J. Schwartz MD
AssocIateProfessor
0epartmentofAnesthesIology,YaleUnIversItySchoolof|edIcIne;AttendIngPhysIcIan,
YaleNewHavenHospItal,NewHaven,ConnectIcut
Harry A. Seifert MD
AdjunctAssIstantProfessorofClInIcalAnesthesIology
0epartmentofAnesthesIologyandCrItIcalCare,TheChIldren'sHospItalofPhIladelphIa,
PhIladelphIa,PennsylvanIa
Aarti Sharma MD
AssIstantProfessor
0epartmentofAnesthesIology,WeIllCornell|edIcalCenter,NewYorkPresbyterIan
HospItal,NewYork,NewYork
Andrew Shaw BSc, MBBS, FRCA, FCCM
AssocIateProfessor
0epartmentofAnesthesIology,0ukeUnIversIty;AttendIngAnesthesIologIst,0ukeUnIversIty
|edIcalCenter,0urham,NorthCarolIna
Nikolaos J. Skubas MD, FASE
AssocIateProfessor
0epartmentofAnesthesIology,WeIllCornell|edIcalCollege;AssocIateAttendIng,New
YorkHospItalWeIllCornell|edIcalCenter,NewYork,NewYork
Hugh M. Smith MD, PhD
nstructor
0epartmentofAnesthesIology,|ayoClInIcCollegeof|edIcIne,|ayoClInIc,Fochester,
|Innesota
Karen J. Souter BBS, FRCA
AssocIateProfessor
0epartmentofAnesthesIologyandPaIn|edIcIne,UnIversItyofWashIngton,Seattle,
WashIngton
Bruce D. Spiess MD, FAHA
ProfessorofAnesthesIologyandEmergency|edIcIne;0Irectorof7IrgInIaCommonwealth
UnIversItyFeanImatIon
EngIneerIngShockCenter,7IrgInIaCommonwealthUnIversIty|edIcalCenter,FIchmond,
7IgInIa
Mark Stafford-Smith MD, CM, FRCP, FASE
Professor
0epartmentofAnesthesIology,0ukeUnIversIty|edIcalCenter,0urham,NorthCarolIna
M. Christine Stock MD
Professor
0epartmentofAnesthesIology,NorthwesternUnIversItyFeInbergSchoolof|edIcIne,
Northweston|emorIalHospItal,ChIcago,llInoIs
Robert K. Stoelting MD
EmerItusProfessorandPastChaIr
0epartmentofAnesthesIa,ndIanaUnIversItySchoolof|edIcIne,ndIanapolIs,ndIana
Karen J. Souter BBS, FRCA
AssocIateProfessor
0epartmentofAnesthesIologyandPaIn|edIcIne,UnIversItyofWashIngton,Seattle,
WashIngton
David F. Stowe MD, PhD
Professor
0espartmentofAnesthesIologyandPhysIology,|edIcalCollegeofWIsconsIn,Froedtert
HospItalEZablockI7A|edIcalCenter,|IlwaukeeFegIonal|edIcalCenter,|Ilwaukee,
WIsconsIn
Wariya Sukhupragarn MD, FRCAT
AssIstantProfessor
0epartmentofAnesthesIology,ChIang|aIUnIversIty,|aharajNakornChIang|aIHospItal,
ChIang|aI,ThaIland;FesearchFellowInAIrway|anagement,0epartmentof
AnesthesIology,YaleUnIversItySchoolof|edIcIne,YaleNewHavenHospItal,NewHaven,
ConnectIcut
Santhanam Suresh MD
Professor
0epartmentofAnesthesIology,NorthwesternUnIversItyFeInbergSchoolof|edIcIne,
ChIldren's|emorIalHospItal,ChIcago,llInoIs
Christer H. Svensn MD, PhD, DEAA, MBA
AssocIateProfessor
0epartmentofAnesthesIology,WeIll|edIcalCollegeofCornellUnIversIty,NewYork
PresbyterIanHospItal,NewYork,NewYork
Stephen J. Thomas MD
TopkIn7anPoznakProfessorand7IceChaIrman
0epartmentofAnesthesIology,WeIll|edIcalCollegeofCornellUnIversIty,NewYork
PresbyterIanHospItal,NewYork,NewYork
Miriam M. Treggiari MD, PhD, MPH
AssocIateProfessor
0epartmentofAnesthesIologyandPaIn|edIcIne,UnIversItyofWashIngton,HarborvIew
|edIcalCenter,Seattle,WashIngton
Ban Tsui BSc, MSc, MD, FRCPC
Professor
0epartmentofAnesthesIologyandPaIn|edIcIne,UnIversItyofAlberta;0Irector,FegIonal
AnesthesIaandPaInServIce,UnIversItyofAlbertaHospItal,StolleryChIldren'sHospItal,
Edmonton,Alberta,Canada
Jeffrey S. Vender MD, FCCM, FCCP
0epartmentofAnesthesIology
NorthShoreUnIversItyHealthSystem,Evanston,llInoIs
J. Scott Walton MD
AssocIateProfessor
0epartmentofAnesthesIaandPerIoperatIve|edIcIne,|edIcalUnIversItyofSouth
CarolIna,Charleston,SouthCarolIna
Mark A. Warner MD
Professor
0epartmentofAnesthesIology,|ayoClInIc,Fochester,|Innesota
Denise J. Wedel MD
Professor
0epartmentofAnesthesIology,|ayoClInIcCollegeof|edIcIne,Fochester,|Innesota
Paul F. White PhD, MD
ProfessorandHolderofthe|argaret|Ilam|c0ermott;0IstInguIshedChaIrIn
AnesthesIology
0epartmentofAnesthesIologyEPaIn|anagement,UnIversItyofTexasSouthwestern
|edIcalCenter,0allas,Texas
Charles W. Whitten MD
ProfessorandChaIr
0epartmentofAnesthesIologyandPaIn|anagement,UnIversItyofTexasSouthwestern
|edIcalCenter,0allas,Texas
Scott W. Wolf MD
AssIstantProfessor
0epartmentofAnesthesIology,NorthwesternUnIversItyFeInbergSchoolof|edIcIne,
Northwestern|emorIalHospItal,ChIcago,llInoIs
Cynthia A. Wong MD
AssocIateProfessor
0epartmentofAnesthesIology,NorthwesternUnIversItyFeInbergSchoolof|edIcIne;
|edIcal0IrectorofDbstetrIcAnesthesIa,Northwestern|emorIalHospItal,ChIcago,llInoIs
James R. Zaidan MD, MBA
ProfessorandChaIr
0epartmentofAnesthesIology,EmoryUnIversItyHospItal,Atlanta,CeorgIa
Editors: Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.;
Stock, M. Christine
Title: Clinical Anesthesia, 6th Edition
CopyrIght2009LIppIncottWIllIamsEWIlkIns
Frontof8ookPreface
Preface
WelcometothesIxthedItIonofClinical Anesthesia.ThepublIcatIonofthIsedItIonoccurs
atatImeofgreatclInIcal,educatIonal,andresearchadvances.AtnotImeInour
specIalty'shIstoryIstheobservatIonmoretruethatthemajorachIevementsInsurgery
couldnotoccurwIthouttheaccompanyIngvIsIonofskIllfulanesthesIologIsts.EverydayIn
operatIngroomsaroundtheworldanesthesIologIstsarechallengedtomeetexemplary
levelsofclInIcalcarewhIleensurIngthehIghestlevelofpatIentsafety.Tomeetthese
needsneweducatIonalparadIgmsarebeIngemployedwhIchrequIreeducatIonInavarIety
offormatsandsettIngs.
TheprImegoalofClinical AnesthesiafromItsInceptIonhasbeen:
TodevelopatextbookthatsupportseffIcIentandrapIdacquIsItIonofknowledge.
TheedItorshaveemployedavarIetyofeducatIonalmethodstoachIevethIsobjectIve
makIngClinical Anesthesia,InrealIty,aserIesofInterconnectedpublIcatIonsusIngthe
prIntedword,electronIcmedIum,andthenternet.DureffortshavebeenrecognIzedwIth
numerousInternatIonalawards.WIththepublIcatIonofeachedItIon,wetrytodevelop
InnovatIveandcontemporarywaystodIssemInateknowledgetoourreader.WIththIs
edItIon,wearethefIrstanesthesIatexttousepodcastIngasoneofthenewestmethodsto
rapIdlytransmItclInIcallyrelevantInformatIon,whIlealsoassIstIngpractIonerswhoare
preparIngfor8oardexamInatIonsandrecertIfIcatIon.
StartIngwIththecover,youwIllseemajorchangesInthetextbook.0rs.|.ChrIstIneStock
and|IchaelK.CahalanhavejoInedtheEdItors.8othChrIsand|IkebrIngtheIrunIque
talentstoenhanceourabIlItytodelIveraforwardlookIngclInIcaltextthatenhances
acquIsItIonofclInIcallyImportantInformatIonandalIgnschaptercontentwIth
contemporaryeducatIonalgoals.0r.FobertStoeltIngwIllassumeEdItorEmerItusstatus.
8obIsInstrumentalInthesuccessoftheClinical AnesthesiaserIes.HIswrItIngandedItIng
capabIlItIesarelegendary.TheedItorshavebenefItedenormouslyfromhIsInsIghtsInto
modernanesthesIa,aswellashIshandsonapproachtothelogIstIcallycomplextaskof
edItorIalsupervIsIon.
DncethebookIsopened,thereaderwIllbeabletoapprecIateaunIfIedgraphIcformat.All
IllustratIonsandgraphIcsarepresentedtoaugmenttheeducatIonalexperIenceandrapIdly
transmItImportantInformatIon.naddItIon,toareorderedtableofcontents,twonew
chaptershavebeenadded:Inflammation, Wound Healing and Infection,and
Echocardiography.ApproxImatelyathIrdofthecontrIbutorsarenewtothIsedItIon,
IncorporatIngafreshpoIntofvIewtoImportantchaptercontent.Wehaveencouraged
contrIbutorstodevelopclInIcallyrelevantthemesandprIorItIzevarIousclInIcaloptIons
consIderedbymanytobethedefInItIvestrengthofprevIousedItIons.
WerealIzethatredundancIesmayexIstInabookofthIssIze.TheedItorshavetakenevery
opportunItytoreducerepetItIonorevendIsagreementbetweenchapters.However,
clInIcalproblemsaremanageddIfferentlybypractIoners,sothIsdIversItyofapproach
servestoenrIchtheeducatIonalexperIence.
WewIshtoexpressourapprecIatIontoallourcontrIbutorswhoseknowledge,hardwork,
dedIcatIonandtImelysubmIssIonshaveallowedustomaIntaInqualItywhIleworkIngwIth
atIghtproductIonschedule.DurreadershavealsobeenInstrumentalInprovIdIng
commentsthatallowtheedItorstocontInuallyImproveClinical Anesthesiatomeetthe
needsofouraudIence.0r.JorgeCalvezdeservesspecIalrecognItIonforhIsenormous
InputonthelogIstIcalmanagementofourpodcastIngproject.WealsothankChrIstopher
CambIc,|0whoproofreadfordetaIls,aswellasouradmInIstratIveassIstantsCaIlNorup,
FubyWIlson,0eannaWalker,and7IctorIaFamos.WewouldlIketothankouredItorsat
LIppIncottWIllIamsEWIlkInsWoltersKluwer,8rIan8rownandLIsa|cAllIster,fortheIr
commItmenttoexcellence.FInally,weoweadebtofgratItudetoNIcole0ernoskI
|anagIngEdItoratLWW,ChrIs|IllerProductIon|anageratAptara,AngelaPanetta
|arketIngatLWW,andEdSchultes,Jr.|edIaAssIstantatLWWwhosedaytoday
managementofthIsendeavorresultedInapublIcatIonthatexceededtheEdItor's
expectatIons.
Paul G. Barash MD
Bruce F. Cullen MD
Robert K. Stoelting MD
Michael K. Cahalan MD
M. Christine Stock MD
Editors: Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.;
Stock, M. Christine
Title: Clinical Anesthesia, 6th Edition
CopyrIght2009LIppIncottWIllIamsEWIlkIns
TableofContentsSectIonntroductIontoAnesthesIologyChapter1TheHIstoryofAnesthesIa
Chapter1
The History of Anesthesia
Adam K. Jacob
Sandra L. Kopp
Douglas R. Bacon
Hugh M. Smith
Key Points
1. Anesthesiology is a young specialty historically, especially when
compared with surgery or internal medicine.
2. Discoveries in anesthesiology have taken decades to build upon the
observations and experiments of many people, and in some instances
we are still searching. For example, the ideal volatile anesthetic has
yet to be discovered.
3. Regional anesthesia is the direct outgrowth of a chance observation
by an intern who would go on to become a successful
ophthalmologist.
4. Pain medicine began as an outgrowth of regional anesthesia.
5. Much of our current anesthesia equipment is the direct result of
anesthesiologists being unhappy with and needing better tools to
properly anesthetize patients.
6. Many safety standards have been established through the work of
anesthesiologists who were frustrated by the status quo.
7. Organizations of anesthesia professionals have been critical in
establishing high standards in education and proficiency, which in
turn has defined the specialty.
8. Respiratory critical care medicine started as the need by
anesthesiologists to use positive pressure ventilation to help polio
victims.
9. Surgical anesthesia and physician specialization in its administration
have allowed for increasingly complex operations to be performed on
increasingly ill patients.
SurgerywIthoutadequatepaIncontrolmayseemcrueltothemodernreader,andIn
contemporarypractIcewearepronetoforgettherealItIesofpreanesthesIasurgery.Fanny
8urney,awellknownlIteraryartIstfromtheearly19thcentury,descrIbedamastectomy
sheenduredafterreceIvIngawInecordIalashersoleanesthetIc.Assevenmale
assIstantsheldherdown,thesurgerycommenced:Whenthedreadfulsteelwasplunged
IntothebreastcuttIngthroughveInsarterIesfleshnervesneedednoInjunctIonnotto
restraInmycrIes.beganascreamthatlastedunIntermIttentlydurIngthewholetImeof
theIncIsIonEalmostmarvelthatItrIngsnotInmyEarsstIll!SoexcrucIatIngwasthe
agony.DhHeaven!thenfelttheknIferackIngagaInstthebreastbonescrapIngIt!ThIs
performedwhIleyetremaInedInutterlyspeechlesstorture.
1
8urney'sdescrIptIon
IllustratesthedIffIcultyofoverstatIngtheImpactofanesthesIaonthehumancondItIon.
AnepItaphonamonumenttoWIllIamThomasCreen|orton,oneofthefoundersof
anesthesIa,summarIzesthecontrIbutIonofanesthesIa:8EFDFEWHD|InalltImeSurgery
wasAgony.
2
AlthoughmosthumancIvIlIzatIonsevolvedsomemethodfordImInIshIng
patIentdIscomfort,anesthesia,InItsmodernandeffectIvemeanIng,IsacomparatIvely
recentdIscoverywIthtraceableorIgInsInthemId19thcentury.Howwehavechanged
perspectIvesfromoneInwhIchsurgIcalpaIn
P.4
wasterrIbleandexpectedtooneInwhIchpatIentsreasonablyassumetheywIllbesafe,
paInfree,andunawaredurIngextensIveoperatIonsIsafascInatIngstoryandthesubjectof
thIschapter.
AnesthesIologIstsarelIkenootherphysIcIans:weareexpertsatcontrollIngtheaIrwayand
atemergencyresuscItatIon;wearerealtImecardIopulmonologIstsachIevIng
hemodynamIcandrespIratorystabIlItyfortheanesthetIzedpatIent;weare
pharmacologIstsandphysIologIsts,calculatIngapproprIatedosesanddesIredresponses;we
aregurusofpostoperatIvecareandpatIentsafety;weareInternIstsperformIng
perIanesthetIcmedIcalevaluatIons;wearethepaInexpertsacrossallmedIcaldIscIplInes
andapplyspecIalIzedtechnIquesInpaInclInIcsandlaborwards;wemanagetheseverely
sIckandInjuredIncrItIcalcareunIts;weareneurologIsts,selectIvelyblockIng
sympathetIc,sensory,ormotorfunctIonswIthourregIonaltechnIques;wearetraIned
researchersexplorIngscIentIfIcmysteryandclInIcalphenomenon.
AnesthesIologyIsanamalgamofspecIalIzedtechnIques,equIpment,drugs,andknowledge
that,lIkethegrowthrIngsofatree,havebuIltupovertIme.CurrentanesthesIapractIceIs
thesummatIonofIndIvIdualeffortandfortuItousdIscoveryofcenturIes.Everycomponent
ofmodernanesthesIawasatsomepoIntanewdIscoveryandreflectstheexperIence,
knowledge,andInventIvenessofourpredecessors.HIstorIcalexamInatIonenables
understandIngofhowtheseIndIvIdualcomponentsofanesthesIaevolved.Knowledgeofthe
hIstoryofanesthesIaenhancesourapprecIatIonofcurrentpractIceandIntImateswhere
ourspecIaltymIghtbeheaded.
Anesthesia Before Ether
Physical and Psychological Anesthesia
TheEdwInSmIthSurgIcalPapyrus,theoldestknownwrIttensurgIcaldocument,descrIbes
48casesperformedbyanEgyptIansurgeonfromJ000to25008C.WhIlethIsremarkable
surgIcaltreatIsecontaInsnodIrectmentIonofmeasurestolessenpatIentpaInorsufferIng,
EgyptIanpIctographsfromthesameerashowasurgeoncompressInganerveInapatIent's
antecubItalfossawhIleoperatIngonthepatIent'shand.AnotherImagedIsplaysapatIent
compressInghIsownbrachIalplexuswhIleaprocedureIsperformedonhIspalm.
J
nthe
16thcentury,mIlItarysurgeonAmbroIseParbecameadeptatnervecompressIonasa
meansofcreatInganesthesIa.
|edIcalscIencehasbenefItedfromthenaturalrefrIgeratIngpropertIesofIceandsnowas
well.ForcenturIesanatomIcaldIssectIonswereperformedonlyInwInterbecausecolder
temperaturesdelayeddeterIoratIonofthecadaver,andInthe|IddleAgestheanesthetIc
effectsofcoldwaterandIcewererecognIzed.nthe17thcentury,|arcoAurelIoSeverIno
descrIbedthetechnIqueofrefrIgeratIonanesthesIaInwhIchsnowwasplacedInparallel
lInesacrosstheIncIsIonalplanesuchthatthesurgIcalsItebecameInsensatewIthIn
mInutes.ThetechnIqueneverbecamewIdelyused,lIkelybecauseofthechallengeof
maIntaInIngstoresofsnowyearround.
4
SeverInoIsalsoknowntohavesavednumerous
lIvesdurInganepIdemIcofdIphtherIabyperformIngtracheostomIesandInsertIngtrocars
tomaIntaInpatencyoftheaIrway.
5
FormalmanIpulatIonofthepsychetorelIevesurgIcalpaInwasundertakenbyFrench
physIcIansCharles0upotetandJulesCloquetInthelate1820swIthhypnosIs,thencalled
mesmerism.AlthoughtheworkofAnton|esmerwasdIscredItedbytheFrenchAcademyof
ScIenceafterformalInquIryseveraldecadesearlIer,proponentslIke0upotetandCloquet
contInuedwIthmesmerIcexperImentsandpleadedtotheAcademIede|edIcIneto
reconsIderItsutIlIty.
6
nawellattendeddemonstratIonIn1828,Cloquetremovedthe
breastofa64yearoldpatIentwhIleshereportedlyremaInedInacalm,mesmerIcsleep.
ThIsdemonstratIonmadealastIngImpressIonon8rItIshphysIcIanJohnEllIotson,who
becamealeadIngfIgureofthemesmerIcmovementInEnglandInthe18J0sand1840s.
nnovatIveandquIcktoadoptnewadvances,EllIotsonperformedmesmerIc
demonstratIonsandIn184JpublIshedNumerous Cases of Surgical Operations without Pain
in the Mesmeric State.SupportformesmerIsmfadedwhenIn1846renownedsurgeon
FobertLIstonperformedthefIrstoperatIonusIngetheranesthesIaInEnglandand
remarked,ThIsYankeedodgebeatsmesmerIsmallhollow.
7
Early Analgesics and Soporifics
0IoscorIdes,aCreekphysIcIanfromthefIrstcenturyA0,commentedontheanalgesIaof
mandragora,adrugpreparedfromthebarkandleavesofthemandrakeplant.Heobserved
thattheplantsubstancecouldbeboIledInwIne,straIned,andusedInthecaseofpersons
abouttobecutorcauterIzed,whentheywIshtoproduceanesthesIa.
8
|andragorawas
stIllbeIngusedtobenefItpatIentsaslateasthe17thcentury.FromthenInthtothe
thIrteenthcenturIes,thesoporific spongewasadomInantmodeofprovIdIngpaInrelIef
durIngsurgery.|andrakeleaves,alongwIthblacknIghtshade,poppIes,andotherherbs,
wereboIledtogetherandcookedontoasponge.ThespongewasthenreconstItutedInhot
waterandplacedunderthepatIent'snosebeforesurgery.PrIortothehypodermIcsyrInge
androutInevenousaccess,IngestIonandInhalatIonweretheonlyknownroutesfor
admInIsterIngmedIcInestogaInsystemIceffects.PreparedasIndIcatedbypublIshed
reportsofthetIme,thespongegenerallycontaInedmorphIneandscopolamIneInvaryIng
amountsdrugsusedInmodernanesthesIa.
9
AlcoholwasanotherelementofthepreetherarmamentarIumbecauseItwasthoughtto
InducestuporandblunttheImpactofpaIn.AlthoughalcoholIsacentralnervoussystem
depressant,IntheamountsadmInIsteredItproducedlIttleanalgesIaInthesettIngoftrue
surgIcalpaIn.Fanny8urney'saccountunderscorestheIneffectIvenessofalcoholasan
anesthetIc.NotonlydIdthealcoholprovIdemInImalpaIncontrol,ItdIdnothIngtodullher
recollectIonofevents.LaudanumwasanalcoholbasedsolutIonofopIumfIrstcompounded
byParacelsusInthe16thcentury.twaswIldlypopularInthe7IctorIanandFomantIc
perIods,andprescrIbedforawIdevarIetyofaIlmentsfromthecommoncoldto
tuberculosIs.AlthoughapproprIatelyusedasananalgesIcInsomeInstances,Itwas
frequentlymIsusedandabused.LaudanumwasgIvenbynursemaIdstoquIetwaIlIngInfants
andabusedbymanyupperclasswomen,poets,andartIstswhofellvIctImtoItsaddIctIve
potentIal.
Inhaled Anesthetics
NItrousoxIdewasknownforItsabIlItytoInducelIghtheadednessandwasoftenInhaledby
thoseseekIngathrIll.twasnotusedasfrequentlyasetherbecauseItwasmoredIffIcult
tosynthesIzeandstore.twasmadebyheatIngammonIumnItrateInthepresenceofIron
fIlIngs.TheevolvedgaswaspassedthroughwatertoelImInatetoxIcoxIdesofnItrogen
beforebeIngstored.NItrousoxIdewasfIrstpreparedIn177JbyJosephPrIestley,anEnglIsh
clergymanandscIentIst,whoranksamongthegreatpIoneersofchemIstry.WIthoutformal
scIentIfIctraInIng,PrIestleypreparedandexamInedseveralgases,IncludIngnItrousoxIde,
ammonIa,sulfurdIoxIde,oxygen,carbonmonoxIde,andcarbondIoxIde.
Attheendofthe18thcenturyInEngland,therewasastrongInterestInthesupposed
wholesomeeffectsofmIneral
P.5
watersandgases,partIcularlywIthregardtotreatmentofscurvy,tuberculosIs,andother
dIseases.Thomas8eddoesopenedhIsPneumatIcnstItuteclosetothesmallspaof
Hotwells,InthecItyof8rIstol,tostudythebenefIcIaleffectsofInhaledgases.HehIred
Humphry0avyIn1798toconductresearchprojectsforthenstItute.0avyperformed
brIllIantInvestIgatIonsofseveralgasesbutfocusedmuchofhIsattentIononnItrousoxIde.
HIshumanexperImentalresults,combInedwIthresearchonthephysIcalpropertIesofthe
gas,werepublIshedInNitrous Oxide,a580pagebookpublIshedIn1800.ThIsImpressIve
treatIseIsnowbestrememberedforafewIncIdentalobservatIons.0avycommentedthat
nItrousoxIdetransIentlyrelIevedasevereheadache,oblIteratedamInorheadache,and
brIeflyquenchedanaggravatIngtoothache.Themostfrequentlyquotedpassagewasa
casualentry:AsnItrousoxIdeInItsextensIveoperatIonappearscapableofdestroyIng
physIcalpaIn,ItmayprobablybeusedwIthadvantagedurIngsurgIcaloperatIonsInwhIch
nogreateffusIonofbloodtakesplace.
10
ThIsIsperhapsthemostfamousofthemIssed
opportunItIestodIscoversurgIcalanesthesIa.0avy'slastIngnItrousoxIdelegacywas
coInIngthephraselaughInggastodescrIbeItsunIqueproperty.
Almost Discovery: Hickman, Clarke, Long, and Wells
Asthe19thcenturyprogressed,socIetalattItudestowardpaInchanged,perhapsbest
exemplIfIedInthewrItIngsoftheFomantIcpoets.
11
Thus,effortstorelIevepaInwere
undertakenandseveralmorenearbreakthroughsoccurreddeservementIon.AnEnglIsh
surgeonnamedHenryHIllHIckmansearchedIntentIonallyforanInhaledanesthetIcto
relIevepaInInhIspatIents.
12
HIckmanusedhIghconcentratIonsofcarbondIoxIdeInhIs
studIesonmIceanddogs.CarbondIoxIdehassomeanesthetIcpropertIes,asshownbythe
absenceofresponsetoanIncIsIonIntheanImalsofHIckman'sstudy,butItwasnever
determInedIftheanImalswereInsensatebecauseofhypoxIaratherthananesthesIa.
HIckman'sconceptwasmagnIfIcent;hIschoIceofagentwasregrettable.
ThedIscoveryofsurgIcalanesthetIcsInthemoderneraremaInslInkedtoInhaled
anesthetIcs.Thecompoundnowknownasdiethyl etherhadbeenknownforcenturIes;It
mayhavebeensynthesIzedfIrstbyaneIghthcenturyArabIanphIlosopherJabIrIbn
Hayyam,orpossIblybyFaymondLully,a1JthcenturyEuropeanalchemIst.8utdIethyl
etherwascertaInlyknownInthe16thcentury,bothto7alerIusCordusandParacelsuswho
preparedItbydIstIllIngsulfurIcacId(oIlofvItrIol)wIthfortIfIedwInetoproduceanoleum
vitrioli dulce(sweetoIlofvItrIol).DneofthefIrstmIssedobservatIonsontheeffectsof
Inhaledagents,ParacelsusobservedthatethercausedchIckenstofallasleepandawaken
unharmed.HemusthavebeenawareofItsanalgesIcqualItIesbecausehereportedthatIt
couldberecommendedforuseInpaInfulIllnesses.
ForthreecenturIesthereafter,thIssImplecompoundremaInedatherapeutIcagentwIth
onlyoccasIonaluse.SomeofItspropertIeswereexamInedbutwIthoutsustaInedInterest
bydIstInguIshed8rItIshscIentIstsFobert8oyle,saacNewton,and|IchaelFaraday,none
ofwhommadetheconceptuallInktosurgIcalanesthesIa.tsonlyroutIneapplIcatIoncame
asanInexpensIverecreatIonaldrugamongthepoorof8rItaInandreland,whosometImes
drankanounceortwoofetherwhentaxesmadegInprohIbItIvelyexpensIve.
1J
An
AmerIcanvarIatIonofthIspractIcewasconductedbygroupsofstudentswhoheldether
soakedtowelstotheIrfacesatnocturnaletherfrolIcs.
WIllIamE.Clarke,amedIcalstudentfromFochester,NewYork,mayhavegIventhefIrst
etheranesthetIcInJanuary1842.FromtechnIqueslearnedasachemIstrystudentIn18J9,
ClarkeentertaInedhIscompanIonswIthnItrousoxIdeandether.Emboldenedbythese
experIences,headmInIsteredether,fromatowel,toayoungwomannamedHobbIe.Dne
ofherteethwasthenextractedwIthoutpaInbyadentIstnamedElIjahPope.
14
However,It
wassuggestedthatthewoman'sunconscIousnesswasduetohysterIaandClarkewas
advIsedtoconductnofurtheranesthetIcexperIments.
15
Twomonthslater,on|archJ0,1842,CrawfordWIllIamsonLongadmInIsteredetherwItha
towelforsurgIcalanesthesIaInJefferson,CeorgIa.HIspatIent,James|.7enable,wasa
youngmanwhowasalreadyfamIlIarwIthether'sexhIlaratIngeffects,forhereportedIna
certIfIcatethathehadprevIouslyInhaledItandwasfondofItsuse.7enablehadtwosmall
tumorsonhIsneckbutrefusedtohavethemexcIsedbecausehefearedthepaInthat
accompanIedsurgery.KnowIngthat7enablewasfamIlIarwIthether'sactIon,0r.Long
proposedthatethermIghtallevIatepaInandgaInedhIspatIent'sconsenttoproceed.After
InhalIngetherfromthetowelandhavIngtheproceduresuccessfullycompleted,7enable
reportedthathewasunawareoftheremovalofthetumors.
16
ndetermInIngthefIrstfee
foranesthesIaandsurgery,LongsettledonachargeofS2.00.
17
AcommonmId19thcenturyproblemfacIngdentIstswasthatpatIentsrefusedbenefIcIal
treatmentoftheIrteethforfearofthepaInoftheprocedure.FromadentIst'sperspectIve,
paInwasnotsomuchlIfethreatenIngasItwaslIvelIhoodthreatenIng.DneofthefIrst
dentIststoengenderasolutIonwasHoraceWellsofHartford,ConnectIcut,whosegreat
momentofdIscoverycameon0ecember10,1844.HeobservedalectureexhIbItIonon
nItrousoxIdebyanItInerantscIentIst,CardnerQuIncyColton,whoencouragedmembers
oftheaudIencetoInhaleasampleofthegas.WellsobservedayoungmanInjurehIsleg
wIthoutpaInwhIleundertheInfluenceofnItrousoxIde.SensIngthatItmIghtprovIdepaIn
relIefdurIngdentalprocedures,WellscontactedColtonandboldlyproposedanexperIment
InwhIchWellswastobethesubject.ThefollowIngday,ColtongaveWellsnItrousoxIde
beforeafellowdentIst,WIllIamFIggs,extractedatooth.
18
AfterwardWellsdeclaredthat
hehadnotfeltanypaInanddeemedtheexperImentasuccess.ColtontaughtWellsto
preparenItrousoxIde,whIchthedentIstadmInIsteredwIthsuccesstopatIentsInhIs
practIce.HIsapparatusprobablyresembledthatusedbyColton:awoodentubeplacedIn
themouththroughwhIchnItrousoxIdewasbreathedfromasmallbagfIlledwIththegas.
Public Demonstration of Ether Anesthesia
AnotherNewEnglander,WIllIamThomasCreen|orton,brIeflysharedadentalpractIce
wIthWellsInHartford.Wells'daybookshowsthathegave|ortonacourseofInstructIonIn
anesthesIa,but|ortonapparentlymovedto8ostonwIthoutpayIngforthelessons.
19
n
8oston,|ortoncontInuedhIsInterestInanesthesIaandsoughtInstructIonfromchemIst
andphysIcIanCharlesT.Jackson.AfterlearnIngthatetherdroppedontheskInprovIded
analgesIa,hebeganexperImentswIthInhaledether,anagentthatprovedtobemuch
moreversatIlethannItrousoxIde.8ottlesoflIquIdetherwereeasIlytransported,andthe
volatIlItyofthedrugpermIttedeffectIveInhalatIon.TheconcentratIonsrequIredfor
surgIcalanesthesIaweresolowthatpatIentsdIdnotbecomehypoxIcwhenbreathIngether
vaporIzedInaIr.talsopossessedwhatwouldlaterberecognIzedasaunIqueproperty
amongallInhaledanesthetIcs:thequalItyofprovIdIngsurgIcalanesthesIawIthoutcausIng
respIratorydepressIon.ThesepropertIes,combInedwIthaslowrateofInductIon,gavethe
patIentasIgnIfIcantsafetymargInevenInthehandsofrelatIvelyunskIlledanesthetIsts.
20
AfteranesthetIzIngapetdog,|ortonbecameconfIdentofhIsskIllsandanesthetIzed
patIentsInhIsdentaloffIce.
P.6
EncouragedbyhIssuccess,|ortonsoughtanInvItatIontogIveapublIcdemonstratIonIn
the8ullfInchamphItheaterofthe|assachusettsCeneralHospItal,thesamesIteasWells'
faIleddemonstratIon.|anydetaIlsoftheDctober16,1846,demonstratIonarewellknown.
|ortonsecuredpermIssIontoprovIdeananesthetIctoEdwardCIlbertAbbott,apatIentof
surgeonJohnCollInsWarren.WarrenplannedtoexcIseavascularlesIonfromtheleftsIde
ofAbbott'sneckandwasabouttoproceedwhen|ortonarrIvedlate.Hehadbeendelayed
becausehewasoblIgedtowaItforanInstrumentmakertocompleteanewInhaler(FIg.1
1).tconsIstedofalargeglassbulbcontaInIngaspongesoakedwIthcoloredetheranda
spoutthatwasplacedInthepatIent'smouth.AnopenIngontheopposItesIdeofthebulb
allowedaIrtoenterandbedrawnovertheethersoakedspongewItheachbreath.
21
Figure 1-1.|orton'setherInhaler(1846).
TheconversatIonsofthatmornIngwerenotaccuratelyrecorded;however,popular
accountsstatethatthesurgeonrespondedtestIlyto|orton'sapologyforhIstardyarrIval
byremarkIng,SIr,yourpatIentIsready.|ortondIrectedhIsattentIontohIspatIentand
fIrstconductedaveryabbrevIatedpreoperatIveevaluatIon.HeInquIred,AreyouafraId:
AbbottrespondedthathewasnotandtooktheInhalerInhIsmouth.AfterafewmInutes,
|ortonturnedtothesurgeonandsaId,SIr,yourpatIentIsready.CIlbertAbbottlater
reportedthathewasawareofthesurgerybutexperIencednopaIn.Whentheprocedure
ended,WarrenImmedIatelyturnedtohIsaudIenceandutteredthestatement,
Centlemen,thIsIsnohumbug.
22
WhatwouldberecognIzedasAmerIca'sgreatestcontrIbutIonto19thcenturymedIcInehad
occurred.However,|orton,wIshIngtocapItalIzeonhIsdIscovery,refusedtodIvulge
whatagentwasInhIsInhaler.Someweekspassedbefore|ortonadmIttedthattheactIve
componentofthecoloredfluId,whIchhehadcalledLetheon,wassImpledIethylether.
|orton,Wells,Jackson,andtheIrsupporterssoonbecamedrawnIntoInacontentIous,
protracted,andfruItlessdebateoverprIorItyforthedIscovery.ThIsdebatehas
subsequentlybeentermedthe ether controversy.nshort,|ortonhadapplIedforapatent
forLetheon,andwhenItwasgranted,trIedtoreceIveroyaltIesfortheuseofetherasan
anesthetIc.
WhenthedetaIlsof|orton'sanesthetIctechnIquebecamepublIcknowledge,the
InformatIonwastransmIttedbytraIn,stagecoach,andcoastalvesselstootherNorth
AmerIcancItIes,andbyshIptotheworld.AsetherwaseasytoprepareandadmInIster,
anesthetIcswereperformedIn8rItaIn,France,FussIa,SouthAfrIca,AustralIa,andother
countrIesalmostassoonassurgeonsheardthewelcomenewsoftheextraordInary
dIscovery.EventhoughsurgerycouldnowbeperformedwIthpaInputtosleep,the
frequencyofoperatIonsdIdnotrIserapIdly,andseveralyearswouldpassbefore
anesthesIawasunIversallyrecommended.
Chloroform and Obstetrics
JamesYoungSImpsonwasasuccessfulobstetrIcIanofEdInburgh,Scotland,andamongthe
fIrsttouseetherfortherelIefoflaborpaIn.0IssatIsfIedwIthether,SImpsonsoonsoughta
morepleasant,rapIdactInganesthetIc.HeandhIsjunIorassocIatesconductedabold
searchbyInhalIngsamplesofseveralvolatIlechemIcalscollectedforSImpsonby8rItIsh
apothecarIes.0avIdWaldIesuggestedchloroform,whIchhadfIrstbeenpreparedIn18J1.
SImpsonandhIsfrIendsInhaledItafterdInneratapartyInSImpson'shomeontheevenIng
ofNovember4,1847.TheypromptlyfellunconscIousand,whentheyawoke,were
delIghtedwIththeIrsuccess.SImpsonquIcklysetaboutencouragIngtheuseofchloroform.
WIthIn2weeks,hesubmIttedhIsfIrstaccountofItsusetoThe Lancet.
nthe19thcentury,therelIefofobstetrIcpaInhadsIgnIfIcantsocIalramIfIcatIonsand
madeanesthesIadurIngchIldbIrthacontroversIalsubject.SImpsonarguedagaInstthe
prevaIlIngvIew,whIchheldthatrelIevInglaborpaInopposedCod'swIll.ThepaInofthe
parturIentwasvIewedasbothacomponentofpunIshmentandameansofatonementfor
DrIgInalSIn.LessthanayearafteradmInIsterIngthefIrstanesthesIadurIngchIldbIrth,
SImpsonaddressedtheseconcernsInapamphletentItledAnswers to the Religious
Objections Advanced against the Employment of Anaesthetic Agents in Midwifery and
Surgery and Obstetrics.nIt,SImpsonrecognIzedthe8ookofCenesIsasbeIngtherootof
thIssentIment,andnotedthatCodpromIsedtorelIevethedescendantsofAdamandEve
ofthecurse.AddItIonally,SImpsonassertedthatlaborpaInwasaresultofscIentIfIcand
anatomIccauses,andnottheresultofrelIgIouscondemnatIon.HestatedthattheuprIght
posItIonofhumansnecessItatedstrongpelvIcmusclestosupporttheabdomInalcontents.
Asaresult,heargued,theuterusnecessarIlydevelopedstrongmusculaturetoovercome
theresIstanceofthepelvIcfloorandthatgreatcontractIlepowercausedgreatpaIn.
SImpson'spamphletprobablydIdnothaveasIgnIfIcantImpactontheprevaIlIngattItudes,
buthedIdartIculatemanyconceptsthathIscontemporarIesweredebatIngatthetIme.
2J
ChloroformgaInedconsIderablenotorIetyafterJohnSnowusedIttodelIverthelasttwo
chIldrenofQueen7IctorIa.TheQueen'sconsort,PrInceAlbert,IntervIewedJohnSnow
beforehewascalledto8uckInghamPalacetoadmInIsterchloroformattherequestofthe
Queen'sobstetrIcIan.0urIngthemonarch'slabor,SnowgaveanalgesIcdosesofchloroform
onafoldedhandkerchIef.ThIstechnIquewassoontermedchloroform la reine.7IctorIa
abhorredthepaInofchIldbIrthandenjoyedtherelIefthatchloroformprovIded.Shewrote
Inherjournal,0r.SnowgavethatblessedchloroformandtheeffectwassoothIng,
quIetIng,anddelIghtfulbeyondmeasure.
24
WhentheQueen,asheadoftheChurchof
England,endorsedobstetrIcanesthesIa,relIgIousdebateoverthemanagementoflabor
paIntermInatedabruptly.
JohnSnow,alreadyarespectedphysIcIan,tookanInterestInanesthetIcpractIceandwas
soonInvItedtoworkwIthmanyleadIngsurgeonsoftheday.n1848,SnowIntroduceda
chloroformInhaler.HehadrecognIzedtheversatIlItyofthenewagentandcametoprefer
ItInhIspractIce.AtthesametIme,heInItIatedwhatwastobecomeanextraordInary
serIesofexperImentsthatwereremarkableIntheIrscopeandforantIcIpatIng
sophIstIcatedresearchperformedacenturylater.SnowrealIzedthatsuccessfulanesthetIcs
shouldabolIshpaInandunwantedmovements.HeanesthetIzedseveralspecIesofanImals
wIthvaryIngstrengthsofetherandchloroformtodetermInetheconcentratIonrequIredto
preventreflex
P.7
movementfromsharpstImulI.ThIsworkapproxImatedthemodernconceptofmInImum
alveolarconcentratIon.
25
SnowassessedtheanesthetIcactIonofalargenumberof
potentIalanesthetIcsbutdIdnotfIndanytorIvalchloroformorether.HIsstudIesledhIm
torecognIzetherelatIonshIpbetweensolubIlIty,vaporpressure,andanesthetIcpotency,
whIchwasnotfullyapprecIateduntIlafterWorldWar.SnowpublIshedtworemarkable
books,On the Inhalation of the Vapour of Ether(1847)andOn Chloroform and Other
Anaesthetics(1858).ThelatterwasalmostcompletedwhenhedIedofastrokeattheage
of45.
Anesthesia Principles, Equipment, and Standards
Control of the Airway
0efInItIvecontroloftheaIrway,askIllanesthesIologIstsnowconsIderparamount,
developedonlyaftermanyharrowIngandapneIcepIsodesspurredthedevelopmentof
saferaIrwaymanagementtechnIques.PrecedIngtrachealIntubatIon,however,several
ImportanttechnIqueswereproposedtowardtheendofthe19thcenturythatremaIn
IntegraltoanesthesIologyeducatIonandpractIce.JosephCloverwasthefIrstEnglIshman
tourgethenowunIversalpractIceofthrustIngthepatIent'sjawforwardtoovercome
obstructIonoftheupperaIrwaybythetongue.CloveralsopublIshedalandmarkcase
reportIn1877InwhIchheperformedasurgIcalaIrway.DncehIspatIentwasasleep,Clover
dIscoveredthathIspatIenthadatumorofthemouththatobstructedtheaIrway
completely,despItehIstrustedjawthrustmaneuver.HeaverteddIsasterbyInsertInga
smallcurvedcannulaofhIsdesIgnthroughthecrIcothyroIdmembrane.HecontInued
anesthesIavIathecannulauntIlthetumorwasexcIsed.Clover,themodeloftheprepared
anesthesIologIst,remarked,haveneverusedthecannulabeforealthoughIthasbeenmy
companIonatsomethousandsofanaesthetIccases.
26
Tracheal Intubation
ThedevelopmentoftechnIquesandInstrumentsforIntubatIonranksamongthemajor
advancesInthehIstoryofanesthesIology.ThefIrsttrachealtubesweredevelopedforthe
resuscItatIonofdrownIngvIctIms,butwerenotusedInanesthesIauntIl1878.ThefIrstuse
ofelectIveoralIntubatIonforananesthetIcwasundertakenbyScottIshsurgeonWIllIam
|acewan.HehadpractIcedpassIngflexIblemetaltubesthroughthelarynxofacadaver
beforeattemptIngthemaneuveronanawakepatIentwIthanoraltumorattheClasgow
FoyalnfIrmaryonJuly5,1878.
27
8ecausetopIcalanesthesIawasnotyetknown,the
experIencemusthavedemandedfortItudeonthepartof|acewan'spatIent.Dncethetube
wascorrectlyposItIoned,anassIstantbeganachloroformaIranesthetIcvIathetube.Dnce
anesthetIzed,thepatIentsoonstoppedcoughIng.Unfortunately,|acewanabandonedthe
practIcefollowIngafatalItyInwhIchapatIenthadbeensuccessfullyIntubatedwhIle
awakebutthetubebecamedIslodgedoncethepatIentwasasleep.Afterthetubewas
removed,anattempttoprovIdechloroformbymaskanesthesIawasunsuccessfulandthe
patIentdIed.
AnAmerIcansurgeonnamedJosephD'0wyerIsrememberedforhIsextraordInary
dedIcatIontotheadvancementoftrachealIntubatIon.n1885,D'0wyerdesIgnedaserIes
ofmetallaryngealtubes,whIchheInsertedblIndlybetweenthevocalcordsofchIldren
sufferIngadIphtherItIccrIsIs.Threeyearslater,D'0wyerdesIgnedasecondrIgIdtubewIth
aconIcaltIpthatoccludedthelarynxsoeffectIvelythatItcouldbeusedforartIfIcIal
ventIlatIonwhenapplIedwIththebellowsandTpIecetubedesIgnedbyCeorgeFell.The
FellD'0wyerapparatus,asItcametobeknown,wasuseddurIngthoracIcsurgeryby
Fudolph|atasofNewDrleans.|ataswassopleasedwIthItthathepredIcted,The
procedurethatpromIsesthemostbenefItInpreventIngpulmonarycollapseInoperatIons
onthechestIstherhythmIcalmaIntenanceofartIfIcIalrespIratIonbyatubeInthe
glottIsdIrectlyconnectedwIthabellows.
AfterD'0wyer'sdeath,theoutstandIngpIoneeroftrachealIntubatIonwasFranzKuhn,a
surgeonofKassel,Cermany.From1900untIl1912,KuhnpublIshedseveralartIclesanda
classIcmonograph,Die perorale Intubation,whIchwerenotwellknownInhIslIfetIme
buthavesIncebecomewIdelyapprecIated.
25
HIsworkmIghthavehadamoreprofound
ImpactIfIthadbeentranslatedIntoEnglIsh.KuhndescrIbedtechnIquesoforalandnasal
IntubatIonthatheperformedwIthflexIblemetaltubescomposedofcoIledtubIngsImIlar
tothosenowusedforthespoutofmetalgasolInecans.AfterapplyIngcocaInetothe
aIrway,KuhnIntroducedhIstubeoveracurvedmetalstyletthathedIrectedtowardthe
larynxwIthhIsleftIndexfInger.WhIlehewasawareofthesubglottIccuffsthathadbeen
usedbrIeflyby7IctorEIsenmenger,KuhnpreferredtosealthelarynxbyposItIonInga
supralaryngealflangenearthetube'stIpbeforepackIngthepharynxwIthgauze.Kuhneven
monItoredthepatIent'sbreathsoundscontInuouslythroughamonauralearpIececonnected
toanextensIonofthetrachealtubebyanarrowtube.
ntubatIonofthetracheabypalpatIonwasanuncertaInandsometImestraumatIcact;
surgeonsevenbelIevedthatItwouldbeanatomIcallyImpossIbletovIsualIzethevocal
cordsdIrectly.ThIsmIsapprehensIonwasovercomeIn1895byAlfredKIrsteInIn8erlInwho
devIsedthefIrstdIrectvIsIonlaryngoscope.
28
KIrsteInwasmotIvatedbyafrIend'sreport
thatapatIent'stracheahadbeenaccIdentallyIntubateddurIngesophagoscopy.KIrsteIn
promptlyfabrIcatedahandheldInstrumentthatatfIrstresembledashortenedcylIndrIcal
esophagoscope.HesoonsubstItutedasemIcIrcularbladethatopenedInferIorly.KIrsteIn
couldnowexamInethelarynxwhIlestandIngbehIndhIsseatedpatIent,whoseheadhad
beenplacedInanattItudeapproxImatIngthesnIffIngposItIon.AlthoughAlfredKIrsteIn's
autoscopewasnotusedbyanesthesIologIsts,Itwastheforerunnerofallmodern
laryngoscopes.EndoscopywasrefInedbyChevalIerJacksonInPhIladelphIa,whodesIgneda
UshapedlaryngoscopebyaddIngahandgrIpthatwasparalleltotheblade.TheJackson
bladehasremaInedastandardInstrumentforendoscopIstsbutwasnotfavoredby
anesthesIologIsts.TwolaryngoscopesthatcloselyresembledmodernLshapedInstruments
weredesIgnedIn1910and191JbytwoAmerIcansurgeons,HenryJanewayandCeorge
0orrance,butneItherInstrumentachIevedlastIngusedespItetheIrexcellentdesIgns.
29
8eforetheIntroductIonofmusclerelaxantsInthe1940s,IntubatIonofthetracheacouldbe
challengIng.ThIschallengewasmadesomewhateasIer,however,wIththeadventof
laryngoscopebladesspecIfIcallydesIgnedtoIncreasevIsualIzatIonofthevocalcords.
Fobert|IllerofSanAntonIo,Texas,andFobert|acIntoshofDxfordUnIversItycreated
theIrrespectIvelynamedbladeswIthInanIntervalof2years.n1941,|Illerbrought
forwardtheslender,straIghtbladewIthaslIghtcurvenearthetIptoeasethepassageof
thetubethroughthelarynx.Although|Iller'sbladewasarefInement,thetechnIqueofIts
usewasIdentIcaltothatofearlIermodelsastheepIglottIswaslIftedtoexposethe
larynx.
J0
The|acIntoshblade,whIchIsplacedInthevallecularatherthanundertheepIglottIs,was
InventedasanIncIdentalresultofatonsIllectomy.SIrFobert|acIntoshlaterdescrIbed
thecIrcumstancesofItsdIscoveryInanapprecIatIonofthe
P.8
careerofhIstechnIcIan,|r.FIchardSalt,whoconstructedtheblade.AsSIrFobert
recalled,A8oyle0avIsgag,asIzelargerthanIntended,wasInsertedfortonsIllectomy,
andwhenthemouthwasfullyopenedthecordscameIntovIew.ThIswasasurprIsesInce
conventIonallaryngoscopy,atthatdepthofanaesthesIa,wouldhavebeenImpossIbleIn
thoseprerelaxantdays.WIthInamatterofhours,SalthadmodIfIedthebladeofthe0avIs
gagandattachedalaryngoscopehandletoIt;andstreamlIned(aftertestIngseveral
models),theendresultcameIntowIdespreaduse.
J1
|acIntoshunderestImatedthe
popularItyoftheblade,asmorethan800,000havebeenproducedandmanyspecIal
purposeversIonshavebeenmarketed.
ThemostdIstInguIshedInnovatorIntrachealIntubatIonwastheselftraIned8rItIsh
anesthetIstvan(later,SIrvan)|agIll.
J2
n1919,whIleservIngIntheFoyalArmyasa
generalmedIcaloffIcer,|agIllwasassIgnedtoamIlItaryhospItalnearLondon.Although
hehadonlyrudImentarytraInIngInanesthesIa,|agIllwasoblIgedtoacceptanassIgnment
totheanesthesIaservIce,whereheworkedwIthanotherneophyte,StanleyFowbotham.
JJ
Together,|agIllandFowbothamattendedcasualtIesdIsfIguredbyseverefacIalInjurIes
whounderwentrepeatedrestoratIveoperatIons.TheseproceduresrequIredthatthe
surgeon,HaroldCIllIes,haveunrestrIctedaccesstothefaceandaIrway.ThesepatIents
presentedformIdablechallenges,butboth|agIllandFowbothambecameadeptat
trachealIntubatIonandquIcklyunderstoodItscurrentlImItatIons.8ecausetheylearned
fromfortuItousobservatIons,theysoonextendedthescopeoftrachealanesthesIa.
TheygaInedexpertIsewIthblIndnasalIntubatIonaftertheylearnedtosoftensemIrIgId
InsufflatIontubesforpassagethroughthenostrIl.EventhoughtheIrorIgInalIntentwasto
posItIonthetIpsofthenasaltubesIntheposterIorpharynx,theslendertubesfrequently
endedupInthetrachea.StImulatedbythIschanceexperIence,theydevelopedtechnIques
ofdelIberatenasotrachealIntubatIon.n1920,|agIlldevIsedanaIdtomanIpulatIngthe
cathetertIp,the|agIllangulatedforceps,whIchcontInuetobemanufacturedaccordIng
tohIsorIgInaldesIgnofnearly90yearsago.
WIththewarover,|agIllenteredcIvIlIanpractIceandsetouttodevelopawIdeboretube
thatwouldresIstkInkIngbutbeconformabletothecontoursoftheupperaIrway.WhIleIn
ahardwarestore,hefoundmIneralIzedredrubbertubIngthathecut,beveled,and
smoothedtoproducetubesthatclInIcIansaroundtheworldwouldcometocall|agIll
tubes.HIstubesremaInedtheunIversalstandardformorethan40yearsuntIlrubber
productsweresupplantedbyInertplastIcs.|agIllalsoredIscoveredtheadvantageof
applyIngcocaInetothenasalmucosa,atechnIquethatgreatlyfacIlItatedawakeblInd
nasalIntubatIon.
n1926,ArthurCuedelbeganaserIesofexperImentsthatledtotheIntroductIonofthe
cuffedtube.CuedeltransformedthebasementofhIsndIanapolIshomeIntoalaboratory
wherehesubjectedeachstepofthepreparatIonandapplIcatIonofhIscuffstoavIgorous
revIew.
J4
HefashIonedcuffsfromtherubberofdentaldams,condoms,andsurgIcalgloves
thatweregluedontotheouterwalloftubes.UsIngashIsmodelanImaltracheasdonated
bythefamIlybutcher,heconsIderedwhetherthecuffshouldbeposItIonedabove,below,
oratthelevelofthevocalcords.HerecommendedthatthecuffbeposItIonedjustbelow
thevocalcordstosealtheaIrway.Waterslaterrecommendedthatcuffsbeconstructedof
twolayersofsoftrubbercementedtogether.ThesedetachablecuffswerefIrst
manufacturedbyWaters'chIldren,whosoldthemtotheForeggerCompany.
CuedelsoughtwaystoshowthesafetyandutIlItyofthecuffedtube.HefIrstfIlledthe
mouthofananesthetIzedandIntubatedpatIentwIthwaterandshowedthatthecuff
sealedtheaIrway.EventhoughthIsexhIbItIonwassuccessful,hesearchedforamore
dramatIctechnIquetocapturetheattentIonofthoseunfamIlIarwIththeadvantagesof
IntubatIon.HereasonedthatIfthecuffpreventedwaterfromenterIngthetracheaofan
IntubatedpatIent,ItshouldalsopreventananImalfromdrownIng,evenIfItwere
submergedunderwater.ToencouragephysIcIansattendIngamedIcalconventIontousehIs
trachealtechnIques,CuedelpreparedthefIrstofseveraldunkeddogdemonstratIons
(FIg.12).AnanesthetIzedandIntubateddog,Cuedel'sownpet,AIrway,wasImmersed
InanaquarIum.AfterthedemonstratIonwascompleted,theanesthetIcwasdIscontInued
beforetheanImalwasremovedfromthewater.AIrwayawokepromptly,shookwaterover
theonlookers,salutedapost,thentrottedfromthehalltotheapplauseoftheaudIence.
Figure 1-2.Thedunkeddog.
AfterapatIentexperIencedanaccIdentalendobronchIalIntubatIon,FalphWaters
reasonedthataverylongcuffedtubecouldbeusedtoventIlatethedependentlungwhIle
theupperlungwasbeIngresected.
J5
DnlearnIngofhIsfrIend'ssuccesswIthIntentIonal
onelunganesthesIa,ArthurCuedelproposedanImportantmodIfIcatIonforchestsurgery,
thedoublecuffedsInglelumentube,whIchwasIntroducedbyEmeryFovenstIne.These
tubeswereeasIlyposItIoned,anadvantageoverbronchIalblockersthathadtobeInserted
byaskIlledbronchoscopIst.n195J,sInglelumentubesweresupplantedbydoublelumen
endobronchIaltubes.ThedoublelumentubecurrentlymostpopularwasdesIgnedbyFrank
Fobertshawof|anchester,England,andIspreparedInbothrIghtandleftsIdedversIons.
FobertshawtubeswerefIrstmanufacturedfrommIneralIzedredrubberbutarenowmade
ofextrudedplastIc,atechnIquerefInedby0avIdSherIdan.SherIdanwasalsothefIrst
persontoembedcentImetermarkIngsalongthesIdeoftrachealtubes,asafetyfeature
thatreducedtherIskofthetube'sbeIngIncorrectlyposItIoned.
Advanced Airway Devices
ConventIonallaryngoscopesprovedInadequateforpatIentswIthdIffIcultaIrways.Afew
clInIcIanscredItharrowIngIntubatIngexperIencesastheIncentIveforInventIon.n1928,a
rIgIdbronchoscopewasspecIfIcallydesIgnedforexamInatIonofthelargeaIrways.FIgId
bronchoscopeswererefInedandusedbypulmonologIsts.AlthoughItwasknownIn1870
thatathreadofglasscouldtransmItlIghtalongItslength,technologIcallImItatIonswere
notovercomeuntIl1964whenShIgetokedadevelopedthefIrstflexIblefIberoptIc
bronchoscope.FIberoptIcassIstedtrachealIntubatIonhasbecomeacommonapproachIn
themanagementofpatIentswIthdIffIcultaIrwayshavIngsurgery.
Foger8ullarddesIredadevIcetosImultaneouslyexamInethelarynxandIntubatethe
vocalcords.Hehadbeenfrustrated
P.9
byfaIledattemptstovIsualIzethelarynxofapatIentwIthPIerreFobInsyndrome.n
response,hedevelopedthe8ullardlaryngoscope,whosefIberoptIcbundleslIebesIdea
curvedblade.SImIlarly,theWuscopewasdesIgnedbyTzuLangWuIn1994tocombIneand
facIlItatevIsualIzatIonandIntubatIonofthetracheaInpatIentswIthdIffIcultaIrways.
J6
0r.A..J.ArchIe8raInfIrstrecognIzedtheprIncIpleofthelaryngealmaskaIrway(L|A)
In1981when,lIkemany8rItIshclInIcIans,heprovIdeddentalanesthesIavIaaColdman
nasalmask.However,unlIkeanybeforehIm,herealIzedthatjustasthedentalmaskcould
befIttedcloselyaboutthenose,acomparablemaskattachedtoawIdeboretubemIghtbe
posItIonedaroundthelarynx.HenotonlyconceIvedofthIsradIcaldepartureInaIrway
management,whIchhefIrstdescrIbedIn198J,
J7
butalsospentyearsInsInglehandedly
fabrIcatIngandtestIngscoresofIncrementalmodIfIcatIons.Scoresof8raIn'sprototypesare
dIsplayedIntheFoyal8erkshIreHospItal,FeadIng,England,wheretheyprovIdeadetaIled
recordoftheevolutIonoftheL|A.HefabrIcatedhIsfIrstmodelsfrom|agIlltubesand
Coldmanmasks,thenrefInedtheIrshapebyperformIngpostmortemstudIesofthe
hypopharynxtodetermInetheformofcuffthatwouldbemostfunctIonal.8eforesIlIcone
rubberwasselected,8raInhadevenmasteredthetechnIqueofformIngmasksfromlIquId
latex.EverydetaIloftheL|A,thenumberandposItIonoftheaperturebars,theshapeand
thesIzeofthemasks,requIredrepeatedmodIfIcatIon.
Early Anesthesia Delivery Systems
ThetransItIonfrometherInhalersandchloroformsoakedhandkerchIefstomore
sophIstIcatedanesthesIadelIveryequIpmentoccurredgradually,wIthIncremental
advancessupplantIngoldermethods.DneoftheearlIestanesthesIaapparatusdesIgnswas
thatofJohnSnow,whohadrealIzedtheInadequacIesofetherInhalersthroughwhIch
patIentsrebreathedvIaamouthpIece.AfterpractIcInganesthesIaforonly2weeks,Snow
createdthefIrstofhIsserIesofIngenIousetherInhalers.
J8
HIsbestknownapparatus
featuredunIdIrectIonalvalveswIthInamalleable,wellfIttIngmaskofhIsowndesIgn,
whIchcloselyresemblestheformofamodernfacemask.ThefacepIecewasconnectedto
thevaporIzerbyabreathIngtube,whIchSnowdelIberatelydesIgnedtobewIderthanthe
humantracheasothatevenrapIdrespIratIonswouldnotbeImpeded.AmetalcoIlwIthIn
thevaporIzerensuredthatthepatIent'sInspIredbreathwasdrawnoveralargesurface
areatopromotetheuptakeofether.ThedevIcealsoIncorporatedawarmwaterbathto
maIntaInthevolatIlItyoftheagent(FIg.1J).SnowdIdnotattempttocapItalIzeonhIs
creatIvIty,IncontrasttoWIllIam|orton;heclosedhIsaccountofItspreparatIonwIththe
generousobservatIon,ThereIsnorestrIctIonrespectIngthemakIngofIt.
J9
8etween1900and1910,contInuousposItIveornegatIvepressuredevIceswerecreatedto
maIntaInInflatIonofthelungsofaspontaneouslybreathIngpatIentoncethechestwas
opened.8rauer(1904)and|urphy(1905)placedthepatIent'sheadandneckInaboxIn
whIchposItIvepressurewascontInuallymaIntaIned.Sauerbruch(1904)createdanegatIve
pressureoperatIngchamberencompassIngboththesurgIcalteamandthepatIent'sbody
andfromwhIchonlythepatIent'sheadprojected.
45
n1907,thefIrstIntermIttentposItIvepressuredevIce,the0raegerPulmotor,was
developedtorhythmIcallyInflatethelungs.ThIsInstrumentandlaterAmerIcanmodels
suchastheEEJFesuscItatorwereusedalmostexclusIvelybyfIrefIghtersandmInerescue
workers.n19J4aSwedIshteamdevelopedtheSpIropulsator,whIchC.Crafoordlater
modIfIedforusedurIngcyclopropaneanesthesIa.
46
tsactIonwascontrolledbyamagnetIc
controlvalvecalledthe flasher,atypefIrstusedtoprovIdeIntermIttentgasflowforthe
lIghtsofnavIgatIonalbuoys.WhenTrIer|orch,a0anIshanesthesIologIst,couldnotobtaIn
aSpIropulsatordurIngWorldWar,hefabrIcatedthe|orchFespIrator,whIchuseda
pIstonpumptorhythmIcallydelIverafIxedvolumeofgastothepatIent.
45
AmajorstImulustothedevelopmentofventIlatorscameasaconsequenceofa
devastatIngepIdemIcofpolIomyelItIsthatstruckCopenhagen,0enmark,In1952.Asscores
ofpatIentswereadmItted,theonlyeffectIveventIlatorysupportthatcouldbeprovIdedto
patIentswIthbulbarparalysIswascontInuousmanualventIlatIonvIaatracheostomy
employIngdevIcessuchasWaters'toandfrocIrcuIt.ThIssucceededonlythroughthe
dedIcatedeffortsofhundredsofvolunteers.|edIcalstudentsservedInrelaystoventIlate
paralyzedpatIents.TheCopenhagencrIsIsstImulatedabroadEuropeanInterestInthe
developmentofportableventIlatorsInantIcIpatIonofanotherepIdemIcofpolIomyelItIs.
AtthIstIme,thecommonpractIceInNorthAmerIcanhospItalswastoplacepolIopatIents
wIthrespIratoryInvolvementInIronlungs,metalcylIndersthatencasedthebodybelow
theneck.nspIratIonwascausedbyIntermIttentnegatIvepressurecreatedbyanelectrIc
motoractIngonapIstonlIkedevIceoccupyIngthefootofthechamber.
SomeearlyAmerIcanventIlatorswereadaptatIonsofrespIratoryassIstmachInesorIgInally
desIgnedforthedelIveryofaerosolIzeddrugsforrespIratorytherapy.Twotypesemployed
the8ennettor8IrdflowsensItIvevalves.The8ennettvalvewasdesIgneddurIngWorld
WarwhenateamofphysIologIstsattheUnIversItyofSouthernCalIfornIaencountered
dIffIcultIesInseparatIngInspIratIonfromexpIratIonInanexperImentalapparatusdesIgned
toprovIdeposItIvepressurebreathIngforavIatorsathIghaltItude.AnengIneer,Fay
8ennett,vIsItedtheIrlaboratory,observedtheIrproblem,andresolvedItwItha
mechanIcalflowsensItIveautomatIcvalve.AsecondvalvIngmechanIsmwaslater
desIgnedbyanaeronautIcalengIneer,Forrest8Ird.
Theuseofthe8Irdand8ennettvalvesgaInedananesthetIcapplIcatIonwhenthegasflow
fromthevalvewasdIrectedIntoarIgIdplastIcjarcontaInIngabreathIngbagorbellowsas
partofananesthesIacIrcuIt.ThesebagInbottledevIcesmImIckedtheactIonofthe
clInIcIan'shandasthegasflowcompressedthebag,therebyprovIdIngposItIvepressure
InspIratIon.PassIveexhalatIonwaspromotedbythedescentofaweIghtonthebagor
bellows.
Carbon Dioxide Absorption
CarbondIoxIde(CD
2
)absorbanceIsabasIcelementofmodernanesthetIcmachInes.twas
InItIallydevelopedtoallowrebreathIngofgasandmInImIzelossofflammablegasesInto
theroom,therebyreducIngtherIskofexplosIon.ncurrentpractIce,ItpermItsdecreased
utIlIzatIonofanesthetIcandreducedcost.ThefIrstCD
2
absorberInanesthesIacameIn
1906fromtheworkofFranzKuhn,aCermansurgeon.HIsuseofcanIstersdevelopedfor
mInerescuesby0raegerwasInnovatIve,buthIscIrcuIthadunfortunatelImItatIons.The
exceptIonallynarrowbreathIngtubesandalargedeadspaceexplaInItsverylImIteduse,
andKuhn'sdevIcewasIgnored.
Afewyearslater,thefIrstAmerIcanmachInewIthaCD
2
absorberwasIndependently
fabrIcatedbyapharmacologIstnamed0ennIsJackson.n1915,Jacksondevelopedanearly
technIqueofCD
2
absorptIonthatpermIttedtheuseofaclosedanesthesIacIrcuIt.Heused
solutIonsofsodIumandcalcIum
P.11
hydroxIdetoabsorbCD
2
.AshIslaboratorywaslocatedInanareaofSt.LouIs,|IssourI,
heavIlyladenwIthcoalsmoke,JacksonreportedthattheapparatusallowedhImthefIrst
breathsofabsolutelyfreshaIrhehadeverenjoyedInthatcIty.ThecomplexItyof
Jackson'sapparatuslImItedItsuseInhospItalpractIce,buthIspIoneerIngworkInthIsfIeld
encouragedFalphWaterstoIntroduceasImplerdevIceusIngsodalImegranules9years
later.WatersposItIonedasodalImecanIster(FIg.14)betweenafacemaskandan
adjacentbreathIngbagtowhIchwasattachedthefreshgasflow.Aslongasthemaskwas
heldagaInsttheface,onlysmallvolumesoffreshgasflowwererequIredandnovalves
wereneeded.
47
Figure 1-4.Waters'carbondIoxIdeabsorbancecanIster.
Waters'devIcefeaturedawkwardposItIonIngofthecanIsterclosetothepatIent'sface.
8rIanSwordovercamethIslImItatIonIn19J0wIthafreestandIngmachInewIth
unIdIrectIonalvalvestocreateacIrclesystemandanInlIneCD
2
absorber.
48
JamesElam
andhIscoworkersattheFoswellParkCancernstItuteIn8uffalo,NewYork,furtherrefIned
theCD
2
absorber,IncreasIngtheeffIcIencyofCD
2
removalwIthamInImumofresIstance
forbreathIng.
49
Consequently,thecIrclesystemIntroducedbySwordInthe19J0s,wItha
fewrefInements,becamethestandardanesthesIacIrcuItInNorthAmerIca.
Flow Meters
AsclosedandsemIclosedcIrcuItsbecamepractIcal,gasflowcouldbemeasuredwIth
greateraccuracy.8ubbleflowmeterswerereplacedwIthdrybobbInsorballbearIng
flowmeters,whIch,althoughtheydIdnotleakfluIds,couldcauseInaccuratemeasurements
Iftheyadheredtotheglasscolumn.n1910,|.NeuhadbeenthefIrsttoapplyrotameters
InanesthesIafortheadmInIstratIonofnItrousoxIdeandoxygen,buthIsmachInewasnota
commercIalsuccess,perhapsbecauseofthegreatcostofnItrousoxIdeInCermanyatthat
tIme.FotametersdesIgnedforuseInCermanIndustrywerefIrstemployedIn8rItaInIn
19J7byFIchardSalt;butasWorldWarapproached,theEnglIshweredenIedaccessto
thesesophIstIcatedflowmeters.AfterWorldWarrotametersbecameregularlyemployed
In8rItIshanesthesIamachInes,althoughmostAmerIcanequIpmentstIllfeatured
nonrotatIngfloats.ThenowunIversalpractIceofdIsplayInggasflowInlIterspermInute
wasnotacustomarypartofallAmerIcanmachInesuntIlmorethanadecadeafterWorld
War.
Vaporizers
TheartofasmoothInductIonwIthapotentanesthetIcwasagreatchallenge,partIcularly
IftheInspIredconcentratIoncouldnotbedetermInedwIthaccuracy.EventheclInIcal
IntroductIonofhalothaneafter1956mIghthavebeensImIlarlythwartedexceptfora
fortunatecoIncIdence:theprIordevelopmentofcalIbratedvaporIzers.Twotypesof
calIbratedvaporIzersdesIgnedforotheranesthetIcshadbecomeavaIlableInthehalf
decadebeforehalothanewasmarketed.ThepromptacceptanceofhalothanewasInpart
becauseofanabIlItytoprovIdeItIncarefullytItratedconcentratIons.
TheCopperKettlewasthefIrsttemperaturecompensated,accuratevaporIzer.thadbeen
developedbyLucIen|orrIsattheUnIversItyofWIsconsInInresponsetoFalphWaters'plan
totestchloroformbygIvIngItIncontrolledconcentratIons.
50
|orrIsachIevedthIsgoalby
passIngameteredflowofoxygenthroughavaporIzerchamberthatcontaInedasIntered
bronzedIsktoseparatetheoxygenIntomInutebubbles.Thegasbecamefullysaturated
wIthanesthetIcvaporasItpercolatedthroughthelIquId.TheconcentratIonofthe
anesthetIcInspIredbythepatIentcouldbecalculatedbyknowIngthevaporpressureofthe
lIquIdanesthetIc,thevolumeofoxygenflowIngthroughthelIquId,andthetotalvolumeof
gasesfromallsourcesenterIngtheanesthesIacIrcuIt.AlthoughexperImentalmodelsof
|orrIs'vaporIzerusedawaterbathtomaIntaInstabIlIty,theexcellentthermal
conductIvItyofcopperwassubstItutedInlatermodels.WhenfIrstmarketed,theCopper
KettledIdnotfeatureamechanIsmtoIndIcatechangesInthetemperature(andvapor
pressure)ofthelIquId.ShuhHsunNgaIproposedtheIncorporatIonofathermometer,a
suggestIonthatwaslateraddedtoallvaporIzersofthatclass.
51
TheCopperKettle
(ForeggerCompany)andthe7ernItrol(DhIo|edIcalProducts)wereunIversalvaporIzers
thatcouldbechargedwIthanyanesthetIclIquId,and,provIdedthatItsvaporpressureand
temperaturewereknown,theInspIredconcentratIoncouldbecalculatedquIckly.
WhenhalothanewasfIrstmarketedIn8rItaIn,aneffectIvetemperaturecompensated,
agentspecIfIcvaporIzerhadrecentlybeenplacedInclInIcaluse.TheTECDTA
(TEmperatureCDmpensatedTrIchloroethyleneAIr)vaporIzerfeaturedabImetallIcstrIp
composedofbrassandanIckelsteelalloy,twometalswIthdIfferentcoeffIcIentsof
expansIon.AstheanesthetIcvaporcooled,thestrIpbenttomoveawayfromtheorIfIce,
therebypermIttIngmorefreshgastoenterthevaporIzIngchamber.ThIsmaIntaIneda
constantInspIredconcentratIondespItechangesIntemperatureandvaporpressure.After
theIrTECDTAvaporIzerwasacceptedIntoanesthetIcpractIce,thetechnologywasusedto
createtheFluotec,thefIrstofaserIesofagentspecIfIctecvaporIzersforuseInthe
operatIngroom.
Patient Monitors
nmanyways,thehIstoryoflatenIneteenthandearly20thcenturyanesthesIologyIsthe
questforthesafestanesthetIc.ThedIscoveryandwIdespreaduseofelectrocardIography,
pulseoxImetry,bloodgasanalysIs,capnography,andneuromuscularblockademonItorIng
havereducedpatIentmorbIdItyandmortalItyandrevolutIonIzedanesthesIapractIce.
WhIlesafermachInesassuredclInIcIansthatapproprIategasmIxturesweredelIveredto
thepatIent,monItorsprovIdedanearly
P.12
warnIngofacutephysIologIcdeterIoratIonbeforepatIentssufferedIrrevocabledamage.
JosephCloverwasoneofthefIrstclInIcIanstoroutInelyperformbasIchemodynamIc
monItorIng.CloverdevelopedthehabItofmonItorInghIspatIents'pulsebutsurprIsIngly,
thIswasacontentIousIssueatthetIme.PromInentScottIshsurgeonsscornedClover's
emphasIsontheactIonofchloroformontheheart.8aronLIsterandotherspreferredthat
senIormedIcalstudentsgIveanesthetIcsandurgedthemtostrIctlycarryoutcertaIn
sImpleInstructIons,amongwhIchIsthatofnevertouchIngthepulse,InorderthattheIr
attentIonmaynotbedIstractedfromtherespIratIon.
52
LIsteralsocounseled,Itappears
thatprelImInaryexamInatIonofthechest,oftenconsIderedIndIspensable,IsquIte
unnecessary,andmorelIkelytoInducethedreadedsyncope,byalarmIngthepatIents,
thantoavertIt.
5J
LIttleprogressInanesthesIacouldcomefromsuchreactIonary
statements.ncontrast,CloverhadobservedtheeffectofchloroformonanImalsand
urgedotheranesthetIststomonItorthepulseatalltImesandtodIscontInuetheanesthetIc
temporarIlyIfanyIrregularItyorweaknesswasobservedInthestrengthofthepulse.
TwoAmerIcansurgeons,CeorgeW.CrIleandHarveyCushIng,developedastrongInterest
InmeasurIngbloodpressuredurInganesthesIa.8othmenwrotethoroughanddetaIled
examInatIonsofbloodpressuremonItorIng;however,CushIng'scontrIbutIonIsbetter
rememberedbecausehewasthefIrstAmerIcantoapplytheFIvaFoccIcuff,whIchhesaw
whIlevIsItIngtaly.CushIngIntroducedtheconceptIn1902andhadbloodpressure
measurementsrecordedonanesthesIarecords.
54
n1894,CushIngandafellowstudentat
Harvard|edIcalSchool,CharlesCodman,InItIatedasystemofrecordIngpatIents'pulsesto
assessthecourseoftheanesthetIcstheyadmInIstered.n1902,CushIngcontInuedthe
practIceofmonItorIngandrecordIngpatIentbloodpressuresandpulses.ThetransItIon
frommanualtoautomatedbloodpressuredevIces,whIchfIrstappearedIn19J6and
operateonanoscIllometrIcprIncIple,hasbeengradual.
ThefIrstprecordIalstethoscopewasbelIevedtohavebeenusedbyS.CrIffIth0avIsat
JohnsHopkInsUnIversIty.
J8
HeadaptedatechnIquedevelopedbyHarveyCushIngIna
laboratoryInwhIchdogswIthsurgIcallyInducedvalvularlesIonshadstethoscopesattached
totheIrchestwallsothatmedIcalstudentsmIghtlIstentobruItscharacterIstIcofa
specIfIcmalformatIon.0avIs'technIquewasforgottenbutwasrehabIlItatedby0r.Fobert
SmIth,anenergetIcpIoneerofpedIatrIcanesthesIologyIn8ostonInthe1940s.ACanadIan
contemporary,AlbertCodesmIth,oftheHospItalforSIckChIldren,Toronto,became
frustratedbytherepeateddIslodgIngofthechestpIeceunderthesurgIcaldrapesand
fabrIcatedhIsfIrstesophagealstethoscopefromurethralcathetersandPenrosedraIns.HIs
brIefreportheraldedItsclInIcalroleasamonItorofbothnormalandadventItIous
respIratoryandcardIacsounds.
55
Electrocardiography, Pulse Oximetry, and Capnography
ClInIcalelectrocardIographybeganwIthWIllemEInthoven'sapplIcatIonofthestrIng
galvanometerIn190J.WIthIntwodecades,ThomasLewIshaddescrIbedItsroleInthe
dIagnosIsofdIsturbancesofcardIacrhythm,whIleJamesHerrIckandHaroldPardeefIrst
drewattentIontothechangesproducedbymyocardIalIschemIa.After1928,cathoderay
oscIlloscopeswereavaIlable,buttherIskofexplosIonowIngtothepresenceofflammable
anesthetIcsforestalledtheIntroductIonoftheelectrocardIogramIntoroutIneanesthetIc
practIceuntIlafterWorldWar.AtthattIme,thesmallscreenoftheheavIlyshIelded
bulletoscIlloscopedIsplayedonlyJsecondsofdata,butthatInformatIonwashIghly
prIzed.
PulseoxImetry,theoptIcalmeasurementofoxygensaturatIonIntIssues,Isoneofthemore
recentaddItIonstotheanesthesIologIst'sarrayofroutInemonItors.AlthoughresearchIn
thIsareabeganIn19J2,ItsfIrstpractIcalapplIcatIoncamedurIngWorldWar.An
AmerIcanphysIologIst,Clen|IllIkan,respondedtoarequestfrom8rItIshcolleaguesIn
avIatIonresearch.|IllIkansetaboutpreparIngaserIesofdevIcestoImprovethesupplyof
oxygenthatwasprovIdedtopIlotsflyIngathIghaltItudeInunpressurIzedaIrcraft.To
monItoroxygendelIveryandtopreventthepIlotfromsuccumbIngtoanunrecognIzed
faIlureofhIsoxygensupply,|IllIkancreatedanoxygensensIngmonItorwornonthepIlot's
earlobe,andcoInedthenameoximetertodescrIbeItsactIon.8eforehIstragIcdeathIna
clImbIngaccIdentIn1947,|IllIkanhadbeguntoassessanesthetIcapplIcatIonsofoxImetry.
FefInementsofoxImetrybyaJapaneseengIneer,TakuoAoyagI,ledtothedevelopmentof
pulseoxImetry.AsJohnSeverInghausrecountedtheepIsode,AoyagIhadattemptedto
elImInatethechangesInasIgnalcausedbypulsatIlevarIatIonswhenherealIzedthatthIs
fluctuatIoncouldbeusedtomeasureboththepulseandoxygensaturatIon.
5J
AnesthesIologIstshaverecognIzedaneedforbreathbybreathmeasurementofrespIratory
andanesthetIcgases.After1954,InfraredabsorptIontechnIquesgaveImmedIatedIsplays
oftheexhaledconcentratIonofCD
2
.TheabIlItytoconfIrmendotrachealIntubatIonand
monItorventIlatIon,asreflectedbyconcentratIonsofCD
2
InrespIredgas,beganIn194J.
AtthattIme,K.LuftdescrIbedtheprIncIpleofInfraredabsorptIonbyCD
2
andhe
developedanapparatusformeasurement.
56
FoutIneapplIcatIonofcapnographyIn
anesthesIapractIcewaspIoneeredby0r.8obSmalhoutand0r.ZdenKalendaInthe
Netherlands.8reathtobreathcontInuousmonItorIngandawaveformdIsplayofCD
2
levels
helpanesthesIologIstsrecognIzeabnormalItIesInmetabolIsm,ventIlatIon,andcIrculatIon.
|orerecently,InfraredanalysIshasbeenperfectedtoenablebreathbybreath
measurementofanesthetIcgasesaswell.ThIstechnologyhaslargelyreplacedmass
spectrometry,whIchInItIallyhadonlyIndustrIalapplIcatIonsbeforeAlbertFaulconerof
the|ayoClInIcfIrstusedIttomonItortheconcentratIonofanexhaledanesthetIcIn1954.
Safety Standards
TheIntroductIonofsafetyfeatureswascoordInatedbytheAmerIcanNatIonalStandards
nstItute(ANS)CommItteeZ79,whIchwassponsoredfrom1956untIl198JbytheAmerIcan
SocIetyofAnesthesIologIsts.SInce198J,representatIvesfromIndustry,government,and
healthcareprofessIonshavemetonCommItteeZ79oftheAmerIcanSocIetyforTestIng
and|aterIals.TheyestablIshvoluntarygoalsthatmaybecomeacceptednatIonal
standardsforthesafetyofanesthesIaequIpment.
FalphTovellvoIcedthefIrstcallforstandardsdurIngWorldWarwhIlehewastheU.S.
ArmyConsultantInAnesthesIologyforEurope.Tovellfoundthat,astherewerefour
dIfferentdImensIonsforconnectors,tubes,masks,andbreathIngbags,supplIesdIspatched
tofIeldhospItalsmIghtnotmatchtheIranesthesIamachInes.AsTovellobserved,Whena
suddenneedforaccessoryequIpmentarose,nursesandcorpsmenwerelIkelytorespondto
ItbybrIngIngpartsthatwouldnotfIt.
57
AlthoughTovell'sreportsdIdnotgaInan
ImmedIateresponse,afterthewar7IncentCollInsandHamIlton0avIstookuphIsconcern
andformedtheANSCommItteeZ79.DneofthecommIttee'smostactIvemembers,LeslIe
Fendell8aker,wroteanaccountofthecommIttee'sdomestIcandInternatIonal
achIevements.
58
HereportedthatTovellencouragedallmanufacturers
P.1J
toselectthenowunIformorIfIceof22mmforalladultandpedIatrIcfacemasksandto
makeeverytrachealtubeconnector15mmIndIameter.ForthefIrsttIme,aZ79desIgned
masktubeelbowadapterwouldfIteverymaskandtrachealtubeconnector.
TheZ79CommItteeIntroducedotheradvances.TrachealtubesofnontoxIcplastIcbeara
Z79orT(mplantatIonTested)mark.ThecommItteealsomandatedtouchIdentIfIcatIon
ofoxygenflowcontrolatthesuggestIonofFoderIckCalverley,
59
whIchreducedtherIsk
thatthewronggaswouldbeselectedbeforeInternalmechanIcalcontrolspreventedthe
selectIonofanhypoxIcmIxture.PInIndexIngreducedthehazardofattachIngawrong
cylInderIntheplaceofoxygen.0IameterIndexIngofconnectorspreventedsImIlarerrors
InhIghpressuretubIng.Formanyyears,however,errorscommIttedInreassemblIng
hospItaloxygensupplylInesledtoaserIesoftragedIesbeforepolarographIcoxygen
analyzerswereaddedtotheInspIratorylImboftheanesthesIacIrcuIt.
The History of Anesthetic Agents and Adjuvants
Inhaled Anesthetics
Throughoutthesecondhalfofthe19thcentury,othercompoundswereexamInedfortheIr
anesthetIcpotentIal.ThepatternoffortuItousdIscoverythatbroughtnItrousoxIde,dIethyl
ether,andchloroformforwardbetween1844and1847contInued.ThenextInhaled
anesthetIcstobeusedroutInely,ethylchlorIdeandethylene,werealsodIscoveredasa
resultofunexpectedobservatIons.EthylchlorIdeandethylenewerefIrstformulatedInthe
18thcentury.EthylchlorIdewasusedasatopIcalanesthetIcandcounterIrrItant;Itwasso
volatIlethattheskIntransIentlyfrozeafterethylchlorIdewassprayedonIt.ts
redIscoveryasananesthetIccameIn1894,whenaSwedIshdentIstnamedCarlsonsprayed
ethylchlorIdeIntoapatIent'smouthtofreezeadentalabscess.CarlsonwassurprIsedto
dIscoverthathIspatIentsuddenlylostconscIousness.
AsthemechanIsmstodelIverdrugswererefIned,entIrelynewclassesofmedIcatIonswere
alsodeveloped,wIththeIntentIonofprovIdIngsafer,morepleasantpaIncontrol.Ethylene
gaswasthefIrstalternatIvetoetherandchloroform,butIthadsomemajor
dIsadvantages.TheredIscoveryofethyleneIn192JalsocamefromaserendIpItous
observatIon.AfterItwaslearnedthatethylenegashadbeenusedtoInhIbIttheopenIngof
carnatIonbudsInChIcagogreenhouses,Itwasspeculatedthatagasthatputflowersto
sleepmIghtalsohaveananesthetIcactIononhumans.ArnoLuckhardtwasthefIrstto
publIshaclInIcalstudyInFebruary192J.WIthInamonth,sabellaHerbInChIcagoandW.
Easson8rownInTorontopresentedtwootherIndependentstudIes.Ethylenewasnota
successfulanesthetIcbecausehIghconcentratIonswererequIredandItwasexplosIve.An
addItIonalsIgnIfIcantshortcomIngwasapartIcularlyunpleasantsmell,whIchcouldonlybe
partIallydIsguIsedbytheuseofoIloforangeoracheapperfume.Whencyclopropanewas
Introduced,ethylenewasabandoned.
TheanesthetIcactIonofcyclopropanewasInadvertentlydIscoveredIn1929.
60
8rownand
HendersonhadprevIouslyshownthatpropylenehaddesIrablepropertIesasananesthetIc
whenfreshlyprepared,butafterstorageInasteelcylInder,ItdeterIoratedtocreatea
toxIcmaterIalthatproducednauseaandcardIacIrregularItIesInhumans.7elyIen
Henderson,aprofessorofpharmacologyattheUnIversItyofToronto,suggestedthatthe
toxIcproductbeIdentIfIed.AfterachemIst,CeorgeLucas,IdentIfIedcyclopropaneamong
thechemIcalsInthetank,hepreparedasampleInlowconcentratIonwIthoxygenand
admInIsteredIttotwokIttens.TheanImalsfellasleepquIetlybutquIcklyrecovered
unharmed.FatherthanbeIngatoxIccontamInant,Lucassawthatcyclopropanewasa
potentanesthetIc.AfterItseffectsInotheranImalswerestudIedandcyclopropaneproved
tobestableafterstorage,humanexperImentatIonbegan.
HendersonwasthefIrstvolunteer;Lucasfollowed.TheythenarrangedapublIc
demonstratIonInwhIchFrederIck8antIng,aNobellaureateforthedIscoveryofInsulIn,
wasanesthetIzedbeforeagroupofphysIcIans.0espItethIspromIsIngbegInnIng,further
researchwasabruptlyhalted.SeveralanesthetIcdeathsInTorontohadbeenattrIbutedto
ethylchlorIde,andconcernaboutCanadIanclInIcaltrIalsofcyclopropaneprevented
humanstudIesfromproceedIng.Fatherthanabandonthestudy,Hendersonencouragedan
AmerIcanfrIend,FalphWaters,tousecyclopropaneattheUnIversItyofWIsconsIn.The
WIsconsIngroupInvestIgatedthedrugthoroughlyandreportedtheIrclInIcalsuccessIn
19J4.
61
n19J0,ChaunceyLeakeand|eIYuChenperformedsuccessfullaboratorytrIalsof
vInethene(dIvInylether)butwerethwartedInItsfurtherdevelopmentbyaprofessorof
surgeryInSanFrancIsco.ronIcally,CanadIans,whohadlostcyclopropanetoWIsconsIn,
learnedofvInethenefromLeakeandChenInCalIfornIaandconductedthefIrsthuman
studyIn19J2attheUnIversItyofAlberta,Edmonton.nternatIonalresearchcollaboratIon
enabledearlyanesthetIcuseofbothcyclopropaneanddIvInylether,advancesthatmay
nothaveoccurredIndependentlyIneIthertheUnItedStatesorCanada.
AllpotentanesthetIcsofthIsperIodwereexplosIvesaveforchloroform,whosehepatIcand
cardIactoxIcItylImIteduseInAmerIca.AnesthetIcexplosIonsremaInedararebut
devastatIngrIsktobothanesthesIologIstandpatIent.ToreducethedangerofexplosIon
durIngtheIncendIarydaysofWorldWar,8rItIshanesthetIststurnedtotrIchloroethylene.
ThIsnonflammableanesthetIcfoundlImItedapplIcatIonInAmerIca,asItdecomposedto
releasephosgenewhenwarmedInthepresenceofsodalIme.8ytheendofWorldWar,
however,anotherclassofnonInflammableanesthetIcswaspreparedforlaboratorytrIals.
Tenyearslater,fluorInatedhydrocarbonsrevolutIonIzedInhalatIonanesthesIa.
FluorIne,thelIghtestandmostreactIvehalogen,formsexceptIonallystablebonds.These
bonds,althoughsometImescreatedwIthexplosIveforce,resIstseparatIonbychemIcalor
thermalmeans.Forthatreason,manyearlyattemptstofluorInatehydrocarbonsIna
controlledmannerwerefrustratedbythemarkedchemIcalactIvItyoffluorIne.n19J0,
thefIrstcommercIalapplIcatIonoffluorInechemIstrycameIntheformoftherefrIgerant,
Freon.ThIswasfollowedbythefIrstattempttoprepareafluorInatedanesthetIcbyHarold
8oothandE.|ay8IxbyIn19J2.AlthoughtheIrdrug,monochlorodIfluoromethane,was
devoIdofanesthetIcactIon,aswereotherdrugsstudIedthatdecade,theIrreport
predIctedfuturedevelopments.AsurveyofthepropertIesof166knowngasessuggested
thatthebestpossIbIlItyoffIndInganewnoncombustIbleanesthetIcgaslayInthefIeldof
organIcfluorIdecompounds.FluorInesubstItutIonforotherhalogenslowerstheboIlIng
poInt,IncreasesstabIlIty,andgenerallydecreasestoxIcIty.
62
Afterthewar,ateamattheUnIversItyof|arylandunderProfessorofPharmacologyJohn
C.Krantz,Jr.,InvestIgatedtheanesthetIcpropertIesofdozensofhydrocarbonsovera
perIodofseveralyears,butonlyone,ethylvInylether,enteredclInIcaluseIn1947.
8ecauseItwasflammable,KrantzrequestedthatItbefluorInated.nresponse,JulIus
ShukyspreparedseveralfluorInatedanalogs.Dneofthese,trIfluoroethylvInylether,or
fluroxene,becamethefIrstfluorInatedanesthetIc.Fluroxenewasmarketedfrom1954untIl
1974.
n1951,CharlesSucklIng,a8rItIshchemIstofmperIalChemIcalndustrIes,wasaskedto
createanewanesthetIc.
P.14
SucklIng,whoalreadyhadanexpertunderstandIngoffluorInatIon,beganbyaskIng
clInIcIanstodescrIbethepropertIesofanIdealanesthetIc.HelearnedfromthIsInquIry
thathIssearchmustconsIderseverallImItIngfactors,IncludIngthevolatIlIty,
InflammabIlIty,stabIlIty,andpotencyofthecompounds.After2yearsofresearchand
testIng,CharlesSucklIngcreatedhalothane.HefIrstdetermInedthathalothanepossessed
anesthetIcactIonbyanesthetIzIngmealwormsandhouseflIesbeforeheforwardedItto
pharmacologIstJamesFaventos.SucklIngalsomadeaccuratepredIctIonsastothe
concentratIonsrequIredforanesthesIaInhIgheranImals.AfterFaventoscompleteda
favorablerevIew,halothanewasofferedto|IchaelJohnstone,arespectedanesthetIstof
|anchester,England,whorecognIzedItsgreatadvantagesoverotheranesthetIcsavaIlable
In1956.AfterJohnstone'sendorsement,halothaneusespreadquIcklyandwIdelywIthInthe
practIceofanesthesIa.
6J
HalothanewasfollowedIn1960bymethoxyflurane,ananesthetIcthatremaInedpopular
foradecade.8y1970,however,ItwaslearnedthatdoserelatednephrotoxIcItyfollowIng
protractedmethoxyfluraneanesthesIawascausedbyInorganIcfluorIde.SImIlarly,because
ofpersIstIngconcernthatrarecasesofhepatItIsfollowInganesthesIamIghtbearesultofa
metabolIteofhalothane,thesearchfornewerInhaledanesthetIcsfocusedonthe
resIstancetometabolIcdegradatIon.
TwofluorInatedlIquIdanesthetIcs,enfluraneandItsIsomerIsoflurane,wereresultsofthe
searchforIncreasedstabIlIty.TheyweresynthesIzedbyFossTerrellIn196Jand1965,
respectIvely.8ecauseenfluranewaseasIertocreate,ItprecededIsoflurane.ts
applIcatIonwasrestrIctedafterItwasshowntobeamarkedcardIovasculardepressantand
tohavesomeconvulsantpropertIes.sofluranewasnearlyabandonedbecauseof
dIffIcultIesInItspurIfIcatIon,butafterLouIseSpeersovercamethIsproblem,several
successfultrIalswerepublIshedIn1971.ThereleaseofIsofluraneforclInIcalusewas
delayedagaInformorethanhalfadecadebycallsforrepeatedtestIngInloweranImals,
owIngtoanunfoundedconcernthatthedrugmIghtbecarcInogenIc.Asaconsequence,
IsofluranereceIvedmorethoroughtestIngthananyotherdrugheretoforeusedIn
anesthesIa.TheerawhenananesthetIccouldbeIntroducedfollowIngasInglefortuItous
observatIonhadgIvenwaytoacautIousprogramofassessmentandreassessment.
Femarkably,noanesthetIcswereIntroducedIntoclInIcaluseforanother20years.FInally,
desfluranewasreleasedIn1992andsevofluranewasreleasedIn1994.Xenon,agashavIng
manypropertIesoftheIdealanesthetIc,wasadmInIsteredtoafewpatIentsIntheearly
1950sbutItnevergaInedpopularItybecauseoftheextremecostsassocIatedwIthIts
removalfromaIr.However,InterestInxenonhasbeenrenewednowthatgas
concentratIonscanbeaccuratelymeasuredwhenadmInIsteredatlowflows,anddevIces
areavaIlabletoscavengeandreusethegas.
Intravenous Anesthetics
PrIortoWIllIamHarvey'sdescrIptIonofacompleteandcontInuousIntravascularcIrcuItIn
De Motu Cordis(1628),ItwaswIdelyheldthatbloodemanatedfromtheheartandwas
propelledtotheperIpherywhereItwasconsumed.TheIdeathatsubstancescouldbe
InjectedIntravascularlyandtravelsystemIcallyprobablyorIgInatedwIthChrIstopherWren.
n1657,WrenInjectedaqueousopIumIntoadogthroughagoosequIllattachedtoapIg's
bladder,renderIngtheanImalstupefIed.
64
WrensImIlarlyInjectedIntravenouscrocus
metallorum,anImpurepreparatIonofantImony,andobservedtheanImalstovomItand
thendIe.KnowledgeofacIrculatorysystemandIntravascularaccessspurredInvestIgatIons
Inotherareas,andWren'scontemporary,FIchardLower,performedthefIrstblood
transfusIonsoflamb'sbloodIntodogsandotheranImals.
nthemId19thcentury,equIpmentnecessaryforeffectIveIntravascularInjectIonswas
conceIved.7accInatIonlancetswereusedInthe18J0stopuncturetheskInandforce
morphInepastesubcutaneouslyforanalgesIa.
65
ThehollowneedleandhypodermIcsyrInge
weredevelopedInthefollowIngdecadesbutwerenotInItIallydesIgnedforIntravenous
use.n1845,0ublInsurgeonFrancIsFyndcreatedthehollowneedleforInjectIonof
morphIneIntonervesInthetreatmentofneuralgIas.SImIlarly,CharlesCabrIelPravaz
desIgnedthefIrstfunctIonalsyrIngeIn185JforperIneuralInjectIons.AlexanderWood,
however,IsgenerallycredItedwIthperfectIngthehypodermIcglasssyrInge.n1855,Wood
publIshedanartIcleontheInjectIonofopIatesIntopaInfulspotsbyuseofhollowneedle
andhIsglasssyrInge.
66
n1872,PIerreDrofLyonsperformedwhatIsperhapsthefIrstsuccessfulIntravenous
surgIcalanesthetIcbyInjectIngchloralhydrateImmedIatelyprIortoIncIsIon.HIs1875
publIcatIondescrIbesItsuseInJ6patIentsbutseveralpostoperatIvedeathslentlIttleto
recommendthIsmethodtootherpractItIoners.
67
n1909,LudwIg8urkhardtproduced
surgIcalanesthesIabyIntravenousInjectIonsofchloroformandetherInCermany.Seven
yearslater,ElIsabeth8redenfeldofSwItzerlandreportedtheuseofIntravenousmorphIne
andscopolamIne.ThetrIalsfaIledtoshowanImprovementoverInhaledtechnIques.
ntravenousanesthesIafoundlIttleapplIcatIonorpopularIty,prImarIlybecauseofalackof
suItabledrugs.nthefollowIngdecades,thIswouldchange.
ThefIrstbarbIturate,barbItal,wassynthesIzedIn190JbyFIscherandvon|erIng.
PhenobarbItalandallothersuccessorsofbarbItalhadveryprotractedactIonandfound
lIttleuseInanesthesIa.After1929,oralpentobarbItalwasusedasasedatIvebefore
surgery,butwhenItwasgIvenInanesthetIcconcentratIons,longperIodsof
unconscIousnessfollowed.ThefIrstshortactIngoxybarbIturatewashexobarbItal(EvIpal),
avaIlableclInIcallyIn19J2.HexobarbItalwasenthusIastIcallyreceIvedbytheanesthesIa
communItIesInEuropeandNorthAmerIcabecauseItsabbrevIatedInductIontImewas
unrIvaledbyanyothertechnIque.ALondonanesthetIst,FonaldJarman,foundthatIthad
adramatIcadvantageoverInhalatIonInductIonsformInorprocedures.JarmanInstructed
hIspatIentstoraIseonearmwhIleheInjectedhexobarbItalIntoaveInoftheopposIte
forearm.WhentheupraIsedarmfell,IndIcatIngtheonsetofhypnosIs,thesurgeoncould
begIn.PatIentswerealsoamazedInthatmanyawokeunabletobelIevetheyhadbeen
anesthetIzed.
68
EventhoughthepromptactIonofhexobarbItalhadadramatIceffectontheconductof
anesthesIa,ItwassoonreplacedbytwothIobarbIturates.n19J2,0onaleeTabernand
ErnestH.7olwIleroftheAbbottCompanysynthesIzedthIopental(Pentothal)andthIamylal
(SurItal).ThesulfatedbarbIturatesprovedtobemoresatIsfactory,potent,andrapId
actIngthanweretheIroxybarbIturateanalogs.ThIopentalwasfIrstadmInIsteredtoa
patIentattheUnIversItyofWIsconsInIn|arch19J4,butthesuccessfulIntroductIonof
thIopentalIntoclInIcalpractIcefollowedathoroughInvestIgatIonconductedbyJohnLundy
andhIscolleaguesatthe|ayoClInIcInJune19J4.
WhenfIrstIntroduced,thIopentalwasoftengIvenInrepeatedIncrementsastheprImary
anesthetIcforprotractedprocedures.tshazardsweresoonapprecIated.AtfIrst,
depressIonofrespIratIonwasmonItoredbythesImpleexpedIentofobservIngthemotIonof
awIspofcottonplacedoverthenose.DnlyafewskIlledpractItIonerswerepreparedto
passatrachealtubeIfthepatIentstoppedbreathIng.SuchpractItIonersrealIzedthat
thIopentalwIthoutsupplementatIondIdnotsuppressaIrwayreflexes,andtheytherefore
encouragedtheprophylactIcprovIsIonoftopIcalanesthesIaoftheaIrway
P.15
beforehand.ThevasodIlatoryeffectsofthIobarbIturateswerewIdelyapprecIatedonly
whenthIopentalcausedcardIovascularcollapseInhypovolemIcburnedcIvIlIanand
mIlItarypatIentsInWorldWar.nresponse,fluIdreplacementwasusedmore
aggressIvelyandthIopentaladmInIsteredwIthgreatercautIon.
n1962,ketamInewassynthesIzedby0r.CalvInStevensattheParke0avIsLaboratorIesIn
AnnArbor,|IchIgan.DneofthecyclohexylamInecompoundsthatIncludesphencyclIdIne,
ketamInewastheonlydrugofthIsgroupthatgaInedclInIcalutIlIty.Theothercompounds
producedundesIrablepostanesthetIcdelIrIumandpsychomImetIcreactIons.n1966,the
neologIsmdIssocIatIveanesthesIawascreatedbyCuenterCorrsenandEdward0omInoto
descrIbethetrancelIkestateofprofoundanalgesIaproducedbyketamIne.
69
twas
releasedforuseIn1970,andalthoughItremaInsprImarIlyanagentforanesthetIc
InductIon,ItsanalgesIcpropertIesareIncreasInglystudIedandusedbypaInspecIalIsts.
EtomIdatewasfIrstdescrIbedbyPaulJanssenandhIscolleaguesIn1964,andorIgInally
gIventhenameHypnomIdate.tskeyadvantages,mInImalhemodynamIcdepressIonand
lackofhIstamInerelease,accountforItsongoIngutIlItyInclInIcalpractIce.twasreleased
foruseIn1974anddespIteItsdrawbacks(paInonInjectIon,myoclonus,postoperatIve
nauseaandvomItIng,andInhIbItIonofadrenalsteroIdogenesIs),etomIdateIsoftenthe
drugofchoIceforanesthetIzInghemodynamIcallyunstablepatIents.
Propofol,or2,6dIIsopropylphenol,wasfIrstsynthesIzedbymperIalChemIcalndustrIes
andtestedclInIcallyIn1977.nvestIgatorsfoundthatItproducedhypnosIsquIcklywIth
mInImalexcItatIonandthatpatIentsawokepromptlyoncethedrugwasdIscontInued.n
addItIontoItsexcellentInductIoncharacterIstIcs,theantIemetIcactIonofpropofolmade
ItanagentofchoIceInpatIentpopulatIonspronetonauseaandemesIs.Fegrettably,
CremophorEL,thesolventwIthwhIchItwasformulated,producedseveralsevere
anaphylactIcreactIonsandItwaswIthdrawnfromuse.Dncepropofolwasreformulated
wIthegglecIthIn,glycerol,andsoybeanoIl,thedrugreenteredclInIcalpractIceand
gaInedgreatsuccess.tspopularItyIn8rItaIncoIncIdedwIththeIntroductIonoftheL|A,
andItwassoonnotedthatpropofolsuppressedpharyngealreflexestoadegreethat
permIttedtheInsertIonofanL|AwIthoutaneedforeIthermusclerelaxantsorpotent
InhaledanesthetIcs.
Local Anesthetics
CenturIesaftertheconquestofPeru,EuropeansbecameawareofthestImulatIng
propertIesofalocal,IndIgenousplantthatthePeruvIanscalledkhoka.Khoka,whIch
meantthe plant,quIcklybecameknownascocaInEurope.n1860,shortlyafterthe
AustrIanCarlvonScherzerImportedenoughcocaleavestoallowforanalysIs,Cerman
chemIstsAlbertNIemannandWIlhelmLossenIsolatedthemaInalkaloIdandnamedIt
cocaine.TwentyfIveyearslater,attherecommendatIonofhIsfrIendSIgmundFreud,Carl
KollerbecameInterestedIntheeffectsofcocaIne.AfterseveralanImalexperIments,
KollersuccessfullydemonstratedtheanalgesIcpropertIesofcocaIneapplIedtotheeyeIna
patIentwIthglaucoma.
70
Unfortunately,nearlysImultaneouswIththefIrstreportsof
cocaIneuse,therewerereportsofcentralnervoussystemandcardIovasculartoxIcIty.
71,72
AsthepopularItyofcocaInegrew,sodIdthefrequencyoftoxIcreactIonsandcocaIne
addIctIons.
7J
SkeptIcIsmabouttheuseofcocaInequIcklygrewwIthInthemedIcal
communIty,forcIngthepharmacologIcalIndustrytodevelopalternatIvelocalanesthetIcs.
n1898,AlfredEIhornsynthesIzednIvaquIne,thefIrstamInoamIdelocalanesthetIc.
74
NIrvaquIneprovedtobeanIrrItanttotIssuesandItsusewasImmedIatelystopped.
FeturnInghIsattentIontowardthedevelopmentofamInoesterlocalanesthetIcs,EIhorn
synthesIzedbenzocaIneIn1900andprocaIne(novocaIne)shortlyafterIn1905.AmIno
esterswerecommonlyusedforlocalInfIltratIonandspInalanesthesIadespItetheIrlow
potencyandhIghlIkelIhoodtocauseallergIcreactIons.TetracaIne,thelast(andprobably
safest)amInoesterlocalanesthetIcdeveloped,provedtobequIteusefulformanyyears.
n1944,NIlsLofgrenand8engtLundquIstdevelopedlIdocaIne,anamInoamIdelocal
anesthetIc.
7J
LIdocaInegaInedImmedIatepopularItybecauseofItspotency,rapIdonset,
decreasedIncIdenceofallergIcreactIons,andoveralleffectIvenessforalltypesofregIonal
anesthetIcblocks.SIncetheIntroductIonoflIdocaIne,alllocalanesthetIcsdevelopedand
marketedhavebeenoftheamInoamIdevarIety.
8ecauseoftheIncreaseInlengthyandsophIstIcatedsurgIcalprocedures,thedevelopment
ofalongactInglocalanesthetIctookprecedence.Fromthatdemand,bupIvacaInewas
IntroducedIn1965.SynthesIzedby8.EkenstamIn1957,
76
bupIvacaInewasInItIally
dIscardedafterItwasfoundtobehIghlytoxIc.8y1980,severalyearsafterbeIng
IntroducedtotheUnItedStates,therewereseveralreportsofalmostsImultaneous
seIzuresandcardIovascularcollapsefollowIngunIntendedIntravascularInjectIon.
77
Shortly
afterthIs,asaresultofthecardIovasculartoxIcItyassocIatedwIthbupIvacaIneandthe
profoundmotorblockassocIatedwIthetIdocaIne,thepharmaceutIcalIndustrybegan
searchIngforanewlongactIngalternatIve.ntroducedIn1996,ropIvacaIneIsstructurally
sImIlartomepIvacaIneandbupIvacaIne,althoughItIspreparedasasInglelevorotatory
IsomerratherthanaracemIcmIxture.ThelevorotatoryIsomerhaslesspotentIalfor
toxIcItythanthedextrorotatoryIsomer.
78
ThepotentIalsafetyofropIvacaIneIs
controversIalbecauseropIvacaIneIsapproxImately25lesspotentthanbupIvacaIne.
Therefore,atequalpotentdosesthemargInofsafetybetweenropIvacaIneand
bupIvacaInebecomeslessapparent,althoughsystemIctoxIcItywIthropIvacaInemay
respondmorequIcklytoconventIonalresuscItatIon.
79
EachlocalanesthetIcdevelopedhashadItsownposItIveandnegatIveattrIbutes,whIchIs
whysomearestIllusedtodayandothershavefallenoutoffavor.Currently,the
pharmaceutIcalIndustryIsIntheprocessofdevelopIngextendedreleaselocalanesthetIcs
usInglIposomesandmIcrospheres.
80,81
Opioids
DpIoIds(hIstorIcallyreferredtoasnarcotics,althoughsemantIcallyIncorrectseeChapter
19)remaIntheanalgesIcworkhorseInanesthesIapractIce.TheyareusedroutInelyInthe
perIoperatIveperIod,InthemanagementofacutepaIn,andInavarIetyoftermInaland
chronIcpaInstates.TheavaIlabIlItyofshort,medIum,andlongactIngopIoIds,aswellas
themanyroutesofadmInIstratIon,gIvesphysIcIansconsIderableflexIbIlItyIntheuseof
theseagents.TheanalgesIcandsedatIngpropertIesofopIumhavebeenknownformore
thantwomIllennIa.CertaInlytheCreeksandChInesecIvIlIzatIonsharnessedthese
propertIesInmedIcalandculturalpractIces.DpIumIsderIvedfromtheseedsofthepoppy
(Papaver somniferum),andIsanamalgamofmorethan25pharmacologIcalkaloIds.The
fIrstalkaloIdIsolated,morphIne,wasextractedbyPrussIanchemIstFreIdrIchA.W.
SerturnerIn180J.HenamedthIsalkaloIdaftertheCreekgodofdreams,|orpheus.
|orphInebecamecommonlyusedasasupplementtoInhaledanesthesIaandfor
postoperatIvepaIncontroldurIngthelatterhalfofthe19thcentury.CodeIne,another
alkaloIdofopIum,wasIsolatedIn18J2byFobIquetbutItsrelatIvelyweakeranalgesIc
potencyandnauseaathIgherdoseslImItsItsroleInmanagIngmoderatetosevere
perIoperatIvesurgIcalpaIn.
P.16
|eperIdInewasthefIrstsynthetIcopIoIdandwasdevelopedIn19J9bytwoCerman
researchersatCFarben,DttoEIslebandD.Schaumann.AlthoughmanypharmacologIsts
arerememberedfortheIntroductIonofasIngledrug,oneprolIfIcresearcher,Paul
Janssen,hassInce195Jbroughtforwardmorethan70agentsfromamong70,000chemIcals
createdInhIslaboratory.HIsproductshavehadprofoundeffectsondIscIplInesas
dIsparateasparasItologyandpsychIatry.ThepaceofproductIveInnovatIonInJanssen's
researchlaboratoryIsastonIshIng.ChemIcalF426J(fentanyl),synthesIzedIn1960,was
followedonlyayearlaterbyF4749(droperIdol),andthenetomIdateIn1964.nnovar,the
fIxedcombInatIonoffentanylanddroperIdol,IslesspopularnowbutJanssen's
phenylpIperIdInederIvatIves,fentanyl,sufentanIlandalfentanIl,arestaplesInthe
anesthesIapharmacopoeIa.FemIfentanIl,anultrashortactIngopIoIdIntroducedbyClaxo
WellcomeIn1996,IsadeparturefromotheropIoIdsInthatIthasveryrapIdonsetand
equallyrapIdoffsetduetometabolIsmbynonspecIfIctIssueesterases.Ketorolac,a
nonsteroIdalantIInflammatorydrug(NSA0)approvedforuseIn1990,wasthefIrst
parenteralNSA0IndIcatedforpostoperatIvepaIn.WItha6to8mgmorphIneequIvalent
analgesIcpotency,KetorolacprovIdessIgnIfIcantpostoperatIvepaIncontrolandhas
partIcularusewhenanopIoIdsparIngapproachIsessentIal.KetorolacuseIslImItedbysIde
effectsandmaybeInapproprIateInpatIentswIthunderlyIngrenaldysfunctIon,bleedIng
problems,orcompromIsedbonehealIng.
Muscle Relaxants
|usclerelaxantsenteredanesthesIapractIcenearlyacenturyafterInhalatIonal
anesthetIcs(Table11).Curare,thefIrstknownneuromuscularblockIngagent,was
orIgInallyusedInhuntIngandtrIbalwarfarebynatIvepeoplesofSouthAmerIca.The
curaresarealkaloIdspreparedfromplantsnatIvetoequatorIalraInforests.The
refInementoftheharmlesssapofseveralspecIesofvInesIntotoxInsthatwerelethalonly
whenInjectedwasanextraordInarytrIumphIntroducedbypaleopharmacologIstsIn
loIncloths.TheIrdIscoverywasthemoreremarkablebecauseItwasIndependently
repeatedonthreeseparatecontInentsSouthAmerIca,AfrIca,andAsIa.Thesejungle
trIbesalsodevelopednearlyIdentIcalmethodsofdelIverIngthetoxInbydarts,whIch,
afterbeIngdIppedIncurare,maIntaInedtheIrpotencyIndefInItelyuntIltheywere
propelledthroughblowpIpestostrIkethefleshofmonkeysandotheranImalsofthe
treetops.|oreover,theAmerIcanndIansknewofthejuIceofanherbthatwould
counteracttheeffectsofthepoIsonIfadmInIsteredIntIme.
82
TheearlIestclInIcaluseofcurareInhumanswastoamelIoratethetortuousmusclespasms
ofInfectIoustetanus.n1858,NewYorkphysIcIanLouIsAlbertSayresreportedtwocasesIn
whIchheattemptedtotreatseveretetanuswIthcurareatthe8ellevueHospItal.8othof
hIspatIentsdIed.SImIlareffortswereundertakentousemusclerelaxantstotreat
epIlepsy,rabIes,andchoreIformdIsorders.TreatmentofParkInsonlIkerIgIdItyandthe
preventIonoftraumafromseIzuretherapyalsoprecededtheuseofcurareInanesthesIa.
8J
nterestIngly,curareantagonIstsweredevelopedwellbeforemusclerelaxantswereever
usedInsurgery.n1900,JacobPal,a7IennesephysIcIan,recognIzedthatcurarecouldbe
antagonIzedbyphysostIgmIne.ThIssubstancehadbeenIsolatedfromthecalabarbean
someJ6yearsearlIerbyScottIshpharmacologIstSIrT.F.Fraser.NeostIgmIne
methylsulphatewassynthesIzedIn19J1andwassIgnIfIcantlymorepotentInantagonIzIng
theeffectsofcurare.
84
n19J8,FIchardandFuthCIllreturnedtoNewYorkfromSouthAmerIca,brIngIngwIth
them11.9kgofcrudecurarecollectedneartheIrEcuadorIanranch.TheIrmotIvatIonwas
amIxtureofpersonalandaltruIstIcgoals.Somemonthsbefore,whIleonanearlIervIsItto
theUnItedStates,FIchardCIlllearnedthathehadmultIplesclerosIs.HIsphysIcIan,0r.
WalterFreeman,mentIonedthepossIbIlItythatcuraremIghthaveatherapeutIcroleIn
themanagementofspastIcdIsorders.WhentheCIllsreturnedtotheUnItedStateswIth
theIrsupplyofcrudecurare,theyencouragedscIentIstsatE.F.SquIbbECo.totakean
InterestInItsunIquepropertIes.SquIbbsoonofferedsemIrefInedcuraretotwogroupsof
AmerIcananesthesIologIsts,whoassessedItsactIonbutquIcklyabandonedtheIrstudIes
whenItcausedtotalrespIratoryparalysIsIntwopatIentsandthedeathoflaboratory
anImals.
TheearlIesteffectIveclInIcalapplIcatIonofcurareInmedIcIneoccurredInphysIatry.After
A.F.|cntyrerefInedaportIonoftherawcurareIn19J9,AbramE.8ennettofDmaha,
Nebraska,InjectedItIntochIldrenwIthspastIcdIsorders.WhIlenopersIstentbenefItcould
beobservedInthesepatIents,henextadmInIsteredIttopatIentsabouttoreceIve
|etrazol,aprecursortoelectroconvulsIvetherapy.8ecauseItelImInatedseIzureInduced
fractures,theytermedItashockabsorber.8y1941,otherpsychIatrIstsfollowedthIs
practIceand,whentheyfoundthattheactIonofcurarewasprotracted,occasIonallyused
neostIgmIneasanantIdote.
CurarewasusedInItIallyInsurgerybyArthurLawenIn1912,butthepublIshedreportwas
wrIttenInCermanandwasIgnoredfordecades.Lawen,aphysIologIstandphysIcIanfrom
LeIpzIg,usedcurareInhIslaboratorybeforeboldlyproducIngabdomInalrelaxatIonata
lIghtlevelofanesthesIaInasurgIcalpatIent.Lawen'seffortswerenotapprecIatedfor
decades,andwhIlehIspIoneerIngworkantIcIpatedlaterclInIcalapplIcatIon,safeuse
wouldhavetoawaIttheIntroductIonofregularIntubatIonofthetracheaandcontrolled
ventIlatIonofthelungs.
85
ThIrtyyearsafterLawen,HaroldCrIffIth,thechIefanesthetIstofthe|ontreal
HomeopathIcHospItal,learnedofA.E.8ennett'ssuccessfuluseofcurareandresolvedto
applyItInanesthesIa.AsCrIffIthwasalreadyamasteroftrachealIntubatIon,hewasmuch
betterpreparedthanweremostofhIscontemporarIestoattendtopotentIal
complIcatIons.DnJanuary2J,1942,CrIffIthandhIsresIdent,EnIdJohnson,anesthetIzed
andIntubatedthetracheaofayoungmanbeforeInjectIngcurareearlyInthecourseofhIs
appendectomy.SatIsfactoryabdomInalrelaxatIonwasobtaInedandthesurgeryproceeded
wIthoutIncIdent.CrIffIthandJohnson'sreportofthesuccessfuluseofcurareInthe25
patIentsoftheIrserIeslaunchedarevolutIonInanesthetIccare.
86
AnesthesIologIstswhopractIcedbeforemusclerelaxantsrecalltheanxIetytheyfeltwhena
prematureattempttoIntubatethetracheaundercyclopropanecausedpersIstIng
laryngospasm.8efore1942,abdomInalrelaxatIonwaspossIbleonlyIfthepatIenttolerated
hIghconcentratIonsofanInhaledanesthetIc,whIchmIghtbrIngprofoundrespIratory
depressIonandprotractedrecovery.Curareandthedrugsthatfollowedtransformed
anesthesIaprofoundly.8ecauseIntubatIonofthetracheacouldnowbetaughtIna
delIberatemanner,aneophytecouldfaIlonafIrstattemptwIthoutcompromIsIngthe
safetyofthepatIent.ForthefIrsttIme,abdomInalrelaxatIoncouldbeattaInedwhen
curarewassupplementedbylIghtplanesofInhaledanesthetIcsorbyacombInatIonof
IntravenousagentsprovIdIngbalancedanesthesIa.NewfrontIersopened.Sedatedand
paralyzedpatIentscouldnowsuccessfullyundergothemajorphysIologIctrespassesof
cardIopulmonarybypass,delIberatehypothermIa,orlongtermrespIratorysupportafter
surgery.
CredItforsuccessfulandsafeIntroductIonofcurareanddtubocurarIneIntoanesthesIa
mustInpartbegIventoaSquIbbresearchernamedH.A.Holaday.Crude,unstandardIzed
preparatIonsofcurareproduceduncertaInclInIcaleffectsandundesIrablesIdeeffects
relatedtovarIousImpurItIes.solatIon
P.17
ofdtubocurarIneIn19J5renewedclInIcalInterestbutamethodforstandardIzIng
ntocostrInandItspurerderIvatIve,dtubocurarIne,hadyettobedevIsed.ntheearly
1940s,InpartasaresultofCrIffIthandJohnson'ssuccessfultrIals,SquIbbembarkedon
wIdescaleproductIon.HoladaydevelopedarelIable,easIlyreproducIblemethodfor
standardIzIngcuraredosesthatbecameknownastherabbItheaddropassay(FIg.15).The
assayconsIstedofaqueouscuraresolutIonInjectedIntravenouslyIn0.1mLdosesevery15
secondsuntIltheendpoInt,whentherabbItbecameunabletoraIseItshead,was
reached.
87
Table 1-1 Events in the Development of Muscle Relaxants
YEAR EVENT
1516
Peter|artyrd'Anghera,De orbe novo,publIshedaccountofSouth
AmerIcanndIanarrowpoIsons
1596
SIrWalterFaleIghprovIdesdetaIledaccountofarrowpoIsoneffectsand
antIdote
1745
Charles|arIedelaCondamInereturnsfromEcuadorandconductscurare
experImentswIthchIckensandattemptedtousesugarasanantIdote
1780
AbbeFelIxFontanaInsertscuraredIrectlyIntoexposedscIatIcnerveof
rabbItwIthouteffect,concludesthatmechanIsmIsthedestructIonofthe
IrrItabIlItyofvoluntarymuscles.PublIshesOn the American Poison Ticunas
(nameofSouthAmerIcantrIbe)
1811
8enjamInCollIns8rodIedemonstratesthatanImalsmechanIcally
ventIlatedmaysurvIvesIgnIfIcantdosesofcurare
1812
WIllIamSewellsuggestsuseofcurareInhydrophobIa(rabIes)and
tetanus
1844
Claude8ernarddetermInesthatdeathoccursbyrespIratoryfaIlure,
motornervesareunabletotransmItstImulIfromhIghercenters,
dIfferentIaleffectonmuscleswIthperIpheralandthoracIcmusclesbeIng
affectedbeforerespIratorymuscles.8ernardconcludesthatthesIteof
actIonIsthejunctIonbetweenmusclesandnerves,neuromuscular
junctIon
1858
LouIsAlbertSayres,NewYorkphysIcIan,usescuraretotreattetanusIn
twopatIents
1864
PhysostIgmIneIsolatedfromCalabarbeansbySIrT.F.Fraser,aScottIsh
pharmacologIst
1886
F.8oehm,aCermanchemIst,demonstratedthreeseparateclassesof
1897 alkaloIdsIneachofthreetypesofIndIgenouscontaIners:tubecurares,
potcurares,andcalabashcurares
1900
JacobPalrecognIzesthatphysostIgmInecanantagonIzetheeffectsof
curare
1906
SuccInylcholInepreparedbyFeIdHuntandF.Taveau,experImentedon
rabbItspretreatedwIthcuraretolearnofcardIaceffectsandsoparalysIs
wentunrecognIzed
1912
ArthurLawenusescurareInsurgerybutreportpublIshedInCermansoIt
goeslargelyunrecognIzed
19J8
FIchardandFuthCIllbrInglargequantItyofcuraretoNewYorkfor
furtherstudybypharmaceutIcalcompany
19J9
AbramE.8ennettusescurareInchIldrenwIthspastIcdIsordersandto
preventtraumafrom|etrazoltherapy(precursortoECT)
1942
HaroldCrIffIthandEnIdJohnsonusecurareforabdomInalrelaxatIonIn
surgery
1942
H.A.HalodydevelopsrabbItheaddropassayforstandardIzatIonand
largescaleproductIonofcurareanddtubocurarIne
1948 0ecamethonIum,adepolarIzIngrelaxant,IssynthesIzed
1949
SuccInylcholInepreparedby0anIel8ovet,andthefollowIngyearbyJ.C.
CastIlloandEdwInde8eer
1956
0IstInctIonbetweendepolarIzIngandnondepolarIzIngneuromuscular
blockadeIsmadebyWIllIam0.|.Paton
1964
PancuronIumreleasedforuseInhumans,synthesIzedbySavageand
Hewett
1979
7ecuronIumIntroduced,specIfIcallydesIgnedtobemorehepatIcally
metabolIzedthanpancuronIum
199J |IvacurIumreleasedforclInIcaluse
1994 FocuronIumIntroducedtoclInIcalpractIce
SuccessfulclInIcaluseofcurareledtotheIntroductIonofothermusclerelaxants.8y1948,
gallamIneanddecamethonIumhadbeensynthesIzed.|etubIne,acurareredIscoveredIn
the1970s,wasusedclInIcallyInthesameyear.SuccInylcholInewaspreparedbytheNobel
laureate0anIel8ovetIn1949andwasInwIdeInternatIonalusebeforehIstorIansnoted
thatthedrughadbeensynthesIzedandtestedlongbeforehand.n1906,FeIdHuntandF.
TaveauxpreparedsuccInylcholIneamongaserIesofcholIneesters,whIchtheyhad
InjectedIntorabbItstoobservetheIrcardIaceffects.ftheIrrabbItshadnotbeen
prevIouslyparalyzedwIthcurare,the
P.18
depolarIzIngactIonofsuccInylcholInemIghthavebeenrecognIzeddecadesearlIer.
Figure 1-5.TheFabbItheaddropassay.H.A.HallodayofSquIbbpharmaceutIcal
companydevelopedamethodofstandardIzIngdosesofcurareanddtubocurarInea
normalrabbIt(A)had0.1mlofaqueouscecuranesolutIonInjectedevery15seconds
untIlItcouldnolongerraIseItshead(B).
TheabIlItytomonItorIntraoperatIveneuromuscularblockadewIthnervestImulators
beganIn1958.WorkIngatSt.Thomas'HospItalInLondon,T.H.ChrIstIeandH.ChurchIll
0avIdsondevelopedamethodformonItorIngperIpheralneuromuscularblockadedurIng
anesthesIa.twasnotuntIl1970,however,thatH.H.AlIandcolleaguesdevIsedthe
technIqueofdelIverIngfoursupramaxImalImpulsesdelIveredat2Hz(0.5secondsapart),
oraTraInofFour,asamethodofquantIfyIngthedegreeofresIdualneuromuscular
blockade.
88
FesearchInrelaxantswasrekIndledIn1960whenresearchersbecameawareoftheactIon
ofmaloetIne,arelaxantfromtheCongobasIn.twasremarkableInthatIthadasteroIdal
nucleus.nvestIgatIonsofmaloetIneledtopancuronIumIn1968.nthe1970sand1980s,
researchshIftedtowardIdentIfIcatIonofspecIfIcreceptorbIochemIstryanddevelopment
ofreceptorspecIfIcdrugs.FromtheseIsoquInolInes,fourrelatedproductsemerged:
vecuronIum,pIpecuronIum,rocuronIum,andrapacuronIum.FapacuronIum,releasedInthe
early1990s,waswIthdrawnfromclInIcaluseafterseveralcasesofIntractable
bronchospasmledtobraIndamageordeath.FourclInIcalproductsbasedonthesteroId
parentdrugdtubocurarIne(atracurIum,mIvacurIum,doxacurIum,andcIsatracurIum)also
madeIttoclInIcaluse.FecognItIonthatatracurIumandcIsatracurIumundergo
spontaneousdegradatIonbyHoffmannelImInatIonhasdefInedaroleforthesemuscle
relaxantsInpatIentswIthlIverandrenalInsuffIcIency.
Antiemetics
EffectIvetreatmentforpostoperatIvenauseaandvomItIng(PDN7)evolvedrelatIvely
recentlyandhasbeendrIvenbyIncentIvestolImIthospItalIzatIonexpensesandImprove
patIentsatIsfactIon.8utPDN7IsanoldproblemforwhIchlate19thcenturypractItIoners
recognIzedmanycausesIncludInganxIety,severepaIn,suddenchangesInbloodpressure,
Ileus,IngestIonofblood,andtheresIdualeffectsofopIoIdsandInhalatIonalanesthetIcs.
FIskofpulmonaryaspIratIonofgastrIccontentsandsubsequentdeathfromasphyxIaor
aspIratIonpneumonIawasafearedconsequenceofanesthetIcs,especIallythoseprecedIng
useofcuffedendotrachealtubes.7omItIngandaspIratIondurInganesthesIaledtothe
practIceofmaIntaInInganemptystomachpreoperatIvely,apolIcythatcontInuestoday
despIteevIdencethatclearfluIdsuptoJhoursbeforesurgerydonotIncreasegastrIc
volumes,changegastrIcpH,orIncreasetherIskofaspIratIon.
AvarIetyoftreatmentsfornauseaandvomItIngwereproposedbyearlyanesthetIsts.
JamesCwathemy's1914publIcatIon,Anesthesia,commentedthat8rItIshsurgeons
customarIlygavetInctureofIodIneInateaspoonfulofwatereveryhalfhourforthreeor
fourdoses.nhalatIonofvInegarfumes,andrectalInjectIonofJ0to40dropsoftInctureof
opIumwIth60graInsofsodIumbromIde,werealsothoughttoquIetthevomItIngcenter.
89
DtherpractItIonersattemptedolfactorycontrolbyplacIngapIeceofgauzemoIstenedwIth
essenceoforangeoranaromatIcoIlontheupperlIpofthepatIent.
90
A19J7anesthesIa
textbookencouragedtreatmentofPDN7wIthlateralposItIonIng,Icedsodawater,strong
blackcoffee,andchloretone.
91
CounterIrrItatIon,suchasmustardleafonthe
epIgastrIum,wasalsobelIevedusefulInlImItIngemesIs.
92
Aslateas1951,anesthesIatexts
recommendedoxygenadmInIstratIon,whIffsofammonIaspIrIts,andcontrolofblood
pressureandposItIonIng.
9J
ThecomplexcentralmechanIsmsofnauseaandvomItIngwere
largelyunaffectedbymostofthesetreatments.NewerdrugscapableofIntervenIngat
specIfIcpathwayswereneededtohaveanImpactonPDN7.AsmoreshortactIng
anesthetIcsweredeveloped,theproblemreceIvedsharperfocusInawakepostoperatIve
patIentsIntherecoveryroom.ThenauseaattendInguseofnewerchemotherapyagents
provIdedaddItIonalImpetustothedevelopmentofantIemetIcmedIcatIons.
n1955,anonrandomIzedstudyusIngtheantIhIstamInecyclIzIneshowedareductIonIn
PDN7from27to21InagroupofJ,000patIents.ThefollowIngyear,amorerIgorous
studybyKnappand8eecherreportedasIgnIfIcantbenefItfromprophylaxIswIththe
neuroleptIcchlorpromazIne.n1957,promethazIne(Phenergan)andchlorpromazInewere
bothfoundtoreducePDN7whenusedprophylactIcally.ThIrteenyearslater,adouble
blIndstudyevaluatIngmetoclopramIdewaspublIshedandthatdrugbecameafIrstlIne
drugInthemanagementofPDN7.0roperIdol,releasedIntheearly1960s,becamewIdely
useduntIl2001whenconcernsregardIngprolongatIonofQTIntervalspromptedawarnIng
fromtheFoodand0rugAdmInIstratIonaboutItscontInueduse.
TheantIemetIceffectsofcortIcosteroIdswerefIrstrecognIzedbyoncologIststreatIng
IntracranIaledemafromtumors.
94
SubsequentstudIeshaveborneouttheantIemetIc
propertIesofthIsclassofdrugsIntreatIngPDN7.FecognItIonoftheserotonIn5HTJ
pathwayInPDN7hasledtoaunIque
P.19
classofdrugsdevotedonlytoaddressIngthIspartIcularproblem.Dndansetron,thefIrst
representatIveofthIsdrugclass,wasapprovedbytheFoodand0rugAdmInIstratIonIn
1991.AddItIonalserotonIn5HTJantagonIstshavebeenapprovedandareavaIlabletoday.
Anesthesia Subspecialties
Regional Anesthesia
CocaIne,anextractofthecocaleaf,wasthefIrsteffectIvelocalanesthetIc.AfterAlbert
NIemannrefInedtheactIvealkaloIdandnamedItcocaine,ItwasusedInexperImentsbya
fewInvestIgators.twasnotedthatcocaIneprovIdedtopIcalanesthesIaandeven
producedlocalInsensIbIlItywhenInjected,butCarlKoller,a7IennesesurgIcalIntern,fIrst
recognIzedtheutIlItyofcocaIneInclInIcalpractIce.
n1884,CarlKollerwascompletInghIsmedIcaltraInIngatatImewhenmanyoperatIonson
theeyewereperformedwIthoutgeneralanesthesIa.Almostfourdecadesafterthe
dIscoveryofether,generalanesthesIabymaskstIllhadlImItatIonsforophthalmIcsurgery:
lackofpatIentcooperatIon,InterferenceoftheanesthesIaapparatuswIthsurgIcalaccess,
andthehIghIncIdenceofPDN7.AtthattIme,sIncefInesutureswerenotavaIlableand
surgIcalIncIsIonsoftheeyewerenotclosed,postoperatIvevomItIngthreatenedthe
extrusIonoftheglobe'scontents,puttIngthepatIentatrIskforIrrevocableblIndness.
95
WhIleamedIcalstudent,KollerhadworkedIna7IenneselaboratoryInasearchofa
topIcalophthalmIcanesthetIctoovercomethelImItatIonsofgeneralanesthesIa.
Unfortunately,thesuspensIonsofmorphIne,chloralhydrate,andotherdrugsthathehad
usedhadbeenIneffectual.n1884,Koller'sfrIend,SIgmundFreud,becameInterestedIn
thecerebralstImulatIngeffectsofcocaIneandgavehImasmallsampleInanenvelope,
whIchheplacedInhIspocket.Whentheenvelopeleaked,afewgraInsofcocaInestuckto
Koller'sfIngerandheabsentmIndedlylIckedhIstongue.WhenhIstonguebecamenumb,
KollerInstantlyrealIzedthathehadfoundtheobjectofhIssearch.nhIslaboratory,he
madeasuspensIonofcocaInecrystalsthatheandalaboratoryassocIatetestedIntheeyes
ofafrog,arabbIt,andadog.SatIsfIedwIththeanesthetIceffectsseenIntheanImal
models,KollerdroppedthesolutIonontohIsowncornea.TohIsamazement,hIseyeswere
InsensItIvetothetouchofapIn.
96
AsanIntern,CarlKollercouldnotaffordtoattenda
CongressofCermanDphthalmologIstsInHeIdelbergonSeptember15,1884.However,a
frIendpresentedhIsartIcleatthemeetIngandarevolutIonInophthalmIcsurgeryand
othersurgIcaldIscIplInesbegan.WIthInthenextyear,morethan100artIclessupportIng
theuseofcocaIneappearedInEuropeanandAmerIcanmedIcaljournals.n1888,Koller
ImmIgratedtoNewYork,wherehepractIcedophthalmologyfortheremaInderofhIs
career.
AmerIcansurgeonsquIcklydevelopednewapplIcatIonsforcocaIne.tseffIcacyIn
anesthetIzIngthenose,mouth,larynx,trachea,rectum,andurethrawasdescrIbedIn
Dctober1884.Thenextmonth,thefIrstreportsofItssubcutaneousInjectIonwere
publIshed.n0ecember1884,twoyoungsurgeons,WIllIamHalstedandFIchardHall,
descrIbedblocksofthesensorynervesofthefaceandarm.Halstedevenperformeda
brachIalplexusblockbutdIdsounderdIrectvIsIonwhIlethepatIentreceIvedanInhaled
anesthetIc.
97
Unfortunately,selfexperImentatIonwIthcocaInewashazardous,asboth
surgeonsbecameaddIcted.
98
AddIctIonwasanIllunderstoodbutfrequentproblemInthe
late19thcentury,especIallywhencocaIneandmorphInewerepresentInmanypatent
medIcInesandfolkremedIes.
DtherregIonalanesthetIctechnIqueswereattemptedbeforetheendofthe19thcentury.
Thetermspinal anesthesiawascoInedIn1885byLeonardCornIng,aneurologIstwhohad
observedHallandHalsted.CornIngwantedtoassesstheactIonofcocaIneasaspecIfIc
therapyforneurologIcproblems.AfterfIrstassessIngItsactIonInadog,producInga
blockadeofrapIdonsetthatwasconfInedtotheanImal'srearlegs,heperformeda
neuraxIalblockusIngcocaIneonamanaddIctedtomasturbatIon.CornIngadmInIstered
onedosewIthouteffect,thenafteraseconddose,thepatIent'slegsfeltsleepy.Theman
hadImpaIredsensIbIlItyInhIslowerextremItyafterabout20mInutesandleftCornIng's
offIcenonetheworsefortheexperIence.
99
AlthoughCornIngdIdnotdescrIbeescapeof
cerebrospInalfluId(CSF)IneIthercase,ItIslIkelythatthedoghadaspInalanesthetIcand
thatthemanhadanepIduralanesthetIc.NotherapeutIcbenefItwasdescrIbed,but
CornIngclosedhIsaccountandhIsattentIontothesubjectbysuggestIngthatcocaInIzatIon
mIghtIntImebeasubstItuteforetherIzatIonIngenItourInaryorotherbranchesof
surgery.
100
Twootherauthors,August8IerandTheodorTuffIer,descrIbedauthentIcspInalanesthesIa,
wIthmentIonofCSF,InjectIonofcocaIne,andanapproprIatelyshortonsetofactIon.na
comparatIverevIewoftheorIgInalartIclesby8Ier,TuffIer,andCornIng,Itwasconcluded
thatCornIng'sInjectIonwasextradural,and8IermerItedthecredItforIntroducIngspInal
anesthesIa.
101
FourteenyearspassedbeforespInalanesthesIawasperformedforsurgery.ntheInterval,
HeInrIchQuInckeofKIel,Cermany,haddescrIbedhIstechnIqueoflumbarpuncture.He
offeredthevaluableobservatIonthatItwasmostsafelyperformedatthelevelofthethIrd
orfourthlumbarInterspacebecauseentryatthatlevelwasbelowthetermInatIonofthe
spInalcord.QuIncke'stechnIquewasusedInKIelforthefIrstdelIberatecocaInIzatIonof
thespInalcordIn1899byhIssurgIcalcolleague,August8Ier.SIxpatIentsreceIvedsmall
dosesofcocaIneIntrathecally,butbecausesomecrIedoutdurIngsurgerywhIleothers
vomItedandexperIencedheadaches,8IerconsIderedItnecessarytoconductfurther
experImentsbeforecontInuIngthIstechnIqueforsurgery.
Professor8IerpermIttedhIsassIstant,0r.HIldebrandt,toperformalumbarpuncture,but
aftertheneedlepenetratedthedura,HIldebrandtcouldnotfItthesyrIngetotheneedle
andalargevolumeoftheprofessor'sspInalfluIdescaped.TheywereatthepoIntof
abandonIngthestudywhenHIldebrandtvolunteeredtobethesubjectofasecondattempt.
TheIrpersIstencewasrewardedwIthanastonIshIngsuccess.TwentythreemInutesafter
thespInalInjectIon,8Iernoted:AstrongblowwIthanIronhammeragaInstthetIbIawas
notfeltaspaIn.After25mInutes:StrongpressureandpullIngonatestIclewerenot
paInful.
94
TheycelebratedtheIrsuccesswIthwIneandcIgars.ThatnIght,bothdeveloped
vIolentheadaches,whIchtheyattrIbutedatfIrsttotheIrcelebratIon.8Ier'sheadachewas
relIevedafter9daysofbedrest.HIldebrandt,asahouseoffIcer,dIdnothavetheluxuryof
contInuedrest.8IerpostulatedthattheIrheadacheswerearesultofthelossoflarge
volumesofCSFandurgedthatthIsbeavoIdedIfpossIble.ThehIghIncIdenceof
complIcatIonsfollowInglumbarpuncturewIthwIdeboreneedlesandthetoxIcreactIons
attrIbutedtococaIneexplaInhIslaterlossofInterestInspInalanesthesIa.
102
SurgeonsInseveralothercountrIessoonpractIcedspInalanesthesIaandprogressoccurred
bymanysmallcontrIbutIonstothetechnIque.TheodorTuffIerpublIshedthefIrstserIesof
125spInalanesthetIcsfromFranceandhelatercounseledthatthesolutIonshouldnotbe
InjectedbeforeCSFwasseen.ThefIrstAmerIcanreportwasbyFudolph|atasofNew
Drleans,whosefIrstpatIentdevelopedpostanesthetIcmenIngIsmus,afrequent
complIcatIonthatwasovercomeInpartbytheuseofhermetIcallysealedsterIlesolutIons
recommendedbyE.W.LeeofPhIladelphIaandsterIleglovesasadvocatedbyHalsted.
0urIng1899,0udleyTaItandCuIdloCaglIerIofSanFrancIsco
P.20
performedexperImentalstudIesInanImalsandtherapeutIcspInalsfororthopaedIc
patIents.TheyencouragedtheuseoffIneneedlestolessentheescapeofCSFandurged
thattheskInanddeepertIssuesbeInfIltratedbeforehandwIthlocalanesthesIa.
10J
ThIshad
beensuggestedearlIerbyWIllIamHalstedandtheforemostadvocateofInfIltratIon
anesthesIa,CarlLudwIgSchleIchof8erlIn.AnearlyAmerIcanspecIalIstInanesthesIa,
DrmondColdan,publIshedananesthesIarecordapproprIateforrecordIngthecourseof
IntraspInalcocaInIzatIonIn1900.nthesameyear,HeInrIch8raunlearnedofanewly
descrIbedextractoftheadrenalgland,epInephrIne,whIchheusedtoprolongtheactIonof
localanesthetIcswIthgreatsuccess.8raundevelopedseveralnewnerveblocks,coInedthe
termconduction anesthesia,andIsrememberedbyEuropeanwrItersasthefatherof
conductIonanesthesIa.8raunwasthefIrstpersontouseprocaIne,whIch,alongwIth
stovaIne,wasoneofthefIrstsynthetIclocalanesthetIcsproducedtoreducethetoxIcItyof
cocaIne.
8efore1907,anesthesIologIstsweresometImesdIsappoIntedtoobservethattheIrspInal
anesthetIcswereIncomplete.|ostbelIevedthatthedrugspreadsolelybylocaldIffusIon
beforethepropertyofbarIcItywasInvestIgatedbyArthur8arker,aLondonsurgeon.
104
8arkerconstructedaglasstubeshapedtofollowthecurvesofthehumanspIneandusedIt
todemonstratethelImItedspreadofcoloredsolutIonsthathehadInjectedthroughaT
pIeceInthelumbarregIon.8arkerapplIedthIsobservatIontousesolutIonsofstovaIne
madehyperbarIcbytheaddItIonof5glucose,whIchworkedInamorepredIctable
fashIon.AftertheInjectIonwascomplete,8arkerplacedhIspatIent'sheadonpIllowsto
contaIntheanesthetIcbelowthenIpplelIne.LIncolnSIseacknowledged8arker'sworkIn
19J5whenheIntroducedtheuseofhyperbarIcsolutIonsoftetracaIne(PontocaIne).John
AdrIanIadvancedtheconceptfurtherIn1946whenheusedahyperbarIcsolutIonto
producesaddleblock,orperInealanesthesIa.AdrIanI'spatIentsremaInedseatedafter
InjectIonasthedrugdescendedtothesacralnerves.
TaIt,Jonnesco,andotherearlymastersofspInalanesthesIausedacervIcalapproachfor
thyroIdectomyandthoracIcprocedures,butthIsradIcalapproachwassupplantedIn1928
bythelumbarInjectIonofhypobarIcsolutIonsoflIghtnupercaInebyC.P.PItkIn.
AlthoughtheuseofhypobarIcsolutIonsIsnowlImItedprImarIlytopatIentsposItIonedIn
thejackknIfeposItIon,theIrformeruseforthoracIcproceduresdemandedskIllandprecIse
tImIng.TheenthusIastsofhypobarIcanesthesIadevIsedformulastoattempttopredIctthe
tImeInsecondsneededforawarmedsolutIonofhypobarIcnupercaInetospreadIn
patIentsofvaryIngsIzefromItssIteofInjectIonInthelumbarareatothelevelofthe
fourththoracIcdermatome.
TherecurrIngproblemofInadequateduratIonofsIngleInjectIonspInalanesthesIaleda
PhIladelphIasurgeon,WIllIamLemmon,todevIseanapparatusforcontInuousspInal
anesthesIaIn1940.
105
LemmonbeganwIththepatIentInthelateralposItIon.ThespInal
tapwasperformedwIthamalleablesIlverneedle,whIchwasleftInposItIon.Asthe
patIentwasturnedsupIne,theneedlewasposItIonedthroughaholeInthemattressand
table.AddItIonalInjectIonsoflocalanesthetIccouldbeperformedasrequIred.|alleable
sIlverneedlesalsofoundalesscumbersomeandmorecommonapplIcatIonIn1942when
WaldoEdwardsandFobertHIngsonencouragedtheuseofLemmon'sneedlesforcontInuous
caudalanesthesIaInobstetrIcs.n1944EdwardTuohyofthe|ayoClInIcIntroducedtwo
ImportantmodIfIcatIonsofthecontInuousspInaltechnIques.Hedevelopedthenow
famIlIarTuohyneedle
106
asameansofImprovIngtheeaseofpassageoflacqueredsIlk
ureteralcathetersthroughwhIchheInjectedIncrementaldosesoflocalanesthetIc.
107
n1949,|artInezCurbeloofHavana,Cuba,usedTuohy'sneedleandaureteralcatheterto
performthefIrstcontInuousepIduralanesthetIc.SIlkandgumelastIccatheterswere
dIffIculttosterIlIzeandsometImescausedduralInfectIonsbeforebeIngsupersededby
dIsposableplastIcs.Yet,delIberatesIngleInjectIonperIduralanesthesIahadbeenpractIced
occasIonallyfordecadesbeforecontInuoustechnIquesbroughtItgreaterpopularIty.Atthe
begInnIngofthe20thcentury,twoFrenchclInIcIansexperImentedIndependentlywIth
caudalanesthesIa.TheneurologIstJeanAthanaseSIcardapplIedthetechnIquefora
nonsurgIcalpurpose,therelIefofbackpaIn.FernandCathelInusedcaudalanesthesIaasa
lessdangerousalternatIvetospInalanesthesIaforhernIarepaIrs.Healsodemonstrated
thattheepIduralspacetermInatedIntheneckbyInjectIngasolutIonofndIaInkIntothe
caudalcanalofadog.ThelumbarapproachwasfIrstusedsolelyformultIpleparavertebral
nerveblocksbeforethePags0oglIottIsIngleInjectIontechnIquebecameaccepted.As
theyworkedseparately,thetechnIquecarrIesthenamesofbothmen.CaptaInFIdelPags
preparedanelegantdemonstratIonofsegmentalsIngleInjectIonperIduralanesthesIaIn
1921,butdIedsoonafterhIsartIcleappearedInaSpanIshmIlItaryjournal.
108
Tenyears
later,AchIlle|.0oglIottIofTurIn,taly,wroteaclassIcstudythatmadetheepIdural
technIquewellknown.
7J
WhereasPagsusedatactIleapproachtoIdentIfytheepIdural
space,0oglIottIIdentIfIedItbythelossofresIstancetechnIque.
SurgeryontheextremItIeslentItselftootherregIonalanesthesIatechnIques.n1902,
HarveyCushIngcoInedthephraseregional anesthesiaforhIstechnIqueofblockIngeIther
thebrachIalorscIatIcplexusunderdIrectvIsIondurInggeneralanesthesIatoreduce
anesthesIarequIrementsandprovIdepostoperatIvepaInrelIef.
75
FIfteenyearsbeforehIs
publIcatIon,CeorgeCrIleadvancedasImIlarapproachtoreducethestressandshockof
surgery.CrIle,adedIcatedadvocateofregIonalandInfIltratIontechnIquesdurInggeneral
anesthesIa,coInedthetermanoci-association.
109
AnIntravenousregIonaltechnIquewIthprocaInewasreportedIn1908byAugust8Ier,the
surgeonwhohadpIoneeredspInalanesthesIa.8IerInjectedprocaIneIntoaveInofthe
upperlImbbetweentwotournIquets.EventhoughthetechnIqueIstermedtheBier block,
ItwasnotusedformanydecadesuntIlItwasreIntroduced55yearslaterby|ackInnon
Holmes,whomodIfIedthetechnIquebyexsanguInatIonbeforeapplyIngasIngleproxImal
cuff.HolmesusedlIdocaIne,theverysuccessfulamIdelocalanesthetIcsynthesIzedIn194J
byLofgrenandLundquIstofSweden.
SeveralInvestIgatorsachIevedupperextremItyanesthesIabypercutaneousInjectIonsof
thebrachIalplexus.n1911,basedonhIsIntImateknowledgeoftheanatomyofthe
axIllaryarea,HIrschelpromotedablIndaxIllaryInjectIon.nthesameyear,Kulenkampff
descrIbedasupraclavIcularapproachInwhIchtheoperatorsoughtoutparesthesIasofthe
plexuswhIlekeepIngtheneedleatapoIntsuperfIcIaltothefIrstrIbandthepleura.The
rIskofpneumothoraxwIthKulenkampff'sapproachled|ulleytoattemptblocksmore
proxImallybyalateralparavertebralapproach,theprecursorofwhatIsnowpopularly
knownastheWinnie block.
HeInrIch8raunwrotetheearlIesttextbookoflocalanesthesIa,whIchappearedInItsfIrst
EnglIshtranslatIonIn1914.After1922,CastonLabat'sRegional AnesthesiadomInatedthe
AmerIcanmarket.LabatmIgratedfromFrancetothe|ayoClInIcIn|Innesota,wherehe
servedbrIeflybeforetakIngapermanentposItIonatthe8ellevueHospItalInNewYork.He
formedthefIrstAmerIcanSocIetyforFegIonalAnesthesIa.
110
AfterLabat'sdeath,EmeryA.
FovenstInewasrecruItedto8ellevuetocontInueLabat'swork,amongother
responsIbIlItIes.FovensteIncreatedthefIrstAmerIcanclInIcforthetreatmentofchronIc
paIn,whereheandhIsassocIatesrefInedtechnIquesoflytIcandtherapeutIcInjectIonsand
usedtheAmerIcanSocIetyofFegIonalAnesthesIatofurthertheknowledgeofpaIn
managementacrosstheUnItedStates.
111
P.21
ThedevelopmentofthemultIdIscIplInarypaInclInIcwasoneofmanycontrIbutIonsto
anesthesIologymadebyJohnJ.8onIca,arenownedteacherofregIonaltechnIques.0urIng
hIsperIodsofmIlItary,cIvIlIan,andunIversItyservIceattheUnIversItyofWashIngton,
8onIcaformulatedaserIesofImprovementsInthemanagementofpatIentswIthchronIc
paIn.HIsclassIctextThe Management of Pain,nowInItsthIrdedItIon,Isregardedasa
standardofthelIteratureofanesthesIa.
Cardiovascular Anesthesia
TheearlIestattemptstooperateontheheartwerelImItedtorepaIrIngcardIacwounds.
TheseattemptsgenerallyfaIleduntIlCermansurgeonLudwIgFehnrepaIredarIght
ventrIcularstabwoundInSeptember1896.
112
0espItethIssuccess,thefIeldwasnotready
toadvance.ThetabooofcardIacsurgerywassummarIzedbyTheodore8Illrothwhenhe
supposedlysaIdanysurgeonwhowouldattemptanoperatIonontheheartshouldlosethe
respectofhIscolleagues.
11J
TheresIstancetosuchoperatIonswaspartlybecauseof
fledglInganesthetIcmedIcatIons,lackofadequatemonItors,andevenaclear
understandIngofcardIovascularphysIologythatpervadesmodernanesthesIapractIce.
Fortunately,theturnofthe20thcenturysawmanyadvancesInanesthesIapractIce,blood
typIngandtransfusIon,antIcoagulatIon,antIbIosIs,aswellassurgIcalInstrumentatIonand
technIque.SomecontInuedtoattemptprocedureslIkeclosedmItralvalvotomyInthe
mIdstofthesetechnologIcaladvancements,butoutcomeswerestIllverypoorwIth
mortalItyratesexceedIng80.|anybelIevethatthesuccessfullIgatIonofa7yearold
gIrl'spatentductusarterIosusbyFobertCrossIn19J8servedasthelandmarkcasefor
moderncardIacsurgery.SoonafterCross'achIevement,ahostofnewprocedureswere
developedforrepaIrIngcongenItalcardIaclesIons,IncludIngthefIrst8lalockTaussIgshunt
performedona15montholdbluebabyIn1944.
114
Althoughtheshunthadbeen
successfullydemonstratedInanImalmodels,AustInLamont,ChIefofAnesthesIaatJohns
HopkIns,wasnotsupportIveoftheprocedure.HeemphatIcallystatedwIllnotputthat
chIldtodeathandlefttheopendropetheroxygenanesthetIctoresIdentanesthesIologIst
|erelHarmel.
115
Lamontattendedonthesecond8lalockTaussIgshunt2monthslater.
Together,HarmelandLamontwouldpublIshthefIrstartIcleonanesthesIaforcardIac
surgeryIn1946basedon100caseswIthAlfred8lalockandrepaIrofcongenItalpulmonIc
stenosIs.
116
ClosedcardIacsurgeryensuedandanesthesIapIoneerslIkeWIllIam|cQuIstonandKenneth
KeownworkedsIdebysIdewIthsurgeonsdurIngprocedureslIkethefIrstaortIcpulmonary
anastomosIsandthefIrsttransmyocardIalmItralcommIssurotomy.Neverbeforehad
anesthesIaprovIdersworkedasIntImatelywIthsurgeonsforthepatIent'swelfare.
AnesthesIologIstandWorldWarphysIcIan|axSamuelSadoveremarkedthesmallarms
fIreoftheanesthesIologIstjoInsthespysystemofthelabtobackupthesurgeon'sbIg
artIlleryInacoordInatedattacktoconquerdIsease.
117
Throughthe19J0sand1940s,JohnCIbbonhadbeenexperImentIngwIthseveral
extracorporealcIrcuItdesIgnsandby1947wasabletosuccessfullyplacedogsonheartlung
bypass.ThefIrstsuccessfuluseofCIbbon'scardIopulmonarybypassmachIneInhumansIn
|ay195JwasamonumentaladvanceInthesurgIcaltreatmentofcomplexcardIac
pathologythatstImulatedInternatIonalInterestInopenheartsurgeryandthespecIaltyof
cardIacanesthesIa.
Dverthenextdecade,rapIdgrowthandexpandedapplIcatIonsofcardIacsurgery,
IncludIngartIfIcIalvalvesandcoronaryarterybypassgraftIng,requIredmanymore
anesthesIologIstsacquaIntedwIththesespecIalIzedtechnIques.n1967,J.EarlWaynards
publIshedoneofthefIrstartIclesonanesthetIcmanagementofpatIentsundergoIng
surgeryforcoronaryarterydIsease.
AscardIacsurgeryevolved,sodIdtheperIoperatIvemonItorIngandcareofpatIents
undergoIngcardIacsurgery.PostoperatIvemechanIcalventIlatIonandsurgIcalIntensIve
careunItsappearedbythelate1960s.0evIceslIketheleftatrIalpressuremonItorandthe
IntraaortIcballoonpumpofferednewmethodsofunderstandIngcardIopulmonary
physIologyandtreatIngpostoperatIveventrIcularfaIlure.CardIacanesthesIologIstswere
quIcktobrIngthepulmonaryarterycatheter(PAC)IntotheoperatIngroom,permIttIng
moreprecIsehemodynamIcmonItorIngandInterventIon.JoelKaplan,alreadyknownfor
usIngthe7
5
leadtomonItorformyocardIalIschemIaandnItroglycerInInfusIonstotreat
IschemIa,popularIzedtheuseofthePACtodetectmyocardIalIschemIa.AtTexasHeart
nstItute,SlogoffandKeatsdemonstratedthenegatIveImpactofmyocardIalIschemIaon
clInIcaloutcome.8ytheendofthe1980s,thesameduowouldrevealthatthechoIceof
anesthetIcagenthadlIttleImpactonoutcome,challengIngtheearlIerparadIgmof
IsofluranestealproposedbyFeIz.
0evelopmentslIkecoldpotassIumcardIoplegIa,monItorIngandreversalofheparIn,and
reductIonofbloodlosswIthaprotInInwouldchangethepractIceofcardIacanesthesIa.
TransesophagealechocardIography,IntroducedIntocardIacsurgerybyFoIzen,Cahalan,
andKremerInthe1980s,helpedtofurtherdefInethesubspecIaltyofcardIacanesthesIa.
Neuroanesthesia
8raInsurgeryIsconsIderedbysometobetheoldestofthepractIcedmedIcalarts.
EvIdenceoftrepanatIon,aformofneurosurgeryInwhIchaholeIsdrIlledorscrapedInto
theskulltoaccessthedura,wasdIscoveredInskullsdatIngbackto65008CataFrench
burIalsIte.PrehIstorIcbraInsurgerywasalsopractIcedbycIvIlIzatIonsInSouthAmerIca,
AfrIca,andAsIa.
118
WIththeIntroductIonofInhalatIonalanesthesIaInthemId1800s,ScottIshsurgeonand
neurosurgerypIoneerSIrWIllIam|acewenusedthIsnovelpractIcewhIleperformIngthe
fIrstsuccessfulcranIotomyfortumorremovalIn1879.|acewen,wellknownfor
IntroducIngthetechnIqueoforotrachealIntubatIon,promotedtheIdeaofteachIng
medIcalstudentsatClasgowFoyalnfIrmarytheartofchloroformanesthesIa.
LIke|acewen,SIr7IctorHorselywasaneurosurgeonwIthanInterestInanesthesIa.HIs
experImentsofhowether,chloroform,andmorphIneaffectedIntracranIalcontentsled
hImtoconcludethattheagentofchoIcewaschloroformandthatmorphInehadsome
valuebecauseofItscerebralconstrIctIoneffects.
119
HefIrstpublIshedhIsanesthetIc
technIqueforbraInsurgeryIntheBritish Medical JournalIn1886.
120
Later,heomItted
morphInefromhIsregImenafterdIscoverIngItstendencytoproducerespIratory
depressIon.
|eanwhIle,HarvardmedIcalstudentandaspIrIngneurosurgeonHarveyCushIngdeveloped
thefIrstchartstorecordheartrate,temperature,andrespIratIondurInganesthesIa.Soon
after,hewouldaddbloodpressurereadIngstotherecord.CushIngwasoneofthefIrst
surgeonstorecognIzetheImportanceofdedIcated,specIallytraInedanesthesIapersonnel
versedInneurosurgery.CharlesFrazIer,aneurosurgIcalcontemporaryofCushIng,also
recognIzedthIsneed,statIngthatno[cranIal]operatIonbeundertakenunlesstheservIces
ofaskIlledanesthetIzerareavaIlable.
121
SInceetherandchloroformanesthesIahadsIgnIfIcantdrawbacks,begInnIngIn1918CushIng
andhIscontemporarIesexploredtheadvantagesofregIonalorlocalanesthesIafor
IntracranIalsurgery.PartofthemotIvatIondrIvIngthIschangewastheIncreasedduratIon
InsurgIcaltIme.CushIng
P.22
andcolleaguesusedaslowsurgIcaltechnIqueformostsurgIcalprocedures,wherethe
averageduratIonforcranIaloperatIonswas5hours.
122
ncontrast,earlyneurosurgeons
lIkeHorseleyandSIrPercySargeantcouldperformsImIlarproceduresInlessthan90
mInutes.Therefore,prolongedpatIentexposuretochloroformoretheranesthesIawere
lIkelytoresultInIncreasedbleedIng,postoperatIveheadache,confusIon,and/orvomItIng.
CushIngandcontemporarIesthoughttheuseoflocalorregIonalanesthesIalessenedthe
rIskofthesecomplIcatIons.
Afteradecade,ItwasrealIzedthattheremoteposItIonIngoftheanesthetIstwas
troublesomewhenmanagIngtheaIrwayofanawakeorlIghtlysedatedpatIentundergoIng
cranIalsurgerywIthregIonalanesthesIa.Also,endotrachealtubes,althoughIntroducedat
thebegInnIngofthecentury,hadbecomepopularInstrumentsforsecurIngapatIent's
aIrwayandprovIdIngInhalatIonanesthesIa.CombIned,thesecIrcumstancesledtothe
rapIdresurgenceofpopularItyIngeneralanesthesIaforcranIalsurgery,atrendthatwould
contInuetopresentday.
WhIletheIntroductIonofagentslIkethIopental,curare,andhalothaneadvancedthe
practIceofanesthesIologyIngeneral,thedevelopmentofmethodstomeasurebraIn
electrIcalactIvIty,cerebralbloodflowandmetabolIcratebyKetyandSchmIdt,and
IntracranIalpressurebyLundburgputneuroanesthesIapractIceonascIentIfIcfoundatIon
andopeneddoorstoneuroanesthesIaresearch.
12J
ClInIcIanscIentIstslIkeJohn0.(Jack)
|Ichenfelder,laterknownasthefatherofneuroanesthesIa,conductedbasIcscIenceand
clInIcalresearchoncerebralbloodflowandbraInfunctIonandprotectIonInresponseto
varIousanesthetIcagentsandtechnIques.|anylessonslearneddurIngthIsperIodof
groundbreakIngresearcharestIllcommonlyusedInmodernneuroanesthesIapractIce.
Obstetric Anesthesia
SocIalattItudesaboutpaInassocIatedwIthchIldbIrthbegantochangeInthe1860sand
womenstarteddemandInganesthesIaforchIldbIrth.SocIetalpressuresweresogreatthat
physIcIans,althoughunconvIncedofthebenefItsofanalgesIa,feltoblIgatedtoofferthIs
servIcetotheIrobstetrIcpatIents.
124
n1907anAustrIanphysIcIan,FIchardvon
SteInbuchelusedacombInatIonofmorphIneandscopolamInetoproduceDmmerschlaffor
TwIlIghtSleep.
125
Althoughthesetwodrugswerewellknown,physIcIansremaIned
skeptIcalthatTwIlIghtSleepwasessentIaltolaboranddelIvery,whIchunfortunately
contrastedwIththeopInIonofmostwomen.ThIsmethodgaInedpopularItyafterCerman
obstetrIcIansCarlCaussand8ernhardtKronIgwIdelypublIcIzedthetechnIque.Numerous
advertIsementstoutedthebenefItsofTwIlIghtSleep(analgesIa,partIalpaInrelIef,and
amnesIa)ascomparedtoetherandchloroform,whIchresultedIntotalunconscIousness.
126
CaussrecognIzedthenarrowtherapeutIcmargInofthesemedIcatIonsandgaveprecIse
InstructIonsonItsuse:thefIrstInjectIon(morphIne10mgandscopolamIne)wastobe
gIvenshortlyafteractIvelaborbeganthIswasIntendedtobluntthepaInoflaborand
subsequentInjectIonsconsIstedofonlyscopolamIne,whIchwasdosedtooblIteratethe
memoryoflabor.8ecauseoftheeffectsofscopolamIne,manypatIentsbecamedIsorIented
andwouldscreamandthrashaboutdurInglaboranddelIvery.CaussbelIevedthathecould
mInImIzethIsreactIonbydecreasIngthesensoryInput;therefore,hewouldputpatIentsIn
adarkroom,covertheIreyeswIthgauze,andInsertoIlsoakedcottonIntotheIrears.The
patIentswereoftenconfInedtoapaddedbedandrestraInedwIthleatherstrapsdurIngthe
delIvery.
127
DvertIme,thedosesofmorphIneadmInIsteredseemedtoIncrease,although
therewerefew,Ifany,reportsofadverseneonataleffects.7IrgInIaApgar'ssystemfor
evaluatIngnewborns,developedIn195J,demonstratedthatthereactuallywasa
dIfferenceIntheneonatesofmotherswhohadbeenanesthetIzed.
128
ThebulkoftheInterestInthIstechnIqueappearstohavebeenpopularratherthan
medIcaland,forabrIefperIod,wasIntenselyfollowedIntheUnItedStates.
129
PublIc
enthusIasmforTwIlIghtSleepquIcklysubsIdedafterapromInentadvocateofthemethod
dIeddurIngchIldbIrth.HerphysIcIansclaImedherdeathwasnotrelatedtocomplIcatIons
fromthemethodofTwIlIghtSleepthatwasused.
1J0
ThefIrstartIclesdescrIbIngtheobstetrIcapplIcatIonofspInal,epIdural,caudal,
paravertebral,parasacral,andpudendalnerveblocksappearedbetween1900and19J0.
However,theIrbenefItswereunderapprecIatedformanyyearsbecausetheobstetrIcIans
seldomusedthesetechnIques.
1J0
ContInuouscaudalanesthesIawasIntroducedIn1944by
HIngsonandEdwards
1J1
andspInalanesthesIabecamepopularshortlythereafter.nItIally,
spInalanesthesIacouldbeadmInIsteredbyInexperIencedpersonnelwIthoutmonItorIng.
ThecombInatIonofInexperIencedprovIdersandlackofpatIentmonItorIngledtohIgher
ratesofmorbIdItyandmortalItythanthoseobservedforgeneralanesthesIa.
1J2
Therefore,
theuseofspInalanesthesIawashIghlydIscouragedInthe1950s,leadIngtothedarkages
ofobstetrIcanesthesIawhenpaInrelIefInobstetrIcswasessentIallyabandonedand
womenwereforcedtoendurenaturalchIldbIrthtoavoIdserousanesthesIarelated
complIcatIons.
1JJ
WIthanIncreasedunderstandIngofneuraxIalanesthesIa,InvolvementbywelltraIned
anesthesIologIsts,andanapprecIatIonforthephysIologIcchangesdurIngpregnancy,
maternalandfetalsafetygreatlyImproved.nthepastdecade,anesthesIarelateddeaths
durIngcesareansectIonsundergeneralanesthesIahavebecomemorelIkelythanneuraxIal
anesthesIarelateddeaths,makIngregIonalanesthesIathemethodofchoIce.
1J4,1J5
WIth
theavaIlabIlItyofsafeandeffectIveoptIonsforpaInrelIefdurInglaboranddelIvery,
today'sfocusIsImprovIngthequalItyofthebIrthexperIenceforexpectantparents.
Transfusion Medicine
PaleolIthIccavedrawIngsfoundInFrancedepIctabearlosIngbloodfrommultIplespear
wounds,IndIcatIngthatprImItIvemanunderstoodthesImplerelatIonshIpbetweenblood
andlIfe.
1J6
|orethan10,000yearslater,modernanesthesIologIstsattempttopreservethIs
IntImaterelatIonshIpbyreplacIngfluIdsandbloodproductswhenfacedwIthIntravascular
volumedepletIonordImInIshedoxygencarryIngcapacItyfrombloodloss.
8loodtransfusIonwasfIrstattemptedIn1667byphysIcIantoLouIsX7,Jean8aptIste0enIs.
0enIshadlearnedofFIchardLower'stransfusIonoflamb'sbloodIntoadogtheprevIous
year.Lamb'sbloodwasmostfrequentlyusedbecausethedonatInganImal'sessentIal
qualItIeswerethoughttobetransferredtotherecIpIent.0espItethIsdangeroustrans
specIestransfusIon,0enIs'fIrstpatIentgotbetter.HIsnexttwopatIentswerenotas
fortunate,however,and0enIsavoIdedfurtherattempts.CIventhepooroutcomesofthese
earlybloodtransfusIons,andheatedrelIgIouscontroversyregardIngtheImplIcatIonsof
transferrInganImalspecIfIcqualItIesacrossspecIes,bloodtransfusIonInhumanswas
bannedformorethanahundredyearsInbothFranceandEnglandbegInnIngIn1670.
114
n1900,KarlLandsteInerandSamuelShattockIndependentlyhelpedlaythescIentIfIcbasIs
ofallsubsequenttransfusIonsbyrecognIzIngthatbloodcompatIbIlItywasbasedon
dIfferentbloodgroups.LandsteIner,anAustrIanphysIcIan,orIgInallyorganIzedhuman
bloodIntothreegroupsbasedon
P.2J
substancespresentontheredbloodcells.Thefourthtype,A8group,wasIdentIfIedIn1902
bytwostudents,A.0ecastrelloandA.SturlI.8asedonthesefIndIngs,FeubenDttenberg
performedthefIrsttypespecIfIcbloodtransfusIonIn1907.TransfusIonofphysIologIc
solutIonsoccurredIn18J1,IndependentlyperformedbyD'ShaughnessyandLewInsInCreat
8rItaIn.nhIslettertoThe Lancet,LewInsdescrIbedtransfusInglargevolumesofsalIne
solutIonsIntopatIentswIthcholera.HereportedthathewouldInjectIntoadultsfrom5to
10poundsofsalInesolutIonandrepeatasneeded.
1J7
0espIteItspublIcatIonInapromInent
journal,LewIns'technIquewasapparentlyoverlookedfordecades,andbalanced
physIologIcsolutIonavaIlabIlItywouldhavetoawaItthecomIngofanalytIcalchemIstry.
Professionalism and Anesthesia Practice
Organized Anesthesiology
PhysIcIananesthetIstssoughttoobtaInrespectamongtheIrsurgIcalcolleaguesby
organIzIngprofessIonalsocIetIesandImprovIngthequalItyoftraInIng.ThefIrstAmerIcan
organIzatIonwasfoundedbynInemembersonDctober6,1905,andcalledtheLongsland
SocIetyofAnesthetIstswIthannualduesofS1.00.n1911,theannualassessmentroseto
SJ.00whentheLongslandSocIetybecametheNewYorkSocIetyofAnesthetIsts.Although
theneworganIzatIonstIllcarrIedalocaltItle,Itdrewmembersfromseveralstatesand
hadamembershIpof70physIcIansIn1915.
1J8
DneofthemostnoteworthyfIguresInthestruggletoprofessIonalIzeanesthesIologywas
FrancIsHoffer|c|echan.|c|echanhadbeenapractIcInganesthesIologIstInCIncInnatI
untIl1911,whenhesufferedaseverefIrstattackofrheumatoIdarthrItIs,whIcheventually
lefthImconfInedtoawheelchaIrandforcedhIsretIrementfromtheoperatIngroomIn
1915.|c|echanhadbeenInpractIceonly15years,buthehadwrItten18clInIcalartIcles
InthIsshorttIme.AprolIfIcresearcherandwrIter,|c|echandIdnotpermIthIscrIpplIng
dIseasetosIdelInehIscareer.nsteadofpursuInggoalsInclInIcalmedIcIne,heapplIedhIs
talentstoestablIshInganesthesIologysocIetIes.
1J9
|c|echansupportedhImselfandhIsdevotedwIfethroughedItIngtheQuarterly Anesthesia
Supplementfrom1914untIlAugust1926.HebecameedItorofthefIrstjournaldevotedto
anesthesIa,Current Researches in Anesthesia and Analgesia,theprecursorofAnesthesia
and Analgesia,theoldestjournalofthespecIalty.AswellasfosterIngtheorganIzatIonof
thenternatIonalAnesthesIaFesearchSocIety(AFS)In1925,|c|echanandhIswIfe,
Laurette,becameoverseasambassadorsofAmerIcananesthesIa.SInceLaurettewas
French,Itwasunderstandablethat|c|echancombInedhIsownIdeasabout
anesthesIologywIthconceptsfromabroad.
12J
n1926,|c|echanheldtheCongressofAnesthetIstsInajoIntconferencewIththeSectIon
onAnaesthetIcsofthe8rItIsh|edIcalAssocIatIon.Subsequently,hetraveledthroughout
Europe,gIvInglecturesandnetworkIngphysIcIansInthefIeld.DnhIsfInalreturnto
AmerIca,hewasgravelyIllandwasconfInedtobedfor2years.HIshardworkandconstant
travelpaIddIvIdends,however:In1929,theAFS,whIch|c|echanfoundedIn1922,had
membersnotonlyfromNorthAmerIcabutalsofromseveralEuropeancountrIes,Japan,
ndIa,ArgentIna,and8razIl.
122
nthe19J0s,|c|echanexpandedhIsmIssIonfromorganIzInganesthesIologIststo
promotIngtheacademIcaspectsofthespecIalty.n19J1,workbeganonwhatwould
becomethenternatIonalCollegeofAnesthetIsts.ThIsbodybegantoawardfellowshIpsIn
19J5.ForthefIrsttIme,physIcIanswererecognIzedasspecIalIstsInanesthesIology.The
certIfIcatIonqualIfIcatIonswereunIversal,andfellowswererecognIzedasspecIalIstsIn
severalcountrIes.AlthoughthecrIterIaforcertIfIcatIonwerenotstrIct,theCollegewasa
successInraIsIngthestandardsofanesthesIapractIceInmanynatIons.
140
n19J9,
|c|echanfInallysuccumbedtoIllness,andtheanesthesIaworldlostItstIrelessleader.
DtherAmerIcanspromotedthegrowthoforganIzedanesthesIology.FalphWatersandJohn
Lundy,amongothers,partIcIpatedInevolvIngorganIzedanesthesIa.Waters'greatest
contrIbutIontothespecIaltywasraIsIngItsacademIcstandards.AftercompletInghIs
InternshIpIn191J,heenteredmedIcalpractIceInSIouxCIty,owa,wherehegradually
lImItedhIspractIcetoanesthesIa.HIspersonalexperIenceandextensIvereadIngwere
supplementedbytheonlypostgraduatetraInIngavaIlable,a1monthcourseconductedIn
DhIobyE..|cKesson.AtthattIme,thecustomofbecomIngaselfproclaImedspecIalIst
InmedIcIneandsurgerywasnotuncommon.Waters,whowasfrustratedbylowstandards
andwhowouldeventuallyhaveagreatInfluenceonestablIshIngbothanesthesIaresIdency
traInIngandtheformalexamInatIonprocess,recalledthat,before1920,The
requIrementsforspecIalIzatIonInmany|IdwesternhospItalsconsIstedofthepossessIonof
suffIcIentaudacItytoattemptaprocedureandpersuasIvepoweradequatetogaInthe
consentofthepatIentorhIsfamIly.
141
Academic Anesthesia
nanefforttoImproveanesthetIccare,WatersregularlycorrespondedwIth0ennIsJackson
andotherscIentIsts.n1925,herelocatedtoKansasCItywIthagoalofgaInIngan
academIcpostattheUnIversItyofKansas,buttheprofessorofsurgeryfaIledtosupporthIs
proposal.ThelargercItydIdallowhImtoInItIatehIsfreestandIngoutpatIentsurgIcal
facIlIty,The0owntownSurgIcalClInIc,whIchfeaturedoneofthefIrstpostanesthetIc
recoveryrooms.
1J0
n1927,ErwInSchmIdt,professorofsurgeryattheUnIversItyof
WIsconsIn'smedIcalschool,encouraged0eanCharles8ardeentorecruItWaters.
nacceptIngthefIrstAmerIcanacademIcposItIonInanesthesIa,WatersdescrIbedfour
objectIvesthathavebeensInceadoptedbymanyotheracademIcdepartments.HIsgoals
wereasfollows:(1)toprovIdethebestpossIbleservIcetopatIentsoftheInstItutIon;(2)
toteachwhatIsknownoftheprIncIplesofAnesthesIologytoallcandIdatesfortheIr
medIcaldegree;(J)tohelplongtermgraduatestudentsnotonlytogaInafundamental
knowledgeofthesubjectandtomastertheartofadmInIstratIon,butalsotolearnasmuch
aspossIbleoftheeffectIvemethodsofteachIng;(4)toaccompanytheseeffortswIththe
encouragementofasmuchcooperatIveInvestIgatIonasIsconsIstentwIthachIevIngthe
fIrstobjectIves.
129
Waters'personalandprofessIonalqualItIesImpressedtalentedyoungmenandwomenwho
soughtresIdencypostsInhIsdepartment.HeencouragedresIdentstoInItIateresearch
InterestsInwhIchtheycollaboratedwIthtwopharmacologIstswhomWatershadknown
beforearrIvIngInWIsconsIn,ArthurLoevenhartandChaunceyLeake,aswellasotherswIth
whomhebecameassocIatedIn|adIson.ClInIcalconcernswerealsoInvestIgated.Asan
example,anesthesIarecordswerecodedontopunchcardstoformadatabasethatwas
usedtoanalyzedepartmentalactIvItIes.|orbIdItyandmortalItymeetIngs,nowa
requIrementofalltraInIngprograms,alsoorIgInatedIn|adIson.|embersofthe
departmentanddIstInguIshedvIsItorsfromothercentersattendedthesemeetIngs.Asa
consequenceoftheIrcrItIcalrevIewsoftheconductofanesthesIa,responsIbIlItyforan
operatIve
P.24
tragedygraduallypassedfromthepatIenttothephysIcIan.nmorecasualtImes,a
practItIonercouldcomplaIn,ThepatIentdIedbecausehedIdnottakeagoodanesthetIc.
AlternatIvely,thedeathmIghtbeattrIbutedtoamysterIousforcesuchasstatus
lymphatIcus,ofwhIchArthurCuedel,amasterofsardonIchumor,observed,CertaInly
statuslymphatIcusIsattImesagreathelptotheanesthetIst.WhenhehasafatalItyunder
anesthesIawIthnoothercleansIngexplanatIonheIsgladtorecognIzethecondItIonasan
entIty.
129
n1929,JohnLundyatthe|ayoClInIcorganIzedtheAnaesthetIsts'TravelClub,whose
memberswereleadIngAmerIcanorCanadIanteachersofanesthesIa.Eachyearone
memberwasthehostforagroupof20to40anesthesIologIstswhogatheredforaprogram
ofInformaldIscussIons.ThereweredemonstratIonsofpromIsIngInnovatIonsforthe
operatIngroomandlaboratory,whIchwereallsubjectedtowhatIsrememberedasa
hIghspIrIted,energetIc,crItIcalrevIew.
127
TheTravelClubwouldbecrItIcalInthe
upcomIngbattletoformtheAmerIcan8oardofAnesthesIology.
EvendurIngtheleanyearsofthe0epressIon,InternatIonalguestsalsovIsItedWaters'
department.ForCeoffreyKayeofAustralIa,TorstenCordhofSweden,Fobert|acIntosh
and|IchaelNosworthyofEngland,andscoresofothers,Waters'departmentwastheIr
meccaofanesthesIa.FalphWaterstraIned60resIdentsdurIngthe22yearshewasthe
ChIef.From19J7onward,thealumnI,whodeclaredthemselvestheAqualumnIInhIs
honor,returnedannuallyforaprofessIonalandsocIalreunIon.ThIrtyfourAqualumnItook
academIcposItIonsand,ofthese,14becamechaIrpersonsofdepartmentsofanesthesIa.
TheymaIntaInedWaters'professIonalprIncIplesandencouragedteachIngcareersformany
oftheIrowngraduates.
142
HIsendurInglegacywasoncerecognIzedbythedeanwhohad
recruItedhImIn1927,Charles8ardeen,whoobserved,FalphWaterswasthefIrstperson
theUnIversItyhIredtoputpeopletosleep,but,Instead,heawakenedaworldwIde
InterestInanesthesIa.
14J
Establishing a Society
WatersandLundy,alongwIthPaulWoodofNewYorkCIty,hadanImportantroleIn
establIshIngorganIzedanesthesIaandthedefInItIonofthespecIalty.ntheheartofthe
Creat0epressIon,thesethreephysIcIansrealIzedthatanesthesIologyneededtohavea
processtodetermInewhowasananesthetIcspecIalIstwIthAmerIcan|edIcalAssocIatIon
(A|A)backIng.UsIngtheNewYorkSocIetyofAnesthetIsts,ofwhIchPaulWoodwas
secretarytreasurer,anewclassofmembers,Fellows,wascreated.TheFellowscrIterIa
followedestablIshedA|AguIdelInesforspecIaltycertIfIcatIon.However,theA|Awanted
anatIonalorganIzatIontosponsoraspecIaltyboard.TheNewYorkSocIetyofAnesthetIsts
changedItsnametotheAmerIcanSocIetyofAnesthetIsts(ASA)In19J6.CombInedwIththe
AmerIcanSocIetyofFegIonalAnesthesIa,whosepresIdentwasEmeryFovensteIn,the
AmerIcan8oardofAnesthesIology(A8A)wasorganIzedasasubordInateboardtothe
AmerIcan8oardofSurgeryIn19J8.WIth|c|echan'sdeathIn19J9,theA|Afavored
IndependencefortheA8A,andIn1940,Independencewasgranted.
126,1J1
Afewyearslater,theoffIcersoftheAmerIcanSocIetyofAnesthetIstswerechallengedby
0r.|.J.SeIfert,whowrote,AnAnesthetIstIsatechnIcIanandanAnesthesIologIstIsthe
specIfIcauthorItyonanesthesIaandanesthetIcs.cannotunderstandwhyyoudonotterm
yourselvestheAmerIcanSocIetyofAnesthesIologIsts.
1JJ
FalphWaterswasdeclaredthe
fIrstpresIdentofthenewlynamedASAIn1945.nthatyear,whenWorldWarended,7J9
(J7)of1,977ASAmemberswereInthearmedforces.nthesameyear,theASA'sfIrst
0IstInguIshedServIceAwardwaspresentedtoPaul|.WoodforhIstIrelessservIcetothe
specIalty,oneelementofwhIchcanbeexamInedtodayIntheextensIvearchIves
preservedIntheSocIety'sWoodLIbrary|useumatASAheadquarters,ParkFIdge,
llInoIs.
14J
Conclusions
ThIsovervIewofthedevelopmentofanesthesIologyIsbutabrIefoutlIneofourcurrent
rolesInwhIchanesthesIologIstsserveInhospItals,clInIcs,andlaboratorIes.TheoperatIng
roomandobstetrIcdelIverysuIteremaInthecentralInterestofmostspecIalIsts.AsIde
frombeIngthelocatIonwherethetechnIquesdescrIbedInthIschapterfIndregular
applIcatIon,servIceIntheseareasbrIngsusIntoregularcontactwIthnewadvancesIn
pharmacologyandbIoengIneerIng.
Aftersurgery,patIentsaretransportedtothepostanesthesIacareunItorrecoveryroom,
anareathatIsnowconsIderedtheanesthesIologIst'sward.FIftyyearsago,patIentswere
carrIeddIrectlyfromtheoperatIngroomtoasurgIcalwardtobeattendedonlybyajunIor
nurse.ThatpersonlackedboththeskIllsandequIpmenttoIntervenewhencomplIcatIons
occurred.AftertheexperIencesofWorldWartaughtthevalueofcentralIzedcare,
physIcIansandnursescreatedrecoveryrooms,whIchweresoonmandatedforallmajor
hospItals.8y1960theevolutIonofcrItIcalcareprogressedthroughtheuseofmechanIcal
ventIlators.PatIentswhorequIredmanydaysofIntensIvemedIcalandnursIng
managementwerecaredforInacurtaInedcorneroftherecoveryroom.ntIme,curtaIns
drawnaboutoneortwobedsgavewaytofIxedpartItIonsandtherelocatIonofthoseareas
toformIntensIvecareunIts.TheprIncIplesofresuscItatIveandsupportIvecareestablIshed
byanesthesIologIststransformedcrItIcalcaremedIcIne.
ThefutureofanesthesIologyIsabrIghtone.ThesaferdrugsthatoncerevolutIonIzedthe
careofpatIentsundergoIngsurgeryareconstantlybeIngImproved.Theroleofthe
anesthesIologIstcontInuestobroadenasphysIcIanswIthbackgroundsInthespecIaltyhave
developedclInIcsforchronIcpaIncontrolandoutpatIentsurgery.AnesthesIapractIcewIll
contInuetoIncreaseInscope,bothInsIdeandoutsIdetheoperatIngsuIte,suchthat
anesthesIologIstswIllbecomeanIntegralpartoftheentIreperIoperatIveexperIence.
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Editors: Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.;
Stock, M. Christine
Title: Clinical Anesthesia, 6th Edition
CopyrIght2009LIppIncottWIllIamsEWIlkIns
TableofContentsSectIonntroductIontoAnesthesIologyChapter2ScopeofPractIce
Chapter2
Scope of Practice
John H. Eichhorn
Key Points
1. Anesthesia trainees, and many postgraduates also, tend to lack
sufficient knowledge (with sometimes unfortunate results) about
modes of practice or employment, financial matters of all types, and
contracting in particular. They must educate themselves and also
seek expert advice and counsel to survive (and hopefully flourish) in
today's exceedingly complex medical practice milieu.
2. There are several very helpful detailed information resources
concerning practice and OR management available from the
American Society of Anesthesiologists and other sources. Factors
influencing anesthesiology practice conditions are changing rapidly,
and today's anesthesia professionals must be armed with detailed
information about concepts (such as pay for performance) that did
not exist just a few years ago.
3. Securing hospital privileges is far more than a bureaucratic
annoyance and must be taken seriously by anesthesiologists.
4. Anesthesiology is the leading medical specialty in establishing and
promulgating standards of practice that have significantly influenced
practice in a positive manner.
5. The immediate response to a major adverse anesthesia event is
critical to the eventual result. An extremely valuable protocol is
available at www.apsf.org, Resource Center: Clinical Safety Tools.
6. Anesthesiologists need to be involved, concerned, active participants
and leaders in their institution and medical community in order to
enhance their practice function and image.
7. Managed care's influence has waxed and waned but it must always
be considered by modern anesthesia professionals. While cost, value,
outcome, and quality issues are certainly central to all anesthesiology
practices, difficulties in constructing and applying definitive
measurements and rigorous statistical analysis of these parameters
have prevented, so far at least, some of the potential negative
influences of the core features of fully managed health care on
anesthesiology practice.
8. Anesthesiologists must participate in operating room (OR)
management in their facilities and should play a central leadership
role. OR scheduling, staffing, utilization, and patient flow issues are
complex, and anesthesiologists should work hard both to thoroughly
understand and positively influence them.
9. Anesthesiology personnel issues involve an elaborate balancing act
and groups/departments should give these issues, as well as their
constituent personnel, more attention and energy than has been
done traditionally in the past or the anesthesia provider shortage will
likely continue to worsen.
10. Attention to the many often-underemphasized details of
infrastructure, organization, and administration can transform a
merely endurable anesthesia practice into one that is efficient,
effective, productive, collegial, and even fun.
|edIcalpractIce,IncludIngItsInfrastructureandfunctIonaldetaIls,IsevolvIngrapIdlyIn
theUnItedStates.AnesthesIapractIceIsnoexceptIon.nthepast,anesthesIaprofessIonals
tradItIonallywerelIttleInvolvedInthemanagementofmanycomponentsoftheIrpractIce
beyondthestrIctlymedIcalelementsofapplIedphysIologyandpharmacology,
pathophysIology,andtherapeutIcs.ThIswasperhapssomewhatunderstandablebecause
anesthesIaprofessIonalstradItIonallyspentmostoftheIrusuallyverylongworkhoursIna
hospItaloperatIngroom(DF).8usInessmatterswereoftenlefttotheoneor
P.28
twogroupmemberswhowereInterestedorwIllIngtodealwIthanoutsIdecontractor
bIllIngagency.nthatera,verylIttleformalteachIngInpractIcemanagementofanykInd
occurredInanesthesIatraInIngprograms.TodaytheAnesthesIologyFesIdencyFevIew
CommItteeoftheAccredItatIonCouncIlonCraduate|edIcalEducatIonrequIresthatthe
dIdactIccurrIculaofanesthesIologyresIdencIesIncludematerIalonpractIcemanagement.
|osttraInIngprogramsofferatleastacursoryIntroductIontoIssuesofpractIce
management,butthesecanbeInsuffIcIenttopreparesatIsfactorIlytheprofessIonalbeIng
graduatedfortherealInfrastructure,admInIstratIve,busIness,andmanagement
challengesofthemodernpractIceofanesthesIology.
ThIschapterpresentsawIdevarIetyoftopIcsthat,untIlrecently,werenotIncludedIn
anesthesIologytextbooks.SeveralbasIccomponentsareoutlInedofthebackground,
admInIstratIve,organIzatIonal(IncludIngbothpractIcearrangementsanddaIlyfunctIonIng
oftheDF),andfInancIalaspectsofanesthesIologypractIceInthecomplexmodern
envIronment.AlthoughmanyIssuesareundergoIngalmostconstantchange,ItIsImportant
tounderstandthebasIcvocabularyandprIncIplesInthIsdynamIcunIverse.Lackof
understandIngoftheseIssuesmayputanesthesIaprofessIonalsatadIsadvantagewhen
attemptIngtomaxImIzetheeffIcIencyandImpactoftheIrdaIlyactIvItIes,tocreateand
executepractIcearrangements,andtosecurefaIrcompensatIonInanIncreasIngly
complexhealthcaresystemwIthgreaterandgreatercompetItIonforscarcerandscarcer
resources.
Administrative Components of Anesthesiology Practice
Operational and Information Resources
DvervIewsummarIessuchasthIschapterareIntendedasanIntroductIontopractIce
management.Further,fortunately,theAmerIcanSocIetyofAnesthesIologIsts(ASA),the
professIonalassocIatIonforphysIcIananesthesIologIstsIntheUnItedStates,formanyyears
hasmadeavaIlabletoItsmembersextensIveresourcematerIalregardIngpractIceIn
generalandspecIfIcarrangementsforItsexecutIon.CItatIonandavaIlabIlItyofthIs
materIalcanbefoundontheASAWebsIte,www.asahq.org.Elementsareupdated
perIodIcallybytheASAthroughItsphysIcIanoffIcers,commIttees,taskforces,
admInIstratIveandsupportstaff,andItsvarIousoffIces.Althoughmanyofthedocuments
generatedandeventheadvIcegIvenInresponsetomembers'questIonscontaInbroad
brushgeneralItIesthatmustbeInterpretedIneachIndIvIdualpractIcesItuatIon,these
nonethelessstandasasolIdfoundatIononwhIchmanyanesthesIologypractIcescanbe
formulated.ProspectIvefamIlIarItywIththeprIncIplesoutlInedIntheASAmaterIallIkely
couldhelpavoIdsomeoftheproblemsleadIngtocallsforhelp.Selectedkeydocuments
havebeencompIledandboundIntoonevolume.
1
Also,eachsprIng,theASAoffersa
PractIce|anagementConference,followIngwhIchthelecturematerIalsarepublIshedIn
anannualvolume(seewww.asahq.org,PublIcatIonsandServIces,PublIcatIonson
PractIce|anagement).
Background
TheASAGuidelines for the Ethical Practice of Anesthesiology
1
IncludessectIonsonthe
prIncIplesofmedIcalethIcs;thedefInItIonofmedIcaldIrectIonofnonphysIcIanpersonnel
(IncludIngthespecIfIcstatementthatananesthesIologIstengagedInmedIcaldIrectIon
shouldnotpersonallybeadmInIsterInganotheranesthetIc);theanesthesIologIst's
relatIonshIptopatIentsandotherphysIcIans;theanesthesIologIst'sdutIes,responsIbIlItIes,
andrelatIonshIptothehospItal;andtheanesthesIologIst'srelatIonshIptonurse
anesthetIstsandothernonphysIcIanpersonnel.Further,theASApublIshesThe Organization
of an Anesthesia Department
1
andstatesthroughItthattheASAhasadoptedaStatement
ofPolIcy,whIchcontaInsprIncIplesthattheSocIetyurgesItsmemberstoconsIderIn
structurIngtheIrownIndIvIdualmedIcalpractIces.ThIsdocumenthassectIonson
physIcIanresponsIbIlItIesformedIcalcareandonmedIcaladmInIstratIveorganIzatIonand
responsIbIlItIes.8eyondsummarIessuchasthIschapter,referencetotheconsIderablebody
ofmaterIalcreatedandpresentedbytheASA(whIchIncludesathIckvolumespecIfIcally
onthedetaIlsofbusInessarrangements
2
)IsanexcellentstartIngpoInttohelpyoung
anesthesIaprofessIonalsdurIngtraInIngpreparefortheIncreasIngrIgorsofstartIngand
managIngacareerInpractIce.LIkewIse,thereIsagreatdealofInformatIonontheASA
WebsIteconcernIngthemostrecentgovernmentalregulatIons,rulIngs,andbIllIngcodes.
TheASANewslettercontaInsthemonthlycolumnsWashIngtonFeportandPractIce
|anagement,whIchdIssemInaterelatedcurrentdevelopments.
naddItIontotheASAandtheAmerIcanAssocIatIonofNurseAnesthetIsts,most
anesthesIologysubspecIaltysocIetIesandInterestgroupshaveWeblocatIons,asdomost
journals.PartIcularly,theWebsIteoftheAnesthesIaPatIentSafetyFoundatIon,
www.apsf.org,hasbeencItedasespecIallyusefulInpromotIngsafeclInIcalpractIce.
ElectronIcbulletInboardsallowanesthesIologypractItIonersfromaroundtheworldto
ImmedIatelyexchangeIdeasondIversetopIcs,bothmedIcalandadmInIstratIve.
TradItIonally,theASAhasnotmaIntaInedone.However,oneoftheorIgInalsItesthat
remaInsverypopularIswww.gasnet.org,andaWebsearch(anesthesIology+bulletIn
board)usIngasearchengInesuchaswww.google.comrevealsagreatnumberofsItes
thatcontaInavarIetyofdIscussIonsaboutallmannerofanesthesIologyrelatedtopIcs,
IncludIngpractIceorganIzatIon,admInIstratIon,andmanagement.AddItIonally,references
totheentIretyofthemedIcallIteraturearereadIlyaccessIbletoanypractItIoner(suchas
bystartIngwIthwww.nlm.nIh.govtoaccess|edlIne).AmodernanesthesIologypractIce
cannotreasonablyexIstwIthoutreadIlyavaIlablehIghspeednternetconnectIons.
The Credentialing Process and Clinical Privileges
ThesystemofcredentIalIngahealthcareprofessIonalandgrantIngclInIcalprIvIlegesIna
healthcarefacIlItyIsmotIvatedbyafundamentalassumptIonthatapproprIateeducatIon,
traInIng,andexperIence,alongwIththeabsenceofexcessIvenumbersofbadpatIent
outcomes,IncreasethechancesthattheIndIvIdualwIlldelIveracceptablequalItycare.
TheprocessofcredentIalInghealthcareprofessIonalshasbeenthefocusofconsIderable
publIcattentIon(partIcularlyInthemassmedIa),InparttheresultofveryrareIncIdents
ofuntraInedpersons(Impostors)InfIltratIngthehealthcaresystemandsometImesharmIng
patIents.ThemorecommonsItuatIon,however,InvolveshealthprofessIonalswho
exaggeratepastexperIenceandcredentIalsorfaIltodIscloseadversepastexperIences.
TherehasbeensomejustIfIedpublIcItyconcernIngphysIcIanswholosttheIrlIcenses
sequentIallyInseveralstatesandsImplymovedoneachtImetostartpractIceelsewhere
(whIchshouldbemuch,muchmoredIffIcultnow).
ntensepublIcandpolItIcalpressurehasbeenbroughttobearonvarIouslawmakIng
bodIes,regulatoryandlIcensIngagencIes,andhealthcareInstItutIonadmInIstratIonsto
dIscoverandpurgeboth(1)fraudulent,crImInal,anddevIanthealthcareprovIders,and(2)
IncompetentorsImplypoorqualIty
P.29
practItIonerswhosehIstorIesshowsuffIcIentpoorpatIentoutcomestoattractattentIon,
usuallythroughmalpractIcesuIts.dentIfyIngandavoIdIngorcorrectInganIncompetent
practItIonerIsthegoal.7erIfIcatIonofapproprIateeducatIon,traInIng,andexperIenceon
thepartofacandIdateforaposItIonrenderInganesthesIacareassumesspecIal
ImportanceInlIghtofthelegaldoctrIneofvicarious liability,whIchcanbedescrIbedas:If
anIndIvIdual,group,orInstItutIonhIresananesthesIaprovIderorevensImplyapprovesof
thatperson(e.g.,bygrantIngclInIcalprIvIlegesthroughahospItalmedIcalstaff),those
InvolvedInthedecIsIonmaylaterbeheldlIableInthecourts,alongwIththeIndIvIdual,
fortheIndIvIdual'sactIons.ThIswouldbeespecIallytrueIfItwerelaterdIscoveredthat
theoffendIngpractItIoner'spastadverseoutcomeshadnotbeenadequatelyInvestIgated
durIngthecredentIalIngprocess.
DutofthesevarIouslongstandIngconcernshasarIsenthesometImescumbersomeprocess
ofobtaInIngstatelIcensestopractIceandofobtaInInghospItalprIvIleges.ThestrIngent
credentIalIngprocessforhealthcarepractIceIsIntendedbothtoprotectpatIentsandto
safeguardtheIntegrItyoftheprofessIon.Fecently,centralcredentIalIngsystemshave
beendeveloped,IncludIngthoseaffIlIatedwIththeAmerIcan|edIcalAssocIatIon,
AmerIcanDsteopathIcAssocIatIon,and,partIcularly,theFederatIonCredentIals
7erIfIcatIonServIceoftheFederatIonofState|edIcal8oards.ThesesystemsverIfya
physIcIan'sbasIccredentIals(e.g.,IdentIty,cItIzenshIporImmIgratIonstatus,medIcal
educatIon,postgraduatetraInIng,lIcensureexamInatIonhIstory,prIorlIcenses,andboard
actIons)once,andthenthereaftercancertIfythevalIdItyofthesecredentIalstoastate
lIcensIngboardormedIcalfacIlIty.AfewstatesdonotyetacceptthIsverIfIcatIonand
moststatesseekspecIfIcsupplementalInformatIon.
TherearechecklIstsoftherequIrementsforthegrantIngofmedIcalstaffprIvIlegesby
hospItals(seetheAmerIcanHospItalAssocIatIonFesourceCenter,www.aharc.lIbrary.net).
naddItIon,theNatIonalPractItIoner0ata8ankandreportIngsystemadmInIsteredbythe
U.S.governmentnowcontaInsmanyyears'worthofInformatIon.ThIsdatabankIsa
centralreposItoryoflIcensIngandcredentIalsInformatIonaboutphysIcIans.|anyadverse
sItuatIonsInvolvIngaphysIcIanpartIcularlyInstancesofsubstanceabuse,malpractIce
lItIgatIon,ortherevocatIon,suspensIon,orlImItatIonofthatphysIcIan'slIcensetopractIce
medIcIneorabIlItytoholdhospItalprIvIlegesmustbereported(vIathestateboardof
medIcalregIstratIon/lIcensure)totheNatIonalPractItIoner0ata8ank.tIsastatutory
requIrementthatallapplIcatIonsforhospItalstaffprIvIlegesbecrosscheckedagaInstthIs
natIonaldatabank.ThepotentIalmedIcolegallIabIlItyonthepartofafacIlIty'smedIcal
staff,andtheanesthesIologygroupInpartIcular,forfaIlIngtodosoIssIgnIfIcant.The0ata
8ank,however,IsnotacompletesubstItutefordIrectdocumentatIonandbackground
checkIng.Dften,practItIonersreachprIvatenegotIatedsolutIonsfollowIngqualItydrIven
medIcalstaffproblems,therebyavoIdIngthemandatorypublIcreportIng.nsuchcases,a
suspectphysIcIanmaybegIventheoptIontoresIgnmedIcalstaffprIvIlegesandavoId0ata
8ankreportIngratherthanundergofullInvoluntaryprIvIlegerevocatIon(althoughmost
applIcatIonscontaInaquestIonspecIfIcallyaboutthIs).
Documentation
ThedocumentatIonforthecredentIalIngprocessforeachanesthesIapractItIonermustbe
complete.PrIvIlegestoadmInIsteranesthesIamustbeoffIcIallygrantedanddelIneatedIn
wrItIng.
1
ThIscanbestraIghtforwardorItcanbemorecomplextoaccommodate
InstItutIonalneedstoIdentIfypractItIonersspecIallyqualIfIedtopractIceIndesIgnated
anesthesIasubspecIaltyareassuchascardIac,Infant/pedIatrIc,obstetrIc,IntensIvecare,
orpaInmanagement.SpecIfIcdocumentatIonoftheprocessofgrantIngorrenewIng
clInIcalprIvIlegesIsrequIredand,unlIkesomeotherrecords,thedocumentatIonlIkelyIs
protectedasconfIdentIalpeerrevIewInformatIon.AnyquestIonsaboutcomplexsensItIve
IssuessuchasthIsshouldbereferredtoanexperIencedattorneyfamIlIarwIthapplIcable
federalandstatelaw.7erIfIcatIonofanapplIcant'scredentIalsandexperIenceIs
mandatory.8ecauseofanothertypeoflegalcase,someexamplesofwhIchhavebeen
hIghlypublIcIzed,medIcalpractItIonersmaybehesItanttogIveanhonestevaluatIon(or
anyevaluatIonatall)ofIndIvIdualsknowntothemwhoareseekIngaprofessIonalposItIon
elsewhere.DbvIously,someonewrItIngareferenceforacurrentorformercoworkershould
behonest.StIckIngtoclearlydocumentablefactsIsadvIsable.StatIngafactthatIsInthe
publIcrecord(suchasamalpractIcecaselostattrIal)shouldnotjustIfyanobjectIonfrom
thesubjectofthereference.WhethersuchpotentIallynegatIvefactscanbeomIttedby
areferencewrIterIscomplex.ncludIngposItIveopInIonsandenthusIastIc
recommendatIons,ofcourse,Isnoproblem.SomefearthatIncludIngfactsthatmaybe
perceIvedasnegatIve(e.g.,thelostmalpractIcecaseorpersonalproblemssuchasa
hIstoryoftreatmentforsubstanceabuse)and/ornegatIveopInIonswIllprovokea
retalIatorylawsuIt(suchasforlIbel,defamatIonofcharacter,orlossoflIvelIhood)from
thesubjectofthereference.Further,however,therehavebeencasesofthefacIlItydoIng
thehIrIngsuIngreferencewrItersforfaIlIngtomentIon(perceIvedasconcealIng)negatIve
InformatIonaboutanapplIcantwholaterwaschargedwIthsubstandardpractIce.8ecause
ofthecomplexItIesandevenapparentcontradIctIons,manyreferencewrItersInthese
questIonablesItuatIonsconfInetheIrwrIttenmaterIaltobrIef,sImplefactssuchasdates
employedandposItIonheld.Asalways,questIonsaboutcomplexsensItIveIssuessuchas
thIsshouldbereferredtoanexperIencedattorneyfamIlIarwIthapplIcablefederaland
statelaw.
8ecausethereshouldbenohesItatIonforareferencewrItertoIncludeposItIvefactsand
opInIons,receIptofareferencethatIncludesnothIngmorethandatesworkedandposItIon
heldcanbeasuggestIonthattheremaybemoretothestory(althoughsomeentItIeshave
adoptedsuchapolIcyInallcasessImplytoelImInateanyvaluejudgmentsastowhatIs
posItIveornegatIveInformatIon).FeceIptofsuchadates/posItIononlyreferenceabout
apersonapplyIngforaposItIonshouldusuallyprovokeatelephonecalltothewrIter.A
telephonecallIslIkelyadvIsableInallcases,IndependentofwhateverthewrItten
referencecontaIns.Frequently,pertInentquestIonsoverthetelephonecanelIcItmore
candIdInformatIon.nrareInstances,theremaybedIshonestythroughomIssIonbythe
referencegIverevenatthIslevel.ThIsmayInvolveanapplIcantwhoanIndIvIdual,a
departmentorgroup,oranInstItutIonwouldlIketoseeleave.
nallcases,newpersonnelInananesthesIapractIceenvIronmentmustbegIvena
thoroughorIentatIonandcheckout.PolIcy,procedures,andequIpmentmaybeunfamIlIar
toeventhemostthoroughlytraIned,experIenced,andsafepractItIoner.ThIsmay
occasIonallyseemtedIous,butItIssoundandcrItIcallyImportantsafetypolIcy.8eIngIn
themIdstofacrIsIssItuatIoncausedbyunfamIlIarItywIthanewsettIngIsnottheoptImal
orIentatIonsessIon.
AftertheInItIalgrantIngofclInIcalprIvIlegestopractIceanesthesIa,anesthesIa
professIonalsmustperIodIcallyrenewtheIrprIvIlegeswIthIntheInstItutIonorfacIlIty(e.g.,
annuallyoreveryotheryear).Therearemoral,ethIcal,andsocIetaloblIgatIonsonthe
partoftheprIvIlegegrantIngentItytotakethIsprocessserIously.StatelIcensIngbodIes
oftenbecomeawareofproblemswIthhealthprofessIonalsverylateIntheevolutIonofany
dIffIcultIes.AnanesthesIaprofessIonal'speersInthehospItalorfacIlItyaremuchmore
lIkelytonotIceuntowarddevelopmentsastheyfIrstappear.However,prIvIlege
P.J0
renewalsareoftenessentIallyautomatIcandreceIvelIttleofthenecessaryattentIon.
JudIcIouscheckIngofrenewalapplIcatIonsandawarenessofrelevantpeerrevIew
InformatIonIsabsolutelynecessary.TheanesthesIaprofessIonalsoradmInIstrators
responsIbleforevaluatIngstaffmembersandrevIewIngtheIrpractIcesandprIvIlegesmay
bejustIfIablyconcernedaboutretalIatorylegalactIonbyastaffmemberwhoIscensured
ordenIedprIvIlegerenewal.AccordIngly,suchevaluatInggroupsmustbethoroughly
objectIve(totallyelImInatInganyhIntofpolItIcalorfInancIalmotIves)andmusthave
documentatIonthatthestaffpersonInquestIonIsInfactpractIcIngbelowthestandardof
care.CourtdecIsIonshavefoundlIabIlItybyahospItal,ItsmedIcalstaffgroup,orboth,
whentheIncompetenceofastaffmemberwasknownorshouldhavebeenknownandwas
notactedupon.
J
AgaIn,questIonsaboutcomplexsensItIveIssuessuchasthIsshouldbe
referredtoanexperIencedattorneyfamIlIarwIthapplIcablefederalandstatelaw.
AmajorIssueInthegrantIngofclInIcalprIvIleges,especIallyInprocedureorIented
specIaltIessuchasanesthesIology,IswhetherItIsreasonabletocontInuethecommon
practIceofblanketprIvIleges.ThIsprocessIneffectauthorIzesthepractItIonerto
attemptanytreatmentorprocedurenormallyconsIderedwIthInthepurvIewofthe
applIcant'smedIcalspecIalty.TheseconsIderatIonsmayhaveprofoundpolItIcaland
economIcImplIcatIonswIthInmedIcIne,suchaswhIchtypeofsurgeonshouldbedoIng
carotIdendarterectomIesorlumbardIscectomIes.|oreImportant,however,Iswhether
thepractItIonerbeIngevaluatedIsqualIfIedtodoeverythIngtradItIonallyassocIatedwIth
thespecIalty.SpecIfIcally,shouldthegrantIngofprIvIlegestopractIceanesthesIa
automatIcallyapprovethepractItIonertohandlepedIatrIccardIaccases,crItIcallyIll
newborns(suchasadayoldprematureInfantwIthalargedIaphragmatIchernIa),ablatIve
paIntherapy(suchasanalcoholcelIacplexusblockunderfluoroscopy),hIghrIskobstetrIc
cases,andsoforth:ThIsquestIonraIsestheIssueofprocedurespecIfIcorlImIted
prIvIleges.ThequalItyassurance(QA)andrIskmanagementconsIderatIonsInthIsquestIon
areweIghtyIfInexperIencedorInsuffIcIentlyqualIfIedpractItIonersareallowedoreven
expected,becauseofpeerorschedulIngpressures,toundertakemajorchallengesfor
whIchtheyarenotprepared.ThelIkelIhoodofcomplIcatIonsandadverseoutcomewIllbe
hIgher,andthedIffIcultyofdefendIngthepractItIoneragaInstamalpractIceclaImInthe
eventofcatastrophewIllbesIgnIfIcantlyIncreased.
ThereIsnoclearanswertothequestIonofprocedurespecIfIccredentIalIngandgrantIngof
prIvIleges.gnorIngIssuesregardIngqualIfIcatIonstoundertakecomplexandchallengIng
procedureshasclearnegatIvepotentIal.Dntheotherhand,strIngentprocedurespecIfIc
credentIalIngIsImpractIcalInsmallergroups,andInlargergroupsencouragesmanysmall
fIefdoms,wIthaconsequentfurtheratrophyoftheclInIcalskIllsoutsIdethe
practItIoner'sspecIfIcarea(s).EachanesthesIadepartmentorgroupneedstoaddressthese
Issues.Attheveryleast,thecommonpractIceofeveryapplIcantforprIvIleges(newor
renewal)checkIngoffeverylIneontheprIntedlIstofanesthesIaproceduresshouldbe
revIewed.AddItIonally,boardcertIfIcatIonforphysIcIansIsnowessentIallyastandardof
qualItyassuranceofthemInImumskIllsrequIredfortheconsultantpractIceof
anesthesIology.SubspecIaltyboards,suchasthoseInpaInmanagement,crItIcalcare,and
transesophagealechocardIography,furtherobjectIfythecredentIalIngprocess.ThIsIsnow
sIgnIfIcantbecauseInItIalboardcertIfIcatIonaftertheyear2000bytheAmerIcan8oardof
AnesthesIology(A8A)IstImelImItedandsubjecttoperIodIctestIngandrecertIfIcatIon.
Clearly,thIswIllencourageanongoIngprocessofcontInuIngmedIcaleducatIon.|any
states,someInstItutIons,evensomeregulatorybodIeshaverequIrementsforamInImum
numberofhoursofcontInuIngmedIcaleducatIon.0ocumentatIonofmeetIngsucha
standardagaInactsasonetypeofqualItyassurancemechanIsmfortheIndIvIdual
practItIoner,whIleprovIdInganotherobjectIvecredentIalIngmeasurementforthose
grantInglIcensesorprIvIleges.
Professional Staff Participation and Relationships
AllmedIcalcarefacIlItIesandpractIcesettIngsdependontheIrprofessIonalstaffs,of
course,fordaIlyactIvItIesofthedelIveryofhealthcarebut,veryImportantly,theyalso
dependonthosestaffstoprovIdeadmInIstratIvestructureandsupport.|edIcalstaff
actIvItIesareIncreasInglyImportantInachIevIngfavorableaccredItatIonstatus(e.g.,from
theJoIntCommIssIonfortheAccredItatIonofHealthcareDrganIzatIons[JCAHD]),now
oftenknownastheJoIntCommIssIon,andInmeetIngawIdevarIetyofgovernmental
regulatIonsandrevIews.PrIncIpalmedIcalstaffactIvItIesInvolvesometImestIme
consumIngefforts,suchasdutIesasastaffoffIcerorcommItteemember.AnesthesIologIsts
shouldbepartIcIpantsInInfact,shouldplayasIgnIfIcantroleIncredentIalIng,peer
revIew,tIssuerevIew,transfusIonrevIew,DFmanagement,andmedIcaldIrectIonofsame
daysurgeryunIts,postanesthesIacareunIts(PACUs),IntensIvecareunIts(CUs),andpaIn
managementunIts.Also,ItIsveryImportantthatanesthesIologypersonnelbeInvolvedIn
fundraIsIngactIvItIes,benefIts,communItyoutreachprojectssponsoredbythefacIlIty,
andsocIaleventsofthefacIlItystaff.
AnesthesIaprofessIonalsasagrouphaveareputatIonforlackofInvolvementInmedIcal
staffandfacIlItyIssuesbecauseoflackoftIme(becauseoflonghoursIntheDF)orsImply
lackofInterest.nfact,anesthesIologypersonnelarealltoooftenperceIvedInafacIlItyas
theoneswhoslIpInandoutofthebuIldIngessentIallyanonymously(oftendressedvery
casuallyorevenInthepajamalIkecomfortofscrubsuIts)andvIrtuallyunnotIced.ThIsIs
anunfortunatestateofaffaIrs,andIthasfrequentlycomebackInvarIouspaInfulwaysto
hauntthosewhohavenotbeenInvolved,orevennotIced.AnesthesIaprofessIonals
sometImesrespondthatthedemandsforanesthesIologyservIcearesogreatthatthey
sImplyneverhavethetImeortheopportunItytobecomeInvolvedIntheIrfacIlItyand
wIththeIrpeers.fthIsIsreallytrue,ItIsclearthatmoreanesthesIaprofessIonalsmustbe
addedatthatfacIlIty,evenIfdoIngsoslIghtlyreducestheIncomeofthosealreadythere.
fanesthesIaprofessIonalsarenotInvolvedandnotperceIvedasInterested,dedIcated
teamplayers,theywIllbeshutoutofcrItIcalnegotIatIonsanddecIsIons.Althoughone
obvIousInstanceInwhIchotherswIllmakedecIsIonsforanesthesIaprofessIonalsIsthe
dIstrIbutIonofcapItatedorbundledpractIcefeeIncomecollectedbyacentralumbrella
organIzatIon,therearemanysuchsItuatIons,andtheanesthesIaprofessIonalswIllbe
forcedtocomplywIththeresultIngmandates.
SImIlarly,InvolvementwIthafacIlIty,aprofessIonalstaff,oramultIspecIaltygroupgoes
beyondformalorganIzedgovernanceandcommItteeactIvIty.CollegIalrelatIonshIpswIth
professIonalofotherspecIaltIesandwIthadmInIstratorsarecentraltomaIntenanceofa
recognIzedposItIonandavoIdanceofthesItuatIonofexclusIonprevIouslydescrIbed.8eIng
readIlyavaIlableforformalandInformalconsults,partIcularlyregardIngpreoperatIve
patIentworkupandthemaxImallyeffIcIentwaytogetsurgeons'patIentstotheDFIna
tImely,expedIentmanner,IsextremelyImportant.NooneIndIvIdualcanbeeverywhere
allthetIme,butananesthesIologygroupordepartmentshouldstrIvetobealways
responsIvetoanyrequestforhelpfromphysIcIansoradmInIstrators.toftenappearsthat
anesthesIaprofessIonalsfaIltoapprecIatejusthowgreataposItIveImpactarelatIvely
sImpleInvolvement
P.J1
(startInganIntravenouslIneforapedIatrIcIan,helpInganInternIstmanageanCU
ventIlator,orhelpIngafacIlItyadmInIstratorunclogajammedrecoveryroom)mayhave.
Establishing Standards of Practice and Understanding the
Standard of Care
TheIncreasIngfrequencyandIntensItyofproductIonpressure,
4
wIththetacIt(oreven
explIcIt)dIrectIvetoanesthesIaprofessIonalstogofastnomatterwhatandtodomore
wIthless,createssItuatIonsInwhIchanesthesIaprofessIonalsmayconcludethatthey
mustcutcornersandcompromIsemaxImallysafepatIentcarejusttostayInbusIness.ThIs
typeofpressurehasbecomeevengreaterwIththeImplementatIonofmoreandmore
protocolsorparametersforpractIce,somefromprofessIonalsocIetIessuchastheASAand
somemandatedbyordevelopedInconjunctIonwIthpurchasersofhealthcare
(government,InsurancecompanIes,ormanagedcareorganIzatIons).|anyofthese
protocolsaredevIsedtofasttrackpatIentsthroughthemedIcalcaresystem,especIally
whenanelectIveprocedureIsInvolved,InasabsolutelylIttletImeaspossIble,thus
mInImIzIngcosts.0othesefasttrackprotocolsconstItutestandardsofcarethathealth
careprovIdersaremandatedtoImplement:WhataretheImplIcatIonsofdoIngso:Dfnot
doIngso:
TobetterunderstandanswerstosuchquestIons,ItIsImportanttohaveabasIcbackground
Intheconceptofthestandardofcare.
Thestandard of careIstheconductandskIllofaprudentpractItIonerthatcanbeexpected
byareasonablepatIent.ThIsIsaveryImportantmedIcolegalconceptbecauseabad
medIcalresultduetofaIluretomeetthestandardofcareIsmalpractIce.Courtshave
tradItIonallyrelIedonmedIcalexpertsknowledgeableaboutthepoIntInquestIontogIve
opInIonsastowhatIsthestandardofcareandIfIthasbeenmetInanIndIvIdualcase.ThIs
typeofstandardIssomewhatdIfferentfromthestandardspromulgatedbyvarIous
standardsettIngbodIesregardIng,forexample,thecolorofgashosesconnectedtoan
anesthesIamachIneortheInabIlItytoopentwovaporIzersonthatmachIne
sImultaneously.However,IgnorIngtheequIpmentstandardsandtoleratInganunsafe
sItuatIonIsavIolatIonofthestandardofcare.Promulgatedstandards,suchasthevarIous
safetycodesandanesthesIamachInespecIfIcatIons,rapIdlybecomethestandardofcare
becausepatIents(throughtheIrattorneys,Inthecaseofanuntowardevent)expectthe
publIshedstandardstobeobservedbytheprudentpractItIoner.
UltImately,thestandardofcareIswhatajurysaysItIs.However,ItIspossIbleto
antIcIpate,atleastInpart,whatknowledgeandactIonswIllbeexpected.Therearetwo
maInsourcesofInformatIonastoexactlywhatIstheexpectedstandardofcare.
TradItIonally,thebelIefsofferedbyexpertwItnessesInmedIcallIabIlItylawsuItsregardIng
whatIsactuallybeIngdoneInreallIfe(defactostandardsofcare)werethemaInInput
jurIeshadIndecIdIngwhatwasreasonabletoexpectfromthedefendant.TheresultIng
problemIswellknown:exceptInthemostegregIouscases,ItIsusuallypossIbleforthe
lawyerstofIndexpertswhowIllsupporteachofthetwoopposIngsIdes,makIngtheprocess
moresubjectIvethanobjectIve.(8ecauseofthIs,thereareevenASAGuidelines for Expert
Witness Qualifications and TestimonyandanequIvalentdocumentfromtheAmerIcan
AssocIatIonofNurseAnesthetIsts).Dfcourse,therecanbelegItImatedIfferencesofopInIon
amongthoughtful,InsIghtfulexperts,butevenInthesecasesthejurystIllmustdecIdewho
IsmorebelIevable,looksbetter,orsoundsbetter.Thesecond,muchmoreobjectIve,
sourcefordefInIngcertaIncomponentpartsofthestandardofcareIsthepublIshed
standardsofcare,guIdelInes,practIceparameters,andprotocolsnowbecomIngmore
common.TheseserveashardevIdenceofwhatcanbereasonablyexpectedof
practItIonersandcanmakeIteasIerforajuryevaluatIngwhetheramalpractIcedefendant
faIledtomeettheapplIcablestandardofcare.SeveraltypesofdocumentsexIstandhave
dIfferIngImplIcatIons.
Leading the Way
AnesthesIologymaybethemedIcalspecIaltymostInvolvedwIthpublIshedstandardsof
care.thasbeensuggestedthatthenatureofanesthesIapractIce(havIngcertaIncentral
crItIcalfunctIonsrelatIvelyclearlydefInedandcommontoallsItuatIonsandalsohavIngan
emphasIsontechnology)makesItthemostamenableofallthefIeldsofmedIcInetothe
useofpublIshedstandards.TheorIgInalIntraoperatIvemonItorIngstandards
5
areaclassIc
example.TheASAfIrstadoptedItsownsetofbasIcIntraoperatIvemonItorIngstandardsIn
1986andhasmodIfIedthemseveraltImes.ThetextofallASAstandards,guIdelInes,and
statementsIsreadIlyavaIlable(seewww.asahq.org,ClInIcalnformatIon,and
Standards,CuIdelInes,andStatements).
ThIsmonItorIngstandardsdocument(www.asahq.org/
publIcatIonsAndServIces/standards/02.pdf)IncludesclearspecIfIcatIonsforthepresenceof
personneldurIngananesthetIcepIsodeandforcontInualevaluatIonofoxygenatIon,
ventIlatIon,cIrculatIon,andtemperature.TheseASAmonItorIngstandardsveryquIckly
becamepartoftheacceptedstandardofcareInanesthesIapractIce.ThIsmeanstheyare
ImportanttopractIcemanagementbecausetheyhaveprofoundmedIcolegalImplIcatIons:
acatastrophIcaccIdentoccurrIngwhIlethestandardsarebeIngactIvelyIgnoredIsvery
dIffIculttodefendIntheconsequentmalpractIcesuIt,whereasanaccIdentthatoccurs
durIngwelldocumentedfullcomplIancewIththestandardswIllautomatIcallyhavea
strongdefensebecausethestandardofcarewasbeIngmet.SeveralstatesIntheUnIted
StateshavemadecomplIancewIththeseASAstandardsmandatoryunderstateregulatIons
orevenstatutes.7arIousmalpractIceInsurancecompanIesofferdIscountsonmalpractIce
InsurancepolIcypremIumsforcomplIancewIththesestandards,somethIngquItenaturalto
InsurersbecausetheyarefamIlIarwIththeIdeaofmanagIngknownrIskstohelpmInImIze
fInancIallosstothecompany.TheASAmonItorIngstandardshavebeenwIdelyemulatedIn
othermedIcalspecIaltIesandevenInfIeldsoutsIdemedIcIne.
WIthmanyofthesameelementsofthInkIng,theASAadopted8asIcStandardsfor
PreanesthesIaCare(www.asahq.org/publIcatIonsAndServIces/standards/0J.pdf).ThIswas
supplementedsIgnIfIcantlybyanothertypeofdocument,theASAPractice Advisory for
Preanesthesia Evaluation(seewww.asahq.org,PublIcatIonsandServIces,andPractIce
Parameters),a40pagemetaanalysIsofclInIcalaspectsofpreoperatIveevaluatIon.Also,
theASAadoptedStandardsforPostanesthesIaCare,InwhIchtherewasconsIderatIonof
andcollaboratIonwIththeverydetaIledstandardsofpractIceforPACUcarepublIshedby
theAmerIcanSocIetyofPostAnesthesIaNurses(anothergoodexampleofthesourcesof
standardsofcare).ThIsalsowaslatersupplementedbyanextensIvePractice Guideline.
6
AslIghtlydIfferentsItuatIonexIstswIthregardtothestandardsforconductofanesthesIaIn
obstetrIcs.ThesestandardswereorIgInallypassedbytheASAIn1988,Inthesamemanner
astheotherASAstandards,buttheASAmembershIpeventuallyquestIonedwhetherthey
reflectedarealIstIcanddesIrablestandardofcare.AccordIngly,theobstetrIcanesthesIa
standardsweredowngradedIn1990toguIdelInes,specIfIcallytoremovethemandatory
natureofthedocument.8ecausetherewasnoagreementastowhatshouldbeprescrIbed
asthestandardofcare,themedIcolegalImperatIveofpublIshedstandards
P.J2
InthIsInstancehasbeentemporarIlysetasIde.FromamanagementperspectIve,thIs
makestheguIdelInes(www.asahq.org/publIcatIonsAndServIces/standards/45.pdf)noless
valuablebecausetheIntentofoptImIzIngcarethroughtheavoIdanceofcomplIcatIonsIs
nolessoperatIve.However,IntheeventoftheneedtodefendagaInstamalpractIceclaIm
InthIsarea,ItIsclearfromthIssequenceofeventsthattheexactstandardofcareIs
debatableandnotyetfInallyestablIshed(anextremelyImportantmedIcolegal
consIderatIon).AdIfferentASAdocumenthasbeengenerated,Practice Guidelines for
Obstetrical Anesthesia,wIthmoredetaIlandspecIfIcItyaswellasanemphasIsonthe
metaanalytIcapproach.
7
Practice Guidelines
AnImportanttypeofrelatedASAdocumentIsthePractice Guideline(formerlyPractIce
Parameter).ThIshassomeofthesameelementsasastandardofpractIcebutIsmore
IntendedtoguIdejudgment,largelythroughalgorIthmswIthsomeelementofguIdelInes,In
addItIontodIrectIngthedetaIlsofspecIfIcproceduresaswouldaformalstandard.8eyond
thedetaIlsofthemInImumstandardsforcarryIngouttheprocedure,thesepractIce
parameterssetforthalgorIthmsandguIdelInesforhelpIngtodetermIneunderwhat
cIrcumstancesandwIthwhattImIngtoperformIt.Understandably,purchasersofhealth
care(government,InsurancecompanIes,andmanagedcareorganIzatIons[|CDs])wItha
strongdesIretolImItthecostsofmedIcalcarehavegreatInterestInpractIceparameters
aspotentIalvehIclesforhelpIngtoelImInateunnecessaryproceduresandlImIteventhe
necessaryones.
TheASAhasbeenveryactIveIncreatIngandpublIshIngpractIceguIdelInes.ThefIrst
publIshedparameter(sIncerevIsed)concernedtheuseofpulmonaryartery(PA)catheters.
8
tconsIderedtheclInIcaleffectIvenessofPAcatheters,publIcpolIcyIssues(costsand
concernsofpatIentsandprovIders),andrecommendatIons(IndIcatIonsandpractIce
settIngs).Also,theASADifficult Airway AlgorithmwaspublIshed(alsosIncerevIsed).
9
ThIs
thoughtfuldocumentsynthesIzedastrategysummarIzedInadecIsIontreedIagramfor
dealIngacutelywIthaIrwayproblems.thasgreatclInIcalvalueandItIsreasonableto
antIcIpatethatItwIllbeusedtohelpmanypatIents.However,allthesedocumentsare
readIlynotIcedbyplaIntIffs'lawyers,thedIffIcultaIrwayparameterfromtheASAbeIngan
excellentexample.
AnImportantandsofarundecIdedquestIonIswhetherguIdelInesandpractIceparameters
fromrecognIzedentItIessuchastheASAdefinethestandardofcare.ThereIsnosImple
answer.ThIswIllbedecIdedovertImebypractItIoners'actIons,debatesInthelIterature,
mandatesfrommalpractIceInsurers,and,ofcourse,courtdecIsIons.SomeguIdelInes,such
astheU.S.Foodand0rugAdmInIstratIon(F0A)preanesthetIcapparatuscheckout,are
acceptedasthestandardofcare.TherewIllbedebateamongexperts,butthepractItIoner
mustmakethedecIsIonastohowtoapplypractIceparametersandguIdelInessuchas
thosefromtheASA.PractItIonershaveIncorrectlyassumedthattheymustdoeverythIng
specIfIed.ThIsIsclearlynottrue,yetthereIsavalIdconcernthatthesewIllsomedaybe
heldupasdefInIngthestandardofcare.AccordIngly,prudentattentIonwIthInthebounds
ofreasontotheprIncIplesoutlInedInguIdelInesandparameterswIllputthepractItIoner
InatleastareasonablydefensIbleposItIon,whereasradIcaldevIatIonfromthemshouldbe
basedonobvIousexIgencIesofthesItuatIonatthatmomentorclear,defensIble
alternatIvebelIefs(wIthdocumentatIon).
ThemostrecenttypeofdocumenthasbeenthepractIceadvIsory,whIchcanseem
functIonallysImIlar,butappearstohavetheImplIcatIonofmoreconsensuscompromIse
thanprevIousdocuments.ExamplesofpractIceadvIsorIesInclude:ntraoperatIve
Awarenessand8raInFunctIon|onItorIng,PerIoperatIve|anagementofPatIentswIth
CardIacFhythm|anagement0evIces:PacemakersandmplantableCardIoverter
0efIbrIllators,andPerIoperatIve7IsualLossAssocIatedwIthSpIneSurgery.The
potentIalqualItyassuranceandmedIcolegalImplIcatIonsofthesedocumentsareso
ImportanttoanesthesIaprofessIonalsandtheIrpractIces,theASAhaswhatIsessentIallya
guIdelInefortheguIdelInesInIts2007updateofthePolIcyStatementonPractIce
Parameters(seewww.asahq.org,PublIcatIonsandServIces,andStandards,CuIdelInes,
andStatements)InwhIchthedIstInctIonIsmadebetweenevIdencebaseddocumentsand
consensusbaseddocumentswIthexplanatIonsofthebackgroundandformulatIonprocesses
foreach.
Dntheotherhand,practIceprotocols,suchasthoseforthefasttrackmanagementof
coronaryarterybypassgraftpatIents,thatarehandeddownby|CDsorhealthInsurance
companIesareadIfferentmatter.EventhoughthedesIredImplIcatIonIsthatpractItIoners
mustobserve(oratleaststronglyconsIder)them,theydonothavethesameImplIcatIons
IndefInIngthestandardofcareastheotherdocuments.PractItIonersmustavoIdgettIng
trapped.tmaywellnotbeavalIdlegaldefensetojustIfyactIonorthelackofactIon
becauseofacompanyprotocol.AsdIffIcultasItmaybetoreconcIlewIththepayer,the
practItIonerstIllIssubjecttotheclassIcdefInItIonsofstandardofcare.
TheothertypeofstandardsassocIatedwIthmedIcalcarearethoseoftheJoInt
CommIssIon,whIchIsthebestknownmedIcalcarequalItyregulatoryagency.Asnoted,
thesestandardswereformanyyearsconcernedlargelywIthstructure(e.g.,gastanks
chaIneddown)andprocess(e.g.,documentatIoncomplete),butInrecentyearstheyhave
beenexpandedtoIncluderevIewsoftheoutcomeofcare.JoIntCommIssIonstandardsalso
focusoncredentIalIngandprIvIleges,verIfIcatIonthatanesthesIaservIcesareofunIform
qualItythroughoutanInstItutIon,thequalIfIcatIonsofthedIrectoroftheservIce,
contInuIngeducatIon,andbasIcguIdelInesforanesthesIacare(needforpreoperatIveand
postoperatIveevaluatIons,documentatIon,andsoforth).FullJoIntCommIssIon
accredItatIonofahealthcarefacIlItyIsusuallyforJyears.EventhebesthospItalsand
facIlItIesreceIvesomecItatIonsofproblemsordefIcIencIesthatareexpectedtobe
corrected,andanInterImreportofeffortstodosoIsrequIred.fthereareenough
problems,accredItatIoncanbecondItIonalfor1year,wIthacompletereInspectIonatthat
tIme.PreparIngforJoIntCommIssIonInspectIonsstartswIthverIfIcatIonthatessentIal
group/departmentstructureIsInplace;excellentexamplesexIst.
1
TheprocessultImately
Involvesagreatdealofwork,butbecausethestandardsusuallydopromotehIghqualIty
care,themajorItyofthIsworkIshIghlyconstructIveandofbenefIttotheInstItutIonand
ItsmedIcalstaff.
Review Implications
AnothertypeofregulatoryagencyIsthepeerrevIeworganIzatIon.ProfessIonalstandards
revIeworganIzatIons(PSFDs)wereestablIshedIn1972asutIlIzatIonrevIew/QAoverseers
ofthecareoffederallysubsIdIzedpatIents(|edIcareand|edIcaId).0espItetheIrefforts
todealwIthqualItyofcare,thesegroupswereseenbyallInvolvedasprImarIlyInterested
IncostcontaInment.7arIousnegatIvefactorsledtothePSFDsbeIngreplacedIn1984wIth
thepeerrevIeworganIzatIon(PFD).
10
ThereIsaPFDIneachstate,manybeIngassocIated
wIthastatemedIcalassocIatIon.TheobjectIvesofaPFDInclude14goalsrelatedto
hospItaladmIssIons(e.g.,toshIftcaretoanoutpatIentbasIsasmuchaspossIble)and5
relatedtoqualItyofcare(e.g.,toreduceavoIdabledeathsandavoIdablecomplIcatIons).
ThePFDscomprIsefulltImesupportstaffandphysIcIanrevIewerspaIdasconsultantsor
dIrectors.deally,PFDmonItorIngwIlldIscoversuboptImalcare,whIchwIllleadtospecIfIc
recommendatIonsforImprovementInqualIty.ThereIs
P.JJ
aperceptIonthatqualItyofcareeffortsarehamperedbythelackofrealIstIcobjectIves
andalsothatthesePFDgroups,lIkeothersbeforethem,wIlllargelyorentIrelyfunctIonto
lImItthecostofhealthcareservIces.
ThepractIcemanagementImplIcatIonshavebecomeclear.AsIdefromtheasyet
unrealIzedpotentIalforqualItyImprovementeffortsandtheoccasIonaldenIalofpayment
foraprocedure,themostlIkelyInteractIonbetweenthelocalPFDandanesthesIa
professIonalswIllInvolvearequestforperIoperatIveadmIssIonofapatIentwhosecareIs
mandatedtobeoutpatIentsurgery(thIscouldalsooccurIndealIngwIthan|CD).fthe
anesthesIologIstfeels,forexample,thateIther(1)preoperatIveadmIssIonfortreatmentto
optImIzecardIac,pulmonary,dIabetIc,orothermedIcalstatusor(2)postoperatIve
admIssIonformonItorIngoflabIlesItuatIonssuchasuncontrolledhypertensIonwIllreduce
clearanesthetIcrIsksforthepatIent,anapplIcatIontothePFDforapprovalofadmIssIon
mustbemadeandvIgorouslysupported.Alltoooften,however,suchIssuessurfaceaday
orsobeforethescheduledprocedureInapreanesthesIascreenIngclInIcorevenIna
preoperatIveholdIngareaoutsIdetheDFonthedayofsurgery.ThIswIllcontInuetooccur
untIlanesthesIaprovIderseducatetheIrconstItuentsurgeoncommunItyastowhattypesof
assocIatedmedIcalcondItIonsmaydIsqualIfyaproposedpatIentfromtheoutpatIent
(ambulatory)surgIcalschedule.fadequatenotIceIsgIvenbythesurgeon,thepatIentcan
beseenfarenoughInadvancebyananesthesIologIsttoallowapproprIateplannIng.
nthecIrcumstanceInwhIchthefIrstknowledgeofaquestIonablepatIentcomes1or2
daysbeforesurgery,theanesthesIologIstcantrytohavetheprocedurepostponed,If
possIble,orcanundertakethetImeconsumIngtaskofmultIpletelephonecallstogetthe
surgeon'sagreement,getPFDapproval,andmakethenecessaryarrangements.8ecause
neItheralternatIveIspartIcularlyattractIve,especIallyfromadmInIstratIveand
reImbursementperspectIves,theremaybeastrongtemptatIontoletItslIdeandtryto
dealwIththepatIentasanoutpatIenteventhoughthIsmaybequestIonable.nalmostall
cases,ItIslIkelythattherewouldbenoadverseresult(thegetawaywIthIt
phenomenon).However,thepatIentmIghtwellbeexposedtoanavoIdablerIsk.8oth
becauseoftheworkIngsofprobabIlItyandbecauseoftheInevItabletendencytoletsIcker
andsIckerpatIentsslIpbyaslaxpractItIonersrepeatedlygetawaywIthItandarelulled
IntoafalsesenseofsecurIty,soonerorlatertherewIllbeanunfortunateoutcomeorsome
preventablemajormorbIdItyorevenmortalIty.
ThesItuatIonIsworsenedwhenthefIrstcontactwIthaquestIonableambulatorypatIentIs
preoperatIvely(possIblyevenalreadyIntheDF)onthedayofsurgery.Theremaybe
IntensepressurefromthepatIent,thesurgeon,ortheDFadmInIstratorandstaffto
proceedwIthacaseforwhIchtheanesthesIapractItIonerbelIevesthepatIentIspoorly
prepared.TheargumentsmaderegardIngpatIentInconvenIenceandanxIetyarevalId.
However,theyshouldnotoutweIghthebestmedIcalInterestsofthepatIent.AlthoughthIs
IsapoIntInfavorofscreenIngalloutpatIentsbeforethedayofsurgery,theanesthesIa
professIonalfacIngthIssItuatIononthedayofoperatIonshouldstateclearlytoall
concernedthereasonsforpostponIngthesurgery,stressIngtheIssueofavoIdablerIskand
standardsofcare,andthenhelpwIthalternatIvearrangements(IncludIng,Ifnecessary,
dealIngwIththePFDormanagedcareorganIzatIon).
PotentIallIabIlItyInthIsregardIstheothersIdeofthestandardofcareIssue.PartIcularly
concernIngIsthequestIonofpostoperatIveadmIssIonofambulatorypatIentswhohave
beenunstable.tIsanextremelypoordefenseagaInstamalpractIceclaImtostatethat
thepatIentwasdIschargedhome,onlylatertosufferacomplIcatIon,becausethe
PFD/managedcareorganIzatIondeemedthatoperatIveprocedureoutpatIentandnot
InpatIentsurgery.AsbureaucratIcallyannoyIngasItmaybe,ItIsaprudentmanagement
strategytoadmItthepatIentIfthereIsanylegItImatequestIon,thusmInImIzIngthe
chanceforcomplIcatIons,andlaterhagglewIththePFDordIrectlywIththeInvolved
thIrdpartypayer.
Policy and Procedure
DneImportantorganIzatIonalpoIntthatIsoftenoverlookedIstheneedforacomplete
polIcyandproceduremanual.SuchacompIlatIonofdocumentsIsnecessaryforall
practIces,fromthelargestdepartmentscoverIngmultIplehospItalstoasIngleroom
outpatIentfacIlItywIthoneanesthesIaprovIder.SuchamanualcanbeextraordInarIly
valuable,as,forexample,whenItprovIdescrucIalInformatIondurInganemergency.Some
suggestIonsforthecontentofthIscompendIumexIst
11
but,atmInImum,organIzatIonal
andproceduralelementsmustbeIncluded.
TheorganIzatIonalelementsthatshouldbepresentIncludeachartoforganIzatIonand
responsIbIlItIesthatIsnotjustacallschedulebutaclearexplanatIonofwhoIsresponsIble
forwhatfunctIonsofthedepartmentandwhen,wIthattendantdetaIlssuchas
expectatIonsforthepractItIoner'spresencewIthIntheInstItutIonatdesIgnatedhours,
telephoneavaIlabIlIty,pageravaIlabIlIty,themaxImumpermIssIbledIstancefromthe
InstItutIonwhenoncall,andsoforth.ExperIencesuggestsItIsespecIallyImportantfor
theretobeanabsolutelyclearspecIfIcatIonoftheavaIlabIlItyofqualIfIedanesthesIology
personnelforemergencycesareansectIon,partIcularlyInpractIcearrangementsInwhIch
thereareseveralpeopleoncallcoverIngmultIplelocatIons.Sadly,theseIssuesoftenare
onlyconsIderedafteradIsasterhasoccurredthatInvolvedmIscommunIcatIonandthe
mIstakenbelIefbyoneormorepeoplethatsomeoneelsewouldtakecareofanacute
problem.
TheorganIzatIonalcomponentofthepolIcyandproceduremanualshouldalsoIncludea
clearexplanatIonoftheorIentatIonandcheckoutprocedurefornewpersonnel,contInuIng
medIcaleducatIonrequIrementsandopportunItIes,themechanIsmsforevaluatIng
personnelandforcommunIcatIngthIsevaluatIontothem,dIsasterplans(orreferencetoa
separatedIsastermanualorprotocol),QAactIvItIesofthedepartment,andtheformatfor
statIstIcalrecordkeepIng(numberofprocedures,typesofanesthetIcsgIven,typesof
patIentsanesthetIzed,numberandtypesofInvasIvemonItorIngprocedures,numberand
typeofresponsestoemergencycalls,complIcatIons,orwhateverthegroup/department
decIdes).
TheproceduralcomponentofthepolIcyandproceduremanualshouldgIvebothhandy
practIcetIpsandspecIfIcoutlInesofproposedcoursesofactIonforpartIcular
cIrcumstances;ItalsoshouldstorelIttleusedbutvaluableInformatIon.Feferenceshould
bemadetothestatements,guIdelInes,practIceparameters,andstandardsappearIngon
theASAWebsIte.AlsoIncludedshouldbereferencestoorspecIfIcprotocolsfortheareas
mentIonedIntheJCAHDstandards:preanesthetIcevaluatIon,ImmedIatepreInductIonre
evaluatIon,safetyofthepatIentdurIngtheanesthetIcperIod,releaseofthepatIentfrom
anyPACU,recordIngofallpertInenteventsdurInganesthesIa,recordIngofpostanesthesIa
vIsIts,guIdelInesdefInIngtheroleofanesthesIaservIcesInhospItalInfectIoncontrol,and
guIdelInesforsafeuseofgeneralanesthetIcagents.DtherapproprIatetopIcsIncludethe
followIng:
1. FecommendatIonsforpreanesthesIaapparatuscheckout,suchasfromtheF0A
12
(see
Chapter26)
2. CuIdelInesforadmIssIonto,mInImalmonItorIngandduratIonofstayofanInfant,chIld,
oradultIn,andthendIschargefromthePACU
J. ProceduresfortransportIngpatIentsto/fromtheDF,PACU,orCU
P.J4
5. PolIcyonambulatorysurgIcalpatIentsforexample,screenIng,useofregIonal
anesthesIa,dIschargehomecrIterIa
6. PolIcyonevaluatIonandprocessIngofsamedayadmIssIons
7. PolIcyonCUadmIssIonanddIscharge
8. PolIcyonphysIcIansresponsIbleforwrItIngordersInrecoveryroomandCU
9. PolIcyonInformedconsentforanesthesIaandItsdocumentatIon
10. PolIcyontheuseofpatIentsInclInIcalresearch(IfapplIcable)
11. CuIdelInesforthesupportofcadaverIcorgandonorsandItstermInatIon(plusorgan
donatIonaftercardIacdeath)
12. CuIdelInesonenvIronmentalsafety,IncludIngpollutIonwIthtracegasesandelectrIcal
equIpmentInspectIon,maIntenance,andhazardpreventIon
1J. ProcedureforchangeofpersonneldurIngananesthetIcanddocumentatIon(partIcularly
IfaprIntedhandoffprotocolIsused)
14. ProcedurefortheIntroductIonofnewequIpment,drugs,orclInIcalpractIces
15. ProcedureforepIduralandspInalnarcotIcadmInIstratIonandsubsequentpatIent
monItorIng(e.g.,type,mInImumtIme,nursIngunIts)
16. ProcedureforInItIaltreatmentofcardIacorrespIratoryarrest(updatedAdvanced
CardIacLIfeSupportguIdelInes)
17. PolIcyforhandlIngpatIent'srefusalofbloodorbloodproducts,IncludIngthemechanIsm
toobtaInacourtordertotransfuse
18. ProcedureforthemanagementofmalIgnanthyperthermIa
19. ProcedurefortheInductIonandmaIntenanceofbarbIturatecoma
20. ProcedurefortheevaluatIonofsuspectedpseudocholInesterasedefIcIency
21. ProtocolforrespondIngtoanadverseanesthetIcevent(suchasacopyoftheupdateof
theAdverseEventProtocol
1J
)
22. PolIcyonresuscItatIonofdonotresuscItatepatIentsIntheDF
ndIvIdualdepartmentswIlladdtothesesuggestIonsasdIctatedbytheIrspecIfIcneeds.A
thorough,carefullyconceIvedpolIcyandproceduremanualIsavaluabletool.Themanual
shouldberevIewedandupdatedasneededbutatleastannually,wIthapartIcularly
thoroughrevIewprecedIngeachJoIntCommIssIonInspectIon.Eachmemberofagroupor
departmentshouldrevIewthemanualatleastannuallyandsIgnoffInalogIndIcatIng
famIlIarItywIthcurrentpolIcIesandprocedures.
Meetings and Case Discussion
TheremustberegularlyscheduleddepartmentalorgroupmeetIngs.AlthoughdIdactIc
lecturesandcontInuIngeducatIonmeetIngsarevaluableandnecessary,therealsomustbe
regularopportunItIesforopenclInIcaldIscussIonaboutInterestIngcasesandproblem
cases.Also,theJoIntCommIssIonrequIresthattherebeatleastmonthlymeetIngsat
whIchrIskmanagementandQAactIvItIesaredocumentedandreported.Whetherthese
meetIngsarecalledcaseconferences,morbIdItyandmortalItyconferences,ordeathsand
complIcatIonsconferences,theentIredepartmentorgroupshouldgatherforan
InterchangeofIdeas.|orerecentlythesegatherIngshavebeencalledQA meetings.An
openrevIewofdepartmentalstatIstIcsshouldbedone,IncludIngallcomplIcatIons,even
thosethatmayappeartrIvIal.UnusualpatternsofsmalleventsmaypoInttowardalarger
orsystematIcproblem,especIallyIftheyaremorefrequentlyassocIatedwIthone
IndIvIdualpractItIoner.
AproblemcasepresentedatthedepartmentalmeetIngmIghtbeanovertaccIdent,anear
accIdent(crItIcalIncIdent),oranuntowardoutcomeofunknownorIgIn.Honestbut
constructIvedIscussIon,evenofananesthesIaprofessIonal'stechnIcaldefIcIencIesorlack
ofknowledge,shouldtakeplaceInthespIrItofconstructIvepeerrevIew.TheclassIc
questIon,WhatwouldyoudodIfferentlynexttIme:IsagoodwaytostartthedIscussIon.
TheremaybesItuatIonsInwhIchInvItIngthesurgeonortheInternIstInvolvedInaspecIfIc
casewouldbeadvantageous.TheopportunItyforeachtypeofprovIdertohearthe
perspectIveofanotherdIscIplIneIsnotonlyInherentlyeducatIonal,butalsocanpromote
communIcatIonandcooperatIonInfuturepotentIalproblemcases.
FecordsofthesemeetIngsmustbekeptforaccredItatIonpurposes,buttheenshrInIngof
overlydetaIledmInutes(potentIallysubjecttodIscoverybyaplaIntIff'sattorneyatalater
date)mayInhIbIttrueeducatIonalandcorrectIveInterchangesaboutuntowardevents.n
thecIrcumstanceofdIscussIonofacasethatseemslIkelytoprovokelItIgatIon,ItIs
approprIatetobecertaInthatthemeetIngIsclassIfIedasoffIcIalpeerrevIewand
possIblyevenInvItethehospItalattorneyorlegalcounselfromtherelevantmalpractIce
InsurancecarrIer(toguaranteetheprIvacyofthedIscussIonandmInutes).
Support Staff
ThereIsafundamentalneedforsupportstaffIneveryanesthesIapractIce.Even
IndependentpractItIonersrelyInsomemeasureonfacIlItIes,equIpment,andservIces
provIdedbytheorganIzatIonmaIntaInIngtheanesthetIzInglocatIon.nlarge,well
organIzeddepartments,relIanceonsupportstaffIsoftenverygreat.WhatIsoften
overlooked,however,IsaprocessanalogoustothatofcredentIalIngandprIvIlegesfor
anesthesIaprofessIonals,althoughataslIghtlydIfferentlevel.Thepeopleexpectedto
provIdeclInIcalanesthesIapractIcesupportmustbequalIfIedandmustatalltImes
understandwhattheyareexpectedtodoandhowtodoIt.tIssIngularlyunfortunateto
realIzeonlyafterananesthesIacatastrophehasoccurredthatbasIcdetaIlsofsImplework
assIgnments,suchasthechangIngofcarbondIoxIdeabsorbent,wereroutInelyIgnored.
ThIsIndIcatestheneedforsupervIsIonandmonItorIngofthesupportstaffbytheInvolved
practItIoners.Further,suchsupportpersonnelarefavorItetargetsofcostcuttIng
admInIstratorswhodonotunderstandthefunctIonofanesthesIatechnIcIansortheIr
equIvalent.nthemodernera,manyadmInIstratorsseemdrIvenalmostexclusIvelybythe
bottomlIneandcannotapprecIatetheconnectIonbetweenvaluableworkerssuchas
theseandtherevenuestream.EventhoughItIsobvIoustoallwhoworkInanDFthat
theanesthesIasupportpersonnelmakeItpossIblefortheretobepatIentsflowIngthrough
theDF,ItIstheIrresponsIbIlItytoconvIncethefacIlIty'sfIscaladmInIstratorthat
elImInatIonofsuchposItIonsIsgenuInelyfalseeconomybecauseoftheattendantlossIn
effIcIency,partIcularlyInturnIngovertheroombetweensurgerIes.Further,ItIsalsofalse
economytoreducethenumberofpersonnelbelowthatgenuInelyneededtoretrIeve,
clean,sort,dIsassemble,sterIlIze,reassemble,store,anddIstrIbutethetoolsofdaIly
anesthesIapractIce.7Igorousdefense(orInItIatIonofnewposItIonsIfthestaffIs
Inadequate)bytheanesthesIaprofessIonalsshouldbeundertaken,alwayswIththe
realIzatIonthatItmaybenecessaryInsomecIrcumstancesforthemtosupplementthe
budgetfromthefacIlItywIthsomeoftheIrpractIceIncometoguaranteeanadequate
complementofcompetentworkers.
8usInessandorganIzatIonalIssuesInthemanagementofananesthesIapractIcearealso
crItIcallydependentontheexIstenceofasuffIcIentnumberofapproprIatelytraIned
supportstaff.DnefrequentlyoverlookedIssuethatcontrIbutestothe
P.J5
negatIveImpressIongeneratedbysomeanesthesIologypractIcescentersonbeIngcertaIn
thereIssomeoneavaIlabletoanswerthetelephoneat all timesdurIngthehourssurgeons,
otherphysIcIans,andDFschedulIngdesksarelIkelytocall.ThIsseemInglytrIvIal
componentofpractIcemanagementIsveryImportanttothesuccessofananesthesIology
practIceasabusInesswhoseprIncIpalcustomersarethesurgeons.CertaInlythereIsa
commercIalserverclIentrelatIonshIpbothwIththepatIentandthepurchaserofhealth
care;however,theunIquelysymbIotIcnatureoftherelatIonshIpbetweensurgeonsand
anesthesIologIstsIssuchthatavaIlabIlItyevenforsImplejustwantedtoletyouknow
telephonecallsIsgenuInelyImportant.ThepersonwhoanswersthetelephoneIsthe
representatIveofthepractIcetotheworldandmusttakethatresponsIbIlItyserIously.
FromamanagementstandpoInt,sIgnIfIcantImpactonthesuccessofthepractIceasa
busInessoftenhIngesonsuchdetaIls.Further,anesthesIologIstsshouldalwayshave
permanentpersonalelectronIcpagersandrelIablemobIletelephones(ortheradIo
equIvalent)tofacIlItatecommunIcatIonsfromothermembersofthedepartmentorgroup
andfromsupportpersonnel.ThIsmaysoundIntrusIve,buttheunusualposItIonof
anesthesIaprofessIonalsInthespectrumofhealthcareworkersmandatesthIsfeatureof
managIngananesthesIologypractIce.AnesthesIologyprofessIonalsshouldhaveno
hesItatIonaboutspendIngtheIrownpractIceIncometodoso.ThesymbolIsmaloneIs
obvIous.
Anesthesia Equipment and Equipment Maintenance
ProblemswIthanesthesIaequIpmenthavebeendIscussedforsometIme.
14,15,16
However,
comparedwIthhumanerror,overtequIpmentfaIlurerarelycausesIntraoperatIvecrItIcal
IncIdents
17
ordeathsresultIngfromanesthesIacare.AsIdefromtheobvIoushumanerrors
InvolvIngmIsuseoforunfamIlIarItywIththeequIpment,whentherareequIpmentfaIlure
doesoccur,ItoftenappearsthatcorrectmaIntenanceandservIcIngoftheapparatushas
notbeendone.TheseIssuesbecomethefocusofanesthesIapractIcemanagementefforts,
whIchcouldhavesIgnIfIcantlIabIlItyImplIcatIonsbecausetherecanoftenbeconfusIonor
evendIsputesaboutprecIselywhoIsresponsIbleforarrangIngmaIntenanceofthe
anesthesIaequIpmentthefacIlItyorthepractItIonerswhouseItandcollectpractIce
IncomefromthatactIvIty.nmanycases,thefacIlItyassumestheresponsIbIlIty.n
sItuatIonsInwhIchthatIsnottrue,however,ItIsnecessaryforthepractItIonersto
recognIzethatresponsIbIlItyandseekhelpsecurIngaservIcearrangement,becausethIsIs
lIkelyanunfamIlIaroblIgatIonforclInIcIans.
ProgramsforanesthesIaequIpmentmaIntenanceandservIcehavebeenoutlIned.
1,18
A
dIstInctIonIsmadebetweenfaIlureresultIngfromprogressIvedeterIoratIonofequIpment,
whIchshouldbepreventablebecauseItIsobservableandshouldprovokeapproprIate
remedIalactIon,andcatastrophIcfaIlure,whIch,realIstIcally,oftencannotbepredIcted.
PreventIvemaIntenanceformechanIcalpartsIscrItIcalandInvolvesperIodIcperformance
checksevery4to6months.Also,anannualsafetyInspectIonofeachanesthetIzIng
locatIonandtheequIpmentItselfIsnecessary.ForequIpmentservIce,anexcellent
mechanIsmIsarelatIvelyelaboratecrossreferencesystem(possIblykepthandwrIttenIna
notebookbutIdealformaIntenanceonanelectronIcspreadsheetprogram)toIdentIfyboth
thedevIceneedIngservIceandalsothemechanIsmtosecuretheneededmaIntenanceor
repaIr.
EquIpmenthandlIngprIncIplesarestraIghtforward.8eforepurchase,ItmustbeverIfIed
thataproposedpIeceofequIpmentmeetsallapplIcablestandards,whIchwIllusuallybe
truewhendealIngwIthrecognIzedmajormanufacturers.Therenewedeffortsofsome
facIlItyadmInIstratorstosavemoneybyattemptIngtofIndrefurbIshedanesthesIa
machInesandmonItorIngsystemsshouldprovokethoroughrevIewbytheInvolved
practItIoners.DnarrIval,electrIcalequIpmentmustbecheckedforabsenceofhazard
(especIallyleakageofcurrent)andcomplIancewIthapplIcableelectrIcalstandards.
ComplexequIpmentsuchasanesthesIamachInesandventIlatorsshouldbeassembledand
checkedoutbyarepresentatIvefromthemanufacturerormanufacturer'sagent.Thereare
potentIaladversemedIcolegalImplIcatIonswhenrelatIvelyuntraInedpersonnelcertIfya
partIcularpIeceofnewequIpmentasfunctIonIngwIthInspecIfIcatIon,evenIftheydoIt
perfectly.DnarrIval,asheetorsectIonInthedepartmentalmasterequIpmentlogmustbe
createdwIththemake,model,serIalnumber,andInhouseIdentIfIcatIonforeachpIeceof
capItalequIpment.ThIsnotonlyallowsImmedIateIdentIfIcatIonofanyequIpment
InvolvedInafuturerecallorproductalert,butalsoservesasthepermanentreposItoryof
therecordofeveryproblem,problemresolutIon,maIntenance,andservIcIngoccurrIng
untIlthatpartIcularequIpmentIsscrapped.ThIslogmustbekeptuptodateatalltImes.
TherehavebeenrarebutfrIghtenIngexamplesofpotentIallylethalproblemswIth
anesthesIamachInesleadIngtoproductalertnotIcesrequIrIngImmedIateIdentIfIcatIonof
certaInequIpmentandItsservIcestatus.tIsalsoveryImportanttoInvolvethe
manufacturer'srepresentatIveInpreandInservIcetraInIngforthosewhowIllusethenew
equIpment.AnesthesIasystemswIththeIrventIlatIonandmonItorIngcomponentshave
becomesIgnIfIcantlymoreIntegratedandmorecomplex,partIcularlyastheyare
IncreasInglyelectronIcandlessmechanIcal.AccordIngly,ItIscrItIcalthatanesthesIa
professIonalsareproperlytraInedtousetheIrequIpmentsafely.TheperceptIonthat
InadequatetraInIngIscommonandthatthIsrepresentsathreattopatIentsafetyhasled
theAnesthesIaPatIentSafetyFoundatIontoInItIateacampaIgnurgInganesthesIa
departmentsandgroupstoensureorganIzedverIfIedcompletetraInIngofallprofessIonals
whowIllusethIsnewtechnology.
19
Service
8eyondtheadmInIstratIvelIabIlItyImplIcatIons,precIselywhattypeofsupportpersonnel
shouldmaIntaInandservIcemajoranesthesIaequIpmenthasbeenwIdelydebated.Some
groupsordepartmentsrelyonfactoryservIcerepresentatIvesfromtheequIpment
manufacturersforallattentIontoequIpment,othersengageIndependentservIce
contractors,andstIllother(oftenlarger)departmentshaveaccesstopersonnel(eIther
engIneersand/ortechnIcIans)permanentlywIthIntheIrfacIlIty.ThesIngleunderlyIng
prIncIpleIsclear:theperson(s)doIngpreventIvemaIntenanceandservIceonanesthesIa
equIpmentmustbequalIfIed.AnesthesIapractItIonersmaywonderhowtheycanassess
thesequalIfIcatIons.ThebestwayIstounhesItatInglyaskpertInentquestIonsaboutthe
educatIon,traInIng,andexperIenceofthoseInvolved,IncludIngaskIngforreferencesand
speakIngtosupervIsorsandmanagersresponsIbleforthosedoIngthework.Whetheran
engIneerIngtechnIcIanwhospentaweekatacourseatafactorycanperformthemost
complexrepaIrsdependsonavarIetyoffactors,whIchcanbeInvestIgatedbythe
practItIonersultImatelyusIngtheequIpmentInthecareofpatIents.FaIluretobeInvolved
InthIsoversIghtfunctIonexposesthepractIcetoIncreasedlIabIlItyIntheeventofan
untowardoutcomeassocIatedwIthImproperlymaIntaInedorservIcedequIpment.
FeplacementofobsoleteanesthesIamachInesandmonItorIngequIpmentIsakeyelement
ofarIskmodIfIcatIonprogram.TenyearsIsoftencItedasanestImatedusefullIfeforan
anesthesIamachIne,butalthoughanASAstatementrepeatsthatIdea,Italsonotesthat
theASApromulgatedCuIdelInesfor0etermInIngAnesthesIa|achIneDbsolescenceIn
2004that
P.J6
doesnotsubscrIbetoanyspecIfIctImeInterval.AnesthesIamachInesconsIderablymore
than20yearsoldlIkelydonotmeetcertaInofthesafetystandardsnowInforcefornew
machInes(suchasvaporIzerlockout,freshgasratIoprotectIon,andautomatIcenablIngof
theoxygenanalyzer)and,unlessextensIvelyretrofItted,donotIncorporatethenew
technologythatadvancedveryrapIdlydurIngthe1980s,muchofItdIrectlyrelatedtothe
efforttopreventuntowardIncIdents.Further,ItappearsthatthIstechnologywIllcontInue
toadvance,partIcularlybecauseoftheadoptIonofanesthesIaworkstatIonstandardsby
theEuropeanEconomIcUnIonthatareaffectInganesthesIamachInedesIgnworldwIde.
NotethatsomeanesthesIaequIpmentmanufacturers,anxIoustomInImIzetheIrown
potentIallIabIlIty,haverefusedtosupport(wIthpartsandservIce)someoftheoldestof
theIrpIeces(partIcularlygasmachInes)stIllInuse.ThIsdIsownIngofequIpmentbyItsown
manufacturerIsaverystrongmessagetopractItIonersthatsuchequIpmentmustbe
replacedassoonaspossIble.
ShouldapIeceofequIpmentfaIl,ItmustberemovedfromservIceandareplacement
substItuted.Croups,departments,andfacIlItIesareoblIgatedtohavesuffIcIentbackup
equIpmenttocoveranyreasonableIncIdenceoffaIlure.TheequIpmentremovedfrom
servIcemustbeclearlymarkedwIthapromInentlabel(soItIsnotreturnedIntoservIceby
awellmeanIngtechnIcIanorpractItIoner)contaInIngthedate,tIme,persondIscoverIng,
andthedetaIlsoftheproblem.TheresponsIblepersonnelmustbenotIfIedsotheycan
removetheequIpment,makeanentryInthelog,andInItIatetherepaIr.AsIndIcatedIn
theprotocolforresponsetoanadverseevent,
1J
apIeceofequIpmentInvolvedor
suspectedInananesthesIaaccIdentmustbeImmedIatelysequesteredandnottouchedby
anybodypartIcularlynotbyanyequIpmentservIcepersonnel.fasevereaccIdent
occurred,ItmaybenecessaryfortheequIpmentInquestIontobeInspectedatalatertIme
byagroupconsIstIngofqualIfIedrepresentatIvesofthemanufacturer,theservIce
personnel,theplaIntIff'sattorney,theInsurancecompanIesInvolved,andthepractItIoner's
defenseattorney.TheequIpmentshouldthusbeImpoundedfollowInganadverseevent
andtreatedsImIlarlytoanyobjectInaforensIcchaInofevIdence,wIthcareful
documentatIonofpartIesIncontactwIthandresponsIbleforsecurIngtheequIpmentIn
questIonfollowIngsuchanevent.Also,majorequIpmentproblemsmay,Insome
cIrcumstances,reflectapatternoffaIlureduetoadesIgnormanufacturIngfault.These
problemsshouldbereportedtotheF0A's|edIcal0evIceProblemFeportIngsystem
20
vIa
|edWatchonFormJ500(foundatwww.fda.gov/medwatch/Index.html,ortelephone800
F0A1088).ThIssystemacceptsvoluntaryreportsfromusersandrequIresreportsfrom
manufacturerswhenthereIsknowledgeofamedIcaldevIcebeIngInvolvedInaserIous
IncIdent.WhetherornotfIlIngsuchareportwIllhaveaposItIveImpactInsubsequent
lItIgatIonIsImpossIbletoknow,butItIsaworthwhIlepractIcemanagementpoIntthat
needstobeconsIderedIntheunlIkelybutImportantInstanceofarelevanteventInvolvIng
equIpmentfaIlure.
Malpractice Insurance
AllpractItIonersneedlIabIlItyInsurancecoveragespecIfIcforthespecIaltyandroleIn
whIchtheyarepractIcIng.tIsabsolutelycrItIcalthatapplIcantsformedIcallIabIlIty
InsurancebecompletelyhonestInInformIngtheInsurerwhatdutIesandproceduresthey
perform.FaIluretodoso,eItherfromcarelessnessorfromafoolIshlymIsguIdeddesIreto
reducetheresultIngpremIum,maywellresultInretrospectIvedenIalofInsurance
coverageIntheeventofanuntowardoutcomefromanactIvItytheInsurerdIdnotknow
theInsuredengagedIn.
ProofofadequateInsurancecoverageIsusuallyrequIredtosecureorrenewprIvIlegesto
practIceatahealthcarefacIlIty.ThefacIlItymayspecIfycertaInmInImumpolIcylImItsIn
anattempttolImItItsownlIabIlItyexposure.tIsdIffIculttosuggestspecIfIcdollar
amountsforpolIcylImItsbecausethedetaIlsofpractIcevarysomuchamongsItuatIons
andlocatIons.ThemalpractIcecrIsIsofthe1980seasedsIgnIfIcantlyIntheearly1990sfor
anesthesIaprofessIonals,largelybecauseofthedecreaseInnumberandseverItyof
malpractIceclaImsresultIngfromanesthesIacatastrophesasanesthesIacareIntheUnIted
Statesbecamesafer.
21,22,2J
TheexactanalysIsofthIsphenomenoncanbedebated,
24,25
but
ItIsasImplefactthatmalpractIceInsurancerIskratIngshavebeendecreasedand
premIumsforanesthesIaprofessIonalshavenotbeenIncreasedatthesamerateasfor
otherspecIaltIesoverthepast15yearsand,Inmanycases,haveactuallydecreased.n
2008,coveragelImItsofS1mIllIon/SJmIllIonarestIllcommonandwouldseemthe
mInImumadvIsable.ThIspolIcyspecIfIcatIonusuallymeansthattheInsurerwIllcoverup
toS1mIllIonlIabIlItyperclaImanduptoSJmIllIontotalperyear,butthIstermInologyIs
notnecessarIlyunIversal.Therefore,anesthesIaprofessIonalsmustbeabsolutelycertaIn
whattheyarebuyIngwhentheyapplyformalpractIceInsurance.Eventhough
anesthesIologIstshavenotrecentlysufferedagreatnumberofverylargemalpractIce
paymentsorjuryverdIcts,
26
InspecIfIcpartsoftheUnItedStatesknownforapatternof
exorbItantsettlementsandjuryverdIcts,lIabIlItycoveragelImItsofS2mIllIon/S5mIllIon
orevengreatermaybeprudent.AnaddItIonalfeatureInthIsregardIsthepotentIalto
employumbrellalIabIlItycoverageabovethelImItsofthebasepolIcy,aswIllbenoted.
Background
ThefundamentalmechanIsmofmedIcalmalpractIceInsurancechangedsIgnIfIcantlyInthe
lastJdecadesbecauseoftheneedforInsurancecompanIestohavebetterwaystopredIct
theIrlosses(amountspaIdInsettlementsandjudgments).TradItIonally,medIcallIabIlIty
InsurancewassoldonanoccurrencebasIs,meanIngthatIftheInsurancepolIcywasIn
forceatthetImeoftheoccurrenceofanIncIdentresultIngInaclaIm,wheneverwIthIn
thestatuteoflImItatIonsthatclaImmIghtbefIled,thepractItIonerwouldbecovered.
DccurrenceInsurancewassomewhatmoreexpensIvethanthealternatIveclaImsmade
polIcIes,butwasseenasworthItbysome(many)practItIoners.ThesepolIcIescreated
someopenendedexposurefortheInsurerthatsometImesledtounexpectedlargelosses,
evensomelargeenoughtothreatentheexIstenceoftheInsurancecompany.Asaresult,
medIcalmalpractIceInsurershaveconvertedalmostexclusIvelytoclaImsmadeInsurance,
whIchcoversclaImsthatarefIledwhIletheInsuranceIsInforce.PremIumratesforthe
fIrstyearaphysIcIanIsInpractIcearerelatIvelylowbecausethereIslesslIkelIhoodofa
claImcomIngIn(amajorItyofmalpractIcesuItsarefIled1toJyearsaftertheeventIn
questIon).ThepremIumsusuallyIncreaseyearlyforthefIrst5yearsandthenthepolIcyIs
consIderedmature.TheIssuecomeswhenthephysIcIanlater,forwhateverreason,must
changeInsurancecompanIes(e.g.,becauseofrelocatIontoanotherstate).fthephysIcIan
sImplydIscontInuesthepolIcyandaclaImIsfIledthenextyear,therewIllbenoInsurance
coverage.Therefore,thephysIcIanmustsecuretaIlcoverage,sometImesforamInImum
numberofyears(e.g.,5)or,moreoften,IndefInItelytoguaranteelIabIlItyInsurance
protectIonforclaImsfIledafterthephysIcIanIsnolongerprImarIlycoveredbythat
InsurancepolIcy.tmaybepossIbleInsomecIrcumstancestopurchasetaIlcoveragefrom
adIfferentInsurerthanwasInvolvedwIththeprImarypolIcy,butbyfarthemostcommon
thIngdoneIstosImplyextendtheexIstIngInsurancecoveragefortheperIodofthetaIl.
ThIsveryoftenyIeldsabIllfortheentIretaIl
P.J7
coveragepremIum,whIchcanbequItesIzable,potentIallystaggerIngaphysIcIanwho
sImplywantstomovetoanotherstatewherehIsorherexIstIngInsurancecompanyIsnot
lIcensedtoorrefusestodobusIness.ndIvIdualsItuatIonswIllvarywIdely,butItIs
reasonableforanesthesIologIstsorganIzedIntoafIscalentItytoconsIderthIsIssueatthe
tImeoftheInceptIonofthegroupandrecordtheIrpolIcydecIsIonsInwrItIng,ratherthan
facIngthepotentIallydIffIcultquestIonofhowtotreatoneIndIvIduallater.Dther
strategIeshaveoccasIonallybeenemployedwhenInsurIngthetaIlperIod,IncludIng
convertIngtheprevIouspolIcytoparttImestatusforaperIodofyears,andpurchasIng
nosecoveragefromthenewInsurerthatIs,payInganInItIalhIgheryearlypremIum
wIththenewInsurer,whothenwIllcoverclaImsthatmayoccurdurIngthetaIlperIod.
WhateverstrategyIsadopted,ItIscrItIcalthattheIndIvIdualpractItIonerIsabsolutely
certaInthoughpersonalverIfIcatIonthatheorsheIsthoroughlycoveredatthetImeofany
transItIon.ThepotentIalstakesaremuchtoogreattoleavesuchImportantIssuessolelyto
anoffIceclerk.Further,apractItIonerarrIvIngInanewlocatIonIsoftenfIllInganeedor
voIdandIsurgedtobegInclInIcalworkassoonaspossIblebyotherswhohavebeen
shoulderInganIncreasedload.tIsessentIalthatthenewarrIvalverIfywIthconfIrmatIon
InwrItIng(oftencalledabInder)thatmalpractIcelIabIlItyInsurancecoverageIsInforce
beforethereIsanypatIentcontact.
AnothercomponenttothelIabIlItyInsurancesItuatIonIsconsIderatIonoftheadvIsabIlIty
ofpurchasIngyetanothertypeofInsurancecalledumbrella coverage,whIchIsactIvatedat
thetImeoftheneedtopayaclaImthatexceedsthelImItsofcoverageonthestandard
malpractIcelIabIlItyInsurancepolIcy.8ecausesuchanenormousclaImIsextremely
unlIkely,manypractItIonersaretemptedtoforgothecomparatIvelymodestcostofsuch
InsurancecoverageInthenameofeconomy.Asbefore,ItIseasytoseethatthIsIs
potentIallyaveryfalseeconomyIfthereIsahugeclaIm.PractItIonersshouldconsultwIth
theIrfInancIalmanagersandadvIsors,butItIslIkelythatItwouldbeconsIderedwIse
managementtopurchaseumbrellalIabIlItyInsurancecoverage.
|edIcalmalpractIceInsurersarebecomIngIncreasInglyactIveIntryIngtoprevent
IncIdentsthatwIllleadtoInsuranceclaIms.TheyoftensponsorrIskmanagementsemInars
toteachpractIcesandtechnIquestolessenthechancesoflIabIlItyclaImsand,Insome
cases,suggest(orevenmandate)specIfIcpractIces,suchasstrIctdocumentedcomplIance
wIththeASAStandardsfor8asIcAnesthetIc|onItorIng.nreturnforattendanceatsuch
eventsand/orthesIgnIngofcontractsstatIngthatthepractItIonerwIllfollowcertaIn
guIdelInesorstandards,theInsureroftengIvesadIscountonthelIabIlItyInsurance
premIum.Clearly,ItIssoundpractIcemanagementstrategyforpractItIonerstopartIcIpate
maxImallyInsuchprograms.LIkewIse,someInsurersmakecoveragecondItIonalonthe
consIstentImplementatIonofcertaInstrategIessuchasmInImalmonItorIng,even
stIpulatIngthatthepractItIonerwIllnotbecoveredIfItIsfoundthattheguIdelIneswere
beIngconscIouslyIgnoredatthetImeofanuntowardevent.AgaIn,ItIsobvIouslywIse
fromapractIcemanagementstandpoInttocooperatefullywIthsuchstIpulatIons.
Response to an Adverse Event
nspIteofthedecreasedIncIdenceofanesthesIacatastrophes,evenwIththeverybestof
practIce,ItIsstatIstIcallylIkelythateachanesthesIologIstatleastonceInhIsorher
professIonallIfewIllbeInvolvedInamajoranesthesIaaccIdent(seeChapter4).PrecIsely
becausesuchaneventIsrare,veryfewarepreparedforIt.tIsprobablethattheInvolved
personnelwIllhavenorelevantpastexperIenceregardIngwhattodo.AlthoughanobvIous
resourceIsanotheranesthetIstwhohashadsomeexposureorexperIence,oneofthese
maynotbeavaIlableeIther.7arIousauthorshavedIscussedwhattodoInthat
event.
27,28,29
Cooper,etal.
J0
havethoughtfullypresentedtheapproprIateImmedIate
responsetoanaccIdentInastraIghtforward,logIcal,compactformat(thathasbeen
updated
1J
)thatshouldperIodIcallyberevIewedbyallanesthesIologypractItIonersand
shouldbeIncludedInallanesthesIapolIcyandproceduremanuals.ThIsadverseevents
protocolIsalsoalwaysImmedIatelyavaIlableatwww.apsf.org(FesourceCenter,and
ClInIcalSafetyTools).Unfortunately,however,theprIncIpalpersonnelInvolvedIna
sIgnIfIcantuntowardeventmayreactwIthsuchsurprIseorshockastotemporarIlylose
sIghtoflogIc.AtthemomentofrecognItIonthatamajoranesthetIccomplIcatIonhas
occurredorIsoccurrIng,helpmustbecalled.AsuffIcIentnumberofpeopletodealwIth
thesItuatIonmustbeassembledonsIteasquIcklyaspossIble.Forexample,IntheunlIkely
butstIllpossIbleeventthatanesophagealIntubatIongoesunrecognIzedlongenoughto
causeacardIacarrest,theImmedIateneedIsforenoughskIlledpersonneltoconductthe
resuscItatIveefforts,IncludIngmakIngthecorrectdIagnosIsandreplacIngthetubeIntothe
trachea.WhethertheanesthesIologIstapparentlyresponsIbleforthecomplIcatIonshould
dIrecttheImmedIateremedIaleffortswIlldependonthepersonandthesItuatIon.nsuch
acIrcumstance,ItwouldseemwIseforasenIororsupervIsInganesthesIologIstquIcklyto
evaluatethescenarIoandmakeadecIsIon.ThIspersonbecomestheIncIdentsupervIsor
andhasresponsIbIlItyforhelpIngpreventcontInuatIonorrecurrenceoftheIncIdent,for
InvestIgatIngtheIncIdent,andforensurIngdocumentatIonwhIletheorIgInalandhelpIng
anesthesIologIstsfocusoncarIngforthepatIent.Asnoted,InvolvedequIpmentmustbe
sequesteredandnottoucheduntIlsuchtImeasItIscertaInthatItwasnotInvolvedInthe
IncIdent.
ftheaccIdentIsnotfatal,contInuIngcareofthepatIentIscrItIcal.|easuresmaybe
InstItutedtohelplImItdamagefrombraInhypoxIa.Consultantsmaybehelpfulandshould
becalledwIthouthesItatIon.fnotalreadyInvolved,thechIefofanesthesIologymustbe
notIfIedaswellasthefacIlItyadmInIstrator,rIskmanager,andtheanesthesIologIst's
Insurancecompany.TheselatterarecrItIcaltoallowconsIderatIonofImmedIateeffortsto
lImItlaterfInancIalloss.(LIkewIse,thereareoftenprovIsIonsInmedIcalmalpractIce
InsurancepolIcIesthatmIghtlImItorevendenyInsurancecoverageIfthecompanyIsnot
notIfIedofanyreportableeventImmedIately.)fthereIsanInvolvedsurgeonofrecord,he
orsheprobablywIllfIrstnotIfythefamIly,buttheanesthesIologIstandothers(rIsk
manager,InsurancelosscontroloffIcer,orevenlegalcounsel)mIghtapproprIatelybe
Includedattheoutset.FulldIsclosureoffactsastheyarebestknownwIthnoconfessIons,
opInIons,speculatIon,orplacIngofblameIscurrentlystIllbelIevedtobethebest
presentatIon.AnyattempttoconcealorshadethetruthwIlllateronlyconfoundan
alreadydIffIcultsItuatIon.DbvIously,comfortandsupportshouldbeoffered,IncludIng,If
approprIate,theservIcesoffacIlItypersonnelsuchasclergy,socIalworkers,and
counselors.ThereIsanewmovementInmedIcalrIskmanagementandInsurance
advocatIngImmedIatefulldIsclosuretothevIctImorsurvIvors,IncludIngconfessIonsof
medIcaljudgmentandperformanceerrorswIthattendantsIncereapologIes.fIndIcated,
earlyoffersofreasonablecompensatIonmaybeIncluded.TherehavebeenInstanceswhen
thIsoverallstrategyhaspreventedthefIlIngofamalpractIcelawsuItandhasbeen
applaudedbyallInvolvedasanexampleofashIftfromthecultureofblamewIth
punIshmenttoajustculturewIthrestItutIon.AwIdespreadmovementtoImplement
ImmedIatedIsclosureandapologyhasreceIvedsupport.
J1,J2
CertaInstateshaveenactedorproposedsocalled'msorry!legIslatIonIntendedto
preventanyexplanatIonorapologyfrombeIngusedasplaIntIff'sevIdenceInasubsequent
malpractIcesuIt.TheImportanceofthepatIent'sperspectIve
P.J8
onaserIousadverseanesthesIaeventwashIghlIghtedInarIvetIngaccountofthestorIes
ofbothsurvIvorsofanesthesIacatastrophesandthefamIlIesofpatIentswhodIed.
JJ
n
eachcase,onemaInmessagewastheenormousnegatIveImpactoftheperceIvedfaIlure
oftheInvolvedanesthesIaprofessIonalsandtheIrInstItutIonstosharedetaIledInformatIon
aboutwhatexactlyhappened.ArecentrevIewsummarIzeswhatpatIentswantandexpect
followInganadverseevent.
J4
LaudableasthIspolIcyofImmedIatefulldIsclosureand
apologymaysound,ItwouldbemandatoryforanIndIvIdualpractItIonertocheckwIththe
InvolvedlIabIlItyInsurancecarrIer,thepractIcegroup,andthefacIlItyadmInIstratIon
beforeattemptIngIt.
TheprImaryanesthesIaprovIderandanyothersInvolvedmustdocumentrelevant
InformatIon.Never,everchangeanyexIstIngentrIesInthemedIcalrecord.WrItean
amendmentnoteIfneeded,wIthcarefulexplanatIonofwhyamendmentIsnecessary,
partIcularlystressIngexplanatIonsofprofessIonaljudgmentsInvolved.Stateonlyfactsas
theyareknown.|akenojudgmentsaboutcausesorresponsIbIlItyanddonotpoInt
fIngers.ThesameguIdelInesholdtrueforthefIlIngoftheIncIdentreportInthefacIlIty,
whIchshouldbedoneassoonasIspractIcal.Further,alldIscussIonswIththepatIentor
famIlyshouldbecarefullydocumentedInthemedIcalrecord.FecognIzIngthatdetaIled
memorIesoftheeventsmayfadeInthe1toJyearsbeforethepractItIonermayface
deposItIonquestIonsaboutexactlywhathappened,ItIspossIblethatItwIllbe
recommended,ImmedIatelyaftertheIncIdent,thattheInvolvedclInIcalpersonnelsIt
downassoonaspractIcalandwrIteouttheIrownpersonalnotes,whIchwIllInclude
opInIonsandImpressIonsaswellasmaxImallydetaIledaccountsoftheeventsasthey
unfolded.ThesepersonalnotesarenotpartofthemedIcalrecordorthefacIlItyfIles.
ThesenotesshouldbewrIttenInthephysIcalpresenceofanInvolvedattorney
representIngthepractItIoner,evenIfthIsIsnotyetthespecIfIcdefenseattorneysecured
bythemalpractIceInsurancecompany,andthenthatattorneyshouldtakepossessIonof
andkeepthosenotesascasematerIal.ThIsstrategyIsIntendedtomakethepersonal
notesattorneyclIentworkproduct,andthusnotsubjecttoforceddIscovery
(revelatIon)byotherpartIestothecase.
FollowupaftertheImmedIatehandlIngoftheIncIdentwIllInvolvetheprImary
anesthesIologIstbutshouldagaInbedIrectedbyasenIorsupervIsor,whomayormaynot
bethesamepersonastheIncIdentsupervIsor.ThefollowupsupervIsorverIfIesthe
adequacyandcoordInatIonofongoIngcareofthepatIentandfacIlItatescommunIcatIon
amongallInvolved,especIallywIththerIskmanager.Lastly,ItIsnecessarytoverIfythat
adequateposteventdocumentatIonIstakIngplace.
Dfcourse,ItIsexpectedthatsuchanadverseeventwIllbedIscussedIntheapplIcable
morbIdItyandmortalItymeetIng.tIsnecessary,however,tocoordInatethIsactIvItywIth
theInvolvedrIskmanagerandattorneysoastobecompletelycertaInthatthecontents
andconclusIonsofthedIscussIonareclearlyconsIderedpeerrevIewactIvIty,andthusare
shIeldedfromdIscoverybytheplaIntIffs'attorney.
UnpleasantasthIsIstocontemplate,ItIsbettertohaveaclearplanandexecuteItInthe
eventofanaccIdentcausIngInjurytoapatIent.7IgorousImmedIateInterventIonmay
Improvetheoutcomeforallconcerned.
Practice Essentials
The Job Market for Anesthesia Professionals
WhIleItIstruethatInthemId1990s,forthefIrsttIme,uncertaIntyfacedresIdents
fInIshInganesthesIologytraInIngbecauseofaperceptIonthattherewerenotenoughjobs
forphysIcIananesthesIologIstsavaIlable,thatconceptfadedquIckly.AtensIonbetween
supplyanddemanddeveloped,wIthasIgnIfIcantongoIngcomponentoftheIdeathatthere
IsanoverallshortageofanesthesIaprofessIonals.tappearsthatlateInthefIrstdecadeof
the2000sthIsfundamentalparadIgmwIllpersIst.WIththefadIngoftheconceptthat
managedcarewouldsIgnIfIcantlyreducethedemandformedIcalservIcesandalsothe
agIngofthe8aby8oompopulatIon,ItIsclearthatthereIsasIgnIfIcantshortageofall
medIcalprofessIonalsIntheUnItedStates,andthIsespecIallyIncludesanesthesIa
professIonals.
Types of Practice
AtleastthroughthefIrstdecadeofthe21stcentury,resIdentsfInIshInganesthesIology
traInIngwIllstIllneedtochooseamongthreefundamentalpossIbIlItIes:academIcpractIce
InateachInghospItalenvIronment;apractIceexclusIvelyofpatIentcareIntheprIvate
practIcemarketplace;andapractIceexclusIvelyofpatIentcareasanemployeeofa
healthcaresystem,organIzatIon,orfacIlIty.
TeachInghospItalswIthanesthesIologyresIdencyprogramsconstItuteonlyaverysmall
fractIonofthetotalnumberoffacIlItIesrequIrInganesthesIaservIces.TheseacademIc
departmentstendtobeamongthelargestgroupsofanesthesIologIsts,buttheaggregate
fractIonoftheentIreanesthesIologIstpopulatIonIssmall.tIsInterestIng,however,that
bythenatureofthesystem,mostresIdentsfInIshIngtheIrtraInInghavealmostexclusIvely
beenexposedonlytoacademIcanesthesIology.AccordIngly,fInIshIngresIdentsInthepast
oftenwerecomparatIvelyunpreparedtoevaluateandentertheanesthesIologyjob
market.
SpecIaltycertIfIcatIonbytheA8AshouldbethegoalofallanesthesIaresIdencygraduates.
SomefInIshIngresIdentswhoknowtheyareeventuallyheadedforprIvatepractIcehave
startedtheIrattendIngcareersasfulltImejunIorfacultyInanacademIcdepartment.ThIs
allowsthemtoobtaInsomeclInIcalpractIceandsupervIsoryexperIenceandoffersthem
theopportunItytopreparefortheA8AexamInatIonsInthenurturIng,protectedacademIc
envIronmentwIthwhIchtheyarefamIlIar.|ostresIdents,however,donotbecomejunIor
faculty;theyacceptpractIceposItIonsImmedIately.8utsuchnewlytraInedresIdents
shouldtakeIntoaccounttheneedtobecomeA8AcertIfIedandbuIldIntotheIrnew
practIcearrangementsthestIpulatIonthattherewIllbetImeandconsIderatIongIven
towardthIsgoal.
Academic Practice
ForthosewhochoosetostayInacademIcpractIce,anumberofspecIfIccharacterIstIcsof
academIcanesthesIadepartmentscanbeusedasscreenIngquestIons.
How big is the department?JunIorfacultysometImescangetlostInverybIgdepartments
andbetreatedaslIttlebetterthanglorIfIedsenIorresIdents.Dntheotherhand,the
avaIlabIlItyofsubspecIaltyservIceopportunItIesandsIgnIfIcantresearchandeducatIonal
resourcescanmakelargedepartmentsextremelyattractIve.nsmalleracademIc
departments,theremaybefewerresources,butthelIkelIhoodofbeIngquIcklyacceptedas
avaluedandcontrIbutIngmemberoftheteachIngfaculty(andresearchteam,If
approprIate)maybehIgher.nverysmalldepartments,thenumberofexpectatIons,
projects,andInvolvementscouldpotentIallybeoverwhelmIng.AddItIonally,asmall
departmentmaylackadedIcatedresearchInfrastructure,soItmaybenecessaryforthe
facultyInthIssItuatIontocollaboratewIthother,largerdepartmentstoaccomplIsh
meanIngfulacademIcwork.
P.J9
What exactly is expected of junior faculty?fteachIngoneresIdentclasseveryotherweek
Isstandard,thecandIdatemustenthusIastIcallyacceptthatassIgnmentandtheattendant
preparatIonworkandtImeupfront.LIkewIse,IfItIsexpectedthatjunIorfacultywIll,by
defInItIon,beactIvelyInvolvedInpublIshableresearch,specIfIcplansforprojectstowhIch
thecandIdateIsamenablemustbemade.nsuchsItuatIons,clearstIpulatIonsabout
startupresearchfundIngandnonclInIcaltImetocarryouttheprojectsshouldbeobtaIned
asmuchaspossIble(althoughclInIcalworkloaddemandsandrevenuegeneratIon
expectatIonsmaymakethIsverydIffIcultInsomesettIngs).PartIcularlyImportantIs
determInIngwhattheexpectatIonIsconcernIngoutsIdefundIng.Forexample,Itcanbea
rudeshocktorealIzethatprojectswIllsuddenlyhaltafter2yearsIfextramuralfundIng
hasnotbeensecured.
What are the prospects for advancement?|anynewjunIorfacultydIrectlyoutofresIdency
startwIthmedIcalschoolappoIntmentsasInstructorsunlessthereIssomethIngelseIn
theIrbackgroundthatImmedIatelyqualIfIesthemasassIstantprofessors.tIswIseto
understandfromthebegInnIngwhatIttakesInthatdepartmentandmedIcalschoolto
facIlItateacademIcadvancement.TheremaybemorethanoneacademIctrack;the
tenuretrack,forexample,usuallydependsonpublIshedresearchwhereastheclInIcalor
teachertrackrelIesmoreheavIlyonone'svalueInpatIentcareandasaclInIcaleducator.
ThecrIterIaforpromotIonmaybeclearlyspelledoutbytheInstItutIonnumberofpapers
needed,InvolvementandrecognItIonatvarIouslevels,grantssubmIttedandfunded,and
soonorthesystemmaybelessrIgIdanddependmoreheavIlyonthedepartment
chaIrman'sandotherfacultyevaluatIonsandrecommendatIons.neIthercase,careful
InquIrybeforeacceptIngtheposItIoncanavertlatersurprIseanddIsappoIntment.
How much does it pay?TradItIonally,academIcanesthesIologIstshavenotearnedquIteas
muchasthoseInprIvatepractIceInreturnfortheadvantageofmorepredIctable
schedules,contInuedIntellectualstImulatIon,andtheIntangIblerewardsofacademIc
success.ThereIsnowgreatactIvItyandattentIonconcernIngreImbursementof
anesthesIologIsts,andItIsdIffIculttopredIctfutureIncomeforanyanesthesIology
practIcesItuatIon.However,alloftheforcesInfluencIngpaymentforanesthesIacaremay
sIgnIfIcantlydImInIshthetradItIonalIncomedIfferentIalbetweenacademIcandprIvate
practIce.nsomecases,afacultymemberIsexclusIvelyanemployeeoftheInstItutIon,
whIchbIllsandcollectsornegotIatesgroupcontractsforthepatIentcarerenderedbythe
facultymember,andthenpaysanegotIatedamount(eItheranabsolutedollarfIgureora
floatIngamountbasedonvolumeand/orcollectIonsoracombInatIonofthetwo)that
constItutesthefacultyperson'sentIreIncome.Underothermuchlesscommon
arrangements,facultymembersthemselvesmaybeabletobIllandcollectornegotIate
contractsfortheIrclInIcalwork.SomeInstItutIonshavea(comparatIvelysmall)academIc
salaryfromthemedIcalschoolforbeIngonthefaculty,butmanydonot;somechannel
varIableamountsofmoney(fromsocalledPartAclInIcalrevenue)IntotheacademIc
practIceInrecognItIonofteachIngandadmInIstratIonorsImplyasasubsIdyforneeded
servIce.AsalaryfromthemedIcalschool,Ifextant,IsthensupplementedsIgnIfIcantlyby
thepractIceIncome.Usually,thefacultywIllbemembersofsometypeofgroupor
practIceplan(eItherfortheanesthesIadepartmentaloneortheentIrefacultyasawhole)
thatbIllsandcollectsornegotIatescontractsandthendIstrIbutesthepractIceIncometo
thefacultyunderanarrangementthatmustbeexamInedbythecandIdate.nmost
academIcInstItutIons,practIceexpensessuchasalloverheadandmalpractIceInsuranceas
wellasreasonablebenefIts,IncludIngdIscretIonaryfundsformeetIngs,subscrIptIons,
books,dues,andsoforth,areautomatIcallypartofthecompensatIonpackage,whIch
oftenmaynotbetrueInprIvatepractIceandmustbecountedInmakInganycomparIson.
AnImportantcorollaryIssueIsthatofthesourceofthesalarIesofthedepartment's
prImaryanesthesIaprovIdersresIdentsand,Insomecases,nurseanesthetIsts.Although
thehospItalusuallypaysforatleastsomeofthese,arrangementsvary,andItIsImportant
toascertaInwhetherthefacultypractIceIncomeIsalsoexpectedtocoverthecostofthe
prImaryprovIders.Dverall,ItIsreasonabletosoundoutfaculty,bothanesthesIologyand
others,regardIngthepastandlIkelyfuturecommItmentoftheInstItutIontothe
establIshmentandmaIntenanceofreasonablecompensatIonfortheexpectedInvolvement.
Private Practice in the Marketplace
DbvIously,rotatIonstoaprIvatepractIcehospItalInthefInalyearofanesthesIaresIdency
couldhelpgreatlyInthIsregard,butnotallresIdencyprogramsoffersuchopportunItIes.n
thatcase,thefInIshIngresIdentwhoIscertaInaboutgoIngIntoprIvatepractIcemustseek
InformatIononcareerdevelopmentandmentorsfromtheprIvatesector.
ArmedwIthasmuchInformatIonaspossIble,onefundamentalInItIalchoIceIsbetween
IndependentIndIvIdualpractIceandaposItIonwIthagroup(eItherasoleproprIetorshIp,
partnershIp,orcorporatIon)thatfunctIonsasasInglefInancIalentIty.ndependent
practIcemaybecomeIncreasInglylessvIableInmanylocatIonsbecauseoftheneedtobe
abletobIdforcontractswIthmanagedcareentItIes.However,whereIndependent
practIceIspossIble,ItusuallyfIrstInvolvesattemptIngtosecureclInIcalprIvIlegesata
numberofhospItalsorfacIlItIesIntheareaInwhIchonechoosestolIve.ThIsmaynot
alwaysbeeasy,andthIsIssuehasbeenthesubjectofmany(frequentlyunsuccessful)
antItrustsuItsoverrecentyears(seeAntItrustConsIderatIons).ThentheanesthesIologIst
makesItknowntotherespectIvesurgeoncommunItIesthatheorsheIsavaIlabletorender
anesthesIaservIcesandwaItsuntIlthereIsarequestforhIsorherservIces.The
anesthesIologIstobtaInstherequIsItefInancIalInformatIonfromthepatIentandthen
eItherIndIvIduallybIllsandcollectsforservIcesrenderedoremploysaservIcetodobIllIng
andcollectIonforapercentagefee(whIchwIllvarydependIngonthecIrcumstances,
especIallythevolumeofbusIness;forbIllIng[wIthoutschedulIngservIces]Itwouldbe
unlIkelytobe7or,atthemost,8ofactualcollectIons).
HowmuchoftheneededequIpmentandsupplIeswIllbeprovIdedbythehospItalorfacIlIty
andhowmuchbytheIndependentanesthesIologIstvarIeswIdely.fananesthesIologIst
spendsconsIderabletImeInoneoperatIngsuIte,heorshemaypurchaseananesthesIa
machIneexclusIvelyforhIsorherownuseandmoveItfromroomtoroomasneeded.tIs
lIkelytobeImpractIcaltomoveafullyequIppedanesthesIamachInefromhospItalto
hospItalonadaytodaybasIs.AmongthefeaturesofthIsstyleofpractIcearethe
collegIalItyandrelatIonshIpsofagenuIneprIvatepractIcebasedonreferralsandalsothe
abIlItytodecIdeIndependentlyhowmuchtImeonewantstobeavaIlabletowork.The
downsIdeIsthepotentIalunpredIctabIlItyofthedemandforservIceandthetImeneeded
toestablIshreferralpatternsandobtaInbookIngssuffIcIenttogeneratealIvableIncome.
WhenseekIngaposItIonwIthaprIvategroup,theapplIcantshouldsearchforpotentIal
practIceopportunItIesthroughwordofmouth,recruItIngletterssenttothetraInIng
programsupervIsor,journaladvertIsements,andplacementservIces(eIthercommercIalor
professIonal,suchasthatprovIdedattheASAannualmeetIng).SomeofthescreenIng
questIonsarethesameasforanacademIcposItIon,buttheremustbeevenmoreemphasIs
ontheexactdetaIlsofclInIcalexpectatIonsandfInancIalarrangements.SomeresIdents
fInIshresIdency(orfellowshIptraInIngtoanevengreaterextent)veryhIghlyskIlledIn
complex,dIffIcultanesthesIaprocedures.They
P.40
canbesurprIsedtofIndthatInsomeprIvatepractIcegroupsItuatIons,thejunIormost
anesthesIologIstmustwaItsometIme,perhapsevenyears,beforebeIngelIgIbletodo,for
example,openheartanesthesIa,andInthemeantImewIllmostlybeassIgnedmoreroutIne
orlesschallengInganesthetIcs.
FInancIalarrangementsInprIvategrouppractIcesvarywIdely.Somegroupsareloose
organIzatIonalallIancesofIndependentpractItIonerswhobIllandcollectseparatelyand
rotateclInIcalassIgnmentsandcallformutualconvenIence.|anygroupsactalsoasa
fIscalentIty,andtherearemanypossIblevarIatIonsonthIstheme.nmanycIrcumstances
Inthepast,newjunIormembersstartedoutasfunctIonalemployeesofthegroupfora
probatIonaryIntervalbeforebeIngconsIderedforfullmembershIporpartnershIp.ThIsIs
notaclassIcemploymentsItuatIonbecauseItIsIntendedtobetemporaryasapreludeto
fullfInancIalpartIcIpatIonInthegroup.However,therehavebeenenoughInstancesof
establIshedgroupsabusIngthIsarrangementthattheASAIncludesInItsfundamental
StatementofPolIcytheprovIso:ExploItatIonofanesthesIologIstsbyother
anesthesIologIstsIsImproper.
1
ThIsgoesontosaythatafterareasonabletrIalperIod,
IncomeshouldreflectservIcesrendered.Unfortunately,thesestatementsmayhavelIttle
meanIngorImpactongroupsInthemarketplace.SomegroupshaveahIstoryofdemandIng
excessIvelylongtrIalperIodsdurIngwhIchthejunIoranesthesIologIst'sIncomeIsartIfIcIally
lowandthendenyIngpartnershIpandtermInatIngtherelatIonshIptogoontoemploya
newprobatIonerandstartthecycleoveragaIn.AccordIngly,newjunIorstaffattemptIngto
joIngroupsshouldtrytohavesuchanarrangementspelledoutcarefullyIntheagreement
draftedbyanexpertrepresentIngtheanesthesIologIst.AnothervarIatIonofthIs,Inan
attempttodIsguIsethefundamentallyunethIcalnatureofthepractIce,Istoemploy
anesthesIologIstsonafIxedsalarywIththefalseIncentIveofnonIghtorweekendcall.ThIs
IsdIsIngenuous,asmostIncomeIsusuallygenerateddurIngroutInescheduleddaywork,for
whIchtheanesthesIologIstemployeeIspoorlycompensated.YetanotherusurIousscheme
IsforagrouptoemployananesthesIologIstforaperIodofyearsatalowsalaryandthen
requIreafurthercashoutlaytopurchasepartnershIpInthecorporatIon.Asthecashoutlay
canbequItesubstantIal,ItIsfrequentlyborrowedfromthecorporatIon,leadIngtoa
sophIstIcatedformofIndenturedservItude.Sadly,whenthejobmarketcondItIonsarepoor
astheyweresomeyearsago,thetendencyIsfortheretobelesslIkelIhoodofsecurInga
prospectIvecommItmentofpartnershIpataspecIfIedfuturetIme.
Private Practice as an Employee
TherehasbeensometrendtowardanesthesIologIstsbecomIngpermanentemployeesof
anyoneofvarIousfIscalentItIes.ThekeydIfferenceIsthatthereIsnoIntentIonorhopeof
achIevInganequItyposItIon(shareofownershIp,usuallyofapartnershIp,thusbecomInga
fullpartner).HospItals,outpatIentsurgerycenters,multIdIscIplInaryclInIcs,otherfacIlItIes
tIedtoaspecIfIclocatIonwheresurgeryIsperformed,physIcIangroupsthathaveumbrella
fIscalentItIesspecIfIcallycreatedtoserveastheemployerofphysIcIans,andeven
surgeonsmayseektohIreanesthesIologIstsaspermanentemployees.Thecommonthread
InthIssystemIsthatthesefIscalentItIesseetheanesthesIologIstsasaddItIonalwaysof
generatIngprofIts.AgaIn,InmanycasesItwouldappearthatemployeesarenotpaIda
salarythatIscommensuratewIththeIrproductIonofreceIvables.ThatIs,thefIscalentIty
wIllpayasalarysubstantIallybelowcollectIonsgeneratedplusapproprIateoverhead.
ThesearrangementsarepartIcularlyfavoredbysomelarge|CDsIncertaIncItIesthatvIew
anesthesIologIstssImplyasexpensIvenecessItIesthatpreventhospItalsfromrealIzIng
maxImumprofIt(althoughsometImesthereIsapromIseofalIghterormoremanageable
scheduleIntheseposItIonscomparedwIthmarketplaceprIvatepractIce).
NegotIatIngforaposItIonasapermanentfulltImeemployeeIssomewhatsImplerand
morestraIghtforwardthanItIsInmarketplaceprIvatepractIce.tparallelstheusual
understandIngsthatapplytomostregularemployeremployeesItuatIons:jobdescrIptIon,
roleexpectatIons,workIngcondItIons,hours,pay,andbenefIts.TheIdeaof
anesthesIologIstsfunctIonallybecomIngshIftworkersdIsturbsmanyIntheprofessIon
becauseItcontradIctsthetradItIonalprofessIonalmodel.AgaIn,thecomplexnatureand
multIplelevelsofsuchconsIderatIonsmakeItapersonalIssuethatmustbecarefully
evaluatedbyeachIndIvIdualwIthfullawarenessandconsIderatIonoftheIssuesoutlIned
hereandcommensurateresearchofASAresourcesandavaIlabledataaboutcommon
regIonalcIrcumstancesanddetaIlsofanyspecIfIcmedIcalcommunIty.
Practice for a Management Company
DnepromInentnewerdevelopmentIsthegrowthandImpactoflargestate,regIonal,or
evennatIonalmanagementcompanIesthatadvertIsetheprovIsIonofcomprehensIve
anesthesIaservIcesonacontractbasIswIthhospItals,surgerycenters,andclInIcs.These
companIes,somestartedand/ormanagedbyanesthesIaprofessIonals,promIsethefacIlIty
avaIlabIlItyofanesthesIacaredurIngthespecIfIedhoursInreturnforalucratIvecontract
todoso.ThIsrelIevesthefacIlItyfromanyconcernaboutrecruItIng,hIrIng/contractIng,
andretaInInganesthesIaprofessIonals,vIrtuallyelImInatIngconcernaboutdIsruptIonofDF
schedulesduetolImItedavaIlabIlItyofanesthesIacare.TheonlyrequIrementofthe
facIlItyIsapprovalofthealreadypreparedcredentIalIngInformatIonforeachanesthesIa
professIonal.UnlIkemanylocumtenenscompanIesInwhIchanesthesIaprofessIonalsare
consIderedIndependentcontractorsandpaIdfIxedcontractamountsperhour,perday,or
perjobforalImItedIntervalwIthnobenefIts,someofthemanagementcompanIesmay
employanesthesIaprofessIonalsfulltImeonasalarywIthbenefIts(paIdvacatIon,health
Insurance,retIrementcontrIbutIon,andsoforth).Theemploymentagreementwould
stIpulatewhethertravelforassIgnmentsInlocatIonsawayfromtheemployee'spermanent
homewouldberequIredasacondItIonofthefulltImejobortheposItIonwIllalwaysbeIn
thepractItIoner'shomecommunIty.
Practice as a Hospital Employee
WhIlecertIfIedregIsterednurseanesthetIstsInsomelocatIonshavetradItIonallypractIced
ashospItalemployees,untIlrecently,ItwaslesscommonoutsIdefullvertIcallyIntegrated
|CDsforphysIcIananesthesIologIststobehospItal(orfacIlIty)employees.nrecentyears,
oneoftheresponsesofhospItalstorequestsforsubsIdIesfromexclusIvecontractpractIce
groupsofanesthesIologIstshasbeentooffertheanesthesIologIstsfulltImeemployment
statusratherthansubsIdIzeanIndependentpractIcegroupthathasItsownsIgnIfIcant
admInIstratIveandoverheadcosts.
J5
ThehospItallIkelysuggeststhatIntegratIngthe
bIllIng,collectIng,andmanagementfunctIonsaswellasmajoroverheadcostssuchas
malpractIceInsuranceIntotheexIstInglargerhospItaloperatIonwouldbeverycost
effIcIent,allowIngmorefInancIalresourcestogotophysIcIansalarIes,andalsowIth
possIblyasomewhatgreaterpredIctabIlItyInuncertaIntImes.ThehospItalcanalso
guaranteetheavaIlabIlItyofanesthesIacare(arequIrementtosustaIntheDF,oneofthe
maInhospItalrevenuesources)InanerawhensomeanesthesIologIstgroupsmaysImply
walkawayfromahospItalInsearchofgreaterIncomeelsewhere,leavIngthehospItalto
seekacontractprobablywIthoneofthelargeandveryexpensIveanesthesIamanagement
companIes(prevIouslydescrIbed).Dfcourse,Inreturnforemployeestatus,the
anesthesIologIstssurrendersomedegreeofIndependenceandalso,forthegroup'spartners,
theIrequItystakeInsharIngInanysubsequentIncreased
P.41
practIcerevenue.AhospItalmIghtcounterthatconcernwIththecontentIonthat
tradItIonalfeeforservIcepractIcethathasbeensocommonforsolongforprIvate
practIceanesthesIologIstswIllnever againyIeldenoughrevenuetomaIntaIntheIncome
levelsanesthesIologIstshavecometoexpect,sotheywIllnotbelosInganythIng.
Billing and Collecting
npractIcesInwhIchanesthesIologIstsaredIrectlyInvolvedwIththefInancIal
management,theyneedtounderstandasmuchaspossIbleaboutthecomplexworldof
healthcarereImbursement.ThIssIgnIfIcanttaskhasbeenmadeeasIerbytheASA,whIch
sometImeagoaddedasIgnIfIcantcomponenttoItsWashIngton,0.C.,offIce(see
www.asahq.org/government.htm)byaddIngapractIcemanagementcoordInatortothe
staff.DneoftheassocIatedassIgnmentsIshelpIngASAmembersunderstandandworkwIth
thesometImesconfusIngandconvolutedIssuesofeffectIvebIllIngforanesthesIologIsts'
servIces.ThereareoftenupdateswIththelatestInformatIonandcodesInthemonthlyASA
Newsletter.
TherecontInuetobeproposalsforsIgnIfIcantchangesInbIllIngforanesthesIologycare.
However,thebasIcshavechangedonlyslIghtlyInrecentyears.tIsImportantto
understandthatmanyofthemostcontentIousIssues,suchastherequIrementforphysIcIan
supervIsIonofnurseanesthetIstsandtheImplIcatIonsofthatforreImbursement,applyIn
manycIrcumstancesmostlyto|edIcareand,Insomestates,|edIcaId.Thus,thefractIon
ofthepatIentpopulatIoncoveredbythesegovernmentpayersIsImportantInany
consIderatIon.0IfferentpractIcesItuatIonshavedIfferentarrangementsregardIngthe
fInancIalrelatIonshIpsbetweenanesthesIologIstsandnurseanesthetIsts,andthIscanaffect
thecomplexsItuatIonofwhobIllsforwhat.ThenursesmaybeemployeesofahospItal,of
theanesthesIologIstswhomedIcallydIrectthem,orofnooneInthattheyareIndependent
contractorsbIllIngseparately(evenIncasesInwhIchphysIcIansupervIsIonnotmedIcal
dIrectIonIsrequIredbutwherethosephysIcIansdonotbIllforthatcomponent).n1998,
|edIcaremandatedthatananesthesIacareteamofanurseanesthetIstmedIcallydIrected
byananesthesIologIstcouldbIllasateamnomorethan100ofthefeethatwouldapplyIf
theanesthesIologIstdIdthecasealone.TheImplIcatIonsofthIschangearecomplexand
varIableamonganesthesIologypractIces,partIcularlybecausethereIsanothertrendfor
healthcarefacIlItIesthattradItIonallyhademployednurseanesthetIststoseektoshIft
totalfInancIalresponsIbIlItyforthemtotheanesthesIologIstpractIcegroup.Also,complex
relatedIssuesplayedoutIntheearly2000years.ThefederalgovernmentIssuedanew
regulatIonallowIngIndIvIdualstatestooptoutoftherequIrementthatnurse
anesthetIstsbesupervIsedbyphysIcIansandseveralstatesdIdso.ThIswasopposedbythe
ASA.8ecauseperIoperatIvepatIentcare,onecomponentofwhIchIsadmInIsterIng
anesthesIa,IstradItIonallyconsIderedthepractIceofmedIcIne,theImplIcatIonsofthIs
changeasfarastheroleofsurgeonssupervIsIngnurseanesthetIstsandthemalpractIce
lIabIlItystatusofnurseanesthetIstspractIcIngIndependentlywereunclear.Further,the
ImplIcatIonsofallthIsforbIllIngInsurersotherthan|edIcareand|edIcaIdare
exceedInglycomplex.
Classic Methodology
8ecausethereIsstIllwIdespreadapplIcatIonofthetradItIonalmethodofbIllIngfor
anesthesIologyservIces,understandIngItIsveryImportantforanesthesIologIstsstartIng
practIce.nthIssystem,eachanesthetIcgeneratesavalueofsomanyunIts,whIch
representeffortandtIme.AconversIonfactor(dollarsperunIt)thatcanvarywIdely
multIplIedbythenumberofunItsgeneratesanamounttobebIlled.EachanesthetIchasa
basevaluenumberofunIts(e.g.,8foracholecystectomy)andthenthetImetakenforthe
anesthetIcIsdIvIdedIntounIts,usually15mInutesperunIt.Thus,acholecystectomywIth
anesthesIatImeof1hourand50mInuteswouldhave8baseunItsand7.JJtImeunItsfora
totalof15.JJunIts.nsomepractIcesettIngs,ItmaybeallowedtoaddmodIfIers,suchas
extraunItsforcomplexpatIentswIthmultIpleproblemsasreflectedbyanASAphysIcal
statusclassIfIcatIonofJ5and/orE(emergency)orforInsertIonofanarterIalorPA
catheter.ThesumIsthetotalbIllIngunItvalue.0etermInIngthebasevalueforan
anesthetIcInunItsdependsonfullandcorrectunderstandIngofwhatoperatIonwasdone.
AlthoughthIssoundseasy,ItIsthemostdIffIcultcomponentoftradItIonalanesthesIa
bIllIng.TheprocessofdetermInIngtheproceduredoneIsknownascodingbecausethe
procedurenamelIstedontheanesthesIarecordIsassIgnedanIdentIfyIngcodenumber
fromtheunIversallyusedcurrentproceduraltermInology(CPT)4codIngbook.ThIscodeIs
thentranslatedthroughtheASAFelatIve7alueCuIde,whIchassIgnsabaseunItvalueto
thetypeofprocedureIdentIfIedbytheCPT4code.nthepast,someanesthesIologIsts
faIledtounderstandtheImportanceofcorrectcodIngtothesuccessofthebIllIngprocess.
PlacIngthIstaskInthehandsofsomeoneunfamIlIarwIththesystemandwIthsurgIcal
termInologycaneasIlyleadtoIncorrectcodIng.ThIscanfaIltocapturechargesandthe
resultIngIncometowhIchtheanesthesIologIstIsentItledor,worse,cansystematIcally
overchargethepayers,whIchwIllbrIngsanctIons,penaltIesand,IncertaIncases,crImInal
prosecutIon.
nrecentyearsaprevaIlIngoffIcIalattItudehasbeenthattherearenosImple,Innocent
codIngerrors.AllupcodIng(chargIngformoreexpensIveservIcesthanwereactually
delIvered)IsconsIderedtobeprImafacIeevIdenceoffraudandIssubjecttosevere
dIscIplInaryandlegalactIon.AllpractIcesshouldhavedetaIledcomplIanceprogramsIn
placetoensurecorrectcodIngforservIcesrendered.
J6
DutsIdeexperthelp(suchasfroma
healthcarelawfIrmthatspecIalIzesIncomplIanceprograms)IshIghlydesIrableforthe
processofformulatIngandImplementIngacomplIanceplanregardIngcorrectcodIng.
AssemblyandtransferoftheInformatIonnecessarytogeneratebIllsmustbeeffIcIentand
complete.TradItIonally,thIsInvolveddeposItIngInasecurecentrallocatIonapaperextra
copyoftheanesthesIarecordandoftenabIllIngsheetwIthIt,onwhIchwasInscrIbed
thenamesofalltheInvolvedpersonnelandanyaddItIonalInformatIonaboutother
potentIallybIllableservIces,suchasInvasIvemonItors.AnypractIceInvolvedwItha
comprehensIveelectronIcperIoperatIveInformatIonmanagementsystemInthefacIlIty
shouldbeusIngthattoassemblethIsfrontendbIllIngInformatIon.Shortofthat,some
practIcescollectelectronIcInformatIonspecIfIcallygeneratedbytheanesthesIaprovIders
forthatpurpose.TheyhaveequIppedeachstaffmemberwIthahandheldorganIzerInto
whIchdataareenteredandthenthedevIceIssynchedwIthadepartmentalcomputerat
theendoftheday.ftheDFsuItehasWIFI(wIrelesselectronIcconnectIon),thesame
functIoncouldbeaccomplIshedInrealtImewIththeprovIdersenterIngtherequIsIte
InformatIonIntoamInIprogramonalaptopcomputeraffIxedtoeachanesthesIamachIne
(oronecarrIedbyeachstaffmember).DncetheInformatIonhasbeensecured,a
mechanIsmmustbeemployedtogeneratetheactualbIllandcommunIcateIttothepayer
(onpaper,ondIsk,or,usually,dIrectlycomputertocomputer:electronIcclaIms
submIssIon).ThepossIbleexactarrangementsfordoIngthIsvarywIdely.
WhetherananesthesIapractIcethatwIllbebIllIngandcollectIngforanesthesIaservIces
shouldemployItsownInhouseclerIcalandbookkeepIngpersonneltoperformthIsfunctIon
orshouldcontractwIthanoutsIdecompanywhosesolefunctIonIsmedIcalbIllIngand
collectIng(possIbly,Ideally,for
P.42
anesthesIologyonly)canbedebatedendlessly.WhIcheverIschosen,knowledgeable
oversIghtbytheanesthesIaprofessIonalswhoultImatelywIllderIveIncomefromthe
revenuecollectedIsrequIred.UltImately,theentItyactuallysubmIttIngthebIllwIllverIfy
thatIthasbeenpaId(postIngofreceIpts)andmayormaynotactuallyhandletheIncomIng
money.7eryoften,anesthesIapractIcesorIndIvIdualswhouseabIllIngservIce(andeven
somewhohaveInhousebIllIngstaffs)wIllarrangethattheactualpaymentsgodIrectlyto
abanklockbox,whIchIsapostoffIcebox(betterIndIvIdualthanshared,evenIfmore
expensIve)towhIchthepaymentscomeandthengodIrectlyIntoabankaccount.ThIs
systemavoIdsthesItuatIonofhavIngthepeoplewhogeneratethebIllactuallyhandlethe
IncomIngreceIpts,apractIcethathasledtotheftandfraudInafewcases.Eventual
decIsIonsabouthowhardtotrytocollectfrompayerswhodenycoverageandthenfrom
patIentsdIrectlywIlldependonthecIrcumstances,IncludInglocalcustoms.
Table 2-1 Types of Data an Anesthesiology Group Should Track and
Maintain Concerning Its Own Practice
Types of Data the Anesthesiology Group's Computer System Should Track
TransactIonbasedsystem(trackeachcaseandchargeasseparaterecord)
TrackIndIvIdualchargesbyCPT4code
TrackIndIvIdualpaymentsbypayer
TrackalldataelementsonanInterrelatedbasIs
8yplaceofservIce
8ycharge,brokendown
bynumberofunIts(tImeandbase)
byASAmodIfIers
bynumberoflInes
8yCPT4code
8ypayer
8ypaymentcode(fullpayment,dIscount,wrIteoff,orrefund)
8ydIagnosIs(C09code)
8ysurgeon
8yanesthesIologIst
8yanesthesIacareteamprovIder
8ystartandstoptImes
8yage
8ygender
8yemployer
8yZPcode
Type of Information to Generate From These Data
Aggregatenumberofcasesperyearforthegroup
TotalnumberofcasesperyearforeachprovIderwIthInthegroup
NumberofcasesperformedbyanesthesIologIsts
NumberofcasesperformedbytheanesthesIacareteam
AveragenumberofunItspercase(asonemeasureofIntensItypercase)
AveragenumberofunItsperCPT4code
AveragetImeunItspercaseandperCPT4code
CroupshouldbeabletocalculatetImeunItsperIndIvIdualsurgeon
AveragelInechargepercase
ChargespercasebyCPT4code
Paymentspercasebypayer
PatIentmIx
PercenttradItIonalIndemnIty
Percentmanagedcare(brokendownbyeach|CDforwhIchservIcesare
provIded)
Percentselfpay
Percent|edIcare
Percent|edIcaId
CollectIonrateforeachpopulatIonserved
DverallcollectIonrate
CostsperunIt(totalcosts,excludIngcompensatIon+totalunIts)(costsInclude
lIabIlItyInsurance,rent,collectIoncosts,andlegalandaccountIngfees)
CompensatIoncostsperunIt(totalcompensatIon+totalunIts)for|CD
populatIons,utIlIzatIonpatternsbyage,gender,anddIagnosIs
CPT,currentproceduraltermInology;ASA,AmerIcanSocIetyofAnesthesIologIsts;
C09,nternatIonalClassIfIcatIonof0Iseases,nInthrevIsIon;|CD,managedcare
organIzatIon.
FeprIntedfrom|anagedCareFeImbursement|echanIsms:ACuIdefor
AnesthesIologIsts.ParkFIdge,L,AmerIcanSocIetyofAnesthesIologIsts,1994,wIth
permIssIon.
0etaIledsummarystatIstIcsoftheworkdonebyananesthesIologypractIcegroupare
crItIcalforlogIstIcmanagementofpersonnel,schedulIng,andfInancIalanalysIs.
SpreadsheetanddatabasecomputerprogramscustomIzedforanIndIvIdualpractIce's
characterIstIcswIllbeInvaluable.AsummaryofthetypesofdataananesthesIapractIce
shouldtrackIsshownIn
P.4J
Table21.DnceallthedataareassembledandrevIewed,atleastmonthlyanalysIsbya
busInessmanagerorequIvalentaswellasoffIcers/leadersofthepractIcegroupcanspot
trendsveryearlyIntheIrdevelopmentandallowapproprIatecorrectIonorplannIng.Dften
theresponsIblemembersofananesthesIologygroupquestIonhoweffectIvetheIrfInancIal
servIcesoperatIonIs,partIcularlyregardIngnetcollectIons.ThIsIsacomplexIssue
J7
that,
agaIn,oftenrequIresoutsIdehelp.FoutIneInternalaudItscanbeusefulbutcouldbeself
servIng.NobIllIngoffIceorcompanythatIshonestandcompletelyaboveboardshould
everobjecttoaclIent,InthIscasetheanesthesIologypractIcegroup,engagIngan
IndependentoutsIdeaudItortocomeInandthoroughlyexamIneboththeeffIcIencyofthe
operatIonandalsothebooksconcernIngcorrectnessandcompletenessofcollectIons.
AnesthesIabIllIngandcollectIngareamongthemostcomplexchallengesInthemedIcal
reImbursementfIeld.TradItIonalanesthesIareImbursementIsunIqueInallofmedIcIne.
TheexperIenceofmanypeopleovertheyearshassuggestedthatItoftenIswelladvIsedto
dealwIthanentItythatIsnotonlyveryexperIencedInanesthesIabIllIng,butalsodoes
anesthesIabIllIngexclusIvelyorasalargefractIonofItsefforts.tIsverydIffIcultforan
anesthesIologIstorafamIlymembertodobIllIngandcollectIngasasIdeactIvItytoa
normallIfe.ThIshasledtoIneffIcIentandInadequateeffortsInmanycases,IllustratIng
thevalueofpayIngareasonablefeetoaprofessIonalwhowIlldevotegreattImeand
energytothIschallengIngendeavor.
Antitrust Considerations
TherecanbeantItrustImplIcatIonsofbusInessarrangementsInvolvInganesthesIologIsts
partIcularlywIthalltherealIgnments,consolIdatIons,mergers,andcontractsassocIated
wIththeattemptedImplementatIonofmanagedcare.TheapplIcablestatutesand
regulatIonsareoftenpoorlyunderstood.ContrarytopopularbelIef,theantItrustlawsdo
notInvolvetherIghtsofIndIvIdualstoengageInbusIness.Father,thelawsareconcerned
solelywIththepreservatIonofcompetItIonwIthInadefInedmarketplaceandtherIghtsof
theconsumer,IndependentofwhetheranyonevendororprovIderofservIceIsInvolved.
WhenananesthesIologIsthasbeenexcludedfromapartIcularhospItal'sstafforanesthesIa
groupandthensuesbasedonanallegedantItrustvIolatIon,theanesthesIologIstloses
vIrtuallyautomatIcally.ThIsIsbecausethereIsstIllsIgnIfIcantcompetItIonIntherelevant
medIcalcaremarketplace(communItyorregIon)andcompetItIonInthatmarketIsnot
threatenedbytheexclusIonofonephysIcIanfromonestaff.
nessence,IfthereareseveralhospItalsofferIngrelatIvelysImIlarservIcestoan
ImmedIatecommunIty(themarket),denIalofprIvIlegestoonephysIcIanbyonehospItalIs
notantIcompetItIve.f,ontheotherhand,thereIsonlyonehospItalInasmallermarket,
thenthesameact,thesamesetofcIrcumstances,couldbeseenverydIfferently.nthat
case,therewouldbealImItatIonofcompetItIonbecausethehospItaldomInatesand,In
fact,maycontrolthemarketforhospItalservIces.ExclusIonofonephysIcIan,then,could
lImItaccessbytheconsumerstoalternatIvecompetIngservIcesandhencewouldlIkelybe
judgedanantItrustvIolatIon.
TheShermanAntItrustActIsafederallawmorethan100yearsold.SectIon1dealswIth
contracts,combInatIons,conspIracy,andrestraIntoftrade.8ydefInItIon,twoormore
separateeconomIcentItIesmustbeInvolvedInanagreementthatIschallengedasIllegal
forthIssectIontoapply.SectIon2prohIbItsmonopolIesorconspIracytocreatea
monopoly,andItIspossIblethatthIscouldapplytoasIngleeconomIcentItythathas
IllegallygaIneddomInatIonofamarket.ConsIderatIonofpossIblemonopolIstIcdomInatIon
ofamarketInvolvesasItuatIonInwhIchasIngleentItycontrolsatleast50ofthe
busInessInthatmarket.ThestakesarehIghInthattheantItrustlegIslatIonprovIdesfor
trIpledamagesIfalawsuItIssuccessful.TheU.S.0epartmentofJustIceandtheFederal
TradeCommIssIonarekeenlyInterestedInthecurrentrapIdevolutIonInthehealthcare
Industry,andthusareactIvelyInvolvedInevaluatIngsItuatIonsofpossIbleantItrust
vIolatIons.
TherearetwowaystojudgevIolatIons.Undertheper se rule,whIchIsapplIedrelatIvely
rarely,conductthatIsobvIouslylImItIngcompetItIonInamarketIsautomatIcallyIllegal.
TheothertypeofvIolatIonIsbasedontherule of reason,whIchInvolvesacarefulanalysIs
ofthemarketandthestateofcompetItIon.ThemajorItyofcomplaIntsagaInstphysIcIans
arejudgedbythIsrule.ThemorecompetItorsthereareInamarket,thelesslIkelythat
anyoneactIsantIcompetItIve.nacommunItywIthtwohospItals,onesmallerthanthe
other,wIthananesthesIologygrouppractIceexclusIvelyateach,Ifthelarger
anesthesIologypractIcegroupbuysoutandabsorbsthesmaller,leavIngonlyonegroupfor
theonlytwohospItalsInthecommunIty,thatmaybeantIcompetItIve,partIcularlyIfa
newanesthesIologIstseekstopractIcesoloatthosehospItals.
Legal Implications
nthecurrenteraofrapIdlyevolvIngpractIcearrangements,theantItrustlawsare
Important.fphysIcIans(IndIvIdualsorgroups)whonormallywouldbecompetItorsbecause
theyareseparateeconomIcentItIesmeetandagreeontheprIcestheywIllchargeorthe
termstheywIllseekInamanagedcareorInstItutIonalcontract,thatcanbe
antIcompetItIve,monopolIstIc,andhencepossIblyIllegal.NotethatsharIngacommon
offIceandcommonbIllIngservIcealoneIsnotenoughtoconstItuteatruegroup.f,onthe
otherhand,thesamephysIcIansjoInInatrueeconomIcpartnershIptoformanewgroup
(totalIntegratIon)thatIsasIngleeconomIcentIty(andmeetscertaInothercrIterIa)that
wIllsetprIcesandnegotIatecontracts,thatIsperfectlylegal.TheothercrIterIaare
crItIcal.TheremustbecapItalInvestmentandalsorIsksharIng(IfthereIsaprofItorloss,
ItIsdIstrIbutedamongthegroupmembers)thatIs,totalIntegratIonIntoagenuIne
partnershIp(thatIsusuallyIncorporated,sometImesasalImItedlIabIlItycorporatIon).
ThIsIssueIsveryImportantInconsIderIngthedrIveforneworganIzatIonstoputtogether
networksofphysIcIansthatthenseekcontractswIthmajoremployerstoprovIdemedIcal
care.SometImes,hospItalsorclInIcsattempttoformanetworkcomprIsIngallthe
membersofthemedIcalstaffsothattheresultIngentItycanbIdgloballyfortotalcare
contracts.AnynetworkIsajoIntventureofIndependentpractItIoners.fthepartIcIpatIng
physIcIansofonespecIaltyInanetworkareseparateeconomIcentItIesandthenetwork
advertIsesoneprIcefortheIrservIces,thIswouldseemtosuggestanantItrustvIolatIon
(horIzontalprIcefIxIng).nthepast,IfanetworkInvolvedfewerthan20ofonetypeof
medIcalspecIalIstInamarket,thatwascalledasafe harbor,meanIngthatItwas
permIssIblefornonpartnerstogettogetherandnegotIateprIces.Thefederalgovernment
hastrIedtoencourageformatIonofsuchnetworkstohelpreducehealthcarecosts,andas
aresultmadesomerelevantexceptIonstotheapplIcatIonoftheserules.Aslongasthe
networkIsnonexclusIve(othernonnetworkphysIcIansofagIvenspecIaltyarefreeto
practIceInthesamefacIlItIesandcompeteforthesamepatIents),thenetworkcan
comprIseuptoJ0ofthephysIcIansofonespecIaltyInamarket.NotespecIfIcallythat
thIsdoesnotallowalocalspecIaltysocIetyInabIgcItytoserveasabargaInIngagenton
feesforItsmembersbecauseItIsverylIkelythatJ0ofthespecIalIstsInanareawIllbe
membersofthesocIety.TheonlyrealexceptIontothIsprovIsIonIsInthInlypopulated
ruralareaswheretheremaybejustonephysIcIannetwork.nsuchcases
P.44
(whIchare,sofar,rarebecausethemajormanagedcareandnetworkactIvItyhas
occurredmaInlyInheavIlypopulatedurbanareas),thereIsnolImItonhowmanyofone
specIaltycanbecomenetworkmembersandhavethenetworknegotIatefees,aslongas
thenetworkIsnonexclusIve.
FelevantlegIslatIon,regulatIons,andcourtactIonsallhappenrapIdlyandoften.|ergers
amonganesthesIologygroupsInamarketareaforthepurposesofbotheffIcIencyand
strengthInnegotIatIngfeeshavebeenverypopularasaresponsetotherapIdlychangIng
marketplace.AlIstofquestIonsmustbeansweredtodetermIneIfsuchamergerwould
haveantIcompetItIveImplIcatIons.AlthoughcompendIaofrelevantInformatIonare
avaIlabletoanesthesIologIsts,
J8,J9,40
theycannotsubstItuteforexpertadvIceandhelp.
DbvIously,anesthesIologIstscontemplatIngamergerorfacInganyoneofagreatnumberof
othersItuatIonsInthemodernhealthcarearenamustsecureassIstancefromprofessIonal
advIsors,usuallyattorneys,whosejobItIstobeawareofthemostrecentdevelopments,
howtheyapply,andhowbesttoforgeagreementsInformalcontracts.AnesthesIologIsts
hopIngtofIndreputableadvIsorscanstarttheIrsearchwIthwordofmouthreferralsfrom
colleagueswhohaveusedsuchservIces.LocalorstatemedIcalsocIetIesfrequentlyknow
ofattorneyswhospecIalIzeInthIsarea.FInally,theASAWashIngton,0.C.,offIcehas
compIledastatebystatelIstofadvIsorswhohaveworkedsuccessfullywIth
anesthesIologIstsInthepast.
Exclusive Service Contracts
Dften,oneofthelargerIssuesfacedbyanesthesIologIstsseekIngtodefInepractIce
arrangementsconcernsthedesIrabIlItyofconsIderInganexclusIvecontractwIthahealth
carefacIlItytoprovIdeanesthesIaservIces.AnexclusIvecontractstatesthat
anesthesIologIstsseekIngtopractIceatagIvenfacIlItymustbemembersofthegroup
holdIngtheexclusIvecontractand,usually,thatmembersofthegroupwIllpractIce
nowhereelse.AhospItalmaywanttogIveanexclusIvecontractInreturnforaguarantee
ofcoverageaspartofthecontract.Also,thehospItalmaybelIevethatsuchacontractcan
helpensurethequalItyofpractItIonerbecausethecontractcancontaIncredentIalIngand
performancecrIterIa.tIsImportanttounderstandthatthehospItallIkelywIllexercIsea
degreeofcontrolovertheanesthesIologIstswIthsuchacontractInforce,suchasrequIrIng
themtopartIcIpateasprovIdersInanycontractsthehospItalmakeswIththIrdparty
payersandalsotyInghospItalprIvIlegestotheexIstenceofthecontract(thesocalled
cleansweepprovIsIonthatbypassesanydueprocessofthemedIcalstaffshouldthe
hospItaltermInatethecontract).CertaInofthesetypesofprovIsIonsconstItuteeconomic
credentialing,whIchIsdefInedastheuseofeconomIccrIterIaunrelatedtothequalItyof
careorprofessIonalcompetencyofphysIcIansIngrantIngorrenewInghospItalprIvIleges
(suchastheacceptanceofbelowmarketfeesassocIatedwIthahospItalnegotIatedcare
contractorevenrequIrIngfInancIalcontrIbutIonsInsomeformtothehospItal).
TheASAIn199JIssuedastatementcondemnIngeconomIccredentIalIng.
1
The
anesthesIologIstsInvolvedmayacceptsuchanexclusIveservIcescontracttoguarantee
thattheyalonewIllgetthebusInessfromthesurgeonsonstaffatthathospItal,andhence
theresultIngIncome.TheremaybeotherconsIderatIonsonbothsIdes,andthesehave
beenoutlInedInextensIverelevantASApublIcatIonsthatalsoIncludeasamplecontract
forInformatIonpurposesonly.
J6,J9
AlthoughmanyexclusIvecontractswIthanesthesIology
groupsareInforce,thesentIment,partIcularlyfromtheASA,IsagaInstthem.Asstated,It
IscrItIcalthatanesthesIologIstsfacedwIthImportantpractIcemanagementdecIsIonssuch
aswhethertoenterIntoanexclusIvecontractmustseekoutsIdeadvIceandcounsel.There
areagreatmanynuancestotheseIssues,
J9,40,41,42,4J
andanesthesIologIstsareatrIsk
attemptIngtonegotIatesuchcomplexmattersalone,justaspatIentswouldbeatrIskIfa
contractattorneyattemptedtoInducegeneralanesthesIa.
0enIalofhospItalprIvIlegesasaresultoftheexIstenceofanexclusIvecontractwIththe
anesthesIologIstsInplaceatthefacIlItyhasbeenthesourceofmanylawsuIts,IncludIng
thewellknownLouIsIanacaseofHyde v Jefferson Parish.nthatcase,thecourtfoundfor
thedefendantanesthesIologIstsandthehospItal,sayIngthattherewasnoantItrust
vIolatIonbecausetherewasnorealadverseeffectoncompetItIonasfaraspatIentswere
concernedbecausetherewereseveralotherhospItalswIthInthemarkettowhIchthey
couldgo,andthereforetheycouldexercIsetheIrrIghtstotakeadvantageofcompetItIon
Intherelevantmarket.Thus,exIstenceofanexclusIvecontractonlyIntheraresettIng
whereantIcompetItIveeffectsonpatIentscanbeprovedmIghtleadtoalegItImate
antItrustclaImbyaphysIcIandenIedprIvIleges.ThIswasproventrueIntheKessel v
Monongalia County General HospitalcaseInWest7IrgInIaInwhIchanexclusIve
anesthesIologycontractwasheldIllegal.Therefore,agaIn,thesearrangementsareby
defInItIoncomplexandfraughtwIthhazard.AccordIngly,outsIdeadvIceandcounselare
alwaysnecessary.
Hospital Subsidies
|oderneconomIcrealItIeshaveforcedagreatnumberofanesthesIologypractIcegroups
(InbothprIvateandacademIcsettIngs)torecognIzethattheIrpatIentcarerevenue,after
overheadIspaId,doesnotprovIdesuffIcIentcompensatIontoattractandretaInthe
numberandqualItyofstaffnecessarytoprovIdetheexpectedclInIcalservIce(andfulfIll
anyothergroup/departmentmIssIons).AttemptIngtodothesame(ormore)workwIth
fewerstaffmaytemporarIlyprovIdeIncreasedfInancIalcompensatIon.CuttIngbenefIts
(dIscretIonarypersonalprofessIonalexpenses,retIrementcontrIbutIons,orevenInsurance
coverage)mayalsobeacomponentofaresponsetoInadequatepractIcerevenue.
However,theresultIngdecrementsInpersonalsecurIty,InconvenIence,andInqualItyof
lIfeasfarasacuteandchronIcfatIgue,decreasedfamIlyandrecreatIontIme,andtensIon
amongcolleaguesfearfulsomeoneelseIsgettIngabetterdealwIllquIcklyovercomeany
brIefadvantageofasomewhathIgherIncome.Therefore,manypractIcegroupsInsuch
sItuatIonsarerequestIngtheIrhospItal(orotherhealthcarefacIlItywheretheypractIce)
topaythemadIrectcashsubsIdythatIsusedtoaugmentpractIcerevenueInorderto
maIntaInbenefItsandamenItIeswhIlemaIntaInIngorevenIncreasIngthedIrect
compensatIontostaffmembers,hopefullytoamarketcompetItIvelevelthatwIllpromote
recruItmentandretentIonofgroupmembers.
DbvIously,requestsbyapractIcegroupforadIrectsubsIdymustbethoroughlyjustIfIedto
thefacIlItyadmInIstratIonreceIvIngthepetItIon.Thegroup'sbusInessoperatIonshould
alreadyhavebeenexamInedcarefullyforanypossIbledefectsormeanstoenhance
revenuegeneratIon.ExplanatIonofthegeneraltrendofdeclInIngreImbursementsfor
anesthesIaservIcesshouldbecarefullydocumented.FactsandfIguresonthatandalsothe
shortageofanesthesIaprovIderscanbeobtaInedfromjournalartIclesandASA
publIcatIons,partIcularlytheNewsletter.0emandforanesthesIacoverageforthesurgIcal
scheduleIsakeycomponentofthIsproposal.SchedulIngandutIlIzatIon,partIcularlyIf
earlymornIngstaffIngIsrequIredformanyDFsthatareroutInelyunusedlaterdurIngthe
tradItIonalworkday,IsamajorIssuetobeunderstoodandpresented.AnyotherDF
IneffIcIencIescreatedbyhospItalsupportstaffandprevIouseffortstodealwIththem
shouldalsobehIghlIghted.UnfavorablepayermIx,Impactofcontracts,andprograms
InItIatedbythehospItalalsooftenaremajorfactors
P.45
InsItuatIonsofInadequatepractIcerevenue.Always,thegroup'sgoodwIllwIththe
surgeonsandthecommunItyIngeneralshouldbeemphasIzed,aswellasoftheIndIrector
behIndthescenesservIcesandbenefItstheanesthesIologygroupprovIdestothe
hospItal.NotethatthenecessItyforsuchasubsIdyrequestIsprecIselythetImewhenthe
anesthesIaprofessIonalswIllbenefItfrombeIngperceIvedasgoodcItIzensofthehealth
carefacIlIty.AnoverlyaggressIveeffortbeyondtheboundsoflogIccouldprovokethe
facIlItytoconsIderalternatIvearrangements,evenuptothepoIntofputtIngoutarequest
forproposalfromotheranesthesIologypractIcegroups.Therefore,thoughtfulcalculatIons
arerequIredandacarefulbalancemustbesought,seekIngenoughfInancIalsupportto
supplementpractIcerevenuessothatmembers'compensatIonIscompetItIvebutnotso
muchastobeexcessIve.SupportIngstatementsanddocumentsaboutoffersandpotentIal
earnIngselsewheremustbecompletelyhonestandnotexaggeratedorcredIbIlItyandgood
faIthwIllbelost.Further,partofanyagreementwIllbethefullsharIngofthegroup's
detaIledfInancIalInformatIonwIththefacIlItyadmInIstratIon,bothatthetImeofthe
requestandonanongoIngbasIsIfthepaymentIsmorethanaonetImebaIlout.Plans
forrevIewandrenewalshouldbemadeonceasubsIdyIspaId.
AnysubsIdywIlllIkelyrequIreaformalcontract.TheremaybeconcernaboutmalpractIce
lIabIlItyImplIcatIonsforthehospItaleventhoughthepractIcegroupstaysanIndependent
entItyasbefore.TheremaybeInurementorprIvatebenefItconcernsthatcouldbe
perceIvedasathreattothetaxexemptstatusofanonprofIthospItal.Lackof
understandIngoftheapplIcablelawsmayleadtofearsthatasubsIdycouldbeanIllegal
kIckbackoravIolatIonoftheStarkselfreferralprohIbItIon.AsIsalmostalwaysthe
case,expertoutsIdeprofessIonalconsultantadvIce,usuallyfromanattorneywho
specIalIzesexclusIvelyInhealthcarefInancecontractIng,IsmandatoryInsuch
cIrcumstances.TheASAWashIngton,0.C.,offIcemaIntaInslIstsofconsultantswhohave
helpedotheranesthesIologIstsorgroupsInthepastwIthvarIoussubjects,andtheASAhas
somebasIcInformatIononsubsIdIestoanesthesIologypractIcegroups.
44,45,46
New Practice Arrangements
EventhoughtheImpactofmanagedcareplanshaswanedsomewhatoverthefIrstdecade
ofthe21stcentury,varIousIteratIonsstIllexIstandhaveongoIngImpactonanesthesIology
practIce.Further,renewedconcernattheendofthedecadeaboutdIsproportIonate
IncreasesInhealthcarespendIngasapercentageofU.S.grossdomestIcproductandthe
fearofthepostulatedbankruptcyof|edIcareand|edIcaIdagaInraIsethespecterofnew
effortstoImposemanagedcare.
ntheInItIalstagesoftheevolutIonofamanagedcaremarketplace,the|CDusuallyseeks
contractswIthprovIdersbasedondIscountedfeeforservIcearrangements.ThIspreserves
thebasIctradItIonalIdeaofproductIonbasedphysIcIanreImbursement(domore,bIll
more)buttheprIceofeachactofservIcesIslower(theprovIdersareInducedtogIvedeep
dIscountswIththepromIseofsIgnIfIcantvolumesofpatIents);also,the|CDgatekeeper
prImarycarephysIcIansandthe|CDrevIewersarestronglyencouragedtolImItcomplex
andcostlyservIcesasmuchaspossIble.ThereareotherfeaturesIntermIttentlyalongthe
way,suchasglobalfeesandnegotIatedfeeschedules(agreeduponsIngleprIcesfor
IndIvIdualprocedures,IndependentoflengthorcomplexIty).nanapplIcatIonofthe
conceptofrIsksharIng(spendtoomuchforpatIentcareandloseIncome),thIsusuallyIs
InItIallymanIfestIntheformofwIthholds,thepractIceofthe|CDholdIngbacka
fractIonoftheagreeduponpaymenttotheprovIders(e.g.,10or15)andkeepIngthIs
moneyuntIltheendofthefIscalyear.AtthattIme,IfthereIsanymoneyleftIntherIsk
poolorwIthholdaccountafterallthe(partIal)provIderfeesand|CDexpensesarepaId,It
IsdIstrIbutedtotheprovIdersInproportIontotheIrdegreeofpartIcIpatIondurIngthe
year.ThIsIsacleverandpowerfulIncentIvetoprovIderstoreducehealthcareexpenses.
tIsnotaspowerfulasthestageoffullrIsksharIng,however.Asthemanagedcare
marketplacematuresand|CDsgrowandsucceed,theexIstIngorganIzatIonsand,
especIallyanynewones,shIfttoprospectIvecapItatedpaymentsforprovIders.
Prospective Payments
ProspectIvecapItatedpaymentsconstItutesanentIrelynewworldtohealthcareprovIders,
InvolvIngprospectIvecapItatedpaymentsforlargepopulatIonsofpatIents,InwhIcheach
groupofprovIdersInthe|CDreceIvesafIxedamountperenrolledcoveredlIfe(member)
permonth(P|P|)andagrees,exceptInthemostunusualcIrcumstances,toprovIde
whatevercareIsneededbythatpopulatIonforthatprospectIvepayment.Themost
unusualcIrcumstancesInvolvecarveoutarrangementsInwhIchspecIfIcverycostlyand
unusualcondItIonsorprocedures(suchasthebIrthofachIldwIthdIsastrousmultIple
congenItalanomalIes)arecoveredseparatelyonadIscountedfeeforservIcebasIs.WIth
fullcapItatIon,theentIrefInancIalunderpInnIngofAmerIcanmedIcalcaredoesa
completeaboutfacefromthetradItIonalrewardsforgIvIngmorecareanddoIngmore
procedurestonewrewardsforgIvInganddoIngless.SomemanagedcarecontractscontaIn
otherfeaturesIntendedtoprotecttheprovIdersagaInstunexpectedoverutIlIzatIonby
patIentsthatwouldstretchtheprovIdersbeyondtheboundsoftheorIgInalcontractwIth
the|CD.TheprovIsIonssettIngtheboundarIesarecalledrisk corridors,andthestoploss
clausesaddsomedIscountedfeeforservIcepaymentfortheexcesscarebeyondtherIsk
corrIdor(capItatedcontractlImIt).ProvIderswhowereusedtogettIngpaIdmorefordoIng
morecansuddenlyfIndthemselvesgettIngpaIdafIxedamountnomatterhowmuchor
howlIttletheydowIthregardtoaspecIfIedpopulatIonhence,theperceIvedIncentIveto
do,andconsequentlyspend,less.ftheprovIdersrendertoomuchcarewIthInthedefIned
boundaryofthecontract,theyessentIallywIllbeworkIngforfree,theultImateInrIsk
sharIng.
ThereareclearlypotentIalInternalconflIctsInsuchasystem,
47
andhowpatIentsreacted
InItIallytothIsradIcalchangeInattItudeonthepartofphysIcIansdemonstratedthatthIs
overallmechanIsmIsunlIkelytobereadIlyembracedbythegeneralpublIc.Healthcare
provIders(physIcIans,otherhealthcareprofessIonals,andfacIlItIes),Inturn,allIed
themselvesInawIdevarIetyoforganIzatIonstocreatestrengthanddesIrableresourcesto
presenttothe|CDsIncontractnegotIatIons.|anagementservIceorganIzatIonsarejoInt
venturenetworkarrangementsthatdonotInvolvetrueeconomIcIntegratIonamongthe
practItIoners,butmerelyoffercommonservIcestophysIcIanswhomay,asaloosely
organIzedInformalgroup,electtoseek|CDcontracts.PreferredprovIderorganIzatIons
arenetworkarrangementsofotherwIseeconomIcallyIndependentphysIcIanswhoforma
newcorporateentItytoseekmanagedcarecontractsInwhIchtherearesIgnIfIcant
fInancIalIncentIvestopatIentstousethenetworkprovIdersandfInancIalpenaltIesfor
goIngtooutofnetworkprovIders.ThIshasprovedarelatIvelypopularmodelandappears
tobegaInIngwIdeacceptance.PhysIcIanhospItalorganIzatIonsaresImIlarentItIesbut
InvolveunderstandIngsbetweengroupsofphysIcIansandahospItalsothatalargepackage
orbundleofservIcescanbeconstructedasessentIallyonestoppoIntsofcare.ndependent
practIceassocIatIonsarelIkepreferredprovIderorganIzatIonsbutarespecIfIcallyorIented
towardcapItatedcontractsforcoveredlIveswIthsIgnIfIcantrIsksharIngbythe
P.46
provIders.Croups(orclInIcs)wIthoutwallsarecollectIonsofpractItIonerswhofully
IntegrateeconomIcallyIntoasInglefIscalentIty(truepartnershIp)andthencompetefor
|CDcontractsonthebasIsofrIsksharIngIncentIvesamongthepartners.FullyIntegrated
groupsorhealthmaIntenanceorganIzatIons(suchasKaIserPermanenteInCalIfornIaor
HarvardPIlgrImHealthInNewEngland)housethegroupofpartnerprovIderphysIcIansand
assocIatedsupportstaffatasInglelocatIonfortheconvenIenceofpatIents,abIgsellIng
poIntwhentheyseek|CDoremployercontracts.
Changing Paradigm
TheeraofsoloIndependentpractItIonersmaybeendIngInsomelocatIonswhere|CDs
domInatebecausetheorganIzatIonssImplywIllnotcontractwIthoneperson.ndependent
hospItalbasedgroups(lIkelystIllthemostcommonprIvatepractIcemodel)mayface
growIngsImIlardIffIcultIes.
48
ThesesmallergroupsofanesthesIologIstsmayfInd
themselvesatacompetItIvedIsadvantageunlesstheybecomepartofavertIcally
Integrated(multIspecIalty)orhorIzontallyIntegrated(wIthotheranesthesIologIsts)
organIzatIon.AnextensIvecompendIumofrelevantInformatIonhasbeenpreparedbythe
ASA.
J8
8ecauseItappearslIkelythatmanyanesthesIologIstsIntheUnItedStateswIllbe
affectedbyevolvIngchangesInpractIcearrangements,theInformatIonInthIsandrelated
publIcatIons
49
IsveryImportant.NegotIatIonswIth|CDsrequIreexpertadvIce,probably
evenmoresothanthetradItIonalexclusIvecontractswIthhospItalsasprevIouslynoted.
8eforeanynegotIatIoncanevenbeconsIdered,the|CDmustprovIdesIgnIfIcantamounts
ofInformatIonaboutthecoveredpatIentpopulatIon.TheprojectedhealthcareutIlIzatIon
patternofalargegroupofwhItecollarworkers(andtheIrfamIlIes)frommajorupscale
employersInanurbanareawIllbequItedIfferentfromthatofarelatIvelyrural|edIcaId
populatIon.SpecIfIcdemographIcsandpastutIlIzatIonhIstorIesareabsolutelymandatory
foreachproposedpopulatIontobecovered,andthIsInformatIonshouldgodIrectlytothe
advIsIngexpertsforevaluatIon,whethertheproposednegotIatIonIsfordIscountedfeefor
servIce,afeeschedule,globalbundledfees,orfullcapItatIon.
SIgnIfIcantquestIonswerepoIntedlyraIsedaboutthereImbursementImplIcatIonsfor
anesthesIologIstsoftheputatIvemanagedcare/practIcereorganIzatIonrevolutIon.AgaIn,
theASAhasassembledrelevantInformatIon,theunderstandIngofwhIchIsessentIalto
successfulnegotIatIons.
J8
Table21hasalIstofInformatIonananesthesIapractIceshould
haveaboutItsactIvItIes.nItIalconsIderatIonofacapItatedcontractshouldInvolvean
attempttotakeallthedataabouttheexIstIngpractIceandtheproposed|CDcovered
populatIonfromacapItatIonchecklIst
J8
andtranslatebackfromtheproposedcapItated
ratetoIncomefIguresthatwouldcorrelatewIththeexIstIngpractIcestructure,toallowa
comparIsonandanunderstandIngoftherelatIonshIpoftheprojectedworkInthecontract
thetoprojectedIncomefromIt.tIs,ofcourse,ImpossIbletosuggestdollarvaluesfor
capItatedratesforanesthesIologycarebecausedetaIlsandcondItIonsvarysowIdely.Dne
ASApublIcatIon
J8
usedexamples,purelyforIllustratIvepurposes,InvolvIngS2.50orS4.00
P|P|,buttherewereunconfIrmedreportsatthepeakofthemanagedcarebubbleof
capItatedratesaslowasS0.75P|P|foranesthesIology.
0IscountedfeeforservIcearrangementsareeasIerforanesthesIologIststounderstand
becausethesearedIrectlyreferabletoexIstIngfeestructures.FeportsofgroupsInstItutIng
10to50dIscountsoffthestartIngpoIntof80ofusualandcustomaryreImbursementIn
varIouspractIcecIrcumstanceswerecIrculatedatnatIonalmeetIngsofanesthesIologIsts.
WererIgIdlycontrolledfullymaturemanagedcaretodomInatethepractIcecommunIty,It
wouldbelIkelythattheaverageIncomeforanesthesIologIstswoulddecreasefrompast
levels.However,ItlIkelyalsowouldbetruethatanesthesIaprofessIonalswouldcontInue
tohaveIncomesstIllaboveaverageamongallhealthcareprofessIonalsInthatmarket.
AnotherrecentfeatureofthIsdIscussIonIsthetendencyofprIvate(nongovernmental)
contractIngorganIzatIonstoattempttotIetheIrpaymentsforprofessIonalservIcestothe
government's|edIcarerateforspecIfIcCPT4codes.tIscommonforbothcommercIal
IndemnItyInsuranceentItIes(e.g.,8lueShIeld,Aetna,Humana,UnItedHealth)aswellas
|CDstoofferprImarycarephysIcIans,forexample,125ofthe|edIcarepaymentratefor
specIfIcservIces.AlthoughgroupsofprImarycarephysIcIansmayvIewthIsassomewhat
reasonableand,thus,theysIgnsuchcontracts,anesthesIologIstsfaceunIquechallengesIn
thIsregard.EvenwIththemostrecentpromIsefromtheresponsIbleoffIceswIthIn
|edIcareofareImbursementupgradeforanesthesIaservIces,mostanesthesIa
professIonalsstIllbelIevethatthe|edIcarereImbursementrateIsunfaIrlylowforthe
workInvolvedInprovIdInganesthesIacare.ThenewratewouldstIllbelessthanhalfthe
perunItconversIonfactorthatthelargeIndemnItycarrIershavebeenpayIngfor
anesthesIacareInrecentyears.Therefore,125ofwhatmanyanesthesIaprofessIonals
consIderwoefullyInadequatewouldstIllbeInadequate.Thus,InspIteofsometImes
Intensepressure,anesthesIaprofessIonalsInmanymarketshavebeenreluctanttoaccept
IndemnItyInsurancecontractratestIedto|edIcarerates.Asalways,anesthesIa
professIonalsfacedwIthcomplexreImbursementsItuatIonsanddecIsIonsshouldseek
expertadvIcefromthenatIonaloffIcesoftheIrprofessIonalpractIceorganIzatIonsand
fromknowledgeablepaIdconsultantsandattorneys.
Pay for Performance
CommercIalIndemnItyInsuranceentItIes(e.g.,8lueShIeld,Aetna,Humana,UnIted
Health),|CDs,andpartIcularly,thefederalCenterfor|edIcareand|edIcaIdServIces
(C|S)areallcurrentlyfIxatedontheconceptofperformancebasedpaymentsasa
sIgnIfIcantnewwaytolImItthegrowthof(andevenreduce)healthcarecosts,
50
especIally
byreducIngexpensIvecomplIcatIonsofmedIcalcare.ThIspayforperformance
movementbeganwIththefederalTaxFelIefandHealthcareActof2006andcontInues
wIththePhysIcIanQualItyFeportIngnItIatIveIn2008.ThepotentIalImplIcatIonsfor
anesthesIapractIcehavebeensummarIzed.
51
ngeneral,C|SmadestrenuouseffortstoattempttodefIneandpromulgateobjectIve
qualItymeasuresthatcouldbedocumentedasIndIcatorsofthequalItyofhealthcare
delIvered.ThemaInIssueIsthepromotIonofspecIfIccareelementsthathelpavoId
expensIveoutcomesorcomplIcatIonsthatcurrentlygenerateadIsproportIonate
(preventable)fractIonofhealthcarecosts.TheadmInIstratIonofaspIrInandbetablockers
wIthInafIxedbrIefIntervalafterthearrIvalofanacutemyocardIalInfarctIonpatIentIsa
goodexample,asarevarIousparametersInthecareofpatIentswIthcommunItyacquIred
pneumonIaorcongestIveheartfaIlure.0efInIngandvalIdatIngobjectIveandeasIly
quantIfIablesocalledqualItymeasuresthatwIllpreventexpensIvecomplIcatIonsof
anesthesIacareprovedtobemoredIffIcult.TheInItIaltargetedparameterwassomewhat
IndIrect:thetImIngoftheadmInIstratIonofprophylactIcantIbIotIcsprIortosurgIcal
IncIsIon.TheanesthesIaprofessIonalIsjudgedtobeIncomplIancewhentheantIbIotIcIs
admInIsteredwIthInthe1hour(2hoursforvancomycInandfluoroquInolones)prIorto
IncIsIon.ThIsmustbeverIfIablydocumentedontheanesthesIarecord.8enchmarkcrIterIa
suchasanInItIal80complIance(butlIkelyIncreasIngtoatleast95)foraspecIfIc
fInancIalentItybIllIng|edIcareand|edIcaIdmustbemetorthereImbursementfor
anesthesIaservIcesbythatfInancIalentItywIllbe
P.47
reducedbyaspecIfIcfractIon(orapromIsedbonuswIllbewIthheld)asacomplIance
IncentIve,butalsosomewhatasanoffsettotheIncreasedcostoftheconsequent
complIcatIonsassocIatedwIthfaIluretocomply.fperformanceIsIncomplIance,C|SwIll
paythemaxImumallowablereImbursement(payforperformance).
ThesecondtargetIscatheterrelatedbloodstreamInfectIon,andtheperformance
behavIorexpectedofanesthesIaprofessIonalsIsobservanceofstrIctaseptIcprotocol
durIngcentralvascularcatheterplacement(andavoIdIngthefemoralrouteIfatall
possIble).AsofthIswrItIng,thethIrdobjectIveparameterofanesthesIacarequalItyIs
scheduledtotargettemperaturemanagementofthesurgIcalpatIentwIththecomplIance
behavIorbeIngmetbyachIevIngoneofthreepossIblegoals:useofactIvewarmIng
IntraoperatIveordocumentedtemperatureJ6`CeItherInthelastJ0mInutesof
anesthesIaorthefIrstJ0mInutesInthePACU.FuturepotentIalobjectIveperformance
crIterIaIntendedtoencourageavoIdanceofcostlycomplIcatIonsofanesthesIacaremay
IncludeglucosecontrolInmajorsurgery,useofpencIlpoIntspInalneedlesInobstetrIc
anesthesIa,useofelectronIcmedIcalrecords,preoperatIvescreenIngforsleepapnea,
preoperatIvefastIngInstructIons,meperIdIneadmInIstratIonforpostoperatIveshIverIng,
andseveralothers.nallcaseswhenaparameterIsadopted,benchmarkcrIterIafor
degreeofcomplIancewIllbeestablIshedandreImbursementwIllbereducedonewayor
anotherforfaIluretocomply,asdocumentedontherelevantrecordsandselfreportedby
thebIllIngfInancIalentIty(subjecttoaudIt,ofcourse).
HospItalswIllhaveevenmoreatstakeInthesensethatthepayforperformance
movementIscreatIngparadIgmsInwhIchhospItalswIllnotreceIvereImbursementsfor
careassocIatedwIthpreventablecomplIcatIonssuchascatheterrelatedsepsIs,ventIlator
acquIredpneumonIa,anddecubItusulcers.ThIsconcepthasseveralImplIcatIons.DneIs
thatsmallerhospItalsoftenpopulatedbylessacutepatIentswIllbemorelIkelyand
quIckertotransfersIckerpatIentstolargerreferralfacIlItIesInordertoavoIdlosIng
reImbursementassocIatedwIththedevelopmentofpatIentcomplIcatIons.ConcomItantly,
documentatIonofthetImIngofthedevelopmentofcomplIcatIonswIllbecomecrItIcal.fa
hospItalordepartmenthasdocumentedthepreexIstIngpresenceofacomplIcatIonatthe
tImeofapatIent'sadmIssIon,ItshouldnotbepenalIzedforthedevelopmentofthat
condItIon.nthIscontext,anesthesIaprofessIonalscanhaveanImportantrole
documentIngtheexIstenceofpneumonIaorsacraldecubItusulcersIntheIrrecordswhen
theyfIrstseeanewlyadmIttedpatIent,usuallyforpreoperatIveevaluatIon.ThIswIllbe
perceIvedasexcellentInstItutIonalcItIzenshIpbytheanesthesIaprofessIonalbecauseIt
maypreventsIgnIfIcantreImbursementreductIontothehospItal.
HIPAA
The200JImplementatIonofthePrIvacyFuleoftheHealthnsurancePortabIlItyand
AccountabIlItyAct(HPAA)of1996requIredsIgnIfIcantchangesInhowmedIcalrecordsand
patIentInformatIonarehandledInthedaytodaydelIveryofhealthcare.TheImpacton
andrequIrementsforanesthesIologIstsaresummarIzedInacomprehensIvepublIcatIon
fromtheASA
52
thatfollowedtwoeducatIonalsummarIes.
5J,54
AttentIonIsfocusedonprotectedhealthInformatIon(IdentIfIableasfromaspecIfIc
patIentbyname).PatIentsmustbenotIfIedoftheIrprIvacyrIghts.UsuallythIswIllbe
coveredbythehealthcarefacIlItyInwhIchanesthesIologIstswork,butIfseparateprIvate
recordsaremaIntaIned,separatenotIfIcatIonmaybenecessary.PrIvacypolIcIesmustbe
created,adopted,andpromulgatedtoallpractItIoners,allofwhomthenmustbetraIned
InapplIcatIonofthosepolIcIes.Dften,anesthesIologygroupscancombInewIththe
facIlItIesInwhIchtheypractIceasanorganIzedhealthcarearrangementsothatthe
anesthesIapractItIonerscanbecoveredInpartbytheHPAAcomplIanceactIvItIesofthe
facIlIty.AprIvacyoffIcermustbeappoIntedforthepractIcegroup.FInally,andmost
Importantly,medIcalrecordscontaInIngprotectedhealthInformatIonmustbesecuredso
theyarenotreadIlyavaIlabletothosewhodonotneedthemtorendercare.
DneofthemostobvIousapplIcatIonsformanyanesthesIologIstsIsconcernaboutthe
assembledpreoperatIveInformatIonandchartsfortomorrow'scasesthatfrequentlywere
placedpromInentlyIntheDFholdIngareaattheendofoneworkdayInreadInessforthe
nextday'scases.HPAAprovIsIonsrequIrethatallthatpatIentInformatIonbelockedaway
overnIght.AnotherclassIcexampleIswhatmanyDFsrefertoastheboard.Dften,a
largewhItedrymarkerboardoccupIesapromInentwallnearthefrontdeskofanDFsuIte,
andtherooms,cases,andpersonnelassIgnmentsareInscrIbedthereonatthebegInnIngof
thedayandmodIfIedorcrossedoffasthedayprogresses.UnderHPAA,patIents'names
maynotbeusedonsuchaboardIfthereIsanychancethatanyonenotdIrectlyInvolvedIn
theIrcarecouldseethem.AlternatIvely,somefacIlItIestapeacopyoftheday'sDF
schedule(IncludIngpatIents'names,ages,andoperatIons)onthewall,whIchwouldalsobe
avIolatIon.ThesameIstrueforsImIlarboardsorpostedschedulesInDFholdIngareasand
PACUs.AnotherIssueoftenoverlookedthatIsveryproblematIcandprobablytheonethat
concernspatIentsthemostIstheobtaInIngofhIstoryInformatIonInalocatIon,suchasa
bedslotbehIndjustacurtaInIntheDFholdIngarea,wheresensItIvemedIcaland
personalInformatIonIsspokenoutloudwIthInearshotofotherpatIents,otherpatIents'
famIlIes,andnonInvolvedcaregIvers.ThIsconcernIsdIffIculttoaddressandthereIsno
oneunIversallyapplIcablesuggestIon.However,anesthesIaprofessIonalswhoInteractwIth
patIentsInsuchenvIronmentsshouldbeassensItIveasphysIcallypossIbletobeIng
overheardandalsoshouldbrIngsuchconcernstotheattentIonofthefacIlIty
admInIstrators.
Further,manyanesthesIologypractIcesalsomustapplyHPAAprovIsIonstotheIrbIllIng
operatIons;thedetaIlswIllvarydependIngonthemechanIsmsusedandagreatdealwIll
dependonwhIchtypeofelectronIcclaImssubmIssIonsoftwareIsbeIngusedbythebIllIng
entItyactuallysubmIttIngtheclaIms.
55
TelephonecallsandfaxesIntooffIcesmustbe
handledspecIallyIfcontaInIngIdentIfIablepatIentInformatIon.PresentatIonofpatIent
InformatIonforQAorteachIngpurposesmustbefreeofallIdentIfIersunlessspecIfIc
IndIvIdualpermIssIonhasbeenobtaInedonprescrIbedprIntedforms.FequestsforpatIent
InformatIonfromawIdevarIetyofoutsIdeentItIes,IncludIngInsurancecompanIesand
collectIonagencIes,mustbeprocessedInHPAAcomplIantways.HPAApolIcyandactIons,
aswellasenforcementactIvItIes,arebeIngdevelopedovertImeandassItuatIons
develop.ThIssystemdependsInpartonpatIentcomplaIntsforbothenforcementand
polIcyevolutIon.nmanypractIcesandpractIcelocatIons,therehavebeenfeworevenno
formalcomplaIntsofvIolatIonsofpatIentprIvacy,IndIcatIngtheInItIalImplementatIonof
HPAAcomplIancemayhavelargelyhadthedesIredeffect.
Electronic Medical Records
0atabases,spreadsheets,andelectronIctransferofInformatIonarenonspecIfIcfeatures
thathavebeenapplIedtohealthcare.TheclassIcmedIcalrecord,ontheotherhand,has
requIredthecreatIonofentIrelynewsoftwareInanattempttoduplIcatethefunctIonof
thehandwrIttenordIctatedtradItIonalchart.ThIshasaffordedopportunItIestomultIple
P.48
competIngcommercIalentItIestoattempttofIllthIsneed.Usually,competIngproprIetary
systemsareIncompatIbleanddonottalktoeachother.ThIsfactseverelylImItsoneof
thehIghlytoutedbenefItsofmedIcalpractIcesgoIngelectronIc.CostIsanothergreat
barrIer,asIstheformIdabletaskofenterIngtherequIredInformatIonfromtheoldpaper
recordsIntotheelectronIcsystem.TherehasbeengovernmentalandpublIcpressurefor
healthcareInstItutIons,facIlItIes,andpractIcestoadoptelectronIcrecordsbecauseofthe
potentIalforIncreasedlegIbIlItycausIngreductIonInerrorsandconfusIon,greaterspeedof
fIlIngandretrIeval,easytransmIssIonoflargeamountsofInformatIon(suchasfroma
surgeon'soffIcetoananesthesIapractIce'sbookIngoffIceandalsotoahospItal's
preoperatIveclInIcorDFholdIngarea),andQAmonItorIngofvastdatabases.ncreased
easeoftransmIssIonandfIlIngofreImbursementclaImsandcostsavIngsfromclerIcalstaff
downsIzIngareclaImsIntendedtoencouragephysIcIanpractIcegroupstoadoptelectronIc
medIcalrecords(E|Fs).However,experIencetodatehassuggestedthatthecommercIally
avaIlablesoftwaresystems(bothforInstItutIonsandpractIcegroups)arenotasrobustor
relIableasadvertIsedbytheIroftenaggressIvemanufacturers.AccordIngly,theexpected
benefItshavenotmaterIalIzedquIteaspredIcted,partIcularlyInthatcostshavebeen
great,oftenfarInexcessofestImates,andcostsavIngshavebeenmInImalatbest.
PractIcegroupsofanesthesIaprofessIonalsshouldconsIderallofthesenotedpoIntsprIor
toInvestIngInanE|Fsystem.AtmInImum,carefulstudyandevaluatIonofthesame
systemalreadyInplaceInanotheranesthesIologypractIceshouldbeundertaken.
fbasIcE|FImplementatIonhasbeenproblematIcforpractIces,trueelectronIcanesthesIa
InformatIonmanagementsystemshavebeenevenmoredIffIcult.TheseInclude
preoperatIve,IntraoperatIve,postoperatIve,bIllIng,andQAcomponents.Fortheactual
DFanesthesIarecord,severalcommercIalversIonsareavaIlable.0IfferentanesthesIa
professIonalshavevarIousopInIonsabouteaseofImplementatIonandsubsequentuse.
UnlessonemassIvebolusoffullyIntegratednewtechnologyfromasInglemanufacturerIs
InstalledallatonetIme,IntegratIonofanewE|FwIththeexIstInganesthesIamachInes
andmonItorstoensurefullaccuratecaptureofalldataparameterscanoftenbedIffIcult
andfrustratIng.ThefunctIonandvalueofelectronIcanesthesIarecordscanbedebated
endlessly.AllofthemtodaywIllrequIrecomputersonorIntheanesthesIamachIne.These
computersshouldbenternetenabledsothatdemographIcandbIllIngInformatIoncanbe
automatIcallyuploadedtothefacIlIty'sandthepractIce'sdatabase.Anysuchsystemmust
alsoIntegratewIththebIllIngsystemsofthefacIlItyandthepractIceorthetouted
benefItswIllbelargelynegated.AgaIn,thebest,andInsomesenses,theonlywayto
evaluateserIouslyandthoroughlyaproposedmajorInvestmentofmoney,effort,andtIme
IstovIsItafullyupandworkIngInstallatIonofthatelectronIcanesthesIaInformatIon
managementsystemandtalkdIrectlyIndetaIlwIththeusers.Thecosts,Inallsensesof
theword,aresogreatthatItremaInsasIgnIfIcantgambletobethefIrsttopurchaseand
Implementsuchasystem.
Expansion Into Perioperative Medicine, Hospital Care, and
Hyperbaric Medicine
SomeanesthesIologIstsnowfunctIonatleastsomeofthetImeInpreoperatIvescreenIng
clInIcsbecauseofthegreatfractIonofDFpatIentswhodonotspendthenIghtbefore
surgeryInthehospItalorwhodonotcometoahospItalatall.nsuchsettIngs,these
anesthesIologIstsfrequentlyassumearoleanalogoustothatofaprImarycarephysIcIan,
plannIngandexecutIngaworkupofoneormoresIgnIfIcantmedIcalorsurgIcalproblems
beforethepatIentcanreasonablybeexpectedtoundergosurgery.LIkewIse,thIsconcept
wouldbeexcellentforthepostoperatIveperIod.AnanesthesIologIst,completelyfreeofDF
orotherdutIes,couldnotonlymakeatleasttwIcedaIlyroundsofpatIentsaftersurgery
andprovIdeexceedInglycomprehensIvepaInmanagementservIce,butalsocouldfollow
thesurgIcalprogressandmakereports(lIkelyvIaanE|ForemaIl)tothesurgeon'soffIce
oralphanumerIcpocketcommunIcator.AfundamentalaspectofthepractIceof
anesthesIologyIsthemanagementofacuteproblemsInthehospItalsettIng.tIslogIcal
thatanesthesIologIstswouldbeamongthephysIcIansbestsuItedtoprovIdeprImarycare
forpatIentsInthehospItalsettIng.
AnaddItIonalevolvIngopportunItyIsthecreatIonandImplementatIonofrapIdresponse
teamswIthInacutecarehospItals.nessence,studIeshaverevealedthatpatIentson
generalcarenursIngfloorssometImesbegIntodeterIorateand,foronereasonoranother
butoftenbecauseoftheresponsIblephysIcIanbeIngunavaIlableorataconsIderable
dIstanceatthatmoment,thepatIentsarenotevaluatedortreatedInatImelymannerand
oftennotuntIltheyhavefurtherdeterIorated,sometImestoacrItIcalstatus.Therefore,a
natIonaltrendhasdevelopedInwhIchhospItalscreateateamofknowledgeable
professIonals(whohaveotherregularresponsIbIlItIes)whousuallyhavenoprIorknowledge
ofthedeterIoratIngpatIentbutwhowIllrespondwIthInaveryfewmInutestothecall
from(usually)afloornursewhodetectsadeterIoratIngpatIent(e.g.,IncreasIngfever,
relatIvehypotensIonandtachycardIa,absenturIneoutput).Frequently,therapIdresponse
teamInstItutesImmedIatesymptomatIctreatment,arrangesforahIgheracuItylevelof
care,andcontactstheprImaryresponsIblephysIcIan.mportantly,InlargerhospItals,It
hasbeensuggestedthattheInhouseanesthesIologIstsareunIquelyqualIfIedtobekey
membersoftherapIdresponseteambecausetheInterventIonsalmostalwaysInvolve
acutebreadandbutterresuscItatIvecare.AlthoughmanyanesthesIologIstsmaybelIeve
theyalreadyhaveplentyofworkIntheDF,suchpartIcIpatIonwhenpossIblewouldbean
outstandIngandhIghlyvIsIblecontrIbutIontothehospItal'smIssIonofenhancedpatIent
care.Also,suchInterventIonscouldbeseparatelybIllableencountersasconsultatIonsor,
alternatIvely,excellentsupportforthemaIntenanceorevenIncreaseofthehospItal's
fInancIalsubsIdytoItsanesthesIaprofessIonalgroup.
FInally,anesthesIologIstsInsomelocatIonshavebecomeInvolvedInthepractIceof
hyperbarIcmedIcIneandwoundcare.ThIsIslIkelyrelatedtothefamIlIarItyof
anesthesIologIstswIthconceptsofgaslawsandphysIcs,alongwIththeIrconstantpresence
InthehospItal.ThetreatmentofvarIousmedIcalcondItIonsbytheapplIcatIonofoxygen
underIncreasedpressure,usually2toJatmospheresabsolute,atonetImewasoneofthe
morerapIdlygrowInghospItalservIces.AnesthesIologIstsareamongtheleadersofthIs
fIeld,wIthunlImItedopportunItIesforclInIcalcare,teachIng,andresearch.EvenabrIef
dIscussIonofthIsfIeldIsoutsIdethescopeofthIschapter,andInterestedreadersare
referredtotheUnderseaandHyperbarIc|edIcalSocIety(www.umhs.org).
Operating Room Management
TheroleofanesthesIologIstsInDFmanagementhaschangeddramatIcallyInthepastfew
years.WIththecurrentclImateofaconsIderableshortageofanesthesIaprofessIonals,
hospItalssubsIdIzIngmanyanesthesIologygrouppractIces,andanIncreasIngworkload,
partIcIpatIonInDFmanagementIsessentIallymandatory.ThecurrentemphasIsoncost
contaInmentandeffIcIencywIllforceanesthesIologIststotakean
P.49
actIveroleInelImInatIngmanydysfunctIonalaspectsofDFpractIcethatwereprevIously
Ignored.FIrstcasemornIngstarttImeshavechangedfromasuggestIontoamandate.
0elaysofanysortarenowoftentrackedelectronIcallyInrealtImeandcarefully
scrutInIzedtoelImInatewasteandIneffIcIency.Together,anesthesIologIsts,surgeons,DF
nursesandtechnIcIans,andIncreasIngly,professIonaladmInIstrators/managersneedto
determInewhoIsbestqualIfIedtobealeaderInthedaytodaymanagementoftheDF.
56
Clearly,dIfferentgroupshavedIfferentperspectIves.However,anesthesIologIstsareInthe
bestposItIontoseethebIgpIcture,bothoverallandonanygIvenday.Surgeonsare
commonlyelsewherebeforeandaftertheIrIndIvIdualcases(andsometImesforthe
begInnIngandtheendoftheIrcases);nursesandadmInIstratorsmaylackthemedIcal
knowledgetomakeapproprIate,tImelydecIsIons,oftenonthefly.tIsthe
anesthesIologIstwIththeInsIght,overvIew,andunIqueperspectIvewhoIsbestqualIfIedto
provIdeleadershIpInanDFcommunIty.ThesubsequentrecognItIonandapprecIatIonfrom
theothergroups(especIallyhospItaladmInIstratIon)wIllclearlyestablIshthe
anesthesIologIstsasconcernedphysIcIansgenuInelyInterestedInthewelfareoftheDFand
theInstItutIon.
Organization
ThesymbIotIcrelatIonshIpbetweenanesthesIaprofessIonalsandsurgeonsremaIns
unchanged.8othgroupsrecognIzethIsfactandalsothecommongoalofhavIngtheDF
functIonInasafe,expedItIousmanner.TheageoldquestIon,WhoIsInchargeofthe
operatIngroom:stIllconfrontsmanyhospItals/InstItutIons.8ecausesomeanesthesIology
groupsaresubsIdIzedbythehospItal,theDForganIzatIonInsuchcaseshaschanged
accordIngly.|anyhospItaladmInIstratorswanttohaveInputregardIngwhoIsInchargeof
theDFwIthaneyetoIncreasIngeffIcIencyandthroughputwhIlereducIngcost.TheIr
wIsheshaveanevenaddedsIgnIfIcancewhenmoreoftheIrdollarsareInvolvedthrough
theanesthesIologygroupsubsIdy.SometImestherecanbenorealanswerto,Who'sIn
charge:becauseofthecomplexItyoftheInterpersonalrelatIonshIpsIntheDF.Some
InstItutIonshaveaprofessIonalmanager(oftenaformerDFregIsterednurse)whosesole
jobIstoorganIzeandruntheDF.ThIsIndIvIdualmaybevestedwIthenoughauthorItyto
berecognIzedbyallasthepersonIncharge.DtherInstItutIonsostensIblyhaveamedIcal
dIrectoroftheDF.However,theImplIcatIonstothesurgeonsthatananesthesIologIstIs
Incharge,orvIceversa,havecausedmanyInstItutIonstoabandonthetItleorretaInthe
posItIonbutassIgnnoauthorItytoIt.nsuchInstances,InstItutIonsusuallyresolvedIsputes
throughsomeauthorItywIthaphysIcIan'sperspectIve.fthereIsnomedIcaldIrectorwIth
authorItytomakedecIsIonsstIck,centralauthorItyusuallyresIdeswIththeDFcommIttee,
mostoftenpopulatedbyphysIcIans,senIornurses,andadmInIstrators.EveryDFhasthIs
forumformajorpolIcyandfIscaldecIsIons.AspartofcommItteefunctIon,thestandard
practIcesofnegotIatIon,dIplomacy,andlobbyIngforvotesareregularlycarrIedout.The
ImpactofsuchanDFcommItteevarIeswIdelyamongInstItutIons.
0espItetheconstantlychangIngdynamIcsoftheDFmanagementandthefrequentmajor
frustratIons,anesthesIologIstsshouldpursueagreaterroleIndaytodaymanagementIn
everypossIbleapplIcablepractIcesettIng.AnanesthesIologIstwhoIscapableoffacIlItatIng
thestartofcaseswIthmInImaldelaysandsolvIngproblemsontheflyastheyarIsewIll
beInanexcellentposItIontoservehIsorherdepartment.SucceedIngInthIsrolewIllhave
adramatIcposItIveImpactonalltheDFconstItuents.ThesurgeonswIllbelessconcerned
aboutwhoIsInchargebecausetheIrcasesaregettIngdone.ThehospItaladmInIstratIon
wIllwelcometheeffortbecausetheywantsomethIngextraInreturnforanymoneythey
arenowgIvIngtotheanesthesIologygroupsasasubsIdy.Furthermore,theDFcommIttee
(orwhateversystemfordIsputeresolutIonIsInplace)IsstIllfunctIonalandhasnotbeen
cIrcumvented(andwIllbethankfulfortheabsenceofdIsputesneedIngresolutIon).
SomeInstItutIonsusethetermClinical Director of the OR.ThepersonawardedthIs
desIgnatIonshouldbeasenIorlevelIndIvIdualwIthfIrsthandknowledgeoftheDF
envIronmentandfunctIon.AnesthesIologIstshaveabetterunderstandIngofthe
perIoperatIveprocess.TheypossessthemedIcalknowledgetomakeapproprIatedecIsIons.
TheIrIntImateassocIatIonwIthsurgeonsandtheIrpatIentsallowsthemtobestallocate
resources.TheAmerIcanAssocIatIonofClInIcal0IrectorsIn2002reportedthat71of
surveyrespondentsstatedthatananesthesIologIstwasdesIgnatedastheClInIcal0Irector
oftheDF.
Contact and Communication
AnImportantIssuefortheanesthesIaprofessIonalsInanyDFsettIngIswhoamongthe
groupwIllbethecontactpersontoInteractwIththeDFandItsrelatedadmInIstratIve
functIons.nsItuatIonsInwhIcheveryoneIsanIndependentcontractor,theremaybea
tItularchIefwhobydesIgnIsthecontactperson.TheanesthesIologIstInthIsrole
commonlychangesyearlytospreadthedutIesamongallthemembers.Largegroupsor
departmentsthatfunctIonasthesoleprovIdIngentItyforthathospItal/facIlItyoften
IdentIfyanIndIvIdualasthecontactpersontoactasthevoIceforthedepartment.
Furthermore,thesesamegroupsdelIneatesomeoneonadaIlybasIstobetheclInIcal
dIrector,orthepersonrunnIngtheboard.Frequently,thIsposItIonIsbestfIlledbyone
ofasmalldedIcatedfractIonofthegroup(e.g.,threepeople)ratherthanrotatIngthe
responsIbIlItyamongeverymemberofthegroup.ExperIencedboardrunnershavean
InstInctuallyderIvedbetterperspectIveonthenuancesofmanagIngtheoperatIngschedule
InrealtIme.CertaInproceduresmayrequIrespecIfIctraInIng(e.g.,transesophageal
echocardIographyskIlls)thatnotallmembersofthegrouppossess.Clearly,changes
sometImeshavetobemadetomatchtheabIlItyoftheanesthesIaprovIderandthe
requIrementsoftheprocedurewhenurgentoremergentcasesareposted.
AnotherbenefItofaverysmallnumberofdaIlyclInIcaldIrectorsIsarelatIveconsIstency
IntheapplIcatIonofDFpolIcIes,partIcularlyInrelatIonshIptotheschedulIngofcases,
especIallyaddons.DneofthemostfrustratIngaspectstobothsurgeonsandDFpersonnel
IsunpredIctabIlItyandInconsIstencyInthedecIsIonsmadebytheanesthesIa
group/departmentmembers.ApatIentdeemedunacceptableforsurgeryby
anesthesIologIstXon|ondaymaybeperfectlyacceptable,InthesamemedIcalcondItIon,
foranesthesIologIstYonTuesday.0IsagreementsareInevItableInanylargegroup.
However,daytodayDFfunctIonmaybehamperedbyalargenumberofthesetypesof
cIrcumstances.HavIngonememberofaverysmallgroupInchargewIllleadtomore
consIstencyInthIsprocess,especIallyIftheboardrunner/clInIcaldIrectorhasthe
authorItytoswItchpersonneltoaccommodatethesItuatIon.WIthoutstIflIngIndIvIdual
practIces,phIlosophIes,andcomfortlevels,acertaInamountofconsIstencyapplIedto
sImIlarclInIcalscenarIoswIllImproveDFfunctIonImmeasurably.ThesefewdedIcated
dIrectorsshouldbeabletoaccomplIshbothgoalsbetterthanalargerotatInggroup.
AnewerpotentIalcomponentofIntraDFcommunIcatIonsIstheconceptofchecklIstsand
teambrIefIngs.AnalogoustothenowrequIredtImeoutIneachDFprIortosurgIcal
IncIsIonwhenthecorrectIdentItyofthepatIent,theIntendedprocedure,andany
lateralItyInvolvedIsverIfIed,someDFsareattemptIngtohaveasImIlarInterprofessIonal
communIcatIon
P.50
InvolvIngallrelevantDFpersonnel(theteam)prIortothepatIententerIngtheactualDF,
durIngwhIchtheInvolvedsurgeon,anesthesIaprofessIonal,cIrculatIngnurse,scrubperson,
andsupportpersonsasIndIcatedeachacknowledgeasummaryofwhatIsprojectedtotake
placeInthIscase,anyantIcIpatedneedforextraorunusualresourcesorequIpment,any
antIcIpateddIffIcultIesorIncreasedrIsks,andspecIfIcplanstodealwIthanyfeatureofany
ofthesepoIntsthatwouldrequIreInterventIon.nmanymodels,aprIntedsInglepage
checklIstwIthroutInepromptsandfIllInboxesIsusedtofacIlItatetheprocess.Dnestudy
reportedatwothIrds'reductIonIncommunIcatIonfaIluresthathaveotherwIselIkely
causedproblems,rIsks,orIneffIcIencIes.
57
Materials Management
Usually,theInstItutIonalcomponentoftheanesthesIaservIcestaffsandmaIntaInsa
locatIoncontaInIngthespecIfIcsupplIesunIquetothepractIceofanesthesIa(the
workroom).DbjectIvesnecessaryforeffIcIentmaterIalsmanagementIncludethe
standardIzatIonofequIpment,drugs,andsupplIes.AvoIdanceofduplIcatIon,volume
purchasIng,andInventoryreductIonarealsoworthwhIle.ThereneedstobecoordInatIon
wIththeDFstaffastowhoIsresponsIbleforacquIsItIonofroutInehospItalsupplIessuchas
syrInges,needles,tubIng,andIntravenousfluIds.0ecIsIonsastowhIchbrandsofwhIch
supplIestopurchaseIdeallyshouldbemadeasagroup.Dften,whenseveralcompanIes
competeagaInsteachotherInanopenmarket,lowerprIcesarenegotIable.These
negotIatIonsmayoccurbetweentheanesthesIaprofessIonalsandthehospItal
admInIstratIon,orbythephysIcIancomponentsoftheDFcommIttee.nmanycases,
however,hospItalsbelongtolargebuyInggroupsthatdetermInewhatbrandsandmodels
ofequIpmentandsupplIeswIllbeavaIlable,wIthnoexceptIonspossIbleexceptatgreatly
Increasedcost.SometImes,thIsIsfalseeconomyIftheprovIdedItemsareInferIor(cheap)
orannoyIngand,forexample,IfItroutInelytakesopenIngthreeorfourIntravenous
cannulaeIntheprocessofstartIngapreoperatIveIntravenouslIneasopposedtothe
hIgherqualItyandrelIablesIngleonethatmaycostmorepercannulabutIslessexpensIve
overallbecausefarfewerwIllbeused.0IspassIonatepresentatIonofsuchlogIcbya
respectedteamplayersenIoranesthesIologIsttotheDFcommItteeordIrectorofmaterIals
managementmayhelpresolvesuchconundrums.
Scheduling Cases
AnesthesIologIstsneedtopartIcIpateIntheDFschedulIngprocessattheIrfacIlItyor
InstItutIon.nsomefacIlItIestheschedulIngoffIceandtheassocIatedclerIcalpersonnel
workundertheanesthesIagroup.Commonly,schedulIngfallsundertheDFstaff's
responsIbIlIty.0IrectcontrolofthescheduleusuallyresIdeswIththeDFsupervIsoror
chargeperson,frequentlyanurse.Whateverthearrangements,theanesthesIagroupmust
haveadIrectlIneofcommunIcatIonwIththeschedulIngsystem.Thenecessarynumberof
anesthesIaprofessIonalsthatmustbesupplIedoftenchangesonadaIlybasIsperthe
caseloadandsometImesbecauseofInstItutIonalpolIcydecIsIons.Afterhourscallmustbe
arranged,polIcychangesfactoredIn,andaddItIons/subtractIonstothesurgIcalload(day
today,weektoweek,andlongtermassurgIcalpractIcescomeandgoInthatDF)dealt
wIthaswell.TheseIssuesareImportantevenwhenalltheanesthesIaprofessIonalsare
IndependentlycontractedandarenotaffIlIatedwItheachother.nsuchsItuatIons,the
tItularchIefofanesthesIashouldbetheonetoactasthelInktotheschedulIngsystem.
WhentheanesthesIagroup/departmentfunctIonsasasIngleentIty,thechaIrman/chIef,
clInIcaldIrector,orappoIntedspokespersonwIllbetheIndIvIdualwhorepresentshIsorher
groupatmeetIngsInwhIchschedulIngdecIsIonsaremadeInconjunctIonwIththeDF
supervIsors,surgeons,andhospItaladmInIstrators.
ThereareasmanydIfferentwaystocreateschedulIngpolIcIesasthereareDFsuItes.|ost
hospItals/facIlItIesfollowpatternsestablIshedovertheyears.0espItealltheefforts
dIrectedtowardItscreatIon,theDFschedule(bothweeklytImeallotmentsanddaytoday
schedulIngofspecIfIccases)remaInsoneofthemostcontentIoussubjectsfortheDF.
FecognIzIngthefactthatItIsImpossIbletosatIsfyeveryone,theanesthesIagroupshould
endeavortofacIlItatetheprocessasmuchaspossIble.nItIally,anesthesIologIstsneedto
besympathetIctowardallthesurgeons'desIres/demands(statedorImplIed)andattempt
tocoordInatetheserequestswIththeInstItutIon'sabIlItytoprovIderooms,equIpment,and
staff.Secondly,theanesthesIagroupshouldmakeeverypossIbleefforttoprovIdeenough
anesthesIaservIcesandpersonneltorealIstIcallymeetthegoalsoftheInstItutIon.nlIght
ofthecurrentshortageofanesthesIaprofessIonalsInthIscountry,theseeffortsneedtobe
madewIthagreatdealofopencommunIcatIonamongallcontIngencIesoftheDF
commItteeaswellaseverymemberoftheanesthesIagroup.
FegardIngschedulIng,surgeonsessentIallyfallIntooneofthreegroups.Dnegroupwantsto
operateanytImetheycangettheIrcasesscheduled.ThIsgroupwantstheDFopen24/7.
AnotherlargergroupwantsfIrstcaseofthedayasoftenaspossIblesotheycangetto
theIroffIces.AsmallerthIrdgroupwantseItherthefIrsttImeslotoranopenIngfollowIng
thattImeslot,aseveralhourhIatus,thentoreturntotheDFafteroffIcehoursto
completeaddItIonalcases;usuallystartIngafter5P|.ClearlyacompromIseamongthese
dIsparateconstItuencIesmustbereached.AnesthesIologIstswhoapproachtheDF
commItteeregardIngthIsdIlemmawIthanonconfrontatIonalattItudewIllgreatly
facIlItateagreementonacompromIse.
Types of Schedules
ThemajorItyofDFsuseeItherblockschedulIng(preassIgnedguaranteedDFtImefora
surgeonorsurgIcalservIcetoschedulecasesprIortoanagreeduponcutofftIme;e.g.,24
or48hoursbefore)oropenschedulIng(fIrstcome,fIrstserve).|ostlargeInstItutIonshave
acombInatIonofboth.8lockschedulIngInherentlycontaInsseveraladvantageousaspects
forcreatIngaschedule.8lockschedulIngallowsformorepredIctabIlItyInthedaIlyDF
functIonaswellasaneasyrevIewofutIlIzatIonofallottedtIme.HIstorIcutIlIzatIondata
shouldberevIewedwIthsurgeons,DFstaff,andtheDFcommItteetodetermIneIts
valIdIty.|anyoperatIngsuIteshavefoundItusefultoassemblerathercomprehensIve
statIstIcsaboutwhatoccursIneachDF.SomecomputerIzedschedulIngsystems(see
followIngdIscussIon)arepartofalargercomputerIzedperIoperatIveInformatIon
managementsystemthatautomatIcallygeneratesstatIstIcs.CraphIcexamplesare1J
monthstatIstIcalcontrolchartsorrunchartsthatshowthenumberofcases,number
ofDFmInutesusedforthosecases(andwhen,suchasInblock,exceedIngblock,evenIngs,
nIghts,weekends,andsoforth),numberofcancellatIons(andmultIpleotherrelated
parametersIfdesIred)byservIce,byIndIvIdualsurgeon,andtotalforthecurrentmonth
andthe12prIormonths,alwayswIthcontrollImIts(usually2S0fromthe1Jmonth
movIngaverage)clearlyIndIcated.AllthesedataarevaluableInthattheygeneratea
clearpIctureofwhatIsactuallygoIngonIntheDF.tIsalsoextremelyvaluableInthat
blocktImeallocatIonshouldberevIewedperIodIcallyandadjustedbasedonchanges,
degreeofutIlIzatIon,andprojectedneeds.nflexIbleblocktImeschedulIngcancreatea
majorpoIntofcontentIonIftheassIgnedblocksarenotregularlyreevaluated.Thesurgeon
orsurgIcalservIcewIththeearlystartIngblockthathabItually
P.51
runsbeyondhIsorherblocktImewIllcreateproblemsforthefollowIngcases.fthIs
surgeonweremadetoscheduleIntothelaterblockonarotatIngbasIs,delaysInhIsorher
startcausedbyothersmayprovokeImprovedaccuracyofhIsorhersubsequentearlycase
postIngs.AdjustmentsInavaIlabIlItyofblocktImecanalsobemadeInthesettIngofthe
releasetIme,thetImeprIortotheoperatIvedatethatagIvenblockIsdeclarednotfull
andbecomesavaIlableforopenschedulIng.SurgeonspreferaslateareleasetImeas
possIbleInordertomaIntaIntheIraccesstotheIrDFblocktIme.However,unused
reservedblocktImewastesresourcesandpreventsanotherservIcefromschedulIng.A
sInglereleasetImerarelyfItsallcIrcumstances,butnegotIatIngservIcespecIfIcrelease
tImesmayleadtoImprovedsatIsfactIonforall.ntheIdealsystem,enoughDFtImeand
equIpmentshouldexIsttoprovIdeforeachsurgIcalservIce'sgenuIneneedswhIleretaInIng
theabIlItytoaddtotheschedule(vIaopenschedulIng)asneeded.SuchanenvIronment
doesnotexIst.nvarIably,InbusyenvIronments,surgIcaldemandexceedsavaIlableblock
andopentIme,leadIngservIcestorequestaddItIonalblocktIme.WhenthIstImeIsnot
granted,servIcesperverselythenscheduleproceduresInopentImebeforefIllIngtheIr
blocktIme.SurgeonswhopreferopentImewouldthenbeshutoutofDFtIme.Dpen
schedulIngmayrewardthosesurgeonswhorunaneffIcIentservIce,butItalsomaybea
sourceofproblemstothosesurgeonswhohaveasIgnIfIcantportIonoftheIrservIcearrIve
unscheduled,suchasorthopaedIcsurgeons.SomedegreeofflexIbIlItywIllbenecessary
whIcheversystemIsused.TheanesthesIagroupshouldadoptaneutralposItIonInthese
dIscussIonswhIlebeIngrealIstIcaboutwhatcanbeaccomplIshedgIventhenumberofDFs
andthelengthofthenormaloperatIngday.
ThehandlIngoftheurgent/emergentcasepostIngprecIpItatesagreatdealofdIscussIonIn
mostDFenvIronments.NostudIesallowdetermInatIonofexactlywhatrateofDF
utIlIzatIonIsthemostcosteffectIve.However,manyInstItutIonssubscrIbetofollowIng
parameters:adjustedutIlIzatIonratesaveragIngbelow70arenotassocIatedwIthfulluse
ofavaIlableblocktIme,wastIngresources,whIleratesabove90arefrequentlyassocIated
wIththeneedforovertImehours.
58
0IfferentDFconstItuencIeshavedIfferentcomfort
zonesfordegreesofutIlIzatIon(Table22).|ostInstItutIonscannotaffordtohaveoneor
twoDFsstaffedandwaItIngunlessthereIsarelIablesteadysupplyoflateopenschedule
addItIons,thatIs,urgentcases/emergencIes,durIngtheregularworkday.AprevIously
agreedupon,clearalgorIthmfortheacceptanceandorderIngofthesecaseswIllneedto
beadopted.ngeneral,crItIcallIfethreatenIngemergencIesandelectIveaddonsare
faIrlystraIghtforwardandatthetwoendsofthespectrum.ThecrItIcalemergencygoesIn
thenextavaIlableroom,whereastheelectIvecasegetsaddedtotheendoftheschedule.
ThesocalledurgentpatIentrequIresthemostjudgment.ndIvIdualservIcesshould
provIdeguIdelInesandlImItatIonsfortheIrexpectedurgentcases.Theseaddoncase
polIcyguIdelInes
59
shouldbecommonknowledgetoeveryoneInvolvedInrunnIngtheDF.
Consequently,thesecases,suchasectopIcpregnancIes,openfractures,thepatIentwIth
obstructedbowel,andeyeInjurIes,canthenbetrIagedandInsertedIntotheelectIve
scheduleasneededwIthmInImaldIscussIonfromthedelayedsurgeon.Thesurgeonswhose
urgentcaseIspresentedasonethatmustImmedIatelybumpanotherservIce'spatIent,yet
couldwaItseveralhoursIfItIstheIrownpatIentthatwIllbedelayed,wIllhavetoface
theIrownprevIouslyagreeduponstandardsInafutureDFcommItteemeetIng.AsImple
waytoexpressonelogIcalpolIcyforurgentcases(e.g.,acuteappendIcItIs,unruptured
ectopIcpregnancy,IntestInalobstructIon)Is:1)bumpthesamesurgeon'selectIve
scheduledcase;2)Ifnone,bumpascheduledcaseonthesameservIce(gynecology,
generalA,andsoforth);J)Ifnone,bumpascheduledcasefromanopenschedulesurgIcal
servIce;and4),Ifnone,bumpascheduledcasefromablockscheduleservIce.
59
Some
InstItutIonsrequIretheattendIngsurgeonofthepostedurgent/emergentpatIenttospeak
personallywIththesurgeonofanybumpedcase.
Table 2-2 Operating Room (or) Utilization: Comfort Zones of the
Operating Room Personnel Constituencies
BLOCK TIME UTILIZATION
(%)
FACILITY
ADMINISTRATION
ANESTHESIOLOGY
GROUP
OR
STAFF
SURGEONS
100 ++
85100 ++++ ++
7084 +++ ++++ + +/
5J69 + +++ +++ ++
55 ++ ++++
+,favorable;,unfavorable.
FeprIntedfrom|azzeIWJ:DFmanagement:Stateoftheart.ProceedIngsofthe
200JConferenceonPractIce|anagement.ParkFIdge,L,AmerIcanSocIetyof
AnesthesIologIsts,200J,p.65wIthpermIssIon.
AnotherareaofburgeonInggrowththatmustbeaccountedforInthedaIlyworkscheduleIs
thenonDFoffsItedIagnostIctest,ortherapeutIcInterventIonthatrequIresanesthesIa
care.nmanyInstancestheseproceduresreplaceoperatIonsthat,Intherecentpast,
wouldhavebeenpostedontheDFscheduleasurgent/emergencycases.Forexample,
cerebralaneurysmcoIlIngandcomputedtomographyguIdedabscessdraInage,among
otherprocedures,aredoneInImagIngsuItes;somepatIents,adultaswellaspedIatrIc,
requIredeepsedatIonorevengeneralanesthesIaformagnetIcresonanceImagIngor
computedtomographyInradIologyorforInvasIveproceduresIncatheterIzatIon
laboratorIes.AddItIonally,dependIngondIstancesInvolvedandlogIstIcs,Itmayevenbe
necessarytoassIgntwopeople,aprImaryprovIderandanattendIng,exclusIvelytothat
oneremotelocatIonwhen,hadthecasecometotheDF,theattendIngmayhavebeen
abletocoveranotherorothercasesalso.HospItaladmInIstratIonortheDFcommIttee
maytrytovIewthesecasesasunrelatedtoDFfunctIonand,thus,purelyaproblemforthe
anesthesIagrouptosolve.ThesecasesmustbetreatedwIththesamemethodology
regardIngaccessandprIorItIzatIonasallotherDFprocedures.
nordertoapportIonhospItalbasedanesthesIaresourcesreasonably,theseoffsIte
proceduresshouldbesubjecttothesameguIdelInesandprocessesasanyotherDFpostIng.
|ostInstItutIonshaveaddedatleastoneextraanesthetIzInglocatIontotheIrformal
operatIngscheduletodesIgnatetheseoffsIte
P.52
procedures(occasIonallywIthanImagInatIvenamesuchasroadshow,outfIeld,or
safarI).FormanyoftheseoffsItecases,thereIslIttleornoreImbursementfor
anesthesIacare.|ostgovernmentplansandInsurancecarrIerswIllprobablynotpayfor
theclaustrophobIcadulttoreceIvemonItoredanesthesIacareorevenageneralanesthetIc
foranobvIouslyneededdIagnostIcmagnetIcresonanceImage,eventhoughthepatIent,
thesurgeon,andthehospItalbenefItfromthetestresults.TheanesthesIagroup,theDF
commIttee,andthehospItaladmInIstratIonneedtoreachcompromIsesregardIngoffsIte
procedures,regardIngschedulIng,allocatIonofanesthesIaresourcesthatwouldotherwIse
gototheDF,andevensubsIdIzatIonofthepersonnelcostsInordertocontInuethIs
obvIouslybenefIcIalservIce.
Computerization
ComputerIzedschedulIngwIlllIkelybenefIteveryDFregardlessofsIze.WhetherthIs
schedulIngfunctIonshouldbeonecomponentofacomprehensIveE|FsystemIsacomplex
questIon,asprevIouslynoted.ntheDF,however,computerIzatIonallowsforafaster,
moreeffIcIentmethodofcasepostIngthananyhandwrIttensystem.Changestothe
schedulecanbemadequIcklywIthoutanylossofInformatIon.FearrangIngthedaIly
scheduleIsmuchsImpleronacomputerthanerasIngandrewrItIngonaledger.
Furthermore,mosthospItalshaveadoptedacomputerdetermInedaveragetImefora
gIvensurgIcalprocedureforthatpartIcularsurgeon.Commonly,thIstImeIstheaverageof
thelast10(or10ofthelast12,wIththelongestandshortestdIscarded)ofthespecIfIc
procedure(e.g.,totalkneereplacement)wIththepotentIaltoaddamodIfIer(e.g.,ItIsa
repeatsurgery)thatshowsamaterIaldIfferenceIntheprojectedtImelength(almost
alwayslonger)foronepartIcularpatIenttype.SupposesurgeonXhasblocktImeof8hours
onagIvendayandwantstoschedulefourproceduresInthatallottedtIme.The
computerIzedschedulIngprogramlooksatsurgeonsX'spastperformancesanddetermInesa
projectedlengthforeachoftheproceduresthatareIdentIfIedtothecomputerusuallyby
CPT4codesorpossIblysomeothercodedevelopedlocallyforfrequentproceduresdoneby
surgeonX.(NotethattherecordedtImelengthIncludestheturnovertIme,thusmakIngthe
casetImedefInItIonfromthetImethepatIententerstheDFuntIlthetImeanyfollowIng
patIententersthatDF[unlessanexceptIonIsenteredspecIfIcallyforanunusual
cIrcumstance].)TheuseofagreeduponcodesInsteadofjusttextdescrIptIonshelpsensure
accuracybecauseItelImInatesanyneedfortheschedulIngclerktoguesswhatthesurgeon
Intendstodo.8ookIngsInmostcIrcumstancesshouldnotbetakenwIthoutthe
accompanyIngcodes(surgeons'offIcesobjectIonsnotwIthstandIng).Thecomputerthen
decIdeswhethersurgeonXwIllfInIshthefourproceduresIntheallottedblocktIme.fthe
computerconcludesthatthefourthcasewouldfInIshsIgnIfIcantly(thedefInItIonofwhIch
canbedetermInedandenteredIntotheprogram)beyondtheavaIlableblocktIme,ItwIll
notacceptthefourthcaseIntothatroom'sscheduleonthatpartIcularday.Thesurgeon
wIllacceptthecomputer'sassIgnedtImesandadjustaccordIngly,plannIngonlythree
cases,orappealforanexceptIonbasedonsomefactornotInthebookIngthatIsclaImed
wIllmaterIallydecreasethetImeneededforatleastoneofthefourcases,whIchthe
surgeonmustexplaIntotheexceptIonczar(anesthesIologyclInIcaldIrectororDFcharge
nurse)oftheday.AnalternatIvemethodhasthecomputersImplyadd(toeachcaseexcept
thelast)aprojectedturnovertImethatIsagreeduponbyallInvolvedatan(often
contentIous)DFcommItteemeetIng.ComputerIzIngtheschedulIngprocesssIgnIfIcantly
reducesanypersonalbIasesandsmoothesouttheentIreoperatIngday.ThelongstandIng
rItualoflateafternoondIsputesbetweenthesurgeonsandtheanesthesIagroupand/orDF
staffwhetherornottostartthelastcasemaybeelImInatedoratleastreducedbythIs
morerealIstIcprospectIveDFschedulIngmethod.
TherearemanyvarIablestoconsIderInanyDFschedulIngsystem.ThepatIentpopulatIon
servedandthenatureoftheInstItutIondIctatetheoverallstructureoftheDFschedule.
nnercItylevel1traumacentersmustaccommodateemergencIesonaregularbasIs,24
hoursaday.ThesecentersareunlIkelytocreateaworkableschedulemorethanadayIn
advance.AnambulatorysurgerycenterservIngplastIcsurgerypatIentsmayseeonlythe
rareemergencybrIngbackbleedIngpatIent.TheIrschedulemaybeaccuratemanydaysIn
advance,wIthahIghdegreeofexpectatIonthatthepatIentwIllarrIveontImeproperly
preparedforsurgery.TheanesthesIagroupatthIsambulatorycentermayrarelyhaveto
makechangestotheschedule,allowIngthemtoproceedwIthafaIrlypredIctabledaIly
workload.AttheInnercItytraumahospItal,agreatdealofflexIbIlItyandconstant
communIcatIonwIththesurgeonswIllberequIredInanattempttogetthecasesdoneIna
reasonabletImeframewIththeInherentconstraIntsplacedontheDFstaff'sresourcesand
thetImeavaIlable.ThesetwoextremeexamplesfromopposIteendsoftheschedulIng
processspectrumcanprovIdeguIdelInesforthemajorItyoftheInstItutIonsthatfall
somewhereInbetween.8eyondopencommunIcatIon,howbesttoworktowardthIsmutual
understandIngdependsonthepartIcularsofthepeopleInvolvedandtheenvIronment,but
someDFsreportbenefItsfromteambuIldIngexercIses,leadershIpretreats,andevenDF
wIdesocIalevents.DFswIthapartIcularlymalIgnanthIstoryoffIngerpoIntIngandbad
feelIngsamongthepersonnelgroupsmayconstItuteoneofthefewInstancesanoutsIde
consultantreallymaybevaluableInthatthereareworkplacepsychologIstswhospecIalIze
InanalyzIngdysfunctIonalworkenvIronmentsandImplementIngchangestoImprovethe
sItuatIonforallInvolved.
Preoperative Clinic
AnanesthesIapreoperatIveevaluatIonclInIc(APEC)thatprovIdesacomprehensIve
perIoperatIvemedIcalevaluatIonusuallyresultsInamoreeffIcIentrunnIngoftheDF
schedule.
60,61
UnantIcIpatedcancellatIonsordelaysareavoIdedwhentheanesthesIagroup
evaluatescomplexpatIentsprIortosurgery.EvenIfthepatIentarrIvestotheDFontIme
thedayofsurgery,InadequatepreoperatIveclearancemandatIngtheorderIngof
addItIonaltestswIllconsumeprecIousDFtImedurIngthedelaywaItIngforresults.
CancellatIonsordelaysadverselyaffecttheeffIcIencyofanyDF.SubsequentcasesInthe
delayedroom,whetherforthesameoradIfferentsurgeon,maygetsIgnIfIcantlydelayed
orforcedtobesqueezedIntoanalreadybusyscheduleonanotherday.ThefInancIal
ImpactofdelaysorcancellatIonsontheInstItutIonIsconsIderable.FevenueIslostwIthno
offsettIngabsenceofexpenses.Worse,expensesmayactuallyIncreasewhenovertImehas
tobepaId,orthesterIleequIpmenthastoberepackagedafterhavIngbeenopenedforthe
canceledprocedure.Evenworse,theInconvenIencedpatIentand/orsurgeonmaygoto
anotherfacIlIty.
DptImaltImIngforpreoperatIveevaluatIonshouldberelatedtotheInstItutIon'sschedulIng
preferences,patIentconvenIence,andtheoverallhealthofthepatIent.EarlIercompletIon
ofthepreoperatIveevaluatIonmaynotreducetheoverallcancellatIonratewhen
comparedwIthamoreproxImateevaluatIon.However,anearlyevaluatIonandclearance
maywellprovIdealargerpoolofpatIentsavaIlabletoplaceontheDFschedule(blockor
open)resultIngInamoreeffIcIentuseofDFtIme.AddItIonally,aprotocoldrIven
evaluatIonprocesscanantIcIpatepossIbleneedfortImeconsumIngInvestIgatIons(suchas
acardIologyevaluatIonforthepatIentwIthprobableangIna).EarlyrecognItIonofafaIled
preoperatIvetestallows
P.5J
tImeforanotherpatIenttobemovedIntothenowvacanttImeslot.Also,early
IdentIfIcatIonofcertaInproblemsrequIrIngspecIalcareonthedayofsurgery(e.g.,
preoperatIveepIduralorPAcatheterplacement)shouldleadtofewerunantIcIpated
delays.Unfortunately,manyIssuesprecIpItatIngdelaysaredIscoveredonthedayof
surgery.SomeofthesepreventabledelaysareunrelatedtothepatIents'healthstatus.
SeemInglysImpleIssuessuchasverIfIcatIonofarIdehomeorIncompletefInancIal
InformatIonalsocontrIbutetounexpecteddelays.AproperlyfunctIonIngAPECmaybeable
toelImInateamajorItyoftheseannoyIngcausesofpreventabledelays.
FegardlessoftheInstItutIonalspecIfIcssurroundIngtheservIceprovIdedbytheAPEC,
furthercostsavIngscanbeobtaInedthroughItsproperusagebytheanesthesIagroup.The
APECfrequentlyreducesdramatIcallythenumberofpreoperatIvetestsperformedby
focusIngonwhIchdIagnostIctestsandmedIcalconsultsarereallyrequIredforanyspecIfIc
patIent.nsomecIrcumstances,theAPECmayalsofunctIonasanaddItIonalsourceof
revenuefortheanesthesIagroupwhenaformalpreoperatIveconsultonacomplIcated
patIentIsorderedwellInadvancebythesurgeon,Inthesamemanneraswouldhave
otherwIsebeendIrectedtoaprImarycarephysIcIanforclearanceforsurgery.The
abIlItytocentralIzepertInentInformatIonIncludIngadmIssIonprecertIfIcatIon/clearance,
fInancIaldata,dIagnostIcandlaboratoryresults,consultreports,andpreoperatIve
recommendatIonsImprovesDFfunctIonbydecreasIngthetImespentsearchIngforall
theseItemsafterchangeshavebeenmadetotheschedule.PatIentandfamIlyeducatIon
performedbytheAPECfrequentlyleadstoanIncreaseInpatIents'overallsatIsfactIonof
theperIoperatIveexperIence.naddItIon,patIentanxIetymaybereducedsecondaryto
themoreIndepthcontactpossIbleInherentIntheAPECprocesswhencomparedwIth
anesthesIapractItIonersmeetInganambulatoryoutpatIentforthefIrsttImeInanDF
holdIngareaImmedIatelyprIortosurgery.TheAPECmodelenablestheanesthesIagroupto
bemoreactIveandproactIveIntheperIoperatIveprocess,ImprovIngtheIrrelatIonswIth
theotherDFconstItuents.
Anesthesiology Personnel Issues
nlIghtofthecurrentandfutureshortageofanesthesIacareprovIders,creatIng,
managIng,andmaIntaInIngastablesupplyofanesthesIapractItIonerspromIsesto
domInatetheDFlandscapeforyearstocome.
62
ActIverecruItIngforanesthesIologIsts
appearstobewIdespreadandIntense,sometImesInvolvIngcreatIvemarketIngand
IncentIves.
6J
TheleanresIdentrecruItIngyearsofthemIdtolate1990scontInuetoImpact
theprofessIon.EventhoughapplIcatIonstoanesthesIologyresIdencIesfromhIghlyqualIfIed
applIcantsreboundedsIgnIfIcantly,
62
ItwIlltakemanymoreyearsofrelatIvelylarge
numbersofanesthesIaresIdencygraduatestoevenbegIntoaddressactualneeds.
64
Further,justastheoverallprojecteddramatIcshortageofphysIcIansIngeneralhasledto
theopenIngandplannIngofseveralnewmedIcalschoolsIntheUnItedStates,perhapsthe
shortageofanesthesIologIsts(stIllestImatedatseveralthousand)wIllprovokethe
establIshmentofnewresIdencytraInIngprograms.Furthermore,thesupplyofnonphysIcIan
anesthesIaprofessIonalsIsalsodwIndlIng.WIththeagIngpopulatIonofnurseanesthetIsts
andthelImItednumberofapplIcatIonstoschoolsInthatprofessIon,aswellasthevery
lImItednumberoftraInIngfacIlItIesforanesthesIologyassIstants,theoverallsupplyof
anesthesIaprofessIonalsremaInsInadequatetomeetcurrentand,atleast,shortterm
futuredemands.TheneedforanesthesIagroupstocreateaflexIble,attractIvework
envIronmentInordertoretaInprovIderswhomIghtleaveorretIrewIllcontInueto
Increase.
ArelatedIssueIsconsIderatIonofwhatIsareasonableworkloadforananesthesIologIst
andhowbesttomeasure,IfpossIble,theclInIcalproductIvItyofananesthesIagroup/
department.ThesequestIonshavebeenthesubjectofconsIderabledIscussIon.
65,66,67,68
8eyondthesImplenumberoffulltImeequIvalents,cases,andDFmInutes,consIderatIon
offactorssuchasthenatureofthefacIlIty,typesofsurgIcalpractIce,patIentacuIty,and
speedofthesurgeonsmustbeIncorporatedtoallowfaIrcomparIsons.ThoughtfulfIlterIng
ofresultIngdatashouldtakeplacebeforedIssemInatIonoftheaggregateInformatIontoall
membersofagroupbecauseoftheunderstandableextremesensItIvItyamongstressedand
fatIguedanesthesIologIststoasuggestIonthattheyarenotworkIngashardastheIr
group/departmentpeers.
ExceptInhIghlyunusualcIrcumstances,flexIbleschedulIngofanesthesIaprofessIonalsand
alsofulfIllIngthedemandsplacedonthegroupbytheInstItutIoncontInuestobea
constantbalancIngact.ThIsdemandassumesaddedsIgnIfIcancebecauseInstItutIonsnow
subsIdIzemanyanesthesIagroups.EvenwhenamajorItyofprovIdersInafacIlItyare
IndependentcontractorswhereItIsrequIredthataspecIfIcsurgeonrequesttheIrservIces,
therearetImeconflIctsrangIngfromnooneatallbeIngavaIlabletounwanteddowntIme.
WhentheanesthesIagroup/departmentacceptstheresponsIbIlItyofprovIdInganesthesIa
servIcesforanInstItutIon,theymustscheduleenoughprovIdersforthatDFsuIteoneach
gIvenday.deally,asuffIcIentnumberofprofessIonalswouldbehIredsothattherewould
alwaysbeenoughpersonneltostaffthemInImumnumberofroomsscheduledonanygIven
day,aswellasafterhourscallduty.ThIssItuatIonrarelyexIstsbecauseItwouldbe
fInancIallydIsadvantageoustohaveanexcessnumberofprovIderswIthnoclInIcal
actIvIty.HavIngexactlytherIghtnumberofanesthesIaprofessIonalsInagroupforthe
clInIcalloadworkswelluntIlone(ormore)ofthemIsoutwIthanunplannedabsencesuch
asanextendedIllnessorafamIlyemergency.|anyacademIcdepartmentshaveanatural
bufferwIthsomeclInIcIansassIgnedIntervalsofnonclInIcaltImeforresearch,teachIng,or
admInIstratIvedutIes.However,repeatedlossofthesenonclInIcaldaysbecauseof
InadequateclInIcalstaffIngIntheDFleadstoundermInIngtheacademIc/researchmIssIon
ofthedepartment.ContInuedlossofthIstImewIlleventuallyleadtofacultyresIgnatIons
(andpossIblemIgratIontoprIvatepractIce),thuselImInatIngtheorIgInalbuffer.
Consequently,anesthesIagroups/departmentsneedtoantIcIpateavaIlableclInIcal
personnelandmatchthemtotheDFdemands.deally,thIsInformatIonshouldbeaccurate
forseveralmonthsIntothefuture.|eetIngthIsspecIfIcatIonhasbecomemoredIffIcultIn
therecentpast.HospItaladmInIstratorsmustofferreasonableassurancestotheanesthesIa
groupprovIdIngservIcethatagIvenDFutIlIzatIonrateIslIkely,aswellasaccuratedata
regardIngreImbursement(payermIxandanypackagecontractsnegotIatedbythe
hospItal).ThesedatamustbeprovIdedaccuratelyandupdatedfrequentlyIfahealthcare
InstItutIonIstoacquIreandretaInananesthesIagroupstaffedwIththepersonneltomeet
theexpecteddemands.
Timing
EachoperatIngenvIronmenthasItsownpersonnelschedulIngsystemandexpectatIonsfor
theanesthesIagroup.0aIlycoordInatIonbetweentheanesthesIagroup'sclInIcaldIrector
andtheDFsupervIsorpermItstheconstructIonofareasonablescheduleshowIngthe
numberofDFsthatdayandwhenthescheduleexpectseachofthemtofInIsh.nvarIably,
somecasestakelongerthanantIcIpatedoraddonsareposted,requIrIngtheDFtorunInto
thelateafternoonorearlyevenIng.|anyanesthesIaprofessIonalsacceptthIsoccurrence
asamatterofcourse.FewanesthesIaprofessIonalswIlltoleratethIssequenceofeventsas
anessentIallydaIlyroutInewhethertheyarepaId
P.54
overtImeornot.ThesepractItIonersbecomeexhaustedandresenttheburdens
contInuouslyplacedonthem.ftheDFscheduleIssuchthataddonsfrequentlyoccurand
electIvecasesrunwellIntotheevenIng,manyanesthesIaprofessIonalswIllopttoprotect
theIrpersonalandfamIlytImeandcutbacktheIrworkInghoursorresIgn.NeItherwouldbe
welcomeInsuchatIghtmarket.UnderthesecIrcumstances,hIrIngaddItIonalpersonnel
whoarescheduledtoarrIveatalatertIme,forexample,11:00A|,andthenprovIdIng
lunchrelIefandstayInglate(e.g.,7:J0P|orlaterIfneeded)tofInIshtheschedulemay
wellbeaveryworthwhIleInvestment.
AnotherpossIblesolutIontothedemandsofanextendedDFscheduleonananesthesIa
group'spersonnelmayrevolvearoundemployIngparttImeanesthesIaprofessIonals.Part
tImeopportunItIescouldenhanceagroup'sabIlItytoattractaddItIonalstaff.nthepast,a
dIsproportIonatelyhIghpercentageofwomenchoseanesthesIologyasacareer.n1970,
womenrepresented7.6ofthephysIcIanpopulatIonbutwere14ofanesthesIologIsts;
muchmorerecently,theymakeup45ofthephysIcIanpopulatIonandonly20of
anesthesIologIsts,proportIonatelyasIgnIfIcantreductIon.
69
8eyondthebasIcdemographIc
shIftamongallphysIcIans,onelIkelypartIalexplanatIonforthedecreasednumberof
womenanesthesIologIstsmaybethelackofparttImeposItIons,whIchwIllhamperan
anesthesIagroup'sabIlItytoattractandkeepatleastsomeofthefemaleanesthesIa
professIonals.
SchedulIngafterhourscoveragealsoaddstothepersonneldIffIcultIesfacIngthe
anesthesIagroup.ThevarIatIonsofcallschemesareendless.ThenatureoftheInstItutIon
andtheworkloaddetermInethedegreeoflatenIghtcoverage.|ajorreferralcentersand
level1traumacentersrequIreInhouseprImaryprovIders.ftheseprovIdersInclude
resIdentsand/ornurseanesthetIsts,thenthesupervIsIngattendIngstaffwIllalsobeIn
house24hoursaday.AcommonsolutIonemployedatmanyInstItutIonsIstostaffthe
evenIng/nIghtcallshIftsforanaverageworkload,recognIzIngthatonsomeoccasIons
therewIllbeIdleDFs,andonothernIghts,thesurgIcaldemandwIllexceedthecallteam's
numbers.
TherearealsomedIcolegalIssuessurroundIngthecallteam'savaIlabIlIty.Atasmall
communItyhospItalwIthalImItednumberofIndependentattendIngpractItIoners,the
practItIonersmayagreetocovercallonarotatIngbasIs.TheIndIvIdualsnotoncallare
usuallynotoblIgatedtotheDFandmaywellbetrulyunreachable.Whathappensthen
whentheoncallanesthesIologIstIsadmInIsterIngananesthetIcandanothertrue
emergencycasearrIvesIntheDFsuIteandtheremaInIngstaffanesthesIologIstsare
legItImatelyunavaIlable:0oesthatanesthesIologIstleavehIsorhercurrentpatIentunder
thecareofanDFnurseandgonextdoortotendtoamoreacutely(possIblycrItIcally)Ill
patIent:ShouldthepatIentbetransferredfromtheemergencydepartmenttoanother
(hopefullynearby)hospItal:ThesequestIonshavenoeasyanswers.Clearly,those
practItIonersonthescenehavetoassessInrealtImetherelatIverIsksandbenefItsand
makethedIffIcultdecIsIons.fthecalldutyrequIresthepractItIoner(s)frequentlytowork
muchorallofthenIght,leavIngtheIndIvIdual(s)stressedandfatIgued,theyshouldnotbe
requIredtoworkthenextdaydurIngnormalworkInghours.
AmorecomplIcatedanswerInvolveswhattodowhenthecallassIgnmentrarelyrequIresa
longnIght'sworkandtheoncallanesthesIaprofessIonalsroutInelyhaveroomsassIgnedto
themthenextday,butatleastonepersonhasjustfInIshedadIffIcult24hourshIftbeIng
awakeandworkIngallnIght.AnesthesIagroupsneedtodecIdehowtohandlethepossIble
callshIftscenarIos,wIthpermutatIonsandcombInatIons,andclearlycommunIcate
prospectIvelytheIrdecIsIonstotheDFcommItteebeforeanydIffIcultdecIsIonhastobe
madeonemornIng.Asalways,themedIcolegalaspectsofanydecIsIonsuchasthIsneedto
betakenIntoconsIderatIon.WhetherornotfatIguewasafactor,thepractItIonerwho
workedthroughoutthenIghtbeforeandappearedtocontrIbutetoananesthetIc
catastrophethenextmornIngwouldhaveaverydIffIcultdefenseIncourt.Further,the
anesthesIologygroupmayalsobeheldlIableInthattheIrpractIce/polIcywasInplace,
allegedlyauthorIzIngthesupposedlydangerousconduct.
Cost and Quality Issues
DneofthemorepervasIveaspectsofAmerIcanmedIcalcareIntoday'senvIronmentIsthe
drIvetomaIntaInandImprovehIghqualItyhealthcarewhIlereducIngthecostofthat
care.Healthcarecostsaccountforaremarkable16ofthegrossdomestIcproduct,nearly
trIplethefractIonageneratIonago.EvenmorealarmIng,IfcostscontInuetoIncreaseat
thecurrentrate,by2016,ItwIllbe20ofthegrossdomestIcproduct.Consequently,all
physIcIans,IncludInganesthesIologIsts,areurgedconstantlytoIncludecostconscIousness
IndecIsIonsbalancIngthenaturaldesIretoprovIdethehIghestpossIblequalItyofcare
wIththeoverallprIorItIesofboththehealthcaresystemandtheIndIvIdualpatIent,all
whIlefacIngIncreasInglylImItedresources.
70
AnesthesIologIstsremaInatargetforlImItIng
healthcareexpendItures.AnesthesIaprofessIonals(dIrectlyandIndIrectly)have
representedJto5ofthetotalhealthcarecostsInthecountry.
71
ComplIcateddecIsIons
arerequIredregardIngwhIchpatIentsaresuItableforambulatorysurgery,what
preoperatIvestudIestoorder,whatanesthetIcdrugsortechnIqueIsbestforthepatIent,
whatmonItorsorequIpmentarereasonablyrequIredtorunanDF,andthelIstgoesonand
on.WIththIsasbackground,anesthesIologIstslegItImatelycanIncludeeconomIc
consIderatIonsIntheIrdecIsIonprocesses.WhenpresentedwIthmultIpleoptIonstoprovIde
fortherapeutIcInterventIonorpatIentassessment,oneshouldnotautomatIcallychoose
themoreexpensIveapproach(justtocoverallthebases)unlessthereIscompellIng
evIdenceprovIngItsvalue.0ecIsIonsthatclearlymaterIallyIncreasecostshouldonlybe
pursuedwhenthebenefItoutweIghstherIsk.nanesthesIacareaswellasmedIcIneIn
general,suchdecIsIonscanbedIffIcultregardIngInterventIonsthatprovIdemargInal
benefItbutcontaInsIgnIfIcantcostIncreases.
72
8ecausecostcontaInmentInItIallyrequIres
accuratecostawareness,anesthesIologIstsneedtofIndouttheactualcostsandbenefItsof
theIranesthesIacaretechnIques.0etaIlswIllbeunIquetoeachpractIcesettIng.8ecause
theywIllbeexcItedthattheanesthesIologIstsactuallycare,usuallyItIspossIbletogetthe
cooperatIonofthefacIlItyadmInIstratIon'sfInancIaldepartmentmembersInresearchIng
andcalculatIngtheactualcostofanesthesIacaresothatthoughtfulevaluatIonsof
potentIalreductIonscanbeInItIated.
AnesthesIadrugexpensesrepresentasmallportIonofthetotalperIoperatIvecosts.
However,thegreatnumberofdosesactuallyadmInIsteredcontrIbutessubstantIallyto
aggregatetotalcosttotheInstItutIonInactualdollars.PrudentdrugselectIoncombIned
wIthapproprIateanesthetIctechnIquecanresultInsubstantIalsavIngs.FeducIngfreshgas
flowfrom5L/mInto2L/mInwhereverpossIblewouldsaveapproxImatelyS100mIllIon
annuallyIntheUnItedStates.
7J
AmajorItyofanesthesIaprofessIonalsusuallyattempta
practIcalapproachtocostsavIngs,buttheyaremorefrequentlyfacedwIthdIffIcult
choIcesregardIngmethodsofanesthesIathatlIkelyproducesImIlaroutcomesbutat
substantIallydIfferentcost.WhencomparIngthetotalcostsofmoreexpensIveanesthetIc
drugsandtechnIquestolesserexpensIveones,manyvarIablesneedtobeaddedtothe
formula.ThecostofanesthetIcdrugsneedstoIncludethecostsofaddItIonalequIpment
suchasspecIalvaporIzersorextraInfusIonpumpsandtheassocIatedmaIntenance.There
areotherIndIrectcoststhatmaybedIffIculttoquantItateandarecommonlyoverlooked.
Someof
P.55
theseIndIrectcostsIncludeIncreasedsetuptIme,possIblyIncreasIngroomturnovertIme,
extendedPACUrecoverytIme,andaddItIonalexpensIvedrugsrequIredtotreatsIde
effects.SometImes,moreexpensIvetechnIquesreduceIndIrectcosts.ApropofolInfusIon,
althoughmoreexpensIvethanvapor,commonlyresultsInadecreasedPACUstayfora
shortnonInvasIveprocedure.ffewerPACUstaffareneededorpatIentthroughputIs
Increased,themoreexpensIvedrugcanreduceoverallcost.Conversely,usIng
comparatIvelyexpensIvepropofolforalongproceduredefInItelyrequIrIngpostoperatIve
admIssIontoanCUIshardlyjustIfIed.TheImpactofshorteractIngdrugsandthosewIth
fewersIdeeffectsIscontextspecIfIc.0urInglongsurgIcalprocedures,suchdrugsmayoffer
lImItedbenefItsoverolder,lessexpensIve,longeractIngalternatIves.
74
Underthese
condItIons,advocatIngcostcontaInmentusIngeducatIonaleffortsmaydecreasedrug
expendIturesforseveralcategorIesofdrugs.
75
0rugsInthesametherapeutIcclasshave
wIdelyvaryIngcosts.TheacquIsItIonexpensesmayvaryasmuchas50foldInsome
pharmacologIccategorIes.tIsestImatedthatthe10hIghestexpendIturedrugsaccountfor
80oftheanesthetIcdrugcostsatsomeInstItutIons.
76
Althoughnewer,moreexpensIve
drugsmaybeeasIertouse,nodataexIsttosupportorrefutethehypothesIsthatthese
drugsprovIdeabetteranesthetIcexperIencewhencomparedwIthcarefullytItrated
older,lessexpensIve,longeractIngdrugsInthesameclass.
EvaluatIonofoutcomesandtheIrsubsequentapplIcatIontocostanalysIscanbederIved
fromtwoprIncIplesources:datapublIshedInthelIteratureanddatacollectedfrom
experIence.Asnoted,computerIzedInformatIonmanagementsystemsareusefultoolsto
trackoutcomesandanalyzetheImpactonthecost/benefItledger.UsIngthecollateddata
InthesamemannerasforDFutIlIzatIonandcaseload,practItIonerscanreadIlyapplya
statIstIcalprocesstoevaluateoutcomesIntheIrpractIce,possIblyIncludIngcorrelatIon
wIthcost.ThIsInformatIonmaytakeonaddedImportanceInthatpublIshedIncIdence
studIesmaynotexIstforthespecIfIcoutcomeananesthesIagroupIssearchIngfor.Cause
andeffectdIagramscantracktheparametersInvolvedIntheprocessandrelatethemto
thevarIousoutcomesdesIred.|ultIplepertInentexamplescouldbeconstructedfromthe
nowextensIvebodyoflIteratureonthefactorscontrIbutIngtopostoperatIvenauseaand
vomItIngandthevarIouspossIblepreventIonsandtreatments,manyofwhIchInvolvevery
expensIvemedIcatIons.Dfcourse,thIscanbedonelocallywIthInanInstItutIon.
nformatIonwouldbecollectedandstoredInthedatabase.deally,thedatabasewould
IdentIfyandtrackasmanyvarIablesasneeded/possIbletodelIneatesourcesforpossIble
ImprovementandItsultImatecostanalysIs.DncethesesourcesforImprovementandthe
ensuIngcostImpactareknown,theanesthesIagroupcandetermInewhetherornotto
pursuechangIngtheIrpractIce.DutcomesrelatedtoadverseeffectscanalsobemonItored.
fanalysIsrevealsasIgnIfIcantdIfferenceInanadverseoutcomeamongpractItIoners,
afteralltheothervarIablessuchassurgeon,patIentmIx,andsoforthareelImInated,the
outcomedatabasecanInvestIgatetheanesthetIctechnIqueusedbythatpractItIoner.f
sIgnIfIcantvarIatIonsareIdentIfIed,thatpractItIonerwouldbeabletolearnofthese
varIatIonsInanonthreatenIngmannerbecausecomputerderIveddataIsusedasopposed
toaspecIfIccaseanalysIs,whIchmIghtleadthatpractItIonertofeelsIngledoutforpublIc
crItIcIsm.ThedatabasebecomesatoolbothforQAandprofessIonaleducatIon.
Conclusion
PractIceandDFmanagementInanesthesIologytodayIsmorecomplexandmoreImportant
thaneverbefore.AttentIontodetaIlsthatprevIouslyeItherdIdnotexIstorwere
perceIvedasunImportantcanlIkelymakethedIfferencebetweensuccessandfaIlureIn
anesthesIologypractIce.
DutlInedherearebasIcdescrIptIonsandunderstandIngsofmanydIfferentadmInIstratIve,
organIzatIonal,fInancIal,andpersonnelcomponentsandfactorsInthepractIceof
anesthesIology.DngoIngsIgnIfIcantchangesInthehealthcaresystemwIllprovIdea
contInuIngarrayofchallenges.ApplIcatIonoftheprIncIplespresentedherewIllallow
anesthesIologIststoextrapolatecreatIvelyfromthesebasIcstotheIrownIndIvIdual
cIrcumstancesandthenforgeaheadInanesthesIologypractIcethatIseffIcIent,effectIve,
productIve,collegIal,andevenfun.
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Editors: Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.;
Stock, M. Christine
Title: Clinical Anesthesia, 6th Edition
CopyrIght2009LIppIncottWIllIamsEWIlkIns
TableofContentsSectIonntroductIontoAnesthesIologyChapterJDccupatIonalHealth
ChapterJ
Occupational Health
Arnold J. Berry
Jonathan D. Katz
Key Points
1. With the use of scavenging equipment, routine machine
maintenance, and appropriate work practices, exposure to waste
anesthetic gases can be reduced to levels below those recommended
by National Institute for Occupational Safety and Health (NIOSH).
2. Twenty-four percent of anesthesia personnel manifest evidence of
contact dermatitis in response to latex exposure and approximately
15% are sensitized and vulnerable to allergic reactions.
3. Vigilance is one of the most critical tasks performed by
anesthesiologists. The vigilance task is adversely affected by several
factors including poor equipment engineering and design, excessive
noise in the operating room, impediments to interpersonal
communication, production pressure, and fatigue.
4. Sleep deprivation and fatigue are common among anesthesiologists.
Sleep deprivation can have deleterious effects on cognition,
performance, mood, and health.
5. The risk of exposure to infectious pathogens can be reduced by the
routine use of standard precautions, transmission-based precautions
for infected patients, and safety devices designed to prevent
needlestick injuries.
6. Hepatitis B vaccine is recommended for all anesthesia personnel
because of the increased risk for occupational transmission of this
blood-borne pathogen.
7. Many consider chemical dependency to be the primary occupational
hazard among anesthesiologists. An incidence of 1 to 2% of
controlled substance abuse has been repeatedly reported within
anesthesia training programs.
8. It remains controversial whether anesthesiologists are, on average,
vulnerable to premature death. However, by correcting for the fact
that living anesthesiologists are, on average, younger than most
other specialists, it is apparent that anesthesiologists do not die
younger.
AnesthesIapersonnelspendlonghours,Infact,mostoftheIrwakIngdays,Inan
envIronmentfIlledwIthmanypotentIalhazardstheoperatIngroom.ThIssettIngIsunIque
amongworkplacesasaresultofthepotentIalexposuretochemIcalvapors,IonIzIng
radIatIon,andInfectIousagents.AddItIonally,anesthesIapersonnelaresubjectto
heIghtenedlevelsofpsychologIcalstressengenderedbythehIghstakesnatureofthe
practIceandthelongperIodsofsustaInedtImeonduty.AlthoughsuchphysIcalhazardsas
fIresandexplosIonsfromflammableanesthetIcagentsarecurrentlyoflImItedconcern,
occupatIonalIllnesses,suchasalcoholanddrugabuse,arewellrecognIzedassIgnIfIcant
wIthIntheanesthesIacommunIty.Somehazards,suchasexposuretotracelevelsofwaste
anesthetIcgases,havebeenextensIvelystudIed.Dthers,lIkesuIcIde,havebeenrecognIzed
butnotadequatelypursued.DnlywIthInthepastfewdecadeshaveepIdemIologIcsurveys
beenconductedtoassessthehealthofanesthesIapersonnel.ngeneral,thepotentIal
healthrIskstothoseworkIngIntheoperatIngroommaybesIgnIfIcant,butwIthawareness
oftheproblemsandtheuseofproperprecautIons,theyarenotformIdable.
P.58
Physical Hazards
Anesthetic Gases
AlthoughtheInhalatIonanesthetIcsdIethylether,nItrousoxIde,andchloroformwerefIrst
usedInthe1840s,thebIologIceffectsofoccupatIonalexposuretoanesthetIcagentswere
notInvestIgateduntIlthe1960s.FeportsontheeffectsofchronIcenvIronmentalexposure
toanesthetIcshaveIncludedepIdemIologIcsurveys,InvItrostudIes,cellularresearch,and
studIesInlaboratoryanImalsandhumans.AreasaddressedIncludethepotentIalInfluence
oftraceanesthetIcconcentratIonsontheIncIdenceInaffectedpopulatIonsofthe
followIng:death,InfertIlIty,spontaneousabortIon,congenItalmalformatIons,cancer,
hematopoIetIcdIseases,lIverdIsease,neurologIcdIsease,psychomotor,andbehavIoral
changes.
Anesthetic Levels in the Operating Room
ThefIrstreportofoccupatIonalexposuretomodernanesthetIcswasbyLIndeand8ruceIn
1969.
1
TheysampledaIratvarIousdIstancesfromthepopoffvalveofanesthesIa
machInesandnotedanaverageconcentratIonofhalothaneof10partspermIllIon(ppm)
andofnItrousoxIdeof1J0ppm.(PartspermIllIonIsavolumepervolumeunItof
measurement;10,000ppmequals1.)EndexpIredaIrsamplestakenfrom24
anesthesIologIstsafterworkrevealed0to12ppmofhalothane.twaslaterdemonstrated
thatwIthapproprIatescavengIngequIpmentIntegratedwIththeanesthesIabreathIng
cIrcuItandwIthadequateaIrexchangeIntheoperatIngroom,levelsofwasteanesthetIc
gasescouldbesIgnIfIcantlyreduced.
WasteanesthetIcconcentratIonsInmodernoperatIngroomswhereroutInescavengIngIs
performedareconsIderablylessthanthosefoundIntheearlystudIes.
2,J
ThIsraIsesthe
questIonsofwhetherchronIcexposuretotheselowlevelsofwasteanesthetIcgases
actuallyconstItutesasIgnIfIcantoccupatIonalhazardandwhetherresultsfromstudIes
performedInunscavengedoperatIngroomsareapplIcabletocurrentpractIce.
Epidemiologic Studies
EpIdemIologIcsurveyswereamongthefIrststudIestosuggestthepossIbIlItyofahazard
resultIngfromexposuretotracelevelsofanesthetIcs.AlthoughepIdemIologIcstudIesmay
beusefulInassessIngproblemsofthIstype,theyhavethepotentIalforerrorsassocIated
wIththecollectIonofdataandtheIrInterpretatIon.7alIdepIdemIologIcstudIesrequIre
approprIatedesIgnstrategIesIncludIngthepresenceofanapproprIatecontrolgroupfor
thecohortbeIngstudIed.WhenquestIonnaIresareusedtoobtaInpersonalmedIcal
InformatIon,thedatamaybemIsleadIngbecauseIndIvIdualsmayknowInglyor
unknowInglygIveIncorrectInformatIonbasedsolelyonremembereddata(recallbIas).
CauseandeffectrelatIonshIpsorcausalItycannotbedocumentedbyepIdemIologIc
observatIonalstudIesunlessallotherpossIbleetIologIes(confounders)canberuledoutor
otherlInesofevIdenceareusedforsubstantIatIon.FewepIdemIologIcstudIesonthe
effectsofoccupatIonalexposuretowasteanesthetIcgasesfulfIllthesedesIgncrIterIa.
Reproductive Outcome
DneofthelargestepIdemIologIcstudIestoassesstheeffectsoftraceanesthetIcson
reproductIveoutcomewasconductedbytheAmerIcanSocIetyofAnesthesIologIsts(ASA).
4
QuestIonnaIresweresentto49,585operatIngroompersonnelwhohadpotentIalexposure
towasteanesthetIcgases(membersoftheASA,theAmerIcanAssocIatIonofNurse
AnesthetIsts,theAssocIatIonofDperatIngFoomNurses,andtheAssocIatIonofDperatIng
FoomTechnIcIans).Anonexposedgroupof2J,911fromtheAmerIcanAcademyof
PedIatrIcsandtheAmerIcanNurses'AssocIatIonservedascontrols.Analysesofthesedata
IndIcatedthattherewasanIncreasedrIskofspontaneousabortIonandcongenItal
abnormalItIesInchIldrenofwomenwhoworkedIntheoperatIngroomandanIncreased
rIskofcongenItalabnormalItIesInoffsprIngofunexposedwIvesofmaleoperatIngroom
personnel.SeveralrevIewshaveIdentIfIedInconsIstencIesInthedatausedtocompare
exposedandunexposedgroupsandtomakewIthIngroupcomparIsons.Expectedlevelsof
anesthetIcexposuredIdnotcorrelatewIthreproductIveoutcome.
TheASAsubsequentlycommIssIonedagroupofepIdemIologIstsandbIostatIstIcIansto
evaluateandassessconflIctIngdatafrompublIshedepIdemIologIcsurveys.
5
AfteranalysIs
ofmethods,theyfoundonlyfIvestudIesonspontaneousabortIonandcongenItal
abnormalItIesInoffsprIngofanesthesIapersonnelthatwerefreeoferrorsInstudydesIgn
orstatIstIcalanalysIs.FromthesestudIes,therelatIverIsks(theratIooftherateofdIsease
amongthoseexposedtothatfoundInthosenotexposed)ofspontaneousabortIonfor
femalephysIcIansandfemalenursesworkIngIntheoperatIngroomwere1.4and1.J,
respectIvely(arelatIverIskof1.JrepresentsaJ0IncreaseInrIskwhencomparedwIth
therIskofthecontrolpopulatIon).TheIncreasedrelatIverIskforcongenItalabnormalItIes
wasofborderlInestatIstIcalsIgnIfIcanceforexposedphysIcIansonly.Althoughtheyfounda
statIstIcallysIgnIfIcantrelatIverIskofspontaneousabortIonandcongenItalabnormalItIes
InwomenworkIngIntheoperatIngroom,therelatIverIskwassmallcomparedwIthother,
betterdocumentedenvIronmentalhazards.TheyalsopoIntedoutthatduratIonandlevel
ofanesthetIcexposurewerenotmeasuredInanyofthestudIesandthatotherconfoundIng
factors,suchasstress,InfectIons,andradIatIonexposure,werenotconsIderedas
confounders.
8ecausepersonnelworkIngInsomedentaloperatorIeshaveexposuretonItrousoxIde,the
dentallIteraturehasalsoaddressedtheseIssues.DnepertInentstudyuseddatacollected
vIatelephoneIntervIewswIth418femaledentalassIstantstoassesstheeffectofnItrous
oxIdeexposureonfertIlIty.
6
FecundabIlIty(theabIlItytoconceIve)wassIgnIfIcantly
reducedInwomenwIth5ormorehoursofexposuretounscavengednItrousoxIdeper
week.nanotherstudyof7,000femaledentalassIstants,questIonnaIreswereusedto
determIneratesofspontaneousabortIon.
7
TherewasanIncreasedrateofspontaneous
abortIonamongwomenwhoworkedforJormorehoursperweekInoffIcesnotusIng
scavengIngdevIcesfornItrousoxIde(relatIverIsk[FF]=2.6,adjustedforage,smokIng,
andnumberofamalgamspreparedperweek).ThesefIndIngsmustbevIewedwIthcautIon
becausetheestImatesofnItrousoxIdeexposurewerebasedsolelyonrespondents'reports,
andmeasurementsofnItrousoxIdeconcentratIonsIntheworkspacewerenotperformed.
Therefore,doseeffectrelatIonshIpscannotbeconfIrmed.tIsImportanttonotethatIn
bothstudIesoffemaledentalassIstants,useofnItrousoxIdeInoffIceswIthscavengIng
devIceswasnotassocIatedwIthanIncreasedrIskforadversereproductIveoutcomes.
6,7
AmetaanalysIsof19epIdemIologIcstudIes,whIchIncludedhospItalworkers,dental
assIstants,andveterInarIansandveterInaryassIstants,demonstratedanIncreasedrIskof
spontaneousabortIonInwomenwIthoccupatIonalexposuretoanesthetIcgases(FF=1.48;
95confIdenceInterval,1.40to1.58).
8
AddItIonalanalysIsdemonstratedthattherelatIve
rIskof1.48correspondedtoanIncreasedabsoluterIskofabortIonof6.2.StratIfIcatIonby
jobcategoryIndIcatedthattherelatIverIskwasgreatestforveterInarIans(FF=2.45),
followed
P.59
bydentalassIstants(FF=1.89)andhospItalworkers(FF=1.J0).WhenthemetaanalysIs
wasconfInedtofIvestudIesthatcontrolledforseveralnonoccupatIonalconfoundIng
varIables,hadapproprIatecontrolgroups,andhadsuffIcIentresponserate,therelatIve
rIskforspontaneousabortIonwas1.90(95confIdenceInterval,1.72to2.09).Theauthor
notedthattheroutIneuseofscavengIngdevIceshasbeenImplementedsIncethetImethat
mostofthestudIesInthIsanalysIswereperformedandthattherewasnorIskof
spontaneousabortIonInstudIesofpersonnelwhoworkedInscavengedenvIronments.
FetrospectIvesurveysoflargenumbersofwomenwhoworkeddurIngpregnancyIndIcate
thatadversereproductIveoutcomesmayberelatedtojobassocIatedcondItIonsother
thanexposuretotraceanesthetIcgases.AsurveyofJ,985SwedIshmIdwIvesdemonstrated
thatnIghtworkwassIgnIfIcantlyassocIatedwIthspontaneousabortIonsafterthe12th
weekofpregnancy(oddsratIo=J.JJ),whIleexposuretonItrousoxIdeappearedtohaveno
effect.
9
UsIngacasecontrolstudydesIgn,Lukeetal
10
foundthatIncreasedworkhours,
hoursworkedwhIlestandIng,andoccupatIonalfatIguewereassocIatedwIthpretermbIrth
InobstetrIcandneonatalnurses.TheseandotherstudIeshaveprovIdeddatathatlInk
spontaneousabortIonInwomenworkIngInhealthcaretojobrelatedfactorsotherthan
exposuretotraceanesthetIcgases.ThIscastsdoubtonthevalIdItyofearlIerstudIesthat
dIdnotcontrolforoccupatIonalstressessuchasfatIgue,longworkhours,andnIghtshIfts.
AlthoughmanyoftheexIstIngepIdemIologIcstudIeshavepotentIalflawsIndesIgn,the
evIdencetakenasawholesuggeststhatthereIsaslIghtIncreaseIntherelatIverIskof
spontaneousabortIonandcongenItalabnormalItIesInoffsprIngforfemalephysIcIans
workIngIntheoperatIngroom.
11
WhetherthesefIndIngsareattrIbutabletoanesthetIc
exposureorotherworkrelatedcondItIonscannotbedefInItelydetermInedfromthIstype
ofInvestIgatIon.WelldesIgnedsurveysoflargenumbersofpersonnelandapproprIate
controlgroups,controlledforotherfactorssuchasworkhoursandnIghtshIfts,are
necessarytolInktraceanesthetIcexposurestoadversereproductIveoutcomes.The
routIneuseofscavengIngtechnIqueshasgenerallyloweredenvIronmentalanesthetIc
levelsIntheoperatIngroomandmaymakeItmoredIffIculttoproveanyadverse
reproductIveeffectsusIngepIdemIologIcdata.AlthoughItIseasytomeasureandquantIfy
thelevelsofanesthetIcIntheoperatIngroomaIr,ItIshardertomeasureandassessthe
effectofotherpossIblefactors,suchasstress,alteratIonsInworkIngschedule,andfatIgue.
Neoplasms and Other Nonreproductive Diseases
EarlysurveysenumeratIngcausesofdeathamonganesthesIologIstsIndIcatedthatmale
anesthesIologIstshadagreaterrIskofmalIgnancIesofthelymphoIdandretIculoendothelIal
tIssuesandfromsuIcIde,butalowerdeathratefromlungcancerandcoronaryartery
dIsease.
12
0atafromasubsequentprospectIvestudyprovIdednoevIdencetosupportthe
prevIousconclusIonthatlymphoIdmalIgnancIeswereanoccupatIonalhazardfor
anesthesIologIsts.
1J
AnASAsponsoredstudy,publIshedIn1974,foundnodIfferencesIncancerratesbetween
menexposedandthosenotexposedtotraceconcentratIonsofanesthetIcgases.
4
For
womenrespondents,therewasa1.Jfoldto2foldIncreaseIntheoccurrenceofcancerIn
theexposedgroup,resultIngpredomInantlyfromanIncreaseInleukemIaandlymphoma.
TheanalysIsof8urIngetal
5
ofthesedataconfIrmedanIncreaseInrelatIverIskofcancer
Inexposedwomen(FF=1.4)butattrIbutedtheIncreasesolelytocervIcalcancer(FF=
2.8).TheyalsonotedthattheASAstudydIdnotassesstheeffectofconfoundIngvarIables,
suchassexualhIstoryorsmokIng,thatmayhavecontrIbutedtothefIndIngs.tIsdoubtful
thatthecarcInogenIceffectofanesthetIcswouldbesexrelated,andtheconflIctIngresults
formenandwomen,especIallyInlIghtofthelowstatIstIcalsIgnIfIcanceofthedata,cast
doubtthatanesthetIcswerethecausatIveagents.
AnotherASAsponsoredmortalItystudyofanesthesIologIsts,coverIngtheperIodfrom1976
to1995,useddataoncauseofdeathfromtheNatIonal0eathndex.
14
ThemortalItyrIsks
ofacohortof40,242anesthesIologIstswerecomparedwIthamatchedcohortofInternIsts.
TherewasnodIfferencebetweenthetwogroupsInoverallmortalItyrIskormortalItyfrom
cancerorheartdIsease,butthemeanageatdeathwassIgnIfIcantlylowerfor
anesthesIologIstscomparedwIthInternIsts(66.5yearsvs.69.0years).nasubsequent
study,Katz
15
useddatafromtheAmerIcan|edIcalAssocIatIon(A|A)toconcludethat
therewasnostatIstIcaldIfferenceInagespecIfIcmortalItyamonganesthesIologIsts,
InternIsts,andotherphysIcIanswhenagesofthelIvIngmembersofthephysIcIangroups
wereconsIderedIntheanalyses.
EpIdemIologIcobservatIonalstudIesareusefultoolsforattemptIngtoIdentIfyadverse
effectsoftheoperatIngroomenvIronment,IncludIngexposuretomanysubstances,of
whIchwasteanesthetIcgasescomprIsebutonefactor.ThedatafromobservatIonal
surveyscan,atbest,IdentIfyassocIatIonsbutcanneverprovecauseandeffect
relatIonshIpsbetweenanexposuretoacondItIonorsubstanceandadIseaseprocess.|any
surveysthatattempttoassesstheeffectsofwasteanesthetIcgaseshavemethoddesIgn
flawssuchasfaIluretocontrolforpossIbleconfoundIngfactors,andthesehaveresultedIn
conflIctIngconclusIons.Dverall,thereappearstobesomeevIdencethattheoperatIng
roomenvIronmentproducesaslIghtIncreaseIntherateofspontaneousabortIonand
cancerInfemaleanesthesIologIstsandnurses.
5
|ortalItyrIsksfromcancerandheart
dIseaseforanesthesIologIstsdonotdIfferfromthoseforothermedIcalspecIalIsts.
Laboratory Studies
AlongwIthepIdemIologIcstudIes,InvestIgatorshavebeenactIveInthelaboratory,
assessIngtheeffectsofanesthetIcagentsoncell,tIssue,andanImalmodels.tIsthought
thatthIsworkmIghtprovIdethescIentIfIcevIdencelInkInganesthetIcexposuretothe
adverseeffectsthathavebeensuggestedbysomeobservatIonalstudIes.
Cellular Effects
NItrousoxIdeadmInIsteredInclInIcallyusefulconcentratIonsaffectshematopoIetIcand
neuralcellsbyIrreversIblyoxIdIzIngthecobaltatomofvItamIn8
12
fromanactIveto
InactIvestate.ThIsInhIbItsmethIonInesynthetaseandpreventstheconversIonof
methyltetrahydrofolatetotetrahydrofolate,whIchIsrequIredfor0NAsynthesIs,assembly
ofthemyelInsheath,andmethylsubstItutIonsInneurotransmItters.nhIbItIonof
methIonInesynthetaseInIndIvIdualsexposedtohIghconcentratIonsofnItrousoxIdemay
resultInanemIaandpolyneuropathy,butchronIcexposuretotracelevelsfoundIn
scavengedoperatIngroomsdoesnotappeartoproducetheseeffects.
|anystudIeshavebeenperformedInanImalstoassessthecarcInogenIcItyofanesthetIcs.
8ecauseoftheextremevarIabIlItyofstudyprotocols,useofanImalsofdIfferIngspecIes,
andfaIluretoconsIderpossIbleconfoundersInstudydesIgn,adefInItIvelInkbetween
anesthetIcsandcancerhasnotbeenproven.
SeveralInvestIgatorshaveusedtheAmesbacterIalassaysystemforstudyIngthe
mutagenIcItyofanesthetIcs.ThIsassayIsrapId,InexpensIve,andhasahIghtrueposItIve
ratewhencomparedwIthInvIvotests.Halothane,enflurane,methoxyflurane,Isoflurane,
sevofluraneandurInefrompatIents
P.60
anesthetIzedwIththeseagentswasnotmutagenIcusIngthIsassay.UrInefrompeople
workIngInscavengedorunscavengedoperatIngroomswasalsonegatIveformutagens.
DtherstudIeshaveusedanalysesofsIsterchromatIdexchangesorformatIonof
mIcronucleatedlymphocytestoassessforgenotoxIcItyInassocIatIonwIthanesthetIc
exposure.ThesetestsmaybeofInterestbecausetheremaybeanassocIatIonbetween
thesegenetIcchangesandcancer.ThemajorItyofstudIesusIngsIsterchromatIdexchange
testInghavebeennegatIveforenflurane,Isoflurane,andsevofluraneexposure.
16
AnesthetIstsatanInstItutIonwherewastegasscavengIngwasnotusedhadanIncreased
fractIonofmIcronucleatedlymphocytescomparedwIththosepractIcIngInahospItal
wherewasteanesthetIcgaseswerescavenged.
17
LowlevelexposureasoccursIn
scavengedoperatIngroomswasnotassocIatedwIthIncreasedformatIonofmIcronucleated
lymphocytes.ThepredIctIvevaluefortheassocIatIonofthIstesttotheIncIdenceof
cancerIsunclear.
ThedatafromseverallInesofevIdenceIndIcatethatoccupatIonalexposuretothelow
levelsofanesthetIcsfoundwItheffectIvewastegasscavengIngIsnotassocIatedwIth
sIgnIfIcantcellulareffects.
Reproductive Outcome
8ecauseofthesuggestIonfromepIdemIologIcdatathatoccupatIonalexposuretowaste
anesthetIcgasesmayhaveresultedInanIncreasedrateofspontaneousabortIonand
congenItalabnormalItIes,numerousstudIeshavebeenperformedInlaboratoryanImalsto
assessreproductIveoutcome.|ostanImalexperImentsfaIltodemonstratealteratIonsIn
femaleormalefertIlItyorreproductIveoutcomewIthexposuretothesubanesthetIc
concentratIonsofthecurrentlyusedanesthetIcagentsachIevablewIthscavengIngand
approprIateworkpractIces.tIsImportanttorealIzethatdatafromlaboratory
InvestIgatIonsInanImalsmaynotbedIrectlyapplIcabletohumans.
Effects of Trace Anesthetic Levels on Psychomotor Skills
SeveralstudIeshavebeenconductedtoattempttoclarIfywhetherlowconcentratIonsof
anesthetIcsalterthepsychomotorskIllsrequIredforprovIdInghIghqualItycare.none
InvestIgatIon,psychomotortestswereusedtoassesstheeffectofnItrousoxIde(500,50,or
25ppm)aloneorwIthhalothane(10,1.0,or0.5ppm).
18
AfterexposuretothehIghest
concentratIonsofnItrousoxIdeandhalothane,subjects'performancedeclInedonfourof
theseventests.nterestIngly,therewasadecreaseInabIlItyInsIxofseventestsafter
exposuretothesamelevelofnItrousoxIdealone.ExposuretothelowestconcentratIons
studIed,25ppmnItrousoxIdeand0.5ppmhalothane,producednoeffectsasmeasuredby
thIsbatteryoftests.
DtherInvestIgatorsusIngsImIlarprotocolshavefoundnoeffectonpsychomotortest
performanceafterexposuretotraceconcentratIonsofhalothaneornItrousoxIde.The
reasonfordIfferencesInoutcomebetweenstudIesIsunclear,but8ruceandStanley,
19
amongtheorIgInalInvestIgators,haveattrIbutedthepsychologIcaleffectsoflowlevelsof
anesthetIcstounusualsensItIvItyInthegroupofpaIdvolunteersusedInthestudy.
Recommendations of the National Institute for Occupational
Safety and Health
TheNatIonalnstItuteforDccupatIonalSafetyandHealth(NDSH)Isthefederalagency
responsIbleforensurIngthatworkershaveasafeandhealthfulworkIngenvIronment.t
meetsthesegoalsthroughtheconductandfundIngofresearch,througheducatIonof
employersandemployeesaboutoccupatIonalIllnesses,andthroughestablIshIng
occupatIonalhealthstandards.Asecondfederalagency,theDccupatIonalSafetyand
HealthAdmInIstratIon(DSHA),IsresponsIbleforenactIngjobhealthstandards,
InvestIgatIngworksItestodetectvIolatIonofstandards,andenforcIngthestandardsby
cItIngvIolators.n1977,NDSHpublIshedacrIterIadocumentthatIncludedrecommended
exposurelImIts(FEL)forwasteanesthetIcgasesof2ppm(1hourceIlIng)forhalogenated
anesthetIcagents(halothane,enflurane)whenusedaloneor0.5ppmofahalogenated
agentand25ppmofnItrousoxIde(tImeweIghtedaveragedurIngtheperIodofanesthetIc
admInIstratIon).
20
naddItIon,ItstatedthatoperatIngroomemployeesshouldbeadvIsed
ofthepotentIalharmfuleffectsofanesthetIcs.TheguIdelInesproposedthatannual
medIcalandoccupatIonalhIstorIesbeobtaInedfromallpersonnelandthatanyabnormal
outcomesofpregnancIesshouldbedocumented.ThepublIcatIonalsoIncludedInformatIon
onscavengIngproceduresandequIpmentandmethodsformonItorIngconcentratIonsof
wasteanesthetIcgasesIntheaIr.
The1977NDSHcrIterIadocumenthasnotbeenadoptedbyDSHA,whIchhasnotseta
standardpermIssIbleexposurelImItforwasteanesthetIcgases.Somestates,however,
haveInstItutedregulatIonscallIngforroutInemeasurementofambIentnItrousoxIdeIn
operatIngroomsandhavemandatedthatlevelsnotexceedanarbItrarymaxImum.n1994,
NDSHpublIshedanalerttowarnhealthcarepersonnelthatexposuretonItrousoxIdemay
produceharmfuleffects.
21
nthIsdocument,NDSHrecommendsthefollowIngtoreduce
nItrousoxIdeexposure:(1)monItorIngtheaIrInoperatIngrooms;(2)ImplementatIonof
approprIateengIneerIngcontrols,workpractIces,andequIpmentmaIntenanceprocedures;
and(J)InstItutIonofaworkereducatIonprogram.
NDSHhasnotdevelopedFELsfortheagentsmostcommonlyusedIncurrentpractIce
(Isoflurane,sevoflurane,anddesflurane).ThesevolatIleagentshavepotencIes,chemIcal
characterIstIcs,andratesandproductsofmetabolIsmthatdIffersIgnIfIcantlyfromolder
anesthetIcs.n2006,NDSHIssuedarequestforInformatIontopermIttheagencyto
evaluatepossIblehealthrIsksofoccupatIonalexposuretoIsoflurane,sevoflurane,and
desfluraneandtoestablIshFELs.
tIsImportanttonotethatotherorganIzatIonsbothInandoutsIdetheUnItedStateshave
setoccupatIonalexposurelImItsforwasteanesthetIcgasesand,Inmostcases,theseare
greaterthanthoserecommendedbyNDSH.Forexample,theAmerIcanConferenceof
CovernmentalndustrIalHygIenIstshasrecommendedathresholdlImItvaluetIme
weIghtedaverage(calculatedforan8hourshIft)fornItrousoxIdeof50ppm,forenflurane
of75ppm,andforhalothaneof50ppm.
nvIewoftheconflIctIngscIentIfIcdataandpublIshedrecommendatIons,ItIsreasonable
toaskwhatIsanacceptableexposurelevelforwasteanesthetIcgases.AlthoughItmaybe
dIffIculttobecertaInofathresholdconcentratIonbelowwhIchchronIcexposureIssafe,
ItIsprudenttoInstItutemeasuresthatreducewasteanesthetIclevelsIntheoperatIng
roomenvIronmenttoaslowaspossIblewIthoutcompromIsIngpatIentsafety.
|ethodsforreducIngandmonItorIngwastegasesIntheoperatIngroomhavebeen
suggested.
J,21
ThroughtheuseofscavengIngequIpment,equIpmentmaIntenance
procedures,approprIateanesthetIcworkpractIces,andeffIcIentoperatIngroom
ventIlatIonsystems,theenvIronmentalanesthetIcconcentratIoncanbereducedto
mInImallevels.ToensurereducedoccupatIonalexposure,departmentalprogramsshould
IncorporatetheabIlItytomonItorfordetectIonofleaksInthehIghandlowpressure
systemsofanesthetIcmachInes,contamInatIonasaresultoffaultyanesthetIctechnIques
suchaspoormaskfItorleaksaroundthecuffsofendotrachealtubesand
P.61
laryngealmaskaIrways,andscavengIngsystemmalfunctIons(TableJ1).Whentherehave
beenleaksofanesthetIcgases,dIspersIonandremovalofthepollutantsdependonthe
adequacyofroomventIlatIon.StandardsforoperatIngroomconstructIonfromthe
AmerIcannstItuteofArchItectsrequIre15to21aIrexchangesperhourwIthJbrIngIngIn
outsIdeaIr.
22
EnvIronmentallevelsofanesthetIcscanbemeasuredusIngInstantaneously
collectedsamples,contInuousaIrmonItorIng,ortImeweIghtedaverages.
J
WIth
approprIatecare,envIronmentallevelsofanesthetIcsIntheoperatIngroomcanbe
reducedtocomplywIththeFELsestablIshedbyNDSH.
Table 3-1 Sources of Operating Room Contamination
ANESTH ETIC TECHNIQUES
FaIluretoturnoffgasflowcontrolvalvesattheendofananesthetIc
TurnInggasflowonbeforeplacIngmaskonpatIent
PoorlyfIttIngmasks,especIallywIthmaskInductIonofanesthesIa
FlushIngofthecIrcuIt
FIllIngofanesthesIavaporIzers
UncuffedorleakIngtrachealtubes(e.g.,pedIatrIc)orpoorlyfIttInglaryngeal
maskaIrways
PedIatrIccIrcuIts(e.g.,JacksonFeesversIonofthe|apleson0system)
SIdestreamsamplIngcarbondIoxIdeandanesthetIcgasanalyzers
ANESTHESIA MACHINE DELIVERY SYSTEM AND SCAVENGING SYSTEM
Dpen/closedsystem
DcclusIon/malfunctIonofhospItaldIsposalsystem
|aladjustmentofhospItaldIsposalsystemvacuum
Leaks
HIghpressurehosesorconnectors
NItrousoxIdetankmountIng
DrIngs
CD
2
absorbentcanIsters
LowpressurecIrcuIt
OTHER SOURCES
CryosurgeryunIts
CardIopulmonarybypasscIrcuIts
|odIfIedfromTaskForceonTraceAnesthetIcCasesoftheCommItteeon
DccupatIonalHealthofDperatIngFoomPersonnel:WasteAnesthetIcCases:
nformatIonfor|anagementInAnesthetIzIngAreasandthePostanesthesIaCare
UnIt(PACU).ParkFIdge,L,AmerIcanSocIetyofAnesthesIologIsts,1999,wIth
permIssIonfromtheAmerIcanSocIetyofAnesthesIologIsts.Acopyofthefulltext
canbeobtaInedfromtheASA,520N.NorthwestHIghway,ParkFIdge,L60068
257J.
Anesthetic Levels in the Postanesthesia Care Unit
PatIentswhohavereceIvedvolatIleanesthetIcsreleasethesegasesIntotheenvIronment
astheyawakenfromgeneralanesthesIaInthepostanesthesIacareunIt(PACU).na1998
study,thetImeweIghtedaverageconcentratIonsforIsoflurane,desflurane,andnItrous
oxIdewere1.1ppm,2.1ppm,and29ppm,respectIvely,InthebreathIngzoneofPACU
nurses.
2J
HalfofthepatIentswereIntubatedonarrIvalInthePACU,suggestIngthatthey
werestIllpartIallyanesthetIzedandwereexhalIngagreaterconcentratIonofanesthetIc
gasesthanIftheyhadalreadyawakened.ncontrast,otherInvestIgatorsreportedtIme
weIghtednItrousoxIdelevels2.0ppmfromtwoPACUs.
24
ThepractIceIntheseInstItutIons
wastoroutInelydIscontInuenItrousoxIdeattheendofsurgery,approxImately5mInutes
beforethepatIentlefttheoperatIngroom.Also,therewasadequateaIrexchange
documentedInthePACUs.NDSHthresholdlImItsforanesthetIcgasescanbeobtaInedIn
thePACUbyensurIngadequateroomventIlatIonandfreshgasexchangeandby
dIscontInuIngtheanesthetIcgasesInsuffIcIenttImeprIortoleavIngtheoperatIngroom.
Chemicals
Methyl Methacrylate
|ethylmethacrylateIscommonlyusedtocementprosthesestoboneortorepaIrbone
defects.KnowncardIovascularcomplIcatIonsofmethylmethacrylateInsurgIcalpatIents
IncludehypotensIon,bradycardIa,andcardIacarrest.TheeffectsofoccupatIonalexposure
arelesswelldocumented.FeportedrIsksfromrepeatedoccupatIonalexposuretomethyl
methacrylateIncludeskInIrrItatIonandburns,allergIcreactIonsandasthma,eyeIrrItatIon
IncludIngpossIblecornealulceratIon,headache,andneurologIcsIgns.AIrborne
concentratIonsgreaterthan170ppmhavebeenassocIatedwIthchronIclung,lIver,and
kIdneydamage.nonereport,ahealthcareworker(HCW)sufferedsIgnIfIcantlowerlImb
neuropathyafterrepeatedoccupatIonalexposuretomethylmethacrylate.
25
DSHAhas
establIshedan8hour,tImeweIghtedaverageallowableexposureof100ppm.
ConcentratIonsashIghas280ppmhavebeenmeasuredwhenmethylmethacrylateIs
preparedforuseIntheoperatIngroom,butpeakenvIronmental
P.62
concentratIoncanbedecreasedby75whenscavengIngdevIcesareproperlyused.
Allergic Reactions
naddItIontoconcernsabouttoxIceffectsassocIatedwIthexposuretovolatIleanesthetIcs
orchemIcals,anesthesIologIstsmaydevelopsensItIvItIesorallergIcreactIonstosubstances
foundInthehealthcareenvIronment.
Halothane
AllergIcreactIonstovolatIleanesthetIcagentshavebeenassocIatedwIthcontact
dermatItIs,hepatItIs,andanaphylaxIsInIndIvIdualanesthesIologIsts.
26,27
Analysesofsera
frompedIatrIcandgeneralanesthesIologIstsdemonstratedthatexposuretohalothanewas
assocIatedwIthanIncreasedprevalenceofautoantIbodIestocytochromeP4502E1and
hepatIcendoplasmIcretIculumproteIn(EFp58).
28
0espItethepresenceofthese
autoantIbodIes,only1of105pedIatrIcanesthesIologIstshadsymptomsofhepatIcInjury.
ThesedatasuggestthatalthoughautoantIbodIesmayoccurInanesthesIologIstsexposedto
volatIleanesthetIcs,theydonotappeartobethecauseofanesthetIcInducedhepatItIs.
Latex
LatexInsurgIcalandexamInatIongloveshasbecomeacommonsourceofallergIcreactIons
amongoperatIngroompersonnel.nmanycases,HCWswhoareallergIctolatex
experIencetheIrfIrstadversereactIonswhIletheyarepatIentsundergoIngsurgery.The
prevalenceoflatexsensItIvItyamonganesthesIologIstsIsapproxImately15.
29,J0
ThelatexfoundInmedIcalproductsIsactuallyacomposIteofmanysubstancesIncludIng
proteIns,polyIsoprenes,lIpIdsandphospholIpIdscombInedwIthpreservatIves,
accelerators,antIoxIdants,vulcanIzIngcompounds,andlubrIcatIngagents(suchas
cornstarchortalc).TheproteIncontentIsresponsIbleformostofthegeneralIzedallergIc
reactIonstolatexcontaInIngsurgIcalgloves.ThesereactIonsareexacerbatedbythe
presenceofpowderthatenhancesthepotentIaloflatexpartIclestoaerosolIzeandto
spreadtotherespIratorysystemofpersonnelandtoenvIronmentalsurfacesdurIngthe
donnIngorremovalofgloves.
Table 3-2 Types of Reactions to Latex Gloves
REACTION SIGNS/SYMPTOMS CAUSE MANAGEMENT
rrItantcontact
dermatItIs
ScalIng,dryIng
crackIngofskIn
0IrectskIn
IrrItatIonby
gloves,
powder,soaps
dentIfyreactIon,avoId
IrrItant,possIbleuseof
glovelIner,useof
alternatIveproduct
Type7
delayed
hypersensItIvIty
tchIng,
blIsterIng,
crustIng
(delayed672
hours)
ChemIcal
addItIvesused
In
manufacturIng
(suchas
accelerators)
dentIfyoffendIng
chemIcal,possIbleuseof
alternatIveproduct
wIthoutchemIcal
addItIve,possIbleuseof
glovelIner
Type
ImmedIate
hypersensItIvIty

ProteInsfound
Inlatex
dentIfyreactIon;avoId
latexcontaInIng
products;useof
nonlatexorpowder
free,lowproteIngloves
bycoworkers
A.LocalIzed
contact
urtIcarIa
tchIng,hIvesIn
areaofcontact
wIthlatex
(ImmedIate)

AntIhIstamInes,
topIcal/systemIc
steroIds
8.CeneralIzed
reactIon
Funnynose,
swolleneyes,
generalIzedrash
orhIves,
AnaphylaxIsprotocol
bronchospasm,
anaphylaxIs
FeproducedfromAmerIcanSocIetyofAnesthesIologIstsTaskForceonLatex
SensItIvItyoftheCommItteeonDccupatIonalHealthofDperatIngFoomPersonnel:
NaturalFubberLatexAllergy:ConsIderatIonsforAnesthesIologIsts.ParkFIdge,L,
AmerIcanSocIetyofAnesthesIologIsts,2005
(http://www.asahq.org/publIcatIonsAndServIces/latexallergy.pdf)wIthpermIssIon
fromtheAmerIcanSocIetyofAnesthesIologIsts.Acopyofthefulltextcanbe
obtaInedfromtheASA,520N.NorthwestHIghway,ParkFIdge,L60068257J.
rrItantorcontactdermatItIsaccountsforthemajorItyofreactIonsresultIngfromwearIng
latexcontaInInggloves.(TableJ2).TrueallergIcreactIonspresentasTcellmedIated
contactdermatItIs(type7)orasanImmunoglobulInEmedIatedanaphylactIcreactIon.
AnesthesIologIstswhobelIevethattheyareallergIctolatexshouldtakeImmedIatesteps
toassessthIspossIbIlIty.
J1
fadIagnosIsofallergyhasbeenestablIshed,theaffected
anesthesIologIstmustavoIdalldIrectcontactwIthlatexcontaInIngproducts.tIsalso
Importantthatcoworkerswearnonlatexorpowderless,lowlatexallergenglovestolImIt
thelevelsofambIentallergens.8ecausesensItIzatIonIsanIrreversIbleprocess,lImIted
exposureandprImarypreventIonofallergyIsthebestoverallstrategy.AnaphylactIc
reactIonstolatexcanbelIfethreatenIng.
Radiation
|anymodernsurgIcalproceduresrelyheavIlyonfluoroscopIcguIdancetechnIques.Asa
result,anesthesIologIstsareatrIskforbeIngexposedtoexcessIveradIatIon.The
magnItudeofradIatIonabsorbedbyIndIvIdualsIsafunctIonofthreevarIables:(1)total
radIatIonexposureIntensItyandtIme,(2)dIstancefromthesourceofradIatIon,and(J)the
useofradIatIonshIeldIng.ThelattertwoareamenabletomodIfIcatIonbythe
P.6J
anesthesIologIst.Unfortunately,theleadapronsandthyroIdcollarscommonlywornleave
exposedmanyvulnerablesItes,suchasthelongbonesoftheextremItIes,thecranIum,the
skInoftheface,andtheeyes.8ecauseradIatIonexposureIsInverselyproportIonaltothe
squareofthedIstancefromthesource,IncreasIngthIsdIstanceIsmoreunIversally
protectIve.FadIatIonexposurebecomesmInImalatadIstancegreaterthanJ6Inchesfrom
thesource,adIstancethatIseasIlyattaInableInmostanesthetIzInglocatIons.
TheU.S.FegulatoryCommIssIonhasestablIshedanoccupatIonalexposurelImItof5,000
mrem/year.DccupatIonalexposuresamonganesthesIapersonnelhavebeenreportedtobe
consIderablybelowthIslImIt.
J2
However,thesestudIeswereconductedbeforethe
IntroductIonofmanyofthemodernsurgIcalproceduresthatrelyheavIlyonfluoroscopIc
guIdancetechnIques.AmorerecentstudyreportedadoublIngoftheaggregateradIatIon
exposuretothemembersofadepartmentofanesthesIologyIntheyearfollowIngthe
IntroductIonofanelectrophysIologylaboratory.
JJ
PregnantworkerspresentspecIal
concerns,andthedosetothefetusshouldbe500mremdurIngthegestatIonperIod.
DncogenesIs,teratogenesIs,andlongtermgenetIcdefectscanoccurwIthsuffIcIentlyhIgh
exposuretoradIatIon.TherIsksassocIatedwIthradIatIonvaryconsIderably,dependIngon
age,gender,andspecIfIcorgansIteexposure.
J4
However,evenlowlevelsofradIatIon
exposurearenotInconsequentIal.ThestochastIcbIologIceffectsofradIatIonare
cumulatIveandpermanent.
a
TherearenopublIsheddatathatdefInethelowerthreshold
forradIatIonInduceddIsease.Therefore,thegeneraladmonItIonregardIngoccupatIonal
radIatIonexposure,andthebasIsofprotectIonprograms,Isaslowasreasonably
achIevable.
Noise Pollution
NoIsepollutIonIsapotentIalhealthhazardthatIsvIrtuallyuncontrolledInthemodern
hospItalandspecIfIcallyIntheoperatIngroom.NoIseIsquantIfIedbydetermInIngboththe
IntensItyofthesoundIndecIbels(d8)andtheduratIonoftheexposure.NDSHhas
determInedthatthemaxImumlevelforsafenoIseexposureIs90d8for8hours.
J5
Each
IncreaseInnoIseof5d8halvesthepermIssIbleexposuretIme,sothat100d8Isacceptable
forjust2hoursperday.ThemaxImumallowableexposureInanIndustrIalsettIngIs115d8.
ThenoIselevelInmanyoperatIngroomsIssurprIsInglyclosetowhatconstItutesahealth
hazard.
J6
7entIlators,suctIonequIpment,musIc,andconversatIonproducebackground
noIseatalevelof75to90d8.SuperImposedonthIsaresporadIcandunexpectednoIses
causedbydroppedequIpment,surgIcalsawsanddrIlls,andmonItoralarms.FesultantnoIse
levelsfrequentlyexceed120d8andarecomparabletotheclamorofabusyfreeway.
J7
ExcessIvelevelsofnoIsecanhaveanadverseInfluenceontheanesthesIologIst'scapacIty
toperformclInIcaltasks.NoIsecanInterferewIththeabIlItytodIscernconversatIonal
speechandtohearaudItoryalarms.|entaleffIcIencyandshorttermmemoryare
dImInIshedbyexposuretoexcessnoIse.
J6
ComplexpsychomotortasksassocIatedwIth
anesthesIology,suchasmonItorIngandvIgIlance,arepartIcularlysensItIvetotheadverse
InfluencesofnoIsepollutIon.
TherearealsochronIcramIfIcatIonsoflongtermexposuretoexcessIvenoIseInthe
workplace.Attheveryleast,noIsepollutIonIsanImportantfactorIndecreasedworker
productIvIty.AthIghernoIselevels,workersarelIkelytoshowsIgnsofIrrItabIlItyand
demonstrateevIdenceofstress,suchaselevatedbloodpressure.UltImately,hearIngloss
mayensue.
J8
Figure 3-1.DffIcIalsealoftheAmerIcanSocIetyofAnesthesIologIsts.7CLANCEhas
alwaysbeenrecognIzedasthemostcrItIcaloftheanesthesIologIst'stasks.
Dntheotherhand,oneformofbackgroundnoIse,musIc,canprovIdeanumberof
benefIcIaleffects.|usIchasprovedadvantageousasasupplementtosedatIonand
analgesIaforsurgIcalpatIents.
J9,40
SelfselectedbackgroundmusIccancontrIbuteto
reducIngautonomIcresponsesInsurgeonsandImprovIngtheIrperformance.
41
The
benefIcIaleffectsarelesspronouncedwhenthemusIcIschosenbyathIrdparty.The
selectIonofmusIc,andthevolumeatwhIchItIsplayed,shouldbebymutualagreementof
allpartIespresentIntheoperatIngroom.
Human Factors
TheworkperformedbyananesthesIologIstcanbeIntrIcateandIncludesanumberof
complextasks.ExtensIveresearchandmarketIngeffortshavebeendIrectedtowardfIndIng
hIghtechnologysolutIonstoassIsttheanesthesIologIstInmanagIngthIsdemandIng
workload.LessattentIonhasbeengIventoapplyInghumanfactortechnologytoImprove
theworkplaceandensurepatIentsafety.HumanerrorhasbeenIdentIfIedasasIgnIfIcant
causeofpatIentmorbIdItyandmortalIty.
42
AnumberofhumanfactordIffIcultIespotentIallyexIstIntheoperatIngroom.Forexample,
anesthesIaequIpmentIsoftenpoorlydesIgnedorposItIoned.AnesthesIamonItorsand
recordkeepIngequIpmentarefrequentlyplacedsothatattentIonmustbedIrectedaway
fromthepatIentandsurgIcalfIeld.ThIswaswelldemonstratedbyobservatIonsthatthe
InsertIonandmonItorIngofatransesophagealechocardIographaddedsIgnIfIcantlytothe
anesthesIologIst'sworkloadanddIvertedattentIonawayfromotherpatIentspecIfIc
tasks.
4J
TheabIlItytorespondtocrItIcalIncIdentsandtosustaIncomplexmonItorIngtasks,suchas
maIntaInIngvIgIlance
b
areamongthosetasksthataremostvulnerabletothedIstractIons
createdbypoorequIpmentdesIgnorplacement.ThecrItIcalImportanceofthevIgIlance
tasktothepractIceofanesthesIologyIsevIdencedbythefactthatthesealoftheASA
bearsasItsonlymotto,7IgIlance(FIg.J1).
P.64
SeveralaspectsofthevIgIlancetaskdeserveattentIon.ThIsfunctIonIsrepetItIveand
monotonous.ThetaskdoesnotfullyoccupytheanesthesIologIst'smentalactIvIty,but
neItherdoesItleavehImorherfreetoperformothermentalfunctIons.FInally,thetaskIs
complex,requIrIngvIsualattentIonaswellasmanualdexterIty.
7IgIlancetasksaregenerallyperformedatthelevelof90accuracy.
44
nasettIngwhere
thestakesarehIgh,suchasdurInganesthesIa,thIsleavesanunacceptablemargInoferror.
nfact,humanerror,InpartresultIngfromlapsesInattentIon,accountsforalarge
proportIonofthepreventabledeathsandserIousInjurIesresultIngfromanesthetIcmIshaps
IntheUnItedStatesannually.
naddItIontopoorequIpmentdesIgn,anumberofotherfactorsconspIretohamperthe
abIlItyoftheanesthesIologIsttoperformmultIplecomplextasks.AnyfactorthatrequIres
theexpendItureofexcessIveenergytoperformagIventaskproducesapredIctable
decrementInperformance.EventhemosttrIvIalaspectofanoperator'sperformanceplays
asIgnIfIcantroleoverthecourseoftIme.Forexample,IftheanesthesIologIstmustmake
frequentrapIdchangesInobservatIonfromadIm,dIstantscreentoabrIght,nearbyone,
thecontInuousmuscularactIvItyrequIredforpupIldIlatIonandconstrIctIonandlens
accommodatIonpromotesfatIgueandhIndersperformance.
ThedetrImentaleffectsofunnecessaryenergyexpendIturecanbementalaswellas
physIcal.AsmorefunctIonsaremonItoredandmoredataprocesseddurIngthecourseofa
surgIcalprocedure,IncreasInglylargeramountsofmentalworkareexpended.Themental
workvarIesdIrectlywIththedIffIcultyencounteredInextractIngInformatIonfromthe
monItorsanddIsplayscompetIngfortheanesthesIologIst'sattentIon.PoorengIneerIngof
themonItordIsplays,sothatmodeofpresentatIon,sIgnalfrequency,orstrengthIs
suboptImal,canadverselyInfluencetheoperator'sperformance.
EventhealarmsthathavebeendevelopedwIththespecIfIcgoalofsupplementIngthetask
ofvIgIlancecanhaveconsIderabledrawbacks.ngeneral,alarmsarenonspecIfIc(thesame
alarmsIgnalIngasmanyas12dIfferentdevIatIonsfromnormal)andcanbeasourceof
frustratIonandconfusIon.TheyarefrequentlysusceptIbletoartIfactsandfrequentfalse
posItIvealarmsthatcandIstracttheobserverfrommoreclInIcallysIgnIfIcantInformatIon.
tIsnotunusualforfrequentlydIstractIvealarmstobeInactIvated.n2005,theASA
revIsedItsStandardsfor8asIc|onItorIngtomandatethatpulseoxImeterandcapnography
alarmsshouldnotbeturnedoff.
c
NoIsecanhaveadetrImentalInfluenceontheanesthesIologIstworkIngatmultIpletasks.
TheaveragenoIselevelof77decIbelsfoundInoperatIngroomscanreducemental
effIcIencyandshorttermmemory.ngeneral,obtrusIvenoIses,suchasloudtalkIng,
excessIveclangIngofInstruments,andbroadbandnoIse,areassocIatedwIthdecrements
Inperformance.
DrganIzatIonalIssues,suchasfaIledcommunIcatIonamongteammembers,canhavea
detrImentaleffectonananesthesIologIst'sperformance.ThepotentIalfordIsasterasa
resultofpoorcommunIcatIonhasbeenwellIllustratedInanumberofaIrlIne
catastrophes.
45
ThepossIbIlItyformIscommunIcatIonandresultantaccIdentIsheIghtened
IntheoperatIngroomwhere,IncontrasttothestructureInherentInanaIrlInecrew,there
IsanabsenceofawelldefInedhIerarchIcalorganIzatIonandthereareoverlapsInareasof
expertIseandresponsIbIlIty.PoorcommunIcatIoncanleadtoconflIct,compromIsed
patIentsafety,
46
andhasbeenIdentIfIedasarootcauseofJ5ofanesthesIarelated
sentInelevents.
47
EffectIveconflIctresolutIonIsanImportantelementoftheteamworknecessaryfor
successfulsurgIcaloutcomes.ConflIctandunpleasantInterpersonalInteractIonsamong
teammembersareamongthemoststressfulaspectsofthejobofananesthesIologIstand
canhIndersafeanesthetIccare.
48
ConflIctoccursdurIngthemanagementofasmanyas
78ofpatIentsInhIghIntensItyareassuchasoperatIngroomsorcrItIcalcareunIts.
49
SuccessfulresolutIonofconflIctIsaskIllthatcanbelearned.
50
TheaIrlIneIndustryhas
successfullyImplementedcrewresourcemanagementprogramstoImprovethe
performanceofcockpItteams.
51
Fundamentally,mutualrespectIsrequIredamongteam
membersalongwIthawIllIngnesstocarefullylIstenandrecognIzethedIfferencesof
opInIon.nterventIonbyaneutralthIrdpartyIsfrequentlyhelpfulInfIndInganInnovatIve
solutIon.
52
ProductIonpressureIsanorganIzatIonalconcernthathasthepotentIaltocreatean
envIronmentInwhIchIssuesofproductIvItysupersedethoseofsafety.
5J
ProductIon
pressurehasbeenassocIatedwIththecommIssIonoferrorsresultIngfromhasteand/or
delIberatedevIatIonsfromknownsafepractIces.
TheapplIcatIonofsImulatIontechnologyIsgaInIngacceptanceasatooltostudyandteach
humanperformanceIssuesInanesthesIology.
54
tappearstobepartIcularlysuItedto
traInIngnontechnIcalskIllssuchasresourcemanagement,teamwork,and
communIcatIon.
55
Work Hours and Night Call
ProlongedworkhoursthatresultInsleepdeprIvatIonandfatIgueareaubIquItous
componentofmanyanesthesIologIsts'professIonallIves.Tento12hourworkdaysare
common.AddItIonalemergencyandoncallcoveragefrequentlyresultIn24toJ2hour
shIfts.CravensteInetal
56
reportedtheaverageanesthesIologIst'sworkweekwas56hours.
SeventyfourpercentofthestudyrespondentsreportedthattheyhadworkedwIthouta
breakforlongerperIodsthantheypersonallythoughtwassafeand64attrIbutedanerror
InanesthetIcmanagementtofatIgue.Howardetal
57
demonstratedthatresIdentsIntheIr
routIne,nonpostcallstatesufferedfromchronIcsleepdeprIvatIonandhadthesame
degreeofsleepInessasmeasuredInresIdentsfInIshIng24hoursofInhousecall.
LonghoursofworkandnIghtcallareespecIallychallengIngfortheagInganesthesIologIst.
DlderIndIvIdualsarepartIcularlysensItIvetodIsturbancesofthesleepwakecycleandare
IngeneralbettersuItedtophaseadvances(mornIngwork)thanphasedelays(nocturnal
work).
58
0emandsassocIatedwIthnIghtcallhavebeenIdentIfIedasthemoststressful
aspectofpractIceandmostfrequentlycItedImpetustowardretIrement.
58
SleepdeprIvatIonandcIrcadIandIsruptIonhavedeleterIouseffectsoncognItIon,
performance,mood,andhealth.
59
8othacutesleeploss(24hoursofoncallduty)and
chronIcpartIalsleepdeprIvatIon(6hoursofsleeppernIght)resultInasImIlardegreeof
neurobehavIoralImpaIrment.ThenatureanddegreeofImpaIrmentonpsychomotortestIng
wIthacutesleepdeprIvatIonbearsastrIkIngsImIlarItytothatseenwIthalcohol
IntoxIcatIon.
60
ThedeleterIouseffectofsleeplossandfatIgueonworkeffIcIencyandaccuracyIswell
documentedInmanyIndustrIes.
54,61
SleepdeprIvatIonhasbeenImplIcatedasa
contrIbutIngfactorInmanywellpublIcIzedIndustrIalaccIdentssuchasthosethatoccurred
atChernobylandThree|Ilesland.0atacollectedfromresIdentsInmanyclInIcalsettIngs
demonstratethatworkshIftsofgreaterthan24hoursareassocIatedwIthanIncreasedrIsk
ofattentIonalfaIlures,sIgnIfIcantmedIcalerrors,andadversepatIentevents.
62
Dther
studIesIndIcatethatresIdentsworkIngextendedduratIonshIfts
P.65
hadanIncreasedrIskofpercutaneousInjurIesandweremorelIkelytoreportmotor
vehIclecrashesornearmIssIncIdentsdurIngtheIrcommutefromwork.
ComplexcognItIvetasksthatarespecIfIctoanesthesIology,suchasmonItorIngand
accurateclInIcaldecIsIonmakIng,maybeadverselyaffectedbysleepdeprIvatIon.Surveys
ofanesthesIapersonnelhavelInkedfatIgueandanesthetIcerrors,butthesecontaInself
reporteddatathatmaynotbeverIfIable.
56
nastudyofperformanceonananesthesIa
sImulator,resIdentsInthesleepdeprIvedcondItIondemonstratedprogressIveImpaIrment
ofalertness,mood,andperformanceandhadlongerresponselatencytovIgIlance
probes.
54
nspIteofthIs,therewerenosIgnIfIcantdIfferencesIntheclInIcalmanagement
ofthesImulatedpatIentsbetweentherestedandsleepdeprIvedgroups.Subsequenttoa
perIodofsleepdeprIvatIon,performancedoesnotreturntonormallevelsuntIl24hoursof
restandrecoveryhasoccurred.AnInterestIngphenomenonIstheendspurt,InwhIch
prevIouslydeterIoratedperformanceshowsImprovementwhenthesubjectrealIzesthat
thetaskIs90completed.Theconverseundoubtedlyalsooccurs,aletdownwIth
addItIonaldeterIoratIonInperformancewhentheprocedureIsunexpectedlyprolonged.
ThesleeplosspatternexperIencedbyanesthesIologIstswhotakenIghtcallIscomplexand
IncludeselementsofeachofthethreegeneralclassesofsleepdeprIvatIon:total,partIal,
andselectIvesleepdeprIvatIon.SelectIvesleepdeprIvatIonresultIngfromfrequent
InterruptIonsIsmostdIsruptIvetoImportantcomponentsofsleepIncludIngslowwave
sleep(assocIatedwIthbodyrepaIr)andrapIdeyemovementsleep(mIndrepaIr).
ndIcatorsofpsychosocIaldIstress,IncludIngIrrItabIlIty,dIsplacedanger,depressIon,and
anxIety,haveallbeenIdentIfIedInhouseoffIcerssufferIngfromsleepdeprIvatIon.
6J
An
addItIonalareaofconcernIsthepotentIaleffectofsleepdeprIvatIonandchronIcfatIgue
onhealthandpsychosocIaladjustment.WorkschedulesthatdIsruptcIrcadIanrhythmsare
assocIatedwIthImpaIredhealth,emotIonalproblems,andadeclIneInperformance.
NatIonalattentIonwasfocusedontheproblemsassocIatedwIthsleepdeprIvedmedIcal
housestaffbythewellpublIcIzedLIbbyZIoncase.AlargeportIonofthIsclaImhIngedon
theallegatIonthatfatal,avoIdablemIstakesweremadebyexhausted,unsupervIsed
resIdents.AnumberofmedIcalorganIzatIonsandstatelegIslaturessubsequentlytook
actIontolImItexcessIveworkhoursandresultantsleepdeprIvatIonamongphysIcIans,
especIallytraInees.Forexample,theAccredItatIonCouncIlforCraduate|edIcalEducatIon
(ACC|E)hassetunIversalstandardsthatlImItresIdentdutyhourstoanaverageof80
hoursperweekandnomorethanJ0hoursatanyonetIme,lImItthefrequencyofInhouse
call,andmandatethatoffdutytImebeprovIded.Unfortunately,noregulatIonspertaIn
tothepractIcInganesthesIologIstornurseanesthetIst.nthIsarea,medIcIneremaIns
sIgnIfIcantlybehIndotherIndustrIes,mostnotablythetransportandaIrlIneIndustrIes,In
IdentIfyIngandregulatIngworkpractIcesthatpermItexcessIvelylongshIfts.
59
AfterACC|EsetdutyhourlImItsforresIdentsIn200J,InvestIgatorshaveattemptedto
assesstheeffects.AlthoughstudIessuggestthatresIdents'qualItyoflIfehasgenerally
Improved,theeffectoneducatIonIsuncertaInbecausemanyofthestudIescontaIn
sIgnIfIcantmethodflaws.
64
TherehavebeenconflIctIngreportsonwhetherdutyhourlImIts
haveresultedInImprovedpatIentoutcome.
65,66
AlthoughItwasexpectedthatreducIng
resIdentfatIguewouldbeassocIatedwIthfewermedIcalerrors,dutyhourlImItsmayhave
createdunIntendedconsequences,suchasthelossofcontInuItyofcare,anIncreased
lIkelIhoodforfaIluretotransmItcrItIcalInformatIonwhenresponsIbIlItyforcareIs
transferredattheendofshIfts,andtheallocatIonofmanymedIcaltaskstypIcally
performedbyresIdentstononphysIcIanextenders.
SeveralstrategIescanbeusedtopreventfatIgueandtheeffectsofsleepdeprIvatIon
durInglongworkperIods.
59
PersonnelshouldbeeducatedontheproblemsassocIatedwIth
poorsleephabItsoutsIdethehospItal.NapsprIortothestartofcallaswellastheuseof
caffeInecanImprovealertnessdurInglongshIfts.|odafInIlmaybeusefultotreat
sleepInessInIndIvIdualswIthshIftworksleepdIsorder.
67
Infection Hazards
AnesthesIapersonnelareatrIskforacquIrIngInfectIonsbothfrompatIentsandfromother
personnel.7IralInfectIons,reflectIngtheIrprevalenceInthecommunIty,arethemost
sIgnIfIcantthreattoHCWs.|ostcommonly,thesearespreadthroughtherespIratoryroute
amechanIsmthatIs,unfortunately,themostdIffIculttocontroleffectIvely.Dther
InfectIonsarepropagatedbyhandtohandtransmIssIon,andhandwashIngIsconsIdered
thesInglemostImportantInterventIonforprotectIonagaInstthIsformofcontagIon.
68
mmunItyagaInstsomevIralpathogenscanbeprovIdedthroughvaccInatIon.
69
8loodborne
pathogenssuchashepatItIsandhumanImmunodefIcIencyvIrus(H7)causeserIous
InfectIons,buttransmIssIoncanbepreventedwIthmechanIcalbarrIersblockIngportalsof
entryor,InthecaseofhepatItIs8,byproducIngImmunItybyvaccInatIon.
70
Current
recommendatIonsfromtheCentersfor0IseaseControlandPreventIon(C0C)forpre
employmentscreenIng,InfectIoncontrolpractIces,vaccInatIon,postexposuretreatment,
andworkrestrIctIonsforInfectedpersonnelshouldbeconsultedforspecIfIcInformatIon
relatedtoeachpathogen.
70,71,72
Respiratory Viruses
FespIratoryvIruses,whIchareresponsIbleformanycommunItyacquIredInfectIons,are
usuallytransmIttedbytworoutes.SmallpartIcleaerosolsproducedbycoughIng,sneezIng,
ortalkIngcanpropelvIrusesoverlargedIstances.TheInfluenzaandmeaslesvIrusesare
spreadInthIsway.ThesecondmechanIsmInvolveslargedropletsproducedbycoughIngor
sneezIng,contamInatIngthedonor'shandsoranInanImatesurface,whereuponthevIrusIs
transferredtotheoral,nasal,orconjunctIvalmucousmembranesofasusceptIbleperson
byselfInoculatIon.FhInovIrusandrespIratorysyncytIalvIrus(FS7)arespreadbythIs
process.
Influenza Viruses
8ecauseInfluenzavIrusesareeasIlytransmItted,communItyepIdemIcsofInfluenzaare
common,wIthlargeoutbreaksoccurrIngannually.AcutelyIllpatIentsshedvIrusthrough
smallpartIcleaerosolsbycoughIngorsneezIngforaslongas5daysaftertheonsetof
symptoms.FespIratoryIsolatIonprecautIonscanbeusedfortheduratIonoftheclInIcal
IllnessInanattempttopreventspreadtosusceptIbleIndIvIduals.8ecauseoftheIrcontact
wIthnasopharyngealsecretIons,anesthesIologIstscanplayaroleInthespreadofInfluenza
vIrusInhospItals.
nfluenzararelyproducessIgnIfIcantmorbIdItyInhealthypersonnelbutcanresultInhIgh
ratesofabsenteeIsm.HospItalstaff,especIallythosewhocareforpatIentsInhIghrIsk
groups,shouldbeImmunIzedannually(DctoberorNovember)wIththeInactIvated(kIlled
vIrus)InfluenzavIrusvaccIne.
72
AntIgenIcvarIatIonofInfluenzavIrusesoccursovertIme,
sothatnewvIralstraIns(usuallytwotypeAandonetype8)areselectedforInclusIonIn
eachyear'svaccIne.
P.66
ntheUnItedStates,therearefourantIvIralagentsforchemoprophylaxIsandtreatmentof
Influenza:amantadIne,rImantadIne,zanamIvIr,andoseltamIvIr.
72
8ecauseofahIgh
lIkelIhoodofInfluenzaAvIralresIstance,amantadIneandrImantadInearenotcurrently
recommended.TheneuramInIdaseInhIbItorszanamIvIrandoseltamIvIrhavebeenshown
tobeeffectIveInpreventIngandtreatIngbothInfluenzaAand8.0urInghospItaloutbreaks
ofInfluenza,theantIvIralagentszanamIvIrandoseltamIvIrareabout80effectIveIn
preventIngInfluenzaInfectIonInunvaccInatedhospItalpersonneland,IfadmInIstered
wIthIn48hoursoftheonsetofIllness,canreducetheduratIonandseverItyofIllness.
8ecauseofpossIblemorbIdItytohospItalIzedpatIentsandtohospItalpersonnel,ItIs
recommendedthatdurIngcommunItyInfluenzaepIdemIcs,hospItalsshouldconsIder
lImItIngelectIveadmIssIonsandsurgery.
Influenza Pandemic
nthepastcentury,therehavebeenthreeInfluenzapandemIcs(1918,1957,and1968)wIth
theCreatnfluenzaIn1918kIllIngbetween40and50mIllIonpeopleworldwIde.Although
thetImIngandseverItycannotbepredIcted,anotherInfluenzapandemIcIslIkelyand
representsoneofthegreatestpublIchealththreats.
d
ntheeventofapandemIc,thelarge
numberofInfectedpatIentswouldstraInglobalresourcessuchashealthcarefacIlItIesand
equIpment(respIratorsforpersonnelandventIlatorsforpatIents).ContaInmenttoprevent
thespreadofInfectIonrequIresearlyIdentIfIcatIonandIsolatIonofInfectedIndIvIdualsto
lImItdIseasetransmIssIon.ForpatIentsrequIrInghospItalIzatIon,specIfIcwardsshouldbe
establIshedwIthdedIcatedstaff.NDSHcertIfIedrespIrators(N95orhIgher)shouldbeused
bypersonneldurIngactIvItIesorprocedureslIkelytogenerateInfectIousrespIratory
aerosols.
Avian Influenza A
AvIanInfluenzavIrusoccursnaturallyInbIrds,buttherehavebeenoutbreaksInhumans.
7J
ThefIrsthumancaseswerereportedfromAsIa,butthevIrushasbeenIdentIfIedInEurope,
theNearEast,andAfrIca.AvIanInfluenzaAtypeH5N1hasahumanmortalItyofover50.
ClInIcalIllnessbegInsasaseverepneumonIathatmayrapIdlyprogresstoacuterespIratory
dIstresssyndrome.DutbreaksofavIanfluhaveusuallyoccurredInpeoplewhohavehad
closecontactwIthInfectedpoultry.HumantohumantransmIssIonIsuncommon,but
becauseInfluenzavIruseshavetheabIlItytomutate,thereIsconcernthatfutureH5N1
vIrusesmaybecapableofspreadfromonepersontoanother.ThereIsvarIable
susceptIbIlItyofthevIrustocurrentlyavaIlableantIvIralagents.AvaccIneforprophylaxIs
agaInstavIanInfluenzaH5N1wasapprovedforuseIntheUnItedStatesIn2007.
Respiratory Syncytial Virus
FS7IsthemostcommoncauseofserIousbronchIolItIsandlowerrespIratorytractdIsease
InInfantsandyoungchIldrenworldwIde.0urIngperIodswhenFS7IsprevalentInthe
communIty(usuallylateNovemberthrough|ayIntheUnItedStates),manyhospItalIzed
InfantsandchIldrenmaycarrythevIrus.LargenumbersofvIrusarepresentInrespIratory
secretIonsofInfectedchIldren,andalthoughvIablevIruscanberecoveredforupto6
hoursoncontamInatedenvIronmentalsurfaces,ItIsreadIlyInactIvatedwIthsoapand
wateranddIsInfectants.nfectIonofsusceptIblepeopleoccursbyselfInoculatIonwhen
FS7InsecretIonsIstransferredtothehands,whIchthencontactthemucousmembranesof
theeyesornose.
74
AlthoughmostchIldrenhavebeenexposedtoFS7earlyInlIfe,
ImmunItyIsnotpermanentandreInfectIonIscommon.
FS7mayalsobeasIgnIfIcantcauseofIllnessInhealthyelderlypatIentsandthosewIth
chronIccardIacorpulmonarydIsease.
75
FS7IsshedforapproxImately7daysafter
InfectIon.HospItalIzedpatIentswIththevIrusshouldbeIsolated,butdurIngseasonal
outbreakslargenumbersofpatIentsmaymakeIsolatIonImpractIcal.
76
Carefulhand
washIngandtheuseofgowns,gloves,masks,andgoggles(standardprecautIons)haveall
beenshowntoreduceFS7InfectIonInhospItalpersonnel.
Herpes Viruses
7arIcellazostervIrus(7Z7),herpessImplexvIrustypes1and2,andcytomegalovIrus(C|7)
aremembersoftheHerpetovIrIdInefamIly.ClosepersonalcontactIsrequIredfor
transmIssIonofalltheherpesvIrusesexceptfor7Z7,whIchIsspreadbydIrectcontactor
smallpartIcleaerosols.AfterprImaryInfectIonwIthherpesvIruses,theorganIsmbecomes
latentandmayreactIvateatalatertIme.|ostpeopleIntheUnItedStateshavebeen
InfectedwIthalloftheherpesvIrusesbymIddleage.Therefore,nosocomIaltransmIssIonIs
uncommonexceptInthepedIatrIcpopulatIonandInImmunosuppressedpatIents.
Varicella-Zoster Virus
7Z7producesbothchIckenpoxandherpeszoster(shIngles).AlthoughtheprImaryInfectIon
(chIckenpox)IsusuallyuncomplIcatedInhealthychIldren,7Z7InfectIonInadultsmaybe
assocIatedwIthmajormorbIdItyordeath.nfectIondurIngpregnancymayresultInfetal
deathor,rarely,IncongenItaldefects.HealthcareworkerswIthactIve7Z7InfectIoncan
transmItthevIrustoothers.
AftertheprImaryInfectIon,7Z7remaInslatentIndorsalrootorextramedullarycranIal
ganglIa.HerpeszosterresultsfromreactIvatIonofthe7Z7InfectIonandproducesapaInful
vesIcularrashIntheInnervateddermatome.AnesthesIologIstsworkIngInpaInclInIcsmay
beexposedto7Z7whencarIngforpatIentswhohavedIscomfortfromherpeszoster.
7Z7IshIghlycontagIous,especIallyfrompatIentswIthchIckenpoxordIssemInatedzoster.
TheC0CestImatesthattheperIodofcommunIcabIlItybegIns1to2daysbeforetheonset
oftherashandendswhenallthelesIonsarecrusted,usually4to6daysaftertherash
appears.
77
8ecause7Z7maybespreadthroughaIrbornetransmIssIon,respIratoryIsolatIon
shouldbeusedforpatIentswIthchIckenpoxordIssemInatedherpeszoster.
76
Useofgloves
toavoIdcontactwIthvesIcularfluIdIsadequatetoprevent7Z7spreadfrompatIentswIth
localIzedherpeszoster.
|ostadultsIntheUnItedStateshaveprotectIveantIbodIesto7Z7.8ecausetherehave
beenmanyreportsofnosocomIaltransmIssIonof7Z7,ItIsrecommendedthatallHCWs
haveImmunItytothevIrus.AnesthesIapersonnelshouldbequestIonedaboutprIor7Z7
InfectIon,andthosewIthanegatIveorunknownhIstoryofInfectIonshouldbeserologIcally
tested.
77
AllemployeeswIthnegatIvetItersshouldberestrIctedfromcarIngforpatIents
wIthactIve7Z7InfectIonandshouldbeofferedImmunIzatIonwIthtwodosesofthelIve,
attenuatedvarIcellavaccIne.
SusceptIblepersonnelwIthasIgnIfIcantexposuretoanIndIvIdualwIth7Z7InfectIonare
potentIallyInfectIvefrom10to21daysafterexposureandshouldnotcontactpatIents
P.67
durIngthIsperIod.TheyshouldbeofferedvaccInatIonwIthInJto5daysoftheexposure
sInceItmIghtmodIfythedIsease.7arIcellazosterImmuneglobulIncanalsobeconsIdered
butItIsmosteffectIvewhenadmInIsteredwIthIn96hoursafterexposure.
77
Personnel
wIthout7Z7ImmunItyshouldbereassIgnedtoalternatIvelocatIonssothattheydonot
careforpatIentswhohaveactIve7Z7InfectIons.
Herpes Simplex
HerpessImplexvIrus(HS7)InfectIonIsquItecommonInadults.AftervIralentrythrough
themucousmembranesofthemouth,theprImaryInfectIonwIthHS7type1Isusually
clInIcallyInapparentbutmayInvolvesevereorallesIons,fever,andadenopathy.n
healthypeople,theprImaryInfectIonsubsIdesandthevIruspersIstsInalatentstate
wIthInthesensorynerveganglIonInnervatIngthesIteofInfectIon.Anyofseveral
mechanIsmscanreactIvatethevIrustoproducerecurrentInfectIon,whIchmanIfestsInthe
vIcInItyoftheprImarylesIon.
AsecondHS7,type2,IsusuallyassocIatedwIthgenItalInfectIonsandIsspreadbysexual
contact.NewbornsmaybecomeInfectedwIthHS7type2durIngvagInaldelIvery.
HealthcarepersonnelmaybeInoculatedbydIrectcontactwIthbodyfluIdscarryIngeIther
HS7type1or2.
HerpetIcInfectIonofthefInger,herpetIcparonychIaorherpetIcwhItlow,Isan
occupatIonalhazardforanesthesIapersonnel.TheInfectIonusuallybegInsattheportalof
vIralentry,asIteonthedIstalfIngerwheretheIntegrItyoftheskInhasbeenbroken,and
resultsInvesIcleformatIon.WIthInJweeks,thethrobbIngpaInlessensandthelesIons
begIntoheal.UseofacyclovIr,anantIvIraldrugthatInhIbItsreplIcatIonofHS7,may
shortenthecourseoftheprImarycutaneousvIralInfectIon.PersonnelwIthHS7InfectIons
ofthefIngersorhandsshouldnotcontactpatIentsuntIltheIrlesIonsarehealed.
Cytomegalovirus
C|7Infectsbetween50and85ofIndIvIdualsIntheUnItedStatesbeforeage40,wIth
mostInfectIonsproducIngmInImalsymptoms.AftertheprImaryInfectIon,thevIrus
remaInsdormant,andrecurrentdIseaseonlyoccurswIthcompromIseoftheIndIvIdual's
Immunesystem.TransmIssIonofC|7cantakeplacethroughclosecontactwIthan
IndIvIdualexcretIngthevIrusorthroughcontactwIthcontamInatedsalIvaorurIne.tIs
unlIkelythataerosolsorsmalldropletsplayaroleInC|7transmIssIon.
PrImaryorrecurrentC|7InfectIondurIngpregnancyresultsInfetalInfectIonInupto2.5
ofoccurrences.CongenItalC|7syndromemaybefoundInupto10ofInfectedInfants.
Thus,althoughC|7InfectIonusuallydoesnotresultInmorbIdItyInhealthyadults,Itmay
havesIgnIfIcantsequelaeInpregnantwomen.C|7InfectIoncanalsobedeadlyIn
ImmunocompromIsedpatIents,suchasthoseundergoIngbonemarrowtransplantatIon.
ThetwomajorpopulatIonswIthC|7InfectIonInthehospItalIncludeInfectedInfantsand
ImmunocompromIsedpatIents,suchasthosewhohaveundergoneorgantransplantsor
thoseononcologyunIts.FoutIneInfectIoncontrolprocedures(standardprecautIons)are
suffIcIenttopreventC|7InfectIonInHCWs(TablesJJandJ4).
71
Pregnantpersonnel
shouldbemadeawareoftherIsksassocIatedwIthC|7InfectIondurIngpregnancyandof
approprIateInfectIoncontrolprecautIonstobeusedwhencarIngforhIghrIskpatIents.
ThereIsnoevIdencetoIndIcatethatItIsnecessarytoreassIgnpregnantwomenfrom
patIentcareareasInwhIchtheymayhavecontactwIthC|7posItIvepatIents.
Rubella
Dutbreaksofrubella,orCermanmeasles,InhospItalpersonnelhaveresultedInsIgnIfIcant
lossInemployeeworkIngtIme,employeemorbIdIty,andcosttothehospItal.Although
mostadultsIntheUnItedStatesareImmunetorubella,upto20ofwomenof
chIldbearIngagearestIllsusceptIble.FubellaInfectIondurIngthefIrsttrImesterof
pregnancyIsassocIatedwIthcongenItalmalformatIonsorfetaldeath.
FubellaIstransmIttedbycontactwIthnasopharyngealdropletsspreadbyInfected
IndIvIdualscoughIngorsneezIng.PatIentsaremostcontagIouswhIletherashIseruptIng
butcantransmItthevIrusfrom1weekbeforeto5to7daysaftertheonsetoftherash.
0ropletprecautIonsshouldbeusedtopreventtransmIssIon(TableJ4).
76
Table 3-3 Prevention of Occupationally Acquired Infections
INFECTIOUS AGENT
PREVENTIVE MEASURES
a
CytomegalovIrus StandardprecautIons
HepatItIsA 7accIneInsomecases;contactprecautIons
HepatItIs8 7accIne;hepatItIs8ImmuneglobulIn,standardprecautIons
HepatItIsC StandardprecautIons
HerpessImplex
StandardprecautIons;contactprecautIonsIfdIssemInated
dIsease
Human
ImmunodefIcIency
vIrus
StandardprecautIons;postexposureprophylactIc
antIretrovIrals
nfluenza,human 7accIne;prophylactIcantIretrovIrals;dropletprecautIons
|easles 7accIne;aIrborneprecautIons
Fubella 7accIne;dropletprecautIons
Severeacute
respIratory
syndrome
StandardprecautIons;aIrborneprecautIons
TuberculosIs
AIrborneprecautIons;IsonIazIdethambutolforpurIfIed
proteInderIvatIveconversIon
7arIcellazoster
7accIne;varIcellazosterImmuneglobulIn;aIrborneand
contactprecautIons;standardprecautIonsIflocalIzed
dIsease
0ataderIvedfromreference76.
a
solatIonprecautIonsoutlInedInTableJ4.
P.68
P.69
Table 3-4 Health Care Isolation Precautions
a
STANDARD PRECAUTIONS
ThesearetobeusedforthecareofallpatIentsregardlessoftheIrdIagnosIsor
presumedInfectIonstatus.
StandardprecautIonsshouldbeusedInconjunctIonwIthotherformsof
transmIssIonbasedprecautIons(descrIbedlaterIntable)forthecareofspecIfIc
patIents.
1. Hand washing (hand hygiene)
AftertouchIngblood,bodyfluIds,orcontamInatedItemsandenvIronmental
surfacesevenIfglovesareworn.
2. Gloves
WeargloveswhenItIsreasonablyantIcIpatedthattherewIllbecontactwIth
bloodorInfectIousmaterIal,mucousmembranes,nonIntactskIn,or
contamInatedIntactskIn.
ChangeglovesbetweentasksonthesamepatIentwhenthehandswIllmove
fromacontamInatedbodysItetoacleanone.
Femoveglovesafteruse,beforetouchIngnoncontamInatedItemsand
envIronmentalsurfaces.
J. Mask, eye protection, face shield
UsedurIngprocedureslIkelytogeneratesplashesofbloodorbodyfluIdsthat
maycontamInatefaceormucousmembranes.
4. Gown
UsedurIngprocedureslIkelytogeneratesplashesofbloodorbodyfluIdsthat
maycontamInateclothIngorarms.
5. Respiratory hygiene/cough etiquette
EducatehealthcarepersonnelandImplementmethodstocontaInrespIratory
secretIonsInpatIentsandvIsItorsespecIallydurIngseasonaloutbreaksofvIral
respIratorytractInfectIons.
6. Patient-care equipment and instruments/devices
UsePPEwhenhandlIngsoIleddevIcestopreventcontamInatIonofskIn,mucous
membranes,orclothIng.
7. Environmental control
ContamInatedenvIronmentalsurfacesshouldroutInelybecleanedand/or
dIsInfected.
8. Linen
SoIledlInenshouldbehandledInamannerthatpreventscontamInatIonof
personnel,otherpatIents,andenvIronmentalsurfaces.
9. Occupational health and blood-borne pathogens
UsecaretopreventInjurIeswhenusIngordIsposIngofneedlesandsharp
devIces.
ContamInatedneedlesshouldnotberecappedormanIpulatedbyusIngboth
hands.frecappIngIsnecessaryfortheprocedurebeIngperformed,aone
handedscooptechnIqueormechanIcaldevIceforholdIngtheneedlesheath
shouldbeused.
ContamInatedneedlesshouldnotberemovedfromdIsposablesyrIngesbyhand.
0onotbreakorbendcontamInatedneedlesbeforedIsposal.
Afteruse,dIsposablesyrIngesandneedlesandothersharpdevIcesshouldbe
placedInapproprIatepunctureresIstantcontaInerslocatedascloseaspractIcal
totheareaInwhIchtheItemswereused.
|outhpIeces,resuscItatIonbags,orotherventIlatIondevIcesshouldbeavaIlable
foruseasanalternatIvetomouthtomouthventIlatIon.
10. Patient placement
SInglepatIentroomsshouldbeusedforpatIentswhoposearIskfortransmIssIon
ofInfectIousagentstoothers.
TRANSMISSION-BASED PRECAUTIONS
TheseshouldbeusedalongwIthstandardprecautIonsforpatIentsknownor
suspectedtobeInfectedorcolonIzedwIthhIghlytransmIssIblepathogensrequIrIng
addItIonalprecautIons.
AIRBORNE PRECAUTIONS
TheseshouldbeusedforpatIentsknownorsuspectedtobeInfectedwIthmIcro
organIsmstransmIttedbyaIrbornedropletnucleI(partIcles5morsmallerInsIze)
thatcanbedIspersedoverlargedIstancesbyaIrcurrents.
1. Patient placement
ThepatIentshouldbeplacedInasInglepatIentroomwIth(1)documented
negatIveaIrpressurerelatIvetosurroundIngareas,(2)6to12aIrchangesper
hour,(J)dIschargeofaIroutdoorsormonItoredhIgheffIcIencyfIltratIonofroom
aIrbeforetheaIrIscIrculatedtootherareasInthehospItal.
ThedoortotheroomshouldbekeptclosedandthepatIentshouldremaInInthe
room.
2. Respiratory protection
AfIttestedNDSHapprovedN95orhIgherlevelrespIratorshouldbewornwhen
enterIngtheroomofapatIentwIthknownorsuspectedInfectIouspulmonaryor
laryngealtuberculosIsorsmallpox.
SusceptIblepersonnelshouldnotentertheroomofpatIentsknownorsuspected
tohavemeasles,varIcella,dIssemInatedzoster,orsmallpoxIfotherImmune
caregIversareavaIlable.fsusceptIblepersonsmustentertheroomofapatIent
knownorsuspectedtohavemeaslesorvarIcella,theyshouldwearrespIratory
protectIon.PersonsknowntobeImmunetomeaslesorvarIcellaneednotwear
respIratoryprotectIon.
J. Patient transport
PatIentsshouldbetransportedfromtheIsolatIonroomonlyformedIcally
necessarypurposes.WhentransportIsnecessary,asurgIcalmaskshouldbe
placedonthepatIenttopreventdIspersalofdropletsandthepatIentshouldbe
InstructedtofollowrespIratoryhygIene/coughetIquette.
4. Patients with tuberculosis
CurrentC0CguIdelInesshouldbeconsultedforaddItIonalprecautIons.
76
DROPLET PRECAUTIONS
TheseshouldbeusedforpatIentsknownorsuspectedtobeInfectedwIth
mIcroorganIsmstransmIttedbylargepartIcledroplets(partIcleslargerthan5m)
thatcanbegenerateddurIngcoughIng,sneezIng,talkIng,orbyperformIngcertaIn
procedures.
1. Patient placement
ThepatIentshouldbeplacedInasInglepatIentroom.
2. Respiratory protection
PersonnelshouldwearamaskwhenenterIngthepatIent'sroom.
J. Patient transport
PatIentsshouldbetransportedfromtheIsolatIonroomonlyformedIcally
necessarypurposes.WhentransportIsnecessary,asurgIcalmaskshouldbe
placedonthepatIentandtheyshouldbeInstructedtofollowrespIratory
hygIene/coughetIquette.
NomaskIsrequIredforthepersontransportIngthepatIent.
CONTACT PRECAUTIONS
TheseshouldbeusedforpatIentsknownorsuspectedtobeInfectedorcolonIzed
wIthepIdemIologIcallyImportantmIcroorganIsmstransmIttedbydIrectcontact
wIththepatIentorIndIrectcontactwIthenvIronmentalsurfacesorpatIentcare
Items.
1. Patient placement
ThepatIentshouldbeplacedInasInglepatIentroom.
2. Gloves and hand washing
naddItIontowearIngglovesasoutlInedunderstandardprecautIons,gloves
shouldbewornwhenenterIngthepatIent'sroom.
ClovesshouldbechangedaftercontactIngInfectIvematerIalorenvIronmental
surfacesthatmaycontaInhIghconcentratIonsofmIcroorganIsms.
ClovesshouldberemovedbeforeleavIngthepatIent'senvIronmentandhands
shouldbewashedImmedIatelywIthanantImIcrobIalagentorawaterless
antIseptIcagent.
AfterremovalofglovesandhandwashIng,careshouldbetakensothat
contamInatedenvIronmentalsurfacesshouldnotbetouchedtoavoIdtransferof
mIcroorganIsmstootherpatIents.
J. Gown
naddItIontowearIngagownasoutlInedunderstandardprecautIons,agown
(nonsterIle)shouldbewornwhenenterIngtheroomwhenItIsantIcIpatedthat
clothIngwIllhavecontactwIththepatIent,envIronmentalsurfaces,or
contamInatedItemsorIfthepatIentIsIncontInentorhasdIarrhea,an
Ileostomy,acolostomy,orwounddraInagenotcontaInedbyadressIng.
ThegownshouldberemovedbeforeleavIngthepatIent'senvIronment.
ClothIngshouldnotcontactpotentIallycontamInatedsurfacesafterremovalof
thegown.
4. Patient transport
ThepatIentshouldbetransportedfromtheroomforonlymedIcallynecessary
purposes.
fItIsnecessarytotransportthepatIent,InfectedorcolonIzedareasofthe
patIent'sbodyshouldbecoveredtopreventtransmIssIonofmIcroorganIsmsto
otherpatIentsandcontamInatIonofenvIronmentalsurfacesorequIpment.
FemovecontamInatedPPEprIortotransportIngpatIentsanddoncleanPPEto
handlethepatIentatthetransportdestInatIon.
5. Patient-care equipment
UsedIsposablenoncrItIcalpatIentcareequIpment(e.g.,bloodpressurecuffs)or
dedIcatenondIsposableequIpmenttoasInglepatIenttoavoIdtransmIssIonof
mIcroorganIsmstoanotherpatIent.fuseofcommonequIpmentIsunavoIdable,
thenItemsshouldbeadequatelycleanedordIsInfectedbeforeuseonanother
patIent.
PPE,personalprotectIveequIpmentsuchasgloves,gown,eyeshIeld,orface
mask;NDSH,NatIonalnstItuteforDccupatIonalSafetyandHealth;C0C,Centers
for0IseaseControl.
a
ThIstablesummarIzesIsolatIonprecautIons,butthecompleteguIdelIneshouldbe
consultedformoredetaIledInformatIon.
76
EnsurIngImmunItyatthetImeofemployment(evIdenceofprIorvaccInatIonwIthlIve
rubellavaccIneorserologIcconfIrmatIon)shouldpreventnosocomIaltransmIssIonof
rubellatopersonnel.thasbeenshownthathIstoryIsapoorIndIcatorofImmunIty.AlIve,
attenuatedrubellavIrusvaccIne,contaInedInmeasles,mumps,rubellavaccIne,Is
avaIlabletoproduceImmunItyInsusceptIblepersonnel.
69,78
|anystateorlocalhealth
departmentsmandaterubellaImmunItyforallHCWs,andlocalregulatIonsshouldbe
consulted.
Measles (Rubeola)
|easlesvIrusIshIghlytransmIssIblebothbylargedropletsandbytheaIrborneroute.The
vIrusIsfoundInthemucusofthenoseandpharynxoftheInfectedIndIvIdualandIsspread
bycoughIngandsneezIng.ThedIseasecanbetransmIttedfrom4daysprIortotheonsetof
therashto4daysafterItsonset.AIrborneprecautIonsshouldbeusedforInfectedpatIents
(TableJ4).
71,76
ntroductIonofthemeaslesvaccIneIntheUnItedStateshassuccessfully
elImInatedIndIgenouscasesofmeaslesbutImportatIonofmeaslesfromothercountrIes
contInuestooccur.
P.70
HCWsareatIncreasedrIskforacquIrIngmeaslesandtransmIttIngthevIrustosusceptIble
coworkersandpatIents.TheC0CrecommendsthatmedIcalpersonnelhaveadequate
ImmunItytomeasles,asdocumentedbyoneofthefollowIng:evIdenceoftwodosesoflIve
measlesvaccIne,arecordofphysIcIandIagnosedmeasles,orserologIcevIdenceofmeasles
ImmunIty(TableJJ).
69
SusceptIblepersonnelbornInorafter1957shouldreceIvetwo
dosesofthelIvemeaslesvaccIneatthetImeofemployment.
78
Severe Acute Respiratory Syndrome
SevereacuterespIratorysyndrome(SAFS)IsarespIratorytractInfectIonproducedbya
coronavIrus,SAFSassocIatedcoronavIrus(SAFSCo7).AfterthefIrstcaseswerereported
fromAsIaInlate2002,thedIseasequIcklyspreadgloballyIn200JbeforebeIngcontrolled.
SIncethen,globalsurveIllanceforSAFSCo7hasdetectednoconfIrmedcases.8ecauseof
therapIdspreadandthesIgnIfIcantmorbIdItyandmortalItyassocIatedwIththeInfectIon,
thereIsaneedtounderstandthedIsease.HealthcarefacIlItIesshouldbepreparedto
rapIdlyImplementcontrolmeasuresIfnewoutbreaksoccur.
SAFStypIcallypresentswIthahIghfever,greaterthanJ8.0`C,andIsfollowedwIth
symptomsofheadache,generalIzedaches,andcough.SeverepneumonIamayleadto
acuterespIratorydIstresssyndromeanddeath.SAFSIsspreadbyclosepersontoperson
contactthroughvIruscarrIedInlargerespIratorydropletsandpossIblybyaIrborne
transmIssIon.ThevIruscanalsobespreadwhenanIndIvIdualtouchesacontamInated
objectandthenInoculatesthemouth,nose,oreyes.AerosolIzatIonofrespIratory
secretIonsdurIngcoughIngorendotrachealsuctIonInghasbeenassocIatedwIth
transmIssIonofthedIseasetoHCWs,IncludInganesthesIologIstsandcrItIcalcarenurses.
DneofthemostImportantInterventIonstopreventthespreadofSAFSInthehealthcare
settIngIsearlydetectIonandIsolatIonofpatIentswhomaybeInfectedwIthSAFSCo[7
wIthdotabove]
79
Cloves,gown,respIratoryprotectIon(asamInImum,useaNDSH
certIfIedN95fIlterIngrespIrator),andeyeprotectIonshouldbedonnedbeforeenterInga
SAFSpatIent'sroomordurIngprocedureslIkelytogeneraterespIratoryaerosols.
79
Viral Hepatitis
AlthoughmanyvIrusesmayproducehepatItIs,themostcommonaretypeAorInfectIous
hepatItIs,type8(H87)orserumhepatItIs,andtypeC(HC7),whIchIsresponsIbleformost
casesofparenterallytransmIttednonA,non8hepatItIs(NAN8H)IntheUnItedStates.
0eltahepatItIs,causedbyanIncompletevIrus,occursonlyInpeopleInfectedwIthH87.
DutbreaksofanenterIcallytransmIttedNAN8H(hepatItIsE)havebeenreportedfrom
outsIdetheUnItedStatesandareusuallycausedbycontamInatedwater.ThegreatestrIsks
ofoccupatIonaltransmIssIontoanesthesIapersonnelareassocIatedwIthH87andHC7.
Hepatitis A
About20to40ofvIralhepatItIsInadultsIntheUnItedStatesIscausedbythetypeA
vIrus.HepatItIsAIsusuallyaselflImItedIllness,andnochronIccarrIerstateexIsts.Spread
IspredomInantlybythefecaloralroute,eItherbypersontopersoncontactorbyIngestIon
ofcontamInatedfoodorwater.DutbreaksareusuallyfoundInInstItutIonsorotherclosed
groupswheretherehasbeenabreakdownInnormalsanItarycondItIons.HospItalpersonnel
donotappeartobeatIncreasedrIskforhepatItIsAandnosocomIaltransmIssIonIsrare.
PersonnelexposedtopatIentswIthhepatItIsAshouldreceIveImmuneglobulIn
IntramuscularlyassoonaspossIblebutnotmorethan2weeksaftertheexposuretoreduce
thelIkelIhoodofInfectIon.
80
mmuneglobulInprovIdesprotectIonagaInsthepatItIsA
throughpassIvetransferofantIbodIesandIsusedforpostexposureprophylaxIs.HepatItIsA
vaccIneIsnotroutInelyrecommendedforHCWsexceptforthosethatmaybeworkIngIn
countrIeswherehepatItIsAIsendemIc.
69,80
Hepatitis B
HepatItIs8IsasIgnIfIcantoccupatIonalhazardfornonImmuneanesthesIologIstsandother
medIcalpersonnelwhohavefrequentcontactwIthbloodandbloodproducts.The
prevalence(theproportIonofpeoplewhohaveorhavehadthecondItIonatthetImeof
thesurvey)ofhepatItIs8InthegeneralpopulatIonoftheUnItedStatesIsJto5,andthe
carrIerrateIs0.2to0.9basedonserologIcscreenIng.SerosurveysconductedInthe
UnItedStatesandseveralothercountrIesInthe1980sIncludedmorethan2,400
unvaccInatedanesthesIapersonnelanddemonstratedameanprevalenceofH87serologIc
markersof17.8(range,J.2to48.6).
81.
8eforethewIdespreadusageofhepatItIs8
vaccInetheprevalenceofhepatItIs8serologIcmarkersInanesthesIapersonnelranged
from19to49andreflectedtheprevalenceofH87carrIersInthereferralpopulatIonfor
thearea.
AcuteH87InfectIonmaybeasymptomatIcandusuallyresolveswIthoutsIgnIfIcanthepatIc
damage.Lessthan1ofacutelyInfectedpatIentsdevelopfulmInanthepatItIs.
ApproxImately10becomechronIccarrIersofH87(I.e.,serologIcevIdencedemonstrated
for6months).WIthIn2years,halfofthechronIccarrIersresolvetheIrInfectIonwIthout
sIgnIfIcanthepatIcImpaIrment.ChronIcactIvehepatItIs,whIchmayprogresstocIrrhosIs
andIslInkedtohepatocellularcarcInoma,IsfoundmostcommonlyInIndIvIdualswIth
chronIcvIralInfectIonfor2years.
ThedIagnosIsandclassIfIcatIonofthestageofH87InfectIoncanbemadeonthebasIsof
serologIctestIng.AntIbodytothesurfaceantIgen(antIH8s)appearswIthresolutIonofthe
acuteInfectIonandconferslastIngImmunItyagaInstsubsequentH87InfectIons.ChronIc
H87carrIersarelIkelytohavehepatItIs8surfaceantIgen(H8sAg)andantIbodytothecore
antIgen(antIH8c)presentInserumsamples.ThepresenceofhepatItIs8eantIgen(H8eAg)
InserumIsIndIcatIveofactIvevIralreplIcatIonInhepatocytes.
AnesthesIapersonnelareatrIskforoccupatIonallyacquIredH87InfectIonasaresultof
accIdentalpercutaneousormucosalcontactwIthbloodorbodyfluIdsfromInfected
patIents.PatIentgroupswIthahIghprevalenceofH87IncludeImmIgrantsfromendemIc
areas,usersofIllIcItparenteraldrugs,homosexualmen,andpatIentsonhemodIalysIs.
70
CarrIersarefrequentlynotIdentIfIeddurInghospItalIzatIonbecausetheclInIcalhIstoryand
routInepreoperatIvelaboratorytestsmaybeInsuffIcIentfordIagnosIs.TherIskfor
InfectIonafteranH87contamInatedpercutaneousexposure,suchasanaccIdentalneedle
stIck,IsJ7to62IfthesourcepatIentIsH8eAgposItIveand2JtoJ7IfH8eAgnegatIve.
H87canbefoundInsalIva,buttherateoftransmIssIonIssIgnIfIcantlylessaftermucosal
contactwIthInfectedoralsecretIonsthanafterpercutaneousexposurestoblood.H87Isa
hardyvIrusthatmaybeInfectIousforatleast1weekIndrIedbloodonenvIronmental
surfaces.
HepatItIs8IsnowapreventableandatreatabledIsease.TheImplementatIonofroutIne
vaccInatIonhasdramatIcallyreducedtheIncIdenceofnewcasesIntheU.S.populatIon.n
addItIontovaccInatIon,useofstandardprecautIons,useofsafetydevIces,and
postexposureprophylaxIshavesIgnIfIcantlyreducedtherIskofoccupatIonallyacquIred
H87InfectIonandItssequelaeInHCW.
Hepatitis B Vaccine
UseofhepatItIs8vaccIneIstheprImarystrategytopreventoccupatIonaltransmIssIonof
H87toanesthesIapersonnelandotherHCWsatIncreasedrIsk.
70
AdmInIstratIonofthree
dosesofvaccIneIntothedeltoIdmuscleresultsIntheproductIonofprotectIveantIbodIes
(antIH8s)In90ofhealthyHCWs.HospItalsoranesthesIadepartmentsshouldhave
polIcIesforeducatIng,screenIng,andcounselIngpersonnelabouttheIrrIskofacquIrIng
H87InfectIonandshouldmakevaccInatIonavaIlableforsusceptIblepersonnel.
70,82
ToensureadequatepostvaccInatIonImmunIty,serologIctestIngforantIH8sshouldtake
placewIthIn1to2months
P.71
afterthethIrddoseofvaccIne.
70
ProtectIveantIbodIesdevelopInJ0to50of
nonresponders(I.e.,antIH8s10mU/mL)wIthasecondthreedosevaccIneserIes.
NonresponderstovaccInatIon,whoareH8sAgnegatIve,remaInatrIskforH87InfectIon
andshouldbecounseledonstrategIestopreventInfectIonsandtheneedforpostexposure
prophylaxIs.
7accIneInducedantIbodIesdeclIneovertIme,wIthmaxImumtItersaftervaccInatIon
correlatIngdIrectlywIthduratIonofantIbodypersIstence.TheC0Cstatesthatfor
vaccInatedadultswIthnormalImmunestatus,routIneboosterdosesarenotnecessaryand
perIodIcmonItorIngofantIbodyconcentratIonIsnotrecommended.
70
WhensusceptIbleornonvaccInatedanesthesIapersonnelhaveadocumentedexposuretoa
contamInatedneedleortobloodfromanH8sAgposItIvepatIent,postexposureprophylaxIs
wIthH87hyperImmuneglobulInIsrecommended.
70
HepatItIs8vaccIneshouldbeoffered
toanyunvaccInated,susceptIblepersonwhosustaInsabloodorbodyfluIdexposure.
Hepatitis C
HC7causesmostcasesofparenterallytransmIttedNAN8HandIsaleadIngcauseofchronIc
lIverdIseaseIntheUnItedStates.AlthoughantIbodytoHC7(antIHC7)canbedetectedIn
mostpatIentswIthhepatItIsC,ItspresencedoesnotcorrelatewIthresolutIonoftheacute
InfectIonorprogressIonofhepatItIs,andItdoesnotconferImmunItyagaInstHC7
InfectIon.
8J
SeroposItIvItyforHC7FNAIsamarkerofchronIcInfectIonandcontInuedvIral
presence.SIxmajorgenotypesofHC7havebeenIdentIfIedwIththespecIfIcgenotype
beIngpredIctIvefortheresponsetoandtheneededduratIonofantIvIraltherapy.
|ostcasesofacuteHC7InfectIonareasymptomatIc,andupto40wIllcleartheInfectIon
wIthIn6months.ChronIcallyInfectedIndIvIdualshaveahIghrateofprogressIontochronIc
hepatItIswIthabout20developIngcIrrhosIs.HepatocellularcarcInomaoccursIn1to4
ofcIrrhotIcpatIentsperyear.CombInatIontherapywIthInterferonalpha(standardor
pegylated)andrIbavIrInhasbeeneffectIveInthetreatmentofsomecasesofacuteand
chronIchepatItIsC.
84
LIkeH87,HC7IstransmIttedthroughblood,buttherateofoccupatIonalHC7InfectIonIs
lessthanforH87.AlthoughHC7transmIssIonhasbeendocumentedInhealthcaresettIngs,
theprevalenceofantIHC7InHCWsIntheUnItedStatesIsnotgreaterthanthatfoundIn
thegeneralpopulatIon(1.6).ThegreatestrIskofoccupatIonalHC7transmIssIonIs
assocIatedwIthexposuretobloodfromanHC7posItIvesource,andtheaveragerateof
seroconversIonafteraccIdentalpercutaneousexposureIs1.8.
70
HC7hasbeentransmItted
throughbloodsplashestotheeyeandwIthexposurevIanonIntactskIn.HC7IndrIedblood
onenvIronmentalsurfacesmayremaInInfectIousforupto16hours,butenvIronmental
contamInatIondoesnotappeartobeacommonrouteoftransmIssIon.AlthoughHC7can
befoundInthesalIvaofInfectedIndIvIduals,ItIsnotbelIevedtorepresentagreatrIskfor
occupatIonaleahIghra s cu | agreurngheUr Ivapugas e | evItI v
70 8 asao
7ref*!gh aI
o traaaaaaaaadI vr
no I n gwI I nenvIr | th tf aca aelI Iaterfateu cu | agre a s e | * er I I | * eu | * er I I a a a agh aI
o Ibl enceh aI aa | o m
ooc| * *!r I a| * e t
o n f* Ia a ssa smI rtedu | Iopto16hours,o tI
or
o Ib ! Ievedto t s Ion.Althoug r n.Althou re a s e u r atment ou re a s ec
on otIc ca s eu e# t# tr aonn. r nn. # o*! ] | * tmI *!# o*! ]r r o*! r nn !r t th Ib A! or * n. I oI r n. r nn. hou rtf ac n. |a s eu e0 ho r r nn. . s po us Io aho r raIoI r n. rhou rt! nhr n I r nhkIn]r rtm I Iao m uI o . !I r nha s eura c nIbaneute e egw . .# uI
h s Ion.r * ] s p sm ] ] b o as p nhnhkI. I m ( I I sIa u | Iwm
oo cuI o .
o IbIb kIuI o . rt uI
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oauI atmena sm ] o va
o as . ] I Al l I . s entalsurv s va .b I ] | * |I ach
70 8 A l e c atmenl h a#* nmenl
o | rI l h a * Altav t atf an I ] I ] *!b A ]rrac. ont me tmI u! r nha s atmenmenas e u ru ae traaaaaaa tmI u! r nhu* ]I * k IItI o | mI c n nasnhn e# na t
stt
nI!e gsI] Io n tI o kn. r ne a m n
l
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I ]Ir a I o I l l uII o . |||||n m ou rer ] q ] q n krt tt I Ier b l lt Ie l lt n n c | n nn tt ! ltI m
I rm
rr rIt *Jtr I It * a nt * na
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mm| t nt = ] v = * #nt ] m# t rnm S t I

t ttnm* n mana It *=m I o nt |I
] n ] ktm t n t t t t |aI o !m I=n m# mI s m#i . m tm tm *mI o n EmEm m. m t mtm S t *n m mI m# m
tm mm#i . t=m | =r tm * nt m * =
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TheU.S.PublIcHealthServIcerecommendsthatantIretrovIralpostexposureprophylaxIs
(PEP)beofferedtoHCWswhohaveIncurredasIgnIfIcantpercutaneousexposuretoH7
Infectedblood.
92
ThespecIfIcantIretrovIralregImenIsbasedontheseverItyofexposure
andthesourcepatIent.8ecauseprotocolsforchemoprophylaxIsarelIkelytochangewIth
addItIonalresearchandtheIntroductIonofnewantIretrovIraldrugs,themostcurrent
recommendatIonsshouldbeconsultedprIortoInstItutIngpostexposureprophylactIc
therapy.TobemosteffectIve,PEPshouldbeInItIatedassoonaspossIbleafterexposure
(24hours)andcontInuedfor4weeks.HCWsshouldbecounseledonthepotentIaltoxIc
effectsofantIretrovIralssothattheycanmakeanInformeddecIsIonontherIsks
assocIatedwIthPEP.FaIlureofPEPhasbeenattrIbutedtolargevIralInoculum,useofa
sIngleantIvIralagent,drugresIstanceInthevIrusfromthesourcepatIent,anddelayed
InItIatIonorshortduratIonofPEPtherapy.
Occupational Safety and Health Administration Standards,
Standard Precautions, and Transmission-Based Precautions
nthelate1980stheC0CformulatedrecommendatIons,orunIversalprecautIons,for
preventIngtransmIssIonofbloodborneInfectIons(IncludIngH7,H87,andHC7)toHCWs.
TheguIdelIneswerebasedontheepIdemIologyofH87asaworstcasemodelfor
transmIssIonofbloodborneInfectIonsandavaIlableknowledgeoftheepIdemIologyofH7
andHC7.8ecausesomecarrIersofbloodbornevIrusescouldnotbeIdentIfIed,unIversal
precautIonswererecommendedforusedurIngallpatIentcontact.Althoughexposureto
bloodcarrIesthegreatestrIskofoccupatIonallyrelatedtransmIssIonofH7,H87,andHC7,
ItwasrecognIzedthatunIversalprecautIonsshouldalsobeapplIedtosemen,vagInal
secretIons,humantIssues,andthefollowIngbodyfluIds:cerebrospInal,synovIal,pleural,
perItoneal,perIcardIal,andamnIotIc.Subsequently,theC0CsynthesIzedthemajor
featuresofunIversalprecautIonsIntostandardprecautIons,asInglesetofprecautIonsthat
shouldbeapplIedtoallpatIentssInceeverypersonIspotentIallyInfectedorcolonIzed
wIthanorganIsmthatmIghtbetransmItteddurIngcare(TableJ4).
76
StandardprecautIons
wereIncludedInamorecompletesetofIsolatIonprecautIons,whIchcontaInguIdelInes
(contactprecautIons,dropletprecautIons,andaIrborneprecautIons)toreducetherIskof
transmIssIonofbloodborneandotherpathogensInhealthcaresettIngs.
76
StandardprecautIonsIncludetheapproprIateapplIcatIonanduseofhandwashIng,
personalprotectIveequIpment(PPE),andrespIratoryhygIene/coughetIquette.The
selectIonofspecIfIcbarrIersorPPEshouldbecommensuratewIththetaskbeIng
performed.ClovesshouldbeworndurInganycontactwIthmucousmembranesandoral
fluIds,suchasdurIngendotrachealIntubatIonandpharyngealsuctIonIng.Clovesmaybeall
thatIsnecessarydurIngInsertIonofaperIpheralIntravenouscatheter,whereasgloves,
gown,mask,andfaceshIeldmayberequIreddurIngendotrachealIntubatIonInapatIent
wIthhematemesIsordurIngbronchoscopyorendotrachealsuctIonIng.Clovesshouldbe
removedaftertheybecomecontamInatedtopreventdIssemInatIonofbloodorbodyfluIds
toequIpmentorotherItemsthatmaybecontactedbyunglovedpersonnel.Waterless
antIseptIcsshouldbeavaIlabletopermItanesthesIapersonneltowashtheIrhandswIthout
leavIngtheoperatIngroomaftergloveremoval.FespIratoryhygIene/coughetIquette,to
contaInrespIratorysecretIonsInpatIents,hasbeenaddedtostandardprecautIonsto
preventdroplettransmIssIonofrespIratorypathogens,especIallydurIngseasonal
outbreaks.
DSHAhaspromulgatedstandardstoprotectemployeesfromoccupatIonalexposureto
bloodbornepathogens.
82
EmployerssubjecttoDSHAmustcomplywIththesefederal
regulatIons.ThestandardrequIresthattheremustbeanexposurecontrolplanspecIfIcally
detaIlIngthemethodsthattheemployerIsprovIdIngtoreduceemployees'rIskofexposure
tobloodbornepathogens.TheemployermustevaluateengIneerIngcontrolssuchas
needlelessdevIcestoelImInatehazards.WorkpractIcecontrolsareencouragedtoreduce
bloodexposuresbyalterIngthemannerInwhIchpersonnelperformtasks(e.g.,an
InstrumentratherthanfIngersshouldbeusedtohandleneedles).Theemployermust
furnIshapproprIatePPE(e.g.,gloves,gowns)InvarIoussIzestopermItemployeesto
complywIthstandardprecautIons.TheH87vaccInemustbeoffered
P.7J
atnochargetopersonnel.AmechanIsmforpostexposuretreatmentandfollowupmustbe
provIded.AnannualeducatIonalprogramshouldInformemployeesoftheIrrIskforblood
borneInfectIonandtheresourcesavaIlabletopreventbloodexposures.mplementatIonof
standardprecautIonsandDSHAregulatIonshavebeeneffectIveIndecreasIngthenumber
ofexposureIncIdentsthatresultInHCWcontactwIthpatIentbloodandbodyfluIds.
Creutzfeldt-Jakob Disease
CreutzfeldtJakobdIsease(CJ0),causedbyanInfectIousproteInorprIon,maybe
unsuspectedInpatIentspresentIngwIthdementIa.
9J
TheprIonproteInentersbraIncells
andInducesabnormalfoldIngofcellularproteInsleadIngtoIrreversIbledamagewIthloss
ofneurons.|orerecently,IthasbeenrecognIzedthattheprIonstraInassocIatedwIth
bovInespongIformencephalopathymayInfecthumanstoproduceavarIantCJ0(vCJ0).
TherehavebeennoreportedcasesofdIrecthumantohumantransmIssIonofCJ0orvCJ0
bycasualorenvIronmentalcontact,droplet,oraIrborneroutes.atrogenIctransmIssIonof
CJ0orvCJ0topatIentshastakenplacethroughcontamInatedbIologIcproductsand
neurosurgIcalInstrumentsandvIabloodtransfusIon.TherIskoftransmIssIontohospItal
personnelIsunknownbecausesurveIllanceIscomplIcatedbythelongperIodfromthetIme
ofInfectIonuntIltheonsetofsymptoms.StandardprecautIonsshouldbeused.TIssueswIth
greatestrIskofInfectIvItyarebraIn,spInalcord,andeyes.
TheprIonIsdIffIculttoeradIcatefromequIpment,andspecIalsterIlIzatIonmethodsare
requIredforInstrumentsthatcomeIntocontactwIthhIghInfectIvItytIssues.TheWorld
HealthDrganIzatIonhasdevelopedInfectIoncontrolandsterIlIzatIonguIdelInesforCJ0.
e
Tuberculosis
TheIncIdenceoftuberculosIs(T8)InU.S.bornresIdentshasdeclInedsInce1992whIlethe
rateamongforeIgnbornIndIvIdualslIvIngIntheUnItedStateshasIncreasedoverthesame
perIod.AlthoughmostIndIvIdualsInfectedwIthT8aretreatedonanoutpatIentbasIs,
undIagnosedpatIentsmaybehospItalIzedfortheworkupofpulmonarypathologyor
unrelatedcauses.HospItalpersonnelareespecIallyatrIskforInfectIonfromunrecognIzed
cases.
94,95
CroupswIthahIgherprevalenceofT8Include(1)personalcontactsofpeople
wIthactIveT8,(2)peoplefromcountrIeswIthahIghprevalenceofT8,and(J)certaIn
populatIonssuchasthemedIcallyunderservedorthoselIvIngIncongregatesettIngslIke
homelesssheltersorcorrectIonalfacIlItIes.
94
ClobalsurveIllancehasdocumentedthe
emergenceofmultIdrugresIstantT8(resIstancetoatleasttwooftheprImarytreatments,
IsonIazIdandrIfampIn)aswellasextensIvelydrugresIstantorganIsms(resIstancetoat
leasttwooftheprImarytreatments,IsonIazIdandrIfampIn,andtoanyfluoroquInolone
andatleastoneofthreeInjectabledrugs).SeveralhospItaloutbreaksofmultIdrug
resIstantMycobacterium tuberculosisInfectIonhavebeenreported.
95,96
|ortalIty
assocIatedwIththeseoutbreaksIshIgh.
Mycobacterium tuberculosiscanbetransmIttedovergreatdIstancesthroughvIablebacIllI
carrIedonaIrbornepartIcles,1to5mInsIze,bycoughIng,speakIng,orsneezIng.
AIrborneprecautIonsshouldbeusedforIndIvIdualssuspectedofhavIngT8untIltheyare
confIrmedasnontransmIttersbyrepeatsputumexamInatIonthatdemonstratesno
bacIllI.
94
DutbreaksofT8InhealthcarefacIlItIeshavebeenattrIbutedtodelayeddIagnosIs
ofT8InthesourcepatIent,delayedInItIatIonoforInadequateaIrborneprecautIons,
lapsesInprecautIonsdurIngaerosolgeneratIngprocedures,andlackofadequate
respIratoryprotectIonInHCWs.AdmInIstratIonofapproprIatechemotherapyforsuffIcIent
duratIonIsrequIredtocuretheIndIvIdualpatIent,buttreatmentalsobenefItsthe
communItybypreventIngspreadoftheInfectIon.
97
AdecreaseInthehealthcareassocIatedtransmIssIonofT8hasbeenattrIbutedtothe
rIgorousImplementatIonofInfectIoncontrolmeasures.EffectIvepreventIonofspreadto
HCWsrequIresearlyIdentIfIcatIonofInfectedpatIentsandImmedIateInItIatIonofaIrborne
InfectIonIsolatIon(negatIvepressureroomswIthaIrventedoutsIde;seeTableJ4).
94
PatIentsmustremaInInIsolatIonuntIladequatetreatmentIsdocumented.fpatIentswIth
T8mustleavetheIrrooms,theyshouldwearfacemaskstopreventspreadoforganIsms
IntotheaIr.HCWsshouldwearfIttestedrespIratoryprotectIvedevIceswhentheyenteran
IsolatIonroomorwhenperformIngproceduresthatmayInducecoughIng,suchas
endotrachealIntubatIonortrachealsuctIonIng.
94
TheC0CrecommendsthatrespIratory
protectIvedevIcesworntoprotectagaInstM. tuberculosisshouldbeabletofIlter95of
partIcles1mmInsIzeatflowratesof50L/mInandshouldfItthefacewIthaleakagerate
aroundthesealof10documentedbyfIttestIng.
94
HIgheffIcIencypartIculateaIr
respIrators(classIfIedasN95)areNDSHapproveddevIcesthatmeettheC0CcrIterIafor
respIratoryprotectIvedevIcesagaInstM.tuberculosis.
98.
ElectIvesurgeryshouldbe
postponeduntIlInfectedpatIentshavehadanadequatecourseofchemotherapy.fsurgery
IsrequIred,bacterIalfIlters(hIgheffIcIencypartIculatefIlters)shouldbeusedonthe
anesthetIcbreathIngcIrcuItforpatIentswIthT8.
94
PatIentsmustberecoveredInaroom
thatmeetsalltherequIrementsforaIrborneprecautIons.
FoutIneperIodIcscreenIngofemployeesforT8shouldbeIncludedaspartofahospItal's
employeehealthpolIcywIththefrequencyofscreenIngdependentontheprevalenceof
InfectedpatIentsInthehospItalIzedpopulatIon.WhenanewconversIonIsdetectedbyskIn
testIng,ahIstoryofexposureshouldbesoughttodetermInethesourcepatIent.Treatment
orpreventIvetherapyIsbasedonthedrugsusceptIbIlItypatternoftheM. tuberculosisIn
thesourcepatIent,Ifknown.
Viruses in Smoke Plumes
ThelaserIscommonlyusedforvaporIzIngcarcInomatoustumorsandlesIonsthatmay
contaInactIvevIruses.UseoflasersandelectrosurgIcaldevIcesIsassocIatedwIthseveral
hazards,bothtopatIentsandtooperatIngroompersonnel.FIsksIncludethermalburns,
eyeInjurIes,electrIcalhazards,andfIresandexplosIons.ThereIsevIdencethatthesmoke
plumesresultIngfromtIssuevaporIzatIoncontaIntoxIcchemIcalssuchasbenzeneand
formaldehyde,andIn1996,NDSHreleasedahealthhazardalertonthedangersofsmoke
plumes.
99
ClInIcalandlaboratorystudIeshavedemonstratedthatwhenthecarbondIoxIdelaserIs
usedtotreatverrucae(papIllomaandwarts),IntactvIral0NAcouldberecoveredfromthe
plume.7IablevIrusescanbefoundInplumesproducedbybothcarbondIoxIdeandargon
laservaporIzatIonofavIrusloadedcultureplate,butvIablevIrusesarecarrIedonlarger
partIclesthattravel100mmfromthesItebeIngvaporIzed.
100
AcasereportdescrIbeslaryngealpapIllomatosIsInasurgeonwhohadusedalaserto
removeanogenItalcondylomasfromseveralpatIents.
101
Although0NAanalysIsofthe
surgeon'spapIllomasrevealedavIraltypesImIlartothatofthecondylomas,proofof
transmIssIonIslackIng.
P.74
ToprotectoperatIngroompersonnelfromexposuretothevIralandchemIcalcontentof
thelaserplume,ItIsrecommendedthatasmokeevacuatIonsystemwIthahIgheffIcIency
fIlterbeusedwIththesuctIonnozzlebeIngheldascloseaspossIbletothetIssuebeIng
vaporIzed.
102
naddItIon,operatIngroompersonnelworkIngInthevIcInItyofthelaser
plumeshouldweargloves,goggles,andhIgheffIcIencyfIltermasks(N95respIrators).
90,102
Emotional Considerations
Stress
StressIsawellrecognIzedelementoftheoperatIngroomworkplace.However,thereIs
verylIttleobjectIveInformatIonspecIfIcallydIrectedtowardunderstandIngthenatureof
jobrelatedstressamonganesthesIologIsts.
10J,104
StressIsanonspecIfIcresponsetoany
change,demand,pressure,challenge,threat,ortrauma.
48
TherearethreedIstInct
componentsofthestressresponse:theInItIatIngstressors,thepsychologIcalfIltersthat
processandevaluatethestressors,andthecopIngmechanIsmsthatareemployedInan
attempttocontrolthestressfulsItuatIon.
StressonthejobIsunavoIdableandtoacertaIndegreeIsdesIrable.Amoderate,
manageablelevelofstressIsthefuelnecessaryforIndIvIdualachIevement.HansSeyle,
105
apIoneerInthemodernstudyofstress,descrIbedabenefIcIaleffectresultIngfrommIld,
brIef,andcontrollableepIsodesofstress.AssuccInctlystatedbySeyle,
105
Theabsenceof
stressIsdeath.Dntheotherhand,extremedegreesofstress,especIallyIntheworkplace,
canresultInmentalorphysIcaldIsease.
106
ExactlyhowanIndIvIdualrespondstoa
partIcularstressorIstheproductofanumberoffactors,IncludIngage,gender,experIence,
preexIstIngpersonalItystyle,avaIlabledefenseandcopIngmechanIsms,supportsystems,
andconcomItantevents(suchassleepdeprIvatIon).
TheworkplaceofananesthesIologIstfrequentlymIrrorsthecIrcumstancesthatclassIcally
defIneastressfulworkplace.ThereIsabackgroundofchronIc,lowlevelstresspunctuated
byIntermIttentepIsodesofextremestress.Thedemandsareexternallypaced,usuallyout
oftheanesthesIologIst'scontrol.HabItuatIontothedemandsIsdIffIcult.PerturbatIonsare
IntermIttentlybutcontInuouslyInsertedIntothesystem.FInally,faIluretomeetthe
demandsImposedbytheworkplacecanresultInserIousconsequences.
CertaInstressorsarespecIfIctothepractIceofanesthesIology.ConcernsaboutlIabIlIty,
longworkInghoursandnIghtcall,productIonpressures,economIcuncertaInty,and
InterpersonalrelatIonsarefrequentlycItedassourcesofchronIcstressfor
anesthesIologIsts.TheprocessofInducInganesthesIa(partIcularlywIthadIffIcultaIrway)
canbeamongthemostprofoundsourcesofacutestresstoanesthesIologIsts.PhysIologIc
changes,IncludIngheartrateandrhythm,elevatIonsInbloodpressure,andmyocardIal
IschemIa,arenotuncommon.DnestudyreportedIncreasesInthebloodpressureandheart
rateofanesthesIologIstsdurIngallstagesoftheanesthetIcprocedure,especIallydurIngthe
InductIon.
107
TherewasanInverserelatIonshIpbetweentheyearsofexperIenceofthe
anesthesIologIstandthedegreeofstressasmanIfestedbyheartratechange.
nterpersonalrelatIonshIpsImposeasetofdemandsthatcanbeamajorsourceofstressto
ananesthesIologIst.TheoperatIngroomIsunIqueasoneofthefewhospItalsIteswhere
twocoequalphysIcIanssImultaneouslyshareresponsIbIlItyforthecareofapatIent.Asa
result,thereexIstoverlappIngrealmsofclInIcalresponsIbIlItythatcanupsetthe
customaryhIerarchyofcommand.TomanyanesthesIologIsts,aswellassurgeons,thIs
sharedresponsIbIlItyIsthesourceofgreatestconflIctandprofessIonalstress.
50
Dther
workplacesettIngs,mostnotablytheaIrlIneIndustry,havemadebetterprogressIn
IdentIfyIngandcorrectIngsourcesofInterpersonalfrIctIonthatfacIlItatestressandleadto
professIonalerrors.
108
SeveralpersonalItytraIts,InmanycasesIdentIfIablebeforeentrancetomedIcalschool,
canbepredIctIveofthepotentIaltowardmaladaptIveresponsestostress.PromInent
amongtheseIstheobsessIvecompulsIve,dependentcharacterstructure.TheseIndIvIduals
typIcallymanIfestpessImIsm,passIvIty,selfdoubt,andfeelIngsofInsecurIty.They
commonlyrespondtostressbyInternalIzIngangerandbecomInghypochondrIacaland
depressed.UndergraduatestudentswhodemonstratethesecharacterIstIcsweremore
lIkelytohavetheIrmedIcalcareersdIsruptedbyalcoholIsmordrugabuse,psychIatrIc
Illness,andmarItaldIsturbances.
109,110
AnumberofadaptIvecopIngfunctIonsareuseful
forsuccessfulstressmanagement.
48
DnlywhenapproprIatecopIngmechanIsmsbecome
overwhelmedbythemagnItudeofthestressdothedefensestendtobecome
InapproprIate.ThIssItuatIoncangIverIsetomaladaptIvebehavIorandthepersonaland
professIonaldeterIoratIonthatcanleadtodIsorderssuchasdrugaddIctIon,professIonal
burnout,andsuIcIde.
Substance Use, Abuse, and Addiction
llIcItdruguseremaInsoneofoursocIety'smajorafflIctIons.tIsestImatedthat20mIllIon
AmerIcansaredrugabusers,wIthsome5mIllIonaddIcted.Substance abuseIs
characterIzedbysIgnIfIcantadverseconsequencesresultIngfromtherepeateduseofa
substance.
111
WIthaddiction,theIndIvIdualcontInuestouseasubstanceInspIteofhavIng
sIgnIfIcantsubstancerelatedproblemsIncludIngsymptomsofwIthdrawal,theneedfor
largeramountsofthesubstance,unsuccessfulattemptstocontrolItsuse,andtheneedto
spendIncreasIngamountsoftImeseekIngthesubstance.WIthtIme,addIctIonleadsto
health,socIal,andeconomIcproblems.Theterm,chemical dependence,IssometImesused
ratherthanaddIctIon,butItIsamoregenerIctermcoverIngphysIcalorpsychologIcal
dependencytoapsychoactIvesubstance.
Epidemiology
TheabuseofdrugsandconsequentaddIctIonbyphysIcIanshasattractedconsIderable
medIaattentIonandnotorIety.FecognItIonoftheproblemofsubstanceabuseamong
physIcIansIsnotnew.nthefIrstedItIonofThe Principles and Practice of Medicine,edIted
bySIrWIllIamDslerandpublIshedIn1892,ItIsstated:ThehabIt(morphIa)IspartIcularly
prevalentamongwomenandphysIcIanswhousethehypodermIcsyrIngefortheallevIatIon
ofpaIn,asInneuralgIaorscIatIca.
tIsdebatablewhethersubstanceabuseIsmoreprevalentamongphysIcIansthanthe
generalpopulatIon.Hughesetal
112
foundthatphysIcIansabusedalcohol,mInoropIates,
andbenzodIazepInetranquIlIzersmorefrequentlythanthegeneralpopulatIon.nmany
cases,theprescrIptIondrugswereselfprescrIbedandwereconsIderedbythephysIcIanto
beselftreatment.Dntheotherhand,physIcIanswerelesslIkelytousetobaccoorIllIcIt
substances.AreportfromtheNatIonalnstItuteon0rugAbuseconcludesthatHCWssuffer
fromchemIcaldependency(IncludIngalcoholabuse)atarateroughlyequIvalenttothatof
thegeneralpopulatIon(8to12).
11J
ntheeventthatadrugrelatedproblemdoesexIst,physIcIansarelesslIkelythanthe
populatIonIngeneraltoseekprofessIonalassIstance.0enIalplaysamajorroleInthIs
reluctancetoundergocounselIngortherapy.|edIcalstudentslearnearlyIntheIr
educatIontousedenIaltoenablethemtoendurelong,sleeplessnIghtsandthepersonal
shortcomIngsthatInevItablyaccompanythepractIceofmedIcIne.These
P.75
welldevelopeddenIalmechanIsmsenablethephysIcIanaddIcttoconcludethathIsorher
problemIsmInorandthatselftreatmentIspossIble.PhysIcIanstypIcallyenterprograms
fortreatmentonlyaftertheyhavereachedtheendstagesoftheIrIllness.
tIscommonlyreportedthatchemIcaldependencyIsaspecIfIcproblemforthespecIaltyof
anesthesIologyandrepresentsItsprImaryoccupatIonalhazard.
114
Dneexampleofthe
IncreasedIncIdenceofsubstanceabuseamonganesthesIologIstscomesfromearlyreports
fromthe|edIcalAssocIatIonofCeorgIa0Isabled0octors'Program.
115
AnesthesIologIsts
constItuted12ofphysIcIanpatIentstreatedatthecenteralthoughtheyrepresentedonly
J.9ofAmerIcanphysIcIans.Dntheotherhand,otherstudIeshavefaIledtoIdentIfyan
overallexcessprevalenceofsubstanceabuseamonganesthesIologIstswIththenotable
exceptIonofmajoropIates.
116,117
DneverytroublIngaspectofthIsproblemIstheIncreasedIncIdenceofsubstanceabuse
reportedamonganesthesIologyresIdents.nthereportfromthe|edIcalAssocIatIonof
CeorgIa0Isabled0octors'Program,
115
anesthesIologyresIdentsconstItutedJJ.7ofthe
resIdentpopulatIonofthetreatmentgroup,despIterepresentIngonly4.6oftheresIdent
populatIon.TheIncIdenceofcontrolledsubstanceabusewIthInanesthesIologytraInIng
programsIsestImatedtobe1to2.
118
ThIsstatIstIcIspartIcularlysIgnIfIcantbecauseIt
haspersIsteddespIteanIncreasedemphasIsplacedoneducatIonandaccountabIlItyof
controlledsubstances.ACC|ErequIrementsmandatethatanesthesIologyresIdency
programshaveawrIttenpolIcyandaneducatIonalprogramregardIngsubstanceabuse,but
theseeffortshavenotsuccessfullyaddressedtheproblemofsubstanceabuseIntraInIng
programs.
The Disease of Addiction
WhataccountsforthIsunacceptablyhIghprevalenceofsubstanceabuseandaddIctIon
amonganesthesIologIsts:ToanswerthIs,ItIsImportanttounderstandaddIctIonasa
chronIcpsychosocIal,bIogenetIcdIsease.
119
AddIctIonsharesmanycharacterIstIcswIth
othercommonchronIcIllnesses:ItIsaprImarycondItIon(notasymptom),Ithas
establIshedcauses,ItIsassocIatedwIthspecIfIcanatomIcandphysIologIcchanges,Ithasa
setofrecognIzablesIgnsandsymptoms,andIfleftuntreated,IthasapredIctable,
progressIvecourse.
ThecausatIvefactorsInthIsdIseaseprocessInvolveagenetIcpredIsposItIonaswellasthe
envIronment.ThedIseaseresultsfromadynamIcInterplaybetweenasusceptIblehostand
afavorableenvIronment.7ulnerabIlItyInthehostIsanImportantfactorandmay
accountfor40to60oftherIskforaddIctIon.WhatconstItutesanInstIgatIngexposureto
adrugInonepersonmayhaveabsolutelynoeffectonanother.Unfortunately,thereIsnot
apredIctIvetooltoIdentIfythesusceptIbleIndIvIdualuntIlheorshegetsthedIsease.
CausatIvefactorsthoughttobespecIfIctocertaInanesthesIologIstsIncludejobstress,an
orIentatIontowardselfmedIcatIon,lackofexternalrecognItIonandselfrespect,the
avaIlabIlItyofaddIctIngdrugs,andasusceptIblepremorbIdpersonalIty.SelfprescrIptIon
andrecreatIonaluseofdrugsarecommonlyseenasapreludetomoreextensIvesubstance
abuseanddependence.DfconcernIstheIncreasIngrecreatIonaluseofdrugsamong
youngerphysIcIansandmedIcalstudentsandthechoIceofmorepotentdrugswIth
enhancedpotentIalforaddIctIon,suchascocaIne,thesynthetIcopIoIds,andsomeofthe
newerInhalatIonanesthetIcs.|ostnotablehasbeenthesIgnIfIcantIncreaseInpropofol
abuseamongresIdents.
120
ThIsmaybeattrIbutabletothelackofpharmacyaccountIngor
controlofthIsdrugInmanycenters.
AnesthesIologIstsworkInaclImateInwhIchlargequantItIesofpowerfulpsychoactIve
drugsarereadIlyavaIlableandareunIqueamongphysIcIansbecausetheyusuallyprescrIbe
aswellaspersonallyadmInIsterthesedrugs.ncontrast,physIcIansInmostother
specIaltIesprescrIbemedIcatIonswhIleotherpersonneladmInIsterthem.8ecause
avaIlabIlItyofdrugsplaysaroleIntheonsetofthIsdIsease,attentIonhasbeendIrected
towardprogramstoenforceIncreasedaccountabIlItyandregulatIonofcontrolled
substances.
121
However,despItewIdespreadapplIcatIonofprotocolstoenforcegreater
accountabIlIty,suchassatellItepharmacIesforoperatIngsuItes,thefrequencyof
substanceabusehaschangedlIttle,Ifatall,Inrecentyears.
118
ThereIsanapparentassocIatIonbetweenbehavIorbeforeenterIngmedIcalschooland
subsequentdevelopmentofsubstanceabuse.
122
PersonalItyprofIlesofanesthesIologIsts
havesuggestedadIsturbInglyhIghproportIonthatmaybeassocIatedwIthapredIsposItIon
towardmaladaptIvebehavIor.Talbottetal
115
haveobservedthatmanyoftheanesthesIa
resIdentsIntheIrtreatmentprogramspecIfIcallychosethespecIaltyofanesthesIology
becauseoftheknownavaIlabIlItyofpowerfuldrugs.
TheconsequencesofuntreatedaddIctIonareultImatelydevastatIng.ThereIsagradual
andInexorabledeterIoratIonInprofessIonal,famIly,andsocIalrelatIonshIps.The
substanceabuserbecomesIncreasInglywIthdrawnandIsolated,fIrstInhIsorherpersonal
lIfe,andultImatelyInhIsorherprofessIonalexIstence(TableJ5).EveryattemptIsmade
tomaIntaInafacadeofnormalItyatworkbecausedIscoverymeansIsolatIonfromthe
sourceoftheabuseddrug.WhenprofessIonalconductIsfInallyImpaIredsuchthatItIs
apparenttothephysIcIan'scolleagues,thedIseaseIsapproachIngItsendstage.
fnotdetectedandtreated,addIctIonIsoftenafatalIllness.UsIngmortalItydata
collectedbetween1979and1995,Alexanderetal
14
calculatedarelatIverIskof2.79for
drugrelateddeathsamonganesthesIologIstscomparedtoamatchedcohortofInternIsts.
|enketal
12J
found14drugrelateddeathsamongthe79drugabuserswhohadbeenre
enrolledInanesthesIologyresIdencIesaftertreatment.UsIngdatafromamorerecent
survey,CollInsetal
124
reportedthattherewerenInedeathsIn100resIdentswhoretured
toandremaInedInanesthesIologytraInIngprogramsaftertreatmentforchemIcal
dependence.naddItIontohealthhazards,therearesIgnIfIcantlegalandmedIcolegal
consIderatIonsthatmayaffectchemIcallydependentphysIcIans.
114
LawsandregulatIons
varybystatebuttheydetaIlthenecessarystepsforhandlIngthedrugabusIngphysIcIan.n
manystatesdIscIplInaryactIonandcrImInalpenaltIescanbeImposedonphysIcIanswho
knowInglyfaIltoreportanImpaIredcolleague.0IscIplInaryactIontakenagaInstan
ImpaIredphysIcIanmustalsobereportedtotheNatIonalPractItIoner0ata8anktobeIn
complIancewIthfederallaw.|oststatemedIcalsocIetIeshavesanctIonedphysIcIans
healthprograms.WhenchemIcallydependentphysIcIansseektreatmentthroughthIs
venue,thelegalImpactmaybemItIgated,andthedIseasecanbeeffectIvelytreated.
0ebatecontInuesregardIngtheIssueofcompulsoryrandomdrugtestIngofphysIcIans.
125
Preemploymentand/orrandomdrugscreenIngIsalreadywellestablIshedInvarIous
IndustrIes,especIallythosewIthhIghpublIchealthprofIles(nuclear,avIatIon,mIlItary).
|anychaIrsofacademIcanesthesIologyprogramshaveIndIcatedawIllIngnesstoInItIatea
programofrandomdrugscreenIngoftheIrstaff.
118
AlthoughrandomdrugtestIngIsan
establIshedelementofmostreentrycontractsforrecoverInganesthesIologIsts,serIous
questIonsremaInaboutthelegalItyofthIsapproachandItseffectIvenessInpreventIng
substanceabuse.8ecausefentanylandsufentanIlarethedrugsabusedbymanychemIcally
dependentanesthesIologIstsandbecauseroutInedrugscreensdonotdetecttheseagents,
teststhateffectIvelyIdentIfytheIruseareexpensIveandhavelImItedavaIlabIlIty.
WhentherearesuffIcIentdatatoIdentIfyananesthesIologIstashavIngthedIseaseof
addIctIon,anInterventIonshouldbeconductedbyanexperIencedIndIvIdual.Thepurpose
oftheInterventIonIstodemonstratetotheanesthesIologIstthatheorshehasthedIsease
andtoImmedIatelyhavetheperson
P.76
enterafacIlItyforevaluatIonandtreatment.ThephysIcIan,orhIsorhercolleagues,
shouldconsIderreferraltoastateaffIlIatedphysIcIanshealthprogram.
f
Treatmentusually
begInswIthInpatIenttherapyprogressIngtooutpatIentsessIons.ThefamIlyIsactIvely
InvolvedwIthtreatment,andtheIndIvIdualbegInsassocIatIonwIthAlcoholIcsAnonymous
(AA)orNarcotIcsAnonymous(NA).
Table 3-5 Signs of Substance Abuse and Dependence
WHAT TO LOOK FOR OUTSIDE THE HOSPITAL
1. AddIctIonIsadIseaseoflonelInessandIsolatIon.AddIctsquIcklywIthdrawfrom
famIly,frIends,andleIsureactIvItIes.
2. AddIctshaveunusualchangesInbehavIor,IncludIngwIdemoodswIngsand
perIodsofdepressIon,anger,andIrrItabIlItyalternatIngwIthperIodsof
euphorIa.
J. UnexplaInedoverspendIng,legalproblems,gamblIng,extramarItalaffaIrs,and
IncreasedproblemsatworkarecommonlyseenInaddIcts.
4. AnobvIousphysIcalsIgnofalcoholIsmIsthefrequentsmellofalcoholonthe
breath.
5. 0omestIcstrIfe,fIghts,andargumentsmayIncreaseInnumberandIntensIty.
6. SexualdrIvemaysIgnIfIcantlydecrease.
7. ChIldrenmaydevelopbehavIoralproblems.
8. SomeaddIctsfrequentlychangejobsoveraperIodofseveralyearsInan
attempttofIndageographIccurefortheIrdIseaseortohIdeItfrom
coworkers.
9. AddIctsneedtobeneartheIrdrugsource.ForahealthcareprofessIonal,thIs
meanslonghoursatthehospItal,evenwhenoffduty.ForalcoholIcs,Itmeans
callIngInsIcktowork.AlcoholIcsmaydIsappearwIthoutanyexplanatIontobars
orhIdIngplacestodrInksecretly.
10. AddIctsmaysuddenlydevelopthehabItoflockIngthemselvesInthebathroom
orotherroomswhIletheyareusIngdrugs.
11. AddIctsfrequentlyhIdepIlls,syrInges,oralcoholbottlesaroundthehouse.
12. PersonswhoInjectdrugsmayleavebloodyswabsandsyrIngescontaInIngblood
tIngedlIquIdInconspIcuousplaces.
1J. AddIctsmaydIsplayevIdenceofwIthdrawal,especIallydIaphoresIs(sweatIng)
andtremors.
14. NarcotIcaddIctsoftenhavepInpoIntpupIls.
15. WeIghtlossandpaleskInarealsocommonsIgnsofaddIctIon.
16. AddIctsmaybeseenInjectIngdrugs.
17. TragIcally,someaddIctsarefoundcomatoseordeadbeforeanyofthesesIgns
havebeenrecognIzedbyothers.
WHAT TO LOOK FOR INSIDE THE HOSPITAL
1. AddIctssIgnouteverIncreasIngquantItIesofnarcotIcs.
2. AddIctsfrequentlyhaveunusualchangesInbehavIor,suchaswIdemoodswIngs
andperIodsofdepressIon,anger,andIrrItabIlItyalternatIngwIthperIodsof
euphorIa.
J. ChartIngbecomesIncreasInglysloppyandunreadable.
4. AddIctsoftensIgnoutnarcotIcsInInapproprIatelyhIghdosesfortheoperatIon
beIngperformed.
5. TheyrefuselunchandcoffeerelIef.
6. AddIctslIketoworkaloneInordertouseanesthetIctechnIqueswIthout
narcotIcs,falsIfyrecords,anddIvertdrugsforpersonaluse.
7. Theyvolunteerforextracases,oftenwherelargeamountsofnarcotIcsare
avaIlable(e.g.,cardIaccases).
8. TheyfrequentlyrelIeveothers.
9. TheyareoftenatthehospItalwhenoffduty,stayIngclosetotheIrdrugsupply
topreventwIthdrawal.
10. Theyvolunteerfrequentlyforextracall.
11. TheyareoftendIffIculttofIndbetweencases,takIngshortnapsafterusIng.
12. AddIctedanesthesIapersonnelmayInsIstonpersonallyadmInIsterIngnarcotIcs
Intherecoveryroom.
1J. AddIctsmakefrequentrequestsforbathroomrelIef.ThIsIsusuallywherethey
usedrugs.
14. AddIctsmaywearlongsleevedgownstohIdeneedletracksandalsotocombat
thesubjectIvefeelIngofcoldtheyexperIencewhenusIngnarcotIcs.
15. NarcotIcaddIctsoftenhavepInpoIntpupIls.
16. AnaddIct'spatIentsmaycomeIntotherecoveryroomcomplaInIngofpaInoutof
proportIontotheamountofnarcotIcchartedontheanesthesIarecords.
17. WeIghtlossandpaleskInarealsocommonsIgnsofaddIctIon.
18. AddIctsmaybeseenInjectIngdrugs.
19. UntreatedaddIctsarefoundcomatose.
20. UndetectedaddIctsarefounddead.
AdaptedfromFarleyWJ,ArnoldWP:7Ideotape:UnmaskIngaddIctIon:ChemIcal
0ependencyInAnesthesIology.Producedby0avIdsProductIons,ParsIppany,NJ,
fundedbyJanssenPharmaceutIca,PIscataway,NJ,1991.
FeprIntedwIthpermIssIonfromAmerIcanSocIetyofAnesthesIologIsts:TaskForce
onChemIcal0ependenceoftheCommItteeonDccupatIonalHealthofDperatIng
FoomPersonnel:ChemIcal0ependenceInAnesthesIologIsts:WhatYouNeedto
KnowWhenYouNeedtoKnowt.ParkFIdge,L,AmerIcanSocIetyof
AnesthesIologIsts,1998.
ControversyremaInsabouttheultImatecareerpathoftheanesthesIologIstInrecovery.
WIthInthegeneralpopulatIon,therecIdIvIsmrateapproaches60forpatIentswhohave
beentreatedforaddIctIon.However,physIcIansarehIghly
P.77
motIvatedandbetterrehabIlItatIonratesmIghtbeexpected.EarlyreportsprovIded
optImIsmthatInmanycasesanesthesIologIstscouldbesuccessfullyrehabIlItatedand
safelyreturnedtotheIrpractIces.nastudythatexamInedrelapseInaddIctedphysIcIans,
therateofrelapseamonganesthesIologIstswas40andthatofcontrolphysIcIanswas
44.
126
SustaInedrecoveryforlongerthan2yearsoccurredIn81and86,respectIvely.
AlthoughthesedatasuggestedthattheoutcomeforrecoverInganesthesIologIstswas
sImIlartootherphysIcIans,astudyby|enkandcolleagues
12J
drewadIfferentconclusIon.
Among79opIoIddependentanesthesIologyresIdents,therewasa66(52of79)faIlurerate
forsuccessfulrehabIlItatIonandreturntopractIce.EvenmoredIscouragIng,therewere14
suIcIdeoroverdosedeathsamongthe79returnIngtraInees.TheIrconclusIonwasthat
redIrectIonIntoanotherspecIaltyIsthesafercourseafterrehabIlItatIonofnarcotIc
dependentresIdents.UsIngsurveydatafromU.S.traInIngprograms,CollInsetal
124
found
thatonly46ofanesthesIaresIdentstreatedforsubstanceabusesuccessfullycompleted
theIranesthesIologytraInIng,J4chosetoenteratraInIngprogramInanothermedIcal
specIalty,and16leftmedIcIne.Therewere9deathsamongthe100anesthesIaresIdents
thatcontInuedInanesthesIatraInIngprogramsaftertreatment.
0atafromaretrospectIvestudyofhealthcareprofessIonalshasIdentIfIedthreefactors
assocIatedwIthrelapseaftercompletIonoftreatmentforchemIcaldependency.
127
Althoughtheoverallrateforrelapsewas25,therIskwasIncreasedwhentherewasa
famIlyhIstoryofsubstanceabuse(hazardratIo[HF]=2.J)andwhenamajoropIoIdwasthe
abuseddrugInanIndIvIdualwIthacoexIstIngpsychIatrIcdIsorder(dualdIagnosIs,[HF=
5.8]).TherIskofrelapsewasgreatest(HF=1J.J)whenallthreefactorswerepresent,that
Is,famIlyhIstory,majoropIoIduse,anddualdIagnosIs.TreatedanesthesIologIstswho
returnedtothepractIceofanesthesIologyhadagreaterrIskofrelapse(HF=8.5)
comparedwIththosewhodIdnotreturn.8ecauseofthesmallsamplesIze,amoredetaIled
analysIsofrIskfactorsforanesthesIologIstscouldnotbeperformed.
NounIversalrecommendatIonscanbemadeaboutreentryIntothepractIceofanesthesIa
aftertreatment.ToreenterpractIce,therecoverIngphysIcIanmustqualIfyforavalId
lIcensetopractIcemedIcIneandmustberecredentIaledattheIrmedIcalfacIlIty.ThIs
mustbedoneIncomplIancewIththeIrstatelawsandregulatIonsthatdetaIlthe
cIrcumstancesunderwhIcharecoverIngphysIcIancanreturntopractIce.Federallaws,
suchastheAmerIcanswIth0IsabIlItIesAct,ImposeaddItIonalconsIderatIons.AddItIonally,
acarefullywordedcontractIsanImportantfIrststepInthereentryprocesstodefInethe
oblIgatIonsofthephysIcIanandthedepartment.
114,128
ContractsusuallyIncludean
agreementtorefraInfromselfprescrIptIonofmedIcatIon,submIttorandomurInedrug
screens,anddIrectlyobservedadmInIstratIonofnaltrexoneordIsulfIramforatleast6
months.ThereshouldalsoberegularmeetIngswIththedepartmentalsupervIsorto
monItorthereturnprocess.tIsalsogenerallyrecommendedthatthereturnIng
anesthesIologIstnottakenIghtorweekendcallorhandleopIoIdswIthoutdIrectsupervIsIon
foratleastthefIrstJmonths.|onItorIngandtreatmentforanextendedperIodIsmore
lIkelytoreducetherIskforrelapse.0espItealloftheseprecautIons,thepotentIalfor
relapsemustbeantIcIpated.
CuIdelInesfromphysIcIantreatmentcentersmaybehelpfultoassIstInthedecIsIons
surroundIngreentry.
111
ndIvIdualswho,InmostsItuatIons,cansuccessfullyreturntothe
practIceofanesthesIologyImmedIatelyaftertreatment(Category)acceptandunderstand
theIrdIseaseandhavenoevIdenceofaccompanyIngpsychIatrIcdIsorders.Theyhave
strongsupportfromtheIrfamIly,demonstrateabalancedlIfestyle,arecommIttedtotheIr
recoverycontract,andbondwIthAAorNA.TheIranesthesIologydepartmentandhospItal
mustbesupportIveoftheIrreturn,andtheIndIvIdualmusthaveasponsorthatsupports
thereturntoanesthesIology.
CategoryIncludesthoseIndIvIdualswhocouldpossIblyreturntoanesthesIologywIthIna
fewyears.TheymusthavenoormInImaldenIalregardIngtheIrdIseaseandhavenoother
psychIatrIcdIagnoses.TheIrrecoveryskIllsarecontInuallyImprovIngandtheyare
Involved,butnotnecessarIlybonded,wIthAA/NA.AlthoughtheIrfamIlysItuatIonmaybe
characterIzedasdysfunctIonal,thereshouldbetangIbleevIdenceofImprovement.
ndIvIdualswhoshouldnotreturntoanesthesIologyandwouldbestberedIrectedInto
anothermedIcalspecIaltyareIncludedInCategory.TheseIndIvIdualsmayhavehada
hIstoryofprolongedIntravenoussubstanceuseandhaveexperIencedrelapsesandprIor
treatmentfaIlures.TheIrdIseaseremaInsactIve,andtheyhavecoexIstIngsevere
psychIatrIcdIagnoses.
Impairment and Disability
mpaIrment
g
anddIsabIlIty
h
canarIsefromphysIcal,mental,emotIonal,sensoryor
developmentalcauses.Theonsetcanbesudden,asoccurswIthInjuryoracuteIllness,or
moregradual,asIsthecasewIthmanychronIcdIseases.
0ataregardIngtheprevalenceofdIsablIngdIsordersamongphysIcIansaredIffIcultto
obtaIn.SubstancerelateddIsorders(seeSubstanceUse,Abuse,andAddIctIon)occursas
frequentlyamongphysIcIansasInthegeneralpopulatIon
11J
(8to12)andaccountsfor
manycasesofphysIcIanImpaIrment.
i
thasbeenquestIonedwhether,wIththenotable
exceptIonofopIoIdabuse,substancerelateddIseaseIsmorecommonamong
anesthesIologIststhanotherphysIcIans.
124
However,unpublIsheddatacollectedfromone
largeInsuranceunderwrIterIndIcatethattherateofsubstancerelateddIsabIlItyamong
anesthesIologIstsIsJtImesthatseenamongotherphysIcIans(personalcommunIcatIon,
UnumProvIdent).DtherfactorsthatmayleadtoImpaIrmentIncludephysIcalormental
IllnessanddeterIoratIonassocIatedwIthagIng.UnwIllIngnessorInabIlItytokeepupwIth
currentlIteratureandtechnIquescanbeconsIderedaformofImpaIrment.
AmongphysIcIanswhoareImpaIredasaresultofemotIonalIllness,depressIonIsa
promInentfIndIng.nonestudy,approxImatelyJ0ofmedIcalInternswereclInIcally
depressed.
129
ndeed,whenexaggerated,manyofthepersonalItytraItsthatensuresuccess
InthephysIcIan'sworld,suchasselfsacrIfIce,competItIveness,achIevementorIentatIon,
denIaloffeelIngs,andIntellectualIzatIonofemotIons,mayalsoserveasrIskfactorsfor
depressIon.SeveralstudIesonalcoholIcphysIcIanshaveprovIdedsomeInsIghtIntothIslInk
betweenachIevementorIentatIonandemotIonaldIsturbance.nonestudy,morethanhalf
ofthealcoholIcphysIcIansgraduatedIntheupperonethIrdoftheIrmedIcalschoolclass,
2JwereIntheupperonetenthoftheIrclass,andonly5wereIntheloweronethIrdof
theIrclass.
1J0
SImIlarly,areportonalcoholuseInmedIcalschooldemonstratedbetter
fIrstyeargradesandhIgherscoresonPartNatIonal8oardof|edIcalExamInerstests
amongthosestudentsIdentIfIedasalcoholabusers.
1J1
tcanbedIffIculttoapproprIatelyrespondtotheproblemsImposedbytheImpaIredor
unsafeanesthesIologIst.
1J2
P.78
Fortunately,manystatelegIslaturesandmedIcalsocIetIeshaveformalprotocolsthat
addresstheImpaIredphysIcIanInatherapeutIcandnonpunItIvefashIon.ThelIcense
suspensIonpowerofthestateboardofmedIcalexamInersIsusuallyexercIsedonlyIncases
InwhIchthereIsasubstantIalrIsktothepublIcwelfareandtheInvolvedphysIcIanIs
unwIllIngtovoluntarIlysuspendpractIce.|anagementprotocolsfordealIngwIththe
ImpaIredphysIcIanarecoveredInaserIesofartIclesbyCanavanand8axter.
1JJ
The Aging Anesthesiologist
LIttleattentIonhasbeengIventothechallengesfacedbyolderanesthesIologIsts.
58
ThIsIs
IncontrasttothesItuatIonInmostotherIndustrIesInwhIchmuchconsIderatIonIsdIrected
towardthecompetenceandwellbeIngofolderworkers.Forexample,commercIalpIlots
arerequIredtotakeregularmedIcalexamInatIonsandconformtopolIcIesregardInghours
ofwork.
AdvancIngchronologIcageIspredIctablyaccompanIedbychangesInmostorgansystems.
|ostnotableforthesafepractIceofanesthesIologyarethechangescommonlyobservedIn
thecentralnervoussystem.NeuronaldensItyandbraInweIghtdecreasefrom1,J75gat
age20yearsto1,200gatage80years.
1J4
ThereIsanagerelateddeclIneIntraInIng
dependentplastIcItyInthemotorcortexaccompanIedbyadImInIshedabIlItytoreorganIze
InresponsetotraInIng.
1J5
TheseandotheranatomIcchangesareassocIatedwIthcommondecrementsInphysIologIc
functIon.TherearemeasurabledecreasesInhearIng,vIsIon,shorttermmemory,creatIve
thInkIngandproblemsolvIngabIlItIes.LearnIngIsslowerandrequIresmoreeffort.
ntellectualquIcknessandonthespotreasonIngandreactIontImeslow.Thesehavethe
potentIalofadverselyaffectIngtheolderanesthesIologIst'sabIlItytoassImIlateandapply
newknowledgeandtoInstantaneouslyprocessInformatIon,rapIdlymakecomplex
decIsIons,andInItIatetheapproprIateresponse.
1J6
ThesedefIcIencIesareespecIally
exposedInastressfulenvIronmentsuchastheoperatIngroom.
1J7
ThecardIovascularandmusculoskeletalsystemsalsoundergoagerelatedchangesthatcan
affecttheabIlItytopractIceanesthesIology.DneareaofpartIculardIffIcultyfor
anesthesIologIstsIsmaIntaInIngthestamInarequIredforlongworkshIftsandnIghtcall.
SuperImposedonapropensItytosleepdIsturbance,thedemandsofnIghtcalland
assocIatedsleepdeprIvatIonarepartIcularlydIffIcultforolderanesthesIologIsts.NIghtcall
IsconsIderedoneofthemoststressfulaspectsofpractIceandIsoftencItedasareasonfor
retIrementamongolderanesthesIologIsts.
58,1J8
ThephysIologIcchangesthataccompanythenormalagIngprocessareoftencompensated
byadvantagesconferredbyolderage.TheseIncludewIsdom,judgment,andthe
experIenceacquIredbyalIfelongpractIceofthespecIalty.ThereIsastrongcorrelatIon
betweenexperIenceandperformance.
1J9,140
However,thIscorrelatIondoesnotnecessarIly
exIstbetweenexperIenceandcomplexcognItIveskIlls.AspoIntedoutbyWeInger,
141
experIenceIsnotsynonymouswIthexpertIse.
AgIngamonganesthesIologIstsraIsesInterestInglegalIssues.TherearenoagespecIfIc
condItIonsplacedonstatemedIcallIcensureoronthepractIceofanesthesIology.nmost
cases,thedecIsIontolImItpractIceorretIreremaInsatthedIscretIonoftheIndIvIdual
anesthesIologIstbasedonhIsorherselfevaluatIon.AnumberoffederallawsImpactthe
agInganesthesIologIst'srIghtsandresponsIbIlItIesregardIngcontInuatIonofwork.These
IncludetheAge0IscrImInatIonAct,TItle7oftheCIvIlFIghtsAct(EqualPayAct),the
|edIcalandFamIlyLeaveAct,theFaIrLaborStandardsAct,andtheEmployeeFetIrement
ncomeSecurItyAct(EFSA).
AnesthesIology,sImIlartootherhIghstressprofessIons,IscommonlyconsIderedayoung
person'sspecIalty.AnesthesIologIststendtoretIreatayoungeragethandomanyother
specIalIsts.
142
ThedecIsIontoretIreforananesthesIologIstIsfrequentlyprecIpItatedby
thegrowIngburdensofnIghtcallorconcernsaboutdeterIoratIngclInIcalskIlls.nmany
cases,theretIrInganesthesIologIstjustfeltItwastIme.
1J8
AgrowIngnumberofpractIces
areestablIshIngphasedretIrementplansthatpermItsenIoranesthesIologIststoavoIdsome
ofthemoreonerousaspectswhIleremaInIngvItalmembersofapractIce.
14J
AsaresultofanumberofdemographIcfactors,IncludIngthesmallerresIdencyclasssIzes
observeddurIngthemId1990s,themeanageoftheanesthesIologyworkforceIsIncreasIng.
Thegreatestnumber(J0)ofanesthesIologIstsarebetweenage45and54yearsofage,and
56areage45andolder(upfrom4910yearsago).
15
Mortality Among Anesthesiologists
AnumberofstudIeshaveexamInedmortalItyamonganesthesIologIsts.EmployIngdIfferent
databasesandmethods,thesestudIeshavereportedconflIctIngconclusIonsIncludInga
shortened,
14,144
anaverage,
15,145
oraprolonged
146,147
lIfeexpectancy.A2006study
reportedasIgnIfIcantIncreaseInlIfeexpectancyamonganesthesIologIstsdurIngthelast
decade,suchthattheaverageageatdeathIn2001(thelastyearofthestudy)was78
years,thesameasthenatIonalaverageforallAmerIcans.
148
ThecauseofdeathamonganesthesIologIstshasalsobeenextensIvelystudIed.EarlIerwork
foundanIncreasedIncIdenceofcertaIntypesofcancer,IncludIngleukemIaand
lymphoma.
4,12
AmorerecentreportbyAlexanderetal
14
foundnoIncreasedrIskofcancer
relateddeathsamonganesthesIologIstsascomparedwIththecontrolgroup(InternIsts).
SIgnIfIcantlyIncreasedrIsksforanesthesIologIstsresultedfromdrugrelateddeath,suIcIde,
drugrelatedsuIcIde,otherexternalcauses,H7related,andcerebrovasculardIsease.The
rIsktoanesthesIologIstsofdrugrelateddeathswashIghestInthefIrst5yearsafter
graduatIonfrommedIcalschoolandremaInedIncreasedforentIreprofessIonalcareers.
Suicide
thasbeenwelldocumentedthattherateofsuIcIderanksdIsproportIonatelyhIghasa
causeofdeathamongbothmale
149
andfemale
150
physIcIans.SeveralreportshavesIngled
outanesthesIologIstsasbeIngpartIcularlyvulnerable.
14,147,151
However,thIsconclusIonhas
beenquestIonedastheresultofthemethodologIcaldIffIcultIesIncollectIngaccuratedata
onsuIcIdeandthefrequentfaIluretoadequatelycorrectforconfoundIngvarIablesInthe
studypopulatIons.
152
WhymIghttherebeahIghrateofsuIcIdeamonganesthesIologIsts:ApartIalexplanatIon
lIeswIththehIghdegreeofstressthatIsanIntegralpartofthejob.
48
ThereIsaclose
assocIatIonInmanyIndIvIdualsbetweenstressfullIfeeventsandmajordepressIve
dIsorders.
15J
nsusceptIbleIndIvIduals,feelIngsofInabIlItytocoperesultIngfromthe
stressInduceddepressIoncangIvewaytodespaIrandsuIcIdeIdeatIon.
ExtensIvepersonalItyprofIlescollectedfromsuIcIdesusceptIbleIndIvIdualsIndIcate
characterIstIcssuchashIghanxIety,InsecurIty,lowselfesteem,ImpulsIveness,andpoor
selfcontrol.tIsdIsturbIngtonotethatInthestudyofpersonalItytraItsof
anesthesIologIstsbyFeeve,
154
some20manIfestedpsychologIcalprofIlesthatreflecteda
predIsposItIontobehavIoraldIsIntegratIonandattemptedsuIcIdewhenplacedunder
P.79
extremesofstress.ThIsstudyraIsesthedIscomfortIngnotIonthatpremorbIdpersonalIty
characterIstIcsexIstbeforeenterIngspecIaltytraInIngandarenotbeIngIdentIfIedInthe
admIssIonsprocess.
DnespecIfIctypeofstress,thatresultIngfromamalpractIcelawsuIt,mayhaveadIrect
causatIveassocIatIonwIthsuIcIdeamongphysIcIansIngeneralandanesthesIologIstsIn
partIcular.NewspaperreportshavedescrIbedtheemotIonaldeterIoratIonandultImate
suIcIdeofexperIencedphysIcIanswhohavebecomeInvolvedInamalpractIcesuIt.Dne
studyreportedthat4of185anesthesIologIstsbeIngsuedformedIcalmalpractIce
attemptedorcommIttedsuIcIde.
151
SubstanceabuseamonganesthesIapersonnelIs
anotherpotentIalcontrIbutortotheIncreasedsuIcIderate.ndIvIdualswIthchemIcal
dependence,whoarenotIdentIfIedandareIntheendstagesofthedIsease,maydIeof
drugoverdose,acauseofdeaththatcanbedIffIculttodIstInguIshfromsuIcIde.none
recentstudy,drugabusewasamongthehIghestcausesofdeathandthemostfrequent
methodofsuIcIdeamonganesthesIologIsts.
14
0rugoverdoseanddeathwastheInItIal
relapsesymptomIn16(1Jof79)oftheparenteralopIoIdabuserswhohadreentered
theIrresIdencyInanesthesIology.
12J
PhysIcIanswhoareImpaIredfromchemIcal
dependenceandwhoseprIvIlegestopractIcemedIcInehavebeenrevokedarealsoat
heIghtenedrIskforattemptIngsuIcIde.Crawshawetal
155
reported8successfuland2near
mIsssuIcIdeattemptsamong4JphysIcIansplacedonprobatIonfordrugrelateddIsabIlIty.
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Editors: Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.;
Stock, M. Christine
Title: Clinical Anesthesia, 6th Edition
CopyrIght2009LIppIncottWIllIamsEWIlkIns
TableofContentsSectIonntroductIontoAnesthesIologyChapter4AnesthetIcFIsk,QualItymprovementand
LIabIlIty
Chapter4
Anesthetic Risk, Quality Improvement and Liability
Karen L. Posner
Karen B. Domino
Key Points
1. Anesthetic mortality has decreased, but accidental deaths and
disabling complications still occur.
2. Risk management programs are broadly oriented toward reducing the
liability exposure of the organization. Risk management programs
complement quality improvement programs in minimizing liability
exposure while maximizing quality of patient care.
3. Quality improvement programs are generally guided by the
requirements of the Joint Commission that accredits healthcare
organizations. Quality improvement programs focus on improving the
structure, process, and outcome of care.
4. Continuous quality improvement (CQI) is a systems approach to
identifying and improving quality of care.
5. Medical malpractice refers to the legal concept of professional
negligence. The patient-plaintiff must prove that the anesthesiologist
owed the patient a duty, failed to fulfill this duty, that the
anesthesiologist's actions caused an injury, and that the injury
resulted from a breach in the standard of anesthesia care.
6. The most common lawsuits against anesthesiologists (excluding
dental injuries) are for death, brain damage, nerve damage, and
airway injury.
nanesthesIa,asInotherareasoflIfe,everythIngdoesnotalwaysgoasplanned.
UndesIrableoutcomesoccurregardlessofthequalItyofcareprovIded.AnanesthesIarIsk
managementprogramcanworkInconjunctIonwIthaprogramforqualItyImprovementto
mInImIzethelIabIlItyrIskofpractIce,whIleassurIngthehIghestqualItyofcarefor
patIents.Payerssuchas|edIcareareIncreasInglydependIngonaccredItatIonthrough
bodIessuchastheJoIntCommIssIontoensurethatmechanIsmsareInplacetodelIver
qualItyandsafecaretoallpatIents.naddItIon,therehasbeenamovetoward
performancemeasurementlInkedtoreImbursement.ThelegalaspectsofAmerIcan
medIcalpractIcehavealsobecomeIncreasInglyImportantasthepublIchasturnedtothe
courtsforeconomIcredresswhentheIrexpectatIonsofmedIcaltreatmentarenotmet.
ThIschapterdIscussesanesthetIcmortalItyandmorbIdIty,rIskmanagement,contInuous
qualItyImprovement,performancemeasurement,andmedIcallIabIlIty.Thechapter
provIdesbackgroundforthepractItIonerconcernIngtheroleofrIskmanagementactIvIty
InmInImIzIngandmanagInglIabIlItyexposure.AlsodescrIbedIsthemedIcallegalsystem,
themostfrequentcausesoflawsuItsforanesthesIologIsts,andapproprIateactIonsfor
physIcIanstotakeIntheeventofamalpractIcesuIt.
Anesthesia Risk
Mortality and Major Morbidity Related to Anesthesia
EstImatesofanesthesIarelatedmorbIdItyandmortalItyaredIffIculttoquantIfy.Notonly
aretheredIffIcultIesobtaInIngdataoncomplIcatIons,butdIfferentmethodsyIelddIfferent
estImatesofanesthesIarIsk.StudIesdIfferIntheIrdefInItIonsofcomplIcatIons,lengthof
followup,andespecIallyInapproachestoevaluatIonofthecontrIbutIonofanesthesIa
caretopatIentoutcomes.AcomprehensIverevIewofanesthesIacomplIcatIonsIsbeyond
thescopeofthIschapter.AsamplIngofstudIesofanesthesIamortalItyandmorbIdItywIll
bepresentedtoprovIdehIstorIcalperspectIveplusalImItedovervIewofrelatIvelyrecent
fIndIngs.
EarlystudIesestImatedtheanesthesIarelatedmortalItyrateas1per1,560anesthetIcs.
1
|orerecentstudIesusIngdatafromthe1990sestImatetheanesthesIarelateddeathrate
IntheUnItedStatestobe1per10,000anesthetIcs.
2,J,4,5
Someexamplesofmodern
estImatesofanesthesIarelateddeathfromthroughouttheworldareprovIdedInTable4
1.
2,J,4,5,6,7,8,9,10,11,12,1J
0IfferencesInestImatesmaybeInfluencedbydIfferentreportIng
P.8J
methods,defInItIons,anesthesIapractIces,patIentpopulatIon,aswellasactual
dIfferencesInunderlyIngcomplIcatIonrates.Nevertheless,ItIsgenerallyacceptedthat
anesthesIasafetyhasImprovedoverthepast50years.
Table 4-1 Estimates of Anesthesia-Related Death
REFERENCE COUNTRY TIME DATA SOURCES/METHODS RATE OF DEATH
FlIcketal
4
USA
1988
2005
PerIoperatIvecardIac
arrestInpedIatrIc
patIentsatatertIary
referralhospItal(n=
92,881anesthetIcs)
AnesthesIa
attrIbuted
deaths=
0.22/10,000
anesthetIcs
8Ibouletet
al
8
France
1989
1995
ASA14patIents
undergoInganesthesIa(n
=101,769anesthetIcs);
cardIacarrestwIthIn12
hrpostanesthesIa(n=24)
AnesthesIa
relateddeath=
0.6/10,000
anesthetIcs
Newland
etal
2
USA
1989
1999
CardIacarrestswIthIn24
hrofsurgery(n=72,959
anesthetIcs)InateachIng
hospItal
0eathrelatedto
anesthesIa
attrIbutable
perIoperatIve
cardIacarrest=
0.55/10,000
anesthetIcs
Eagleand
0avIs
6
Western
AustralIa
1990
1995
0eathswIthIn48hror
deathsInwhIch
anesthesIawas
consIderedacontrIbutIng
factor(n=500deaths)
AnesthesIa
relateddeath=
1/40,000
anesthetIcs
Lagasse
J
USA
(a)
1992
1994
(a)SuburbanteachIng
hospItal(n=115deaths;n
=J7,924anesthetIcs)
AnesthesIa
relateddeath=
(a)0.79/10,000
anesthetIcs
(b)
1995
1999
(b)UrbanteachIng
hospItal(n=2J2deaths;n
=146,548anesthetIcs)
(b)0.75/10,000
anesthetIcs
0avIs
7
AustralIa
1994
1996
0eathsreportedtothe
commIttee(n=8,500,000
anesthetIcs)
AnesthesIa
relateddeath=
0.16/10,000
anesthetIcs
|orrayet
1994
PedIatrIcpatIentsfrom6J
AnesthesIa
relateddeath=
al
5
USA 1997 hospItals(n=1,089,200
anesthetIcs)
0.J6/10,000
anesthetIcs
KawashIma
etal
10
Japan
1994
1998
QuestIonnaIrestotraInIng
hospItals(n=2,J6J,0J8
anesthetIcs)
0eathtotally
attrIbutableto
anesthesIa=
0.21/10,000
anesthetIcs
Arbouset
al
9
Holland
1995
1997
AlldeathswIthIn24hror
patIentswhoremaIned
unIntentIonallycomatose
24hrpostanesthesIa(n=
811In869,48J
anesthetIcs)64hospItals
AnesthesIa
relateddeath=
1.4/10,000
anesthetIcs
LIenhartet
al
1J
France 1999
NatIonwIdesurveyof
anesthesIarelateddeaths
0eathtotally
relatedto
anesthesIa=
0.069/10,000
0eathpartIally
relatedto
anesthesIa=
0.47/10,000
KawashIma
etal
11
Japan 1999
QuestIonnaIrestotraInIng
hospItals(n=79J,840
anesthetIcs)
0eathtotally
attrIbutableto
anesthesIa=
0.1J/10,000
anesthetIcs
rItaet
al
12
Japan
1999
2002
0eathsasaresultoflIfe
threatenIngeventsInthe
operatIngroom(n=
J,855,J84anesthetIcs)In
traInInghospItals
0eathtotally
attrIbutableto
anesthetIc
management=
0.1/10,000
anesthetIcs
DthercomplIcatIonsrelatedtoanesthesIathathavereceIvedrelatIvelyrecentattentIon
IncludepostoperatIvenerveInjury,awarenessdurInggeneralanesthesIa,eyeInjurIesand
vIsualdefIcIts,dentalInjury,andpostoperatIvecognItIvedysfunctIonInelderlypatIents.
UlnarneuropathyIsoneofthemostcommonnerveInjurIesleadIngtoanesthesIa
malpractIceclaImsIntheUnItedStates.
14
TheIncIdenceofulnarneuropathyhasbeen
estImatedbetweenJ.7and50per10,000patIents(Table42).
15,16,17
LowerextremIty
neuropathyfollowIngsurgeryInthelIthotomyposItIonwasobservedIn2.7per10,000
patIents(Table42).
18
PermanentneurologIcInjuryfollowIngneuraxIalanesthesIawas
estImatedat0to4.2per10,000spInalanesthetIcsand0to7.6per10,000epIdural
anesthetIcs.
19
AwarenessdurInggeneralanesthesIahasbeenestImatedtooccurIn1to2
per1,000patIentsIntertIarycaresettIngs,
20,21
butmayoccurwIthlowerfrequencyIn
ambulatorypatIents.
22
EyeInjurIesarearIskofanesthesIa,IncludIngcornealabrasIonsaswellasmorerare
complIcatIonssuchasblIndnessfromIschemIcoptIcneuropathyorcentralretInalartery
occlusIon(Table42).
2J,24
EyeInjuryafternonocularsurgerywasobservedIn5.6per10,000
patIents.
2J
Newonsetblurred
P.84
vIsIonhasbeenobservedIn4.2ofpatIents(Table42).
24
NewonsetvIsuallossorchanges
lastIngmorethanJ0daysafternoncardIacsurgerywereobservedIn1per125,2J4
patIents.
24
Table 4-2 Rates of Selected Anesthesia Complications
COMPLICATION REFERENCE COUNTRY TIME SPECIFIC COMPLICATION RESULTS
Warneret
al
18
USA
1957
1991
LowerextremIty
motorneuropathy
followIngsurgery
InlIthotomy
posItIon
1/J,608
procedures
Warneret
al
16
USA
1957
1991
PersIstentulnar
neuropathy
followIng
dIagnostIcor
noncardIac
procedureswIth
anesthesIa
1/2,729
patIents
AlvIne
and
Schurrer
15
USA
1980
1981
Ulnarneuropathy
aftergeneral
anesthesIa
0.26
FadIculopathyor
Nerve
Injury
8rullet
al
19
7arIous
1987
1999
perIpheral
neuropathyafter
spInalanesthesIa
J.78/10,000
anesthetIcs
FadIculopathyor
perIpheral
neuropathyafter
epIdural
anesthesIa
2.19/10,000
anesthetIcs
Permanent
neurologIcInjury
afterspInal
anesthesIa
0
4.2/10,000
anesthetIcs
Permanent
neurologIcInjury
afterepIdural
anesthetIc
0
7.6/10,000
anesthetIcs
7arIes
TransIent
neurologIcdefIcIt
afterInterscalene
block
2.84/10,000
anesthetIcs
Warneret
al
17
USA 1995
Ulnarneuropathy
InadultsfollowIng
noncardIacsurgery
0.5
Awareness
andrecall
SandInet
al
20
Sweden
1997
1998
Awarenessand
recallassocIated
wIthgeneral
anesthesIa
18/11,785
procedures
Sebelet
al
21
USA
2001
2002
AwarenesswIth
recallInpatIents
18yroldInseven
academIcmedIcal
centers
0.1J
Pollardet
USA
2002
Awarenessand
recallInaregIonal
1/14,560
al
22
2004 medIcalcenter patIents
Eye
InjurIes
andvIsual
changes
Warneret
al
2J
USA
1986
1998
NewonsetvIsual
lossorvIsual
changeslastIng
J0daysafter
noncardIacsurgery
1/125,2J4
patIents
Warneret
al
24
USA 1999
Newonsetblurred
vIsIonlastIngJ
days
4.2
0ental
Injury
Warneret
al
25
USA
1987
1997
0entalInjurIes
wIthIn7daysof
anesthesIathat
requIred
InterventIon
1/4,5J7
patIents
0amagetoteethordenturesIsperhapsthemostcommonInjuryleadIngtoanesthesIa
malpractIceclaIms.0entalInjurycomplaIntsareusuallyresolvedbyahospItalrIsk
managementdepartment.0entalInjurIesrequIrIngInterventIonwereobservedIn1per
4,5J7patIents.
25
CognItIvedysfunctIonIsobservedInmanyadultpatIentsaftermajorsurgery,butonlythe
elderlyareatsIgnIfIcantrIskforlongtermcognItIveproblems.
26
Thecausefor
postoperatIvecognItIvedysfunctIonIsunknown.
Risk Management
Conceptual Introduction
FIskmanagementandqualItyImprovementprogramsworkhandInhandInmInImIzIng
lIabIlItyexposurewhIlemaxImIzIngqualItyofpatIentcare.AlthoughthefunctIonsofthese
programsvaryfromoneInstItutIontoanother,theyoverlapIntheIrfocusonpatIent
safety.TheycangenerallybedIstInguIshedbytheIrbasIcdIfferenceInorIentatIon.A
hospItalrIskmanagementprogramIsbroadlyorIentedtowardreducIngthelIabIlIty
exposureoftheorganIzatIon.ThIsIncludesnotonlyprofessIonallIabIlIty(andtherefore
patIentsafety)butalsocontracts,employeesafety,publIcsafety,andanyotherlIabIlIty
exposureoftheInstItutIon.QualItyImprovementprogramshaveastheIrmaIngoalthe
contInuousmaIntenanceandImprovementofthequalItyofpatIentcare.Theseprograms
maybebroaderIntheIrpatIentsafetyfocusthanstrIctlyrIskmanagement.QualIty
Improvement(sometImescalledpatient safety)departmentsareresponsIbleforprovIdIng
theresourcestoprovIdesafe,patIentcentered,tImely,effIcIent,effectIve,andequItable
patIentcare.
27
Risk Management in Anesthesia
ThoseaspectsofrIskmanagementthataremostdIrectlyrelevanttothelIabIlItyexposure
oftheanesthesIologIstIncludepreventIonofpatIentInjury,adherencetostandardsof
care,documentatIon,andpatIentrelatIons.
P.85
ThekeyfactorsInthepreventIonofpatIentInjuryarevIgIlance,uptodateknowledge,
andadequatemonItorIng.
28
PhysIologIcmonItorIngofcardIopulmonaryfunctIon,combIned
wIthmonItorIngofequIpmentfunctIon,mIghtbeexpectedtoreduceanesthetIcInjurytoa
mInImum.ThIswastheratIonalefortheadoptIonbytheAmerIcanSocIetyof
AnesthesIologIsts(ASA)ofStandards for Basic Anesthetic Monitoring.
a
TheASAWebsIteshouldberevIewedyearlyforanychangesInthesestandards.twould
alsobereasonabletorevIewtheGuidelines and StatementspublIshedontheASAWebsIte.
tshouldbenotedthat,althoughmembershIpIntheASAIsnotrequIredforthepractIceof
anesthesIology,expertwItnesseswIll,wIthvIrtualcertaInty,holdanypractItIonertothe
ASAstandards.tIsalsopossIblethat,asarIskmanagementstrategy,aprofessIonal
lIabIlItyInsurerorhospItalmayholdanIndIvIdualanesthesIologIsttostandardshIgherthan
thosepromulgatedbytheASA.
AnotherrIskmanagementtoolIstheuseofchecklIstsprIortoeachcase,oratleastdaIly,
InanattempttoreduceequIpmentrelatedmIshaps.
29,J0,J1
Aregularscheduleof
equIpmentmaIntenanceshouldbeestablIshedaswellasprocedurestofollowwhenever
equIpmentmalfunctIonIssuspectedofcontrIbutIngtopatIentInjury.TheASAWebsItehas
recommendatIonsforpreanesthesIacheckoutprocedures
b
aswellasguIdelInesfor
determInInganesthesIamachIneobsolescence.
c
fequIpmentmalfunctIonIssuspectedto
havecontrIbutedtoacomplIcatIon,thedevIceshouldbeImpoundedandexamIned
concurrentlybytherepresentatIvesofthehospItal,theanesthesIologIst,andthe
manufacturer.
AlthoughItmayseemobvIous,qualIfIedanesthesIapersonnelshouldbeIncontInuous
attendancedurIngtheconductofallanesthetIcs.TheonlyexceptIonsshouldbethosethat
laypeople(I.e.,judgeandjury)canunderstand,suchasradIatIonhazardsoran
unexpectedlIfethreatenIngemergencyelsewhere.Eventhen,provIsIonsshouldbemade
formonItorIngthepatIentadequately.AdequatesupervIsIonofnurseanesthetIstsand
resIdentsIsalsoImportant,asIsgoodcommunIcatIonwIthsurgeonswhenadverse
anesthetIcoutcomesoccur.
Informed Consent
nformedconsentregardInganesthesIashouldbedocumentedwIthageneralsurgIcal
consent,whIchshouldIncludeastatementtotheeffectthat,understandthatall
anesthetIcsInvolverIsksofcomplIcatIons,serIousInjury,or,rarely,deathfromboth
knownandunknowncauses.naddItIon,thereshouldbeanoteInthepatIent'srecord
thattherIsksofanesthesIaandalternatIvesweredIscussed,andthatthepatIentaccepted
theproposedanesthetIcplan.AbrIefdocumentatIonIntherecordthatthecommon
complIcatIonsoftheproposedtechnIqueweredIscussedIshelpful.nsomeInstItutIons,a
separatewrIttenanesthesIaconsentformmaybeused,whIchmayIncludemoredetaIl
aboutrIsks.fItIsnecessarytochangetheagreedonanesthesIaplansIgnIfIcantlyafterthe
patIentIspremedIcatedoranesthetIzed,thereasonsforthechangeshouldbedocumented
Intherecord.
Record Keeping
CoodrecordscanformastrongdefenseIftheyareadequate;however,recordscanbe
dIsastrousIfInadequate.TheanesthesIarecordItselfshouldbeasaccurate,complete,and
asneataspossIble.TheuseofautomatedanesthesIarecordsmaybehelpfulInthedefense
ofmalpractIcecases,
J2
buttheymayalsoserveasdamagIngevIdenceforthelackof
vIgIlanceprIortoanadverseevent.naddItIontodocumentIngvItalsIgnsatleastevery5
mInutes,specIalattentIonshouldbepaIdtoensurethatthepatIent'sASAclassIfIcatIon,
themonItorsused,fluIdsadmInIstered,anddosesandtImesofalladmInIstereddrugsare
accuratelycharted.8ecausetheprIncIpalcausesofhypoxIcbraIndamageanddeathdurIng
anesthesIaarerelatedtoventIlatIonand/oroxygenatIon,allrespIratoryvarIablesthatare
monItoredshouldbedocumentedaccurately.tIsImportanttonotewhenthereIsa
changeofanesthesIapersonneldurIngtheconductofacase.Sloppy,InaccurateanesthesIa
records,wIthgapsdurIngcrItIcalevents,canbeextremelydamagIngtothedefensewhen
enlargedandplacedbeforeajury.
What To Do After an Adverse Outcome
facrItIcalIncIdentoccursdurIngtheconductofananesthetIc,theanesthesIologIstshould
document,InnarratIveform,whathappened,whIchdrugswereused,thetImesequence,
andwhowaspresent.ThIsshouldbedocumentedInthepatIent'sprogressnotes,asa
catastrophIcIntraanesthetIceventcannotbesummarIzedadequatelyInasmallamountof
spaceontheusualanesthesIarecord.ThecrItIcalIncIdentnoteshouldbewrIttenassoon
aspossIble.ThereportshouldbeasconsIstentaspossIblewIthconcurrentrecords,suchas
theanesthesIa,operatIngroom,recoveryroom,andcardIacarrestrecords.fsIgnIfIcant
InconsIstencIesexIst,theyshouldbeexplaIned.Fecordsshouldneverbealteredafterthe
fact.fanerrorIsmadeInrecordkeepIng,alIneshouldbedrawnthroughtheerror,
leavIngItlegIble,andthecorrectIonshouldbeInItIaledandtImed.LItIgatIonIsalengthy
process,andacourtappearancetoexplaIntheIncIdenttoajurymaybeyearsaway,when
memorIeshavefaded.
fanesthetIccomplIcatIonsoccur,theanesthesIologIstshouldbehonestwIthboththe
patIentandfamIlyaboutthecause.TheprovIdersshouldprovIdethefactsaboutthe
event,expressregrettothepatIentandfamIlyabouttheoutcome,andgIveaformal
apologyIftheunantIcIpatedoutcomeIstheresultofanerrororsystemfaIlure.
JJ
Some
stateshavelawsmandatIngdIsclosureofserIousadverseeventstopatIents,anddIsclosure
hasbeenIncorporatedIntoqualItyreportIng.SomestatesprohIbItuseofdIsclosure
dIscussIonsasevIdenceInmalpractIcelItIgatIon.WheneverananesthetIccomplIcatIon
becomesapparent,approprIateconsultatIonshouldbeobtaInedquIckly,andthe
departmentalorInstItutIonalrIskmanagementgroupshouldbenotIfIed.fthe
complIcatIonIsapttoleadtoprolongedhospItalIzatIonorpermanentInjury,thelIabIlIty
InsurancecarrIershouldbenotIfIed.ThepatIentshouldbefollowedcloselywhIleInthe
hospItal,wIthtelephonefollowup,IfIndIcated,afterdIscharge.TheanesthesIologIst(s),
surgeon(s),consultIngphysIcIansandtheInstItutIonshouldcoordInateandbeconsIstentIn
theIrexplanatIonstothepatIentorthepatIent'sfamIlyastothecauseofany
complIcatIon.
Special Circumstances: Do Not Attempt Resuscitation and
Jehovah's Witnesses
tIsImportanttorecognIzethatpatIentshavewellestablIshedrIghts,andthatamong
theseIstherIghttorefusespecIfIctreatments.TwosItuatIonsmostrelevanttoanesthesIa
careare0oNotAttemptFesuscItatIon(0NAF)ordersandthespecIalcIrcumstanceof
bloodtransfusIonforJehovah'sWItnesses.
PatIentswIthseveremedIcalcondItIonsmayelecttoforgoresuscItatIonattemptsInthe
eventofcardIacarrest.Such0NAFordersmaybespecIfIedathospItaladmIssIonormay
P.86
beInplaceIntheformofanadvancedIrectIveprIortoadmIssIon.0NAFordersoradvance
dIrectIvesmaybegeneralorspecIfIc,suchasrefusaloftrachealIntubatIonormechanIcal
ventIlatIon.WhenapatIentwIth0NAFstatuspresentsforanesthesIacare,ItIsImportant
todIscussthIswIththepatIentorpatIent'ssurrogatetoclarIfythepatIent'sIntentIons.n
manyhospItals,theInstItutIonalpolIcyIstosuspendthe0NAForderdurIngtheImmedIate
perIoperatIveperIodsIncethecauseforacardIacarrestmaybeeasIlyIdentIfIedand
treated.notherInstItutIons,thepatIentmaychoosetosuspendthe0NAForderdurIngthe
entIreperIoperatIveperIod.tshouldbeclarIfIedwhenthe0NAFordershouldbe
reInstated(e.g.,dIschargefromrecoveryorpossIblylater,whenthepatIenthasrecovered
fromtheprocedure)anddocumentedInthepatIent'schart.TheperIoperatIvestatusof
0NAFordersshouldalsobeclarIfIedwIththesurgeonandotherprovIderswhowIllbe
InvolvedInthepatIent'sperIoperatIvecare.TheASAhaspublIshedEthical Guidelines of
the Anesthesia Care of Patients with Do-Not-Resuscitate Orders.
d
nthecaseofJehovah'sWItnesses,thetreatmentthatmayberefusedIstheadmInIstratIon
ofbloodorbloodproducts.AcentralrelIgIousbelIefofmanyJehovah'sWItnessesIsthat
thefaIthfulwIllbeforbIddenthepleasuresoftheafterlIfeIftheyreceIvebloodorblood
products.Thus,forthemtoreceIveatransfusIonIsamortalsIn,andmanyJehovah's
WItnesseswouldactuallyratherdIeIngracethanlIvewIthnopossIbIlItyofsalvatIon.
AnesthesIologIstsmustrecognIzeandrespectthesebelIefs,butmayalsobecognIzantthat
theseconvIctIonsmayconflIctwIththeIrownpersonal,relIgIous,orethIcalcodes.
Asageneralrule,physIcIansarenotoblIgatedtotreatallpatIentswhoapplyfortreatment
InelectIvesItuatIons.tIswellwIthIntherIghtsofaphysIcIantodeclInetocareforany
patIentwhowIshestoplaceburdensomeconstraIntsonthephysIcIanortounacceptably
lImItthephysIcIan'sabIlItytoprovIdeoptImalcare.WhenpresentedwIththeopportunIty
toprovIdeelectIvecareforaJehovah'sWItness,thephysIcIanmaydeclInetoprovIdeany
careormaylImIt,bymutualconsentwIththepatIent,hIsorheroblIgatIontoadhereto
thepatIent'srelIgIousbelIefs.fsuchanagreementIsreached,Itmustbedocumented
clearlyInthemedIcalrecord,andItIsdesIrabletohavethepatIentcosIgnthenote.Not
allJehovah'sWItnesseshaveIdentIcalbelIefsregardIngbloodtransfusIonsorwhIch
methodsofbloodpreservatIonorsequestratIonwIllbeallowed.SomepatIentswIllnot
allowanybloodthathasleftthebodytobereInfused,yetotherswIllaccept
autotransfusIonIftheIrbloodremaInsInconstantcontactwIththebody(vIatubIng).
Therefore,ItIsImportanttoreachaclearunderstandIngofwhIchtechnIquesforblood
preservatIonaretobeusedandtodocumentthIsplanIntherecord.ParentsofamInor
chIldmaynotlegallypreventthatchIldfromreceIvIngblood.tmaybenecessaryto
obtaInacourtorderInthIscIrcumstance.
National Practitioner Data Bank
tIsusuallytheoblIgatIonofthehospItalrIskmanagementdepartmenttomakereports
andInquIrIestotheNatIonalPractItIoner0ata8ank(NP08),anatIonwIdeInformatIon
systemthattheoretIcallyallowslIcensIngboardsandhospItalsameansofdetectIng
adverseInformatIonaboutphysIcIans.
J4
SImplymovIngIntoanotherstatewouldnolonger
provIdesafehavenforIncompetentphysIcIans.
TheNP08requIresInputfromfIvesources:(1)medIcalmalpractIcepayments,(2)lIcense
actIonsbymedIcalboards,(J)professIonalrevIeworclInIcalprIvIlegeactIonstakenby
hospItalsandotherhealthcareentItIes(IncludIngprofessIonalsocIetIes),(4)actIonstaken
bythe0rugEnforcementAgency,and(5)|edIcare/|edIcaIdexclusIons.Therehasbeena
greatdealofefforttoestablIshamInImummalpractIcepaymentbelowwhIchnoreportIs
necessary,buttodate,anypaymentmadeonbehalfofaphysIcIanInresponsetoawrItten
complaIntorclaImmustbereported.SettlementsmadebycancellatIonofbIllsor
settlementsmadeonverbalcomplaIntsarenotconsIderedareportablepayment.
DnceareporthasbeensubmItted,thephysIcIanIsnotIfIedandmaydIsputetheaccuracy
ofthereport.AtthIstIme,thereportIngentItymaycorrecttheformorvoIdIt.FaIlIng
that,thephysIcIanhastheoptIonofputtIngabrIefstatementInthefIleorappealIngto
theU.S.SecretaryofHealthandHumanServIces,whomayalsoeIthercorrectorvoIdthe
form.ApractItIonermaymakeaqueryabouthIsorherfIleatanytIme.AphysIcIanmay
alsoaddastatementtoareportatanytIme.SuchstatementswIllbeIncludedInany
reportsthataresentInresponsetoInquIrIes.TheexIstenceoftheNP08reportIng
requIrementshasmadephysIcIansreluctanttoallowsettlementofnuIsancesuItsbecause
ItwIllcausetheIrnamestobeaddedtothedatabank.
Quality Improvement and Patient Safety in Anesthesia
QualItyIsaconceptthathascontInuedtoeludeprecIsedefInItIonInmedIcalpractIce.
However,ItIsgenerallyacceptedthatattentIontoqualItywIllImprovepatIentsafetyand
satIsfactIonwIthanesthesIacare.ThefIeldofqualItyImprovementIscontInuallyevolvIng,
asIsthetermInologyusedtodescrIbesuchefforts.AmorerecenttrendIsemphasIson
patIentsafety,thepreventIonofharmfrommedIcalcare.AtthetImeofthIswrItIng,
patIentsafetyInItIatIvesareevolvIngandamovementtowardpayforperformance
(dIrectlInkagebetweencareprocessesandoutcomesandreImbursement)Isonthe
horIzon.ThesewIllbedIscussedInaseparatesectIon.
AnesthesIaqualItyImprovementprogramsattheservIcelevelaregenerallyguIdedby
requIrementsoftheJoIntCommIssIonthataccredItshospItalsandhealthcare
organIzatIons.QualItyImprovementprogramsarebasIcallyorIentedtowardImprovement
ofthestructure,process,andoutcomeofhealthcaredelIvery.AnunderstandIngofthe
fundamentalprIncIplesofqualItyImprovementmayclarIfytherelatIonshIpbetweenthe
contInuallyevolvIngJoIntCommIssIonrequIrementsandmandatedqualItyImprovement
andotherreportIngInItIatIves.
Structure, Process, and Outcome: The Building Blocks of
Quality
AlthoughqualItyofcareIsdIffIculttodefIne,ItIsgenerallyacceptedthatItIscomposedof
threecomponents:structure,process,andoutcome.
J5
StructurereferstothesettIngIn
whIchcarewasprovIded;forexample,personnelandfacIlItIesusedtoprovIdehealthcare
servIcesandthemannerInwhIchtheyareorganIzed.ThIsIncludesthequalIfIcatIonsand
lIcensIngofpersonnel,ratIoofpractItIonerstopatIents,standardsforthefacIlItIesand
equIpmentusedtoprovIdecare,andtheorganIzatIonalstructurewIthInwhIchcareIs
delIvered.TheprocessofcareIncludesthesequenceandcoordInatIonofpatIentcare
actIvItIes;thatIs,whatwasactuallydone.WasapreanesthetIcevaluatIonperformedand
documented:WasthepatIentcontInuouslyattendedandmonItoredthroughoutthe
anesthetIc:OutcomeofcarereferstochangesInhealthstatusofthepatIentfollowIngthe
delIveryofmedIcalcare.AqualIty
P.87
ImprovementprogramfocusesonmeasurIngandImprovIngthesebasIccomponentsof
care.
Continuous quality improvement(CQ)takesasystemsapproachtoIdentIfyIngand
ImprovIngqualItyofcare.
J6,J7
TheoperatorIsjustonepartofacomplexsystem.An
ImportantunderlyIngpremIseIsthatpoorresultsmaybearesultofeItherrandomor
systematIcerror.FandomerrorsareInherentlydIffIculttopreventandprogramsfocused
InthIsdIrectIonaremIsguIded.Systemerrors,however,shouldbecontrollableand
strategIestomInImIzethemshouldbewIthInreach.CQIsbasIcallytheprocessof
contInuallyevaluatInganesthesIapractIcetoIdentIfysystematIcproblems(opportunItIes
forImprovement)andImplementIngstrategIestopreventtheIroccurrence.
ACQprogrammayfocusonundesIrableoutcomesasawaytoIdentIfyopportunItIesfor
ImprovementInthestructureandprocessofcare.ThefocusIsnotonblamebutratheron
IdentIfIcatIonofthecausesofundesIrableoutcomes.nsteadofaskIngwhIchpractItIoners
havethehIghestpatIentmortalItyrates,aCQprogrammayfocusontherelatIonshIp
betweentheprocessofcareandpatIentmortalIty.WhatproportIonofdeathswasrelated
tothepatIent'sdIseaseprocessordebIlItatedcondItIon:ArethesepatIentsbeIng
approprIatelyevaluatedforanesthesIaandsurgery:Werethereanycontrollablecauses,
suchasalackofextrahelpdurIngresuscItatIon:ThelattermayleadtoamodIfIcatIonof
personnelresources(structure)orassIgnments(process)tobesurethatadequatepersonnel
areavaIlableatalltImes.
Formally,theprocessofCQInvolvestheIdentIfIcatIonofopportunItIesforImprovement
throughthecontInualassessmentofImportantaspectsofcare.tIsaprocessthatIs
InstItutedfromthebottomup,bythosewhoareactuallyInvolvedIntheprocesstobe
Improved,ratherthanfromthetopdownbyadmInIstrators.dentIfIcatIonofopportunItIes
forImprovementmaybecarrIedoutbyvarIousmeans,frombraInstormIngsessIons
focusIngonasystematIcevaluatIonofcareactIvItIestothecarefulmeasurementof
IndIcatorsofqualIty(suchasmorbIdItyandmortalIty).nanyevent,onceareasare
IdentIfIedforImprovement,theIrcurrentstatusIsmeasuredanddocumented.ThIsmay
Involvemeasurementofoutcomes,suchasdelayedrecoveryfromanesthesIaorperIpheral
nerveInjury.TheprocessofcareleadIngtotheseproblemsIsthenanalyzed.fachangeIs
IdentIfIedthatshouldleadtoImprovement,ItIsImplemented.AfteranapproprIatetIme,
thestatusIsthenmeasuredagaIntodetermInewhetherImprovementactuallyresulted.
AttentIonmaythenbedIrectedtocontInuIngtoImprovethIsprocessorturnIngtoa
dIfferentprocesstotargetforImprovement.
Difficulty of Outcome Measurement in Anesthesia
mprovementInqualItyofcareIsoftenmeasuredbyareductIonIntherateofadverse
outcomes.However,adverseoutcomesarerelatIvelyrareInanesthesIa,makIng
measurementofImprovementdIffIcult.Forexample,IfanInstItutIonlowersItsmortalIty
rateofsurgerypatIentsfrom1In1,000to0.5In1,000,thIsdIfferencemaynotbe
statIstIcallysIgnIfIcant.notherwords,ItmaybeImpossIbletoknowIfthechangeIn
outcomeresultedfromchangesIncare,oraresImplyrandomfluctuatIons.|anyadverse
outcomesInanesthesIaaresuffIcIentlyraretorenderthemproblematIcasqualIty
Improvementmeasures.
Tocomplementoutcomemeasurement,anesthesIaCQprogramscanfocusoncrItIcal
IncIdents,sentInelevents,andhumanerrors.Critical incidentsareeventsthatcause,or
havethepotentIaltocause,patIentInjuryIfnotnotIcedandcorrectedInatImely
manner.Forexample,apartIaldIsconnectofthebreathIngcIrcuItmaybecorrected
beforepatIentInjuryoccurs,yethasthepotentIalforcausInghypoxIcbraInInjuryor
death.CrItIcalIncIdentsaremorecommonthanadverseoutcomes.|easurementofthe
occurrencerateofImportantcrItIcalIncIdentsmayserveasaproxymeasureforrare
outcomesInanesthesIaInaCQprogramdesIgnedtoImprovepatIentsafetyandprevent
Injury.
Sentinel eventsaresIngle,IsolatedeventsthatmayIndIcateasystemIcproblem.TheJoInt
CommIssIonhasaspecIfIcdefInItIonofsentIneleventsthatwIllbedIscussedlater.n
general,asentIneleventmaybeasIgnIfIcantoralarmIngcrItIcalIncIdentthatdIdnot
resultInpatIentInjury,suchasasyrIngeswapandadmInIstratIonofapotentIallylethal
doseofmedIcatIonthatwasnotedandtreatedpromptly,avoIdIngcatastrophe.Dra
sentIneleventmaybeanunexpectedsIgnIfIcantpatIentInjurysuchasIntraoperatIve
death.neIthercase,aCQprogrammayInvestIgatesentIneleventsInanattemptto
uncoversystemIcproblemsInthedelIveryofcarethatcanbecorrected.Forexample,a
syrIngeswapmaybeanalyzedforconfusIngorunclearlabelIngofmedIcatIonsor
unnecessarymedIcatIonsroutInelystockedontheanesthesIacart,settIngthescenefor
unIntendedmIxup.nthecaseofdeath,allaspectsofthepatIent'shospItalcoursefrom
selectIonforsurgerytoanesthetIcmanagementmaybeanalyzedtodetermIneIfsImIlar
deathscanbepreventedbyachangeInthecaredelIverysystem.
HumanerrorhasgarneredmuchattentIonsInceagovernmentreportthat98,000
AmerIcansmaydIeannuallyfrommedIcalerrorsInhospItals.
J8
Humanerrorsare
InevItableyetpotentIallypreventablebyapproprIatesystemsafeguards.ErrorsofplannIng
InvolveuseofawrongplantoachIeveanaIm.
J9
ErrorsofexecutIonarethefaIlureofa
plannedactIontobecompletedasIntended.
J9
|odernanesthesIaequIpmentIsdesIgned
wIthsafeguardssuchasalarmsystemstodetecterrorsthatcouldleadtopatIentInjury.
DtheranesthesIacareprocessesarealsoamenabletohumanfactorsdesIgnprIncIples,such
ascolorcodIngofdruglabels.AqualItyImprovementprogrammayIdentIfyhumanerrors
andInstItutesafetysystemstoaIdInerrorpreventIon.
Joint Commission Requirements for Quality Improvement
JoIntCommIssIonrequIrementsforqualItyImprovementactIvItIesareupdatedonan
annualbasIs.ngeneral,ahospItalmustadoptamethodforsystematIcallyassessIngand
ImprovIngImportantfunctIonsandprocessesofcareandtheIroutcomesInacyclIcal
fashIon.ThegeneraloutlIneforthIsCQcycleIsthedesIgnofaprocessorfunctIon,
measurementofperformance,assessmentofperformancemeasuresthroughstatIstIcal
analysIsorcomparIsonwIthotherdatasources,andImprovementoftheprocessor
functIon.Thenthecyclerepeats.TheJoIntCommIssIonprovIdesspecIfIcstandardsthat
mustbemet,wIthexamplesofapproprIatemeasuresofperformance.ThegoalofthIs
cycleofdesIgn,measurement,assessment,andImprovementofperformanceofImportant
functIonsandprocessesIstoImprovepatIentsafetyandqualItyofcare.
AnesthesIacareIsoneImportantfunctIonofthecareofpatIentsmonItoredbytheJoInt
CommIssIon.tIsImportantthatpolIcIesandproceduresforadmInIstratIonofanesthesIa
beconsIstentInalllocatIonswIthIntheorganIzatIon.
TheJoIntCommIssIonhasadoptedandannuallyupdatespatIentsafetygoalsforaccredIted
organIzatIons.FecentpatIentsafetygoalsIncludeImprovedaccuracyofpatIent
IdentIfIcatIon,ImprovedeffectIvenessofcommunIcatIon
P.88
amongcaregIversIncludInghandoffs,ImprovedsafetyofmedIcatIonusageIncludIng
antIcoagulatIontherapy,reductIonofhealthcareassocIatedInfectIons,andImproved
recognItIonandresponsetochangesInapatIent'scondItIon.JoIntCommIssIon
accredItatIonvIsItsareunannounced,andInvolvetheInspectorwatchIngpatIentcareto
seethatsafeandacceptablepractIcesareroutInelyImplemented.ntheIntraoperatIve
envIronment,thIsmayInvolvesuchprocessesastImelyadmInIstratIonofantIbIotIcsand
properlabelIngofallsyrIngesontheanesthesIacart.TheJoIntCommIssIonalsorequIres
allsentInelevents(anyunexpectedoccurrencesInvolvIngdeathorserIousphysIcalor
psychologIcalInjuryorrIskthereof)toundergoroot cause analysis.
e
ArootcauseanalysIsIs
typIcallyfacIlItatedbythehospItalandIncludeseveryoneInvolvedInthecareofthe
affectedpatIentInreconstructIngtheeventstoIdentIfysystemprocessflawsthat
facIlItatedmedIcalerror.AnysurgeryonthewrongpatIentorwrongbodypartIsIncluded
InthIspolIcy.TheJoIntCommIssIonpublIshesasentIneleventalertsohealthcare
organIzatIonscanlearnfromtheexperIencesofothersandpreventfuturemedIcalerrors.
Pay for Performance
ArelatIvelyrecentdevelopmentrelatedtoqualItyImprovementIsP4Porpayfor
performance.P4PprogramsprovIdemonetaryIncentIvesforImplementatIonofsafe
practIces,measurIngperformance,and/orachIevIngperformancegoals.ThIsIsarecent
andevolvIngtrend,soonlyaconceptualIntroductIonwIllbeprovIdedhere.AnesthesIa
provIdersandservIcegroupswIllneedtobecognIzantofanyP4PInItIatIvesthatare
operatIveIntheIrlocatIonandwIththeIrpayers.
AtthetImeofthIswrItIng,P4PIsbeIngdrIvenbytheLeapfrogCroup,thenstItuteof
Healthcaremprovement,theCenterfor|edIcareand|edIcaIdServIces(C|S),andthe
NatIonalQualItyForum.ThebasIcconceptInvolvespaymentforqualItyratherthansImply
paymentforservIces.nsomecases,qualItyIncentIvepaymentsareprovIdedforsImply
measurIngprocesses.However,asmeasurementsystemsareImplemented,ItIsexpected
thatbenchmarksforqualItyperformancewIllbeestablIshedandprovIderswIllneedto
showthattheyaremeetIngsuchperformancebenchmarkstoreceIveIncentIvepayments.
Eventually,provIdersfallIngshortofbenchmarkperformancemayseetheIr
reImbursementsreduced.P4PIsbeIngImplementedatboththehospItalandspecIfIc
provIderlevel.C|SandotherpayersmayeventuallylInkreImbursementtoIndIvIdual
provIderprofIles.
AmultItudeofperformancemeasuresarebeIngdevelopedtomeetthebenchmarkIng
challenge.Atpresent,IndIvIdualInstItutIonsarenotbeIngheldtopartIcularbenchmarks
butareexpectedtoadoptsomeofthemajorqualItyIndIcatorsformeasurementand
Improvement.TheseIncludeneverevents,whIchareserIousadverseeventsthatshould
neveroccur.NevereventsIncludesurgeryonthewrongpatIentorlocatIon,unIntentIonal
retentIonofaforeIgnbodyaftersurgery,patIentdeathresultIngfromamedIcatIonerror,
andperIoperatIvedeathofanASA1patIent.Attheendof2007,therewere28never
eventsestablIshedbytheNatIonalQualItyForum.|any,butnotalloftheseeventsare
relevanttoanesthesIacare.ThelIstofnevereventsIsperIodIcallyupdated.
f
Professional Liability
ThIssectIonaddressesthebasIcconceptsofmedIcallIabIlIty.AmoredetaIleddIscussIonof
thestepsofthelawsuItprocessandapproprIateactIonsforphysIcIanstotakewhensuedIs
avaIlablefromtheASA.
g
The Tort System
AlthoughphysIcIansmaybecomeInvolvedInthecrImInallawsystemInaprofessIonal
capacIty,theymorecommonlybecomeInvolvedInthelegalsystemofcIvIllaws.CIvIllaw
IsbroadlydIvIdedIntocontract lawandtort law.AtortmaybelooselydefInedasacIvIl
wrongdoIng;neglIgenceIsonetypeoftort.MalpracticeactuallyreferstoanyprofessIonal
mIsconductbutItsuseInlegaltermstypIcallyreferstoprofessIonalneglIgence.
TobesuccessfulInamalpractIcesuIt,thepatIentplaIntIffmustprovefourthIngs:
1. 0uty:thattheanesthesIologIstowedthepatIentaduty;
2. 8reachofduty:thattheanesthesIologIstfaIledtofulfIllhIsorherduty;
J. CausatIon:thatareasonablyclosecausalrelatIonexIstsbetweentheanesthesIologIst's
actsandtheresultantInjury;and
4. 0amages:thatactualdamageresultedbecauseofabreachofthestandardofcare.
FaIluretoproveanyoneofthesefourelementswIllresultInadecIsIonforthedefendant
anesthesIologIst.
Duty
AsaphysIcIan,theanesthesIologIstestablIshesadutytothepatIentwhenadoctorpatIent
relatIonshIpexIsts.WhenthepatIentIsseenpreoperatIvely,andtheanesthesIologIst
agreestoprovIdeanesthesIacareforthepatIent,adutytothepatIenthasbeen
establIshed.nthemostgeneralterms,thedutytheanesthesIologIstowestothepatIentIs
toadheretothestandard of careforthetreatmentofthepatIent.8ecauseItIsvIrtually
ImpossIbletodelIneatespecIfIcstandardsforallaspectsofmedIcalpractIceandall
eventualItIes,thecourtshavecreatedtheconceptofthereasonable and prudent
physIcIan.ForallspecIaltIes,thereIsanatIonalstandardthathasdIsplacedthelocal
standard.
TherearecertaIngeneraldutIesthatallphysIcIanshavetotheIrpatIents,andbreachIng
thesedutIesmayalsoserveasthebasIsforalawsuIt.DneofthesegeneraldutIesIsthatof
obtaInIngInformedconsentforaprocedure.ConsentmaybewrItten,verbal,orImplIed.
DralconsentIsjustasvalId,albeIthardertoproveyearsafterthefact,aswrIttenconsent.
mplIedconsentforanesthesIacaremaybepresentIncIrcumstancesInwhIchthepatIent
IsunconscIousorunable,foranyreason,togIvehIsorherconsent,butwhereItIs
presumedthatanyreasonableandprudentpatIentwouldgIveconsent.
AlthoughthereareexceptIonstotherequIrementthatconsentbeobtaIned,
anesthesIologIstsshouldbesuretoobtaInconsentwheneverpossIble.FaIluretodoso
could,Intheory,exposetheanesthesIologIsttopossIbleprosecutIonforbattery.
TherequIrementthattheconsentbeinformedIssomewhatmoreopaque.TheguIdelIneIs
determInIngwhetherthepatIentreceIvedafaIrandreasonableaccountoftheproposed
proceduresandtherIsksInherentIntheseprocedures.|oststates
P.89
haveadoptedareasonablepatIentstandard,whIchrequIresthatthephysIcIandIsclose
rIsksthatareasonablepatIentundersImIlarcIrcumstanceswouldwanttoknowtomakean
InformeddecIsIon.8esIdesdIsclosureofcommonrIsks,rIsksthatwouldbeImportantIn
decIdIngwhetherornottoundertaketheproposedtherapyshouldalsobedIscussed.For
regIonalanesthesIa,theseshouldIncludeboththecommonrIsks(e.g.,local
paIn/dIscomfort,InfectIon,headache,transIentneuropathy),aswellasthosethatare
rare,butofmajorconsequence(e.g.,seIzure,cardIacarrest,permanentneuropathy,
paralysIs,anddeath).
Breach of Duty
namalpractIceactIon,expertwItnesseswIllrevIewthemedIcalrecordsofthecaseand
determInewhethertheanesthesIologIstactedInareasonableandprudentmannerInthe
specIfIcsItuatIonandfulfIlledhIsorherdutytothepatIent.ftheyfIndthatthe
anesthesIologIsteItherdIdsomethIngthatshouldnothavebeendone,orfaIledtodo
somethIngthatshouldhavebeendone,thenthedutytoadheretothestandardofcarehas
beenbreached.Therefore,thesecondrequIrementforasuccessfulsuItwIllhavebeen
met.
Causation
JudgesandjurIesareInterestedIndetermInIngwhetherthebreachofdutywasthe
proximate causeoftheInjury.ftheoddsarebetterthaneventhatthebreachofdutyled,
howevercIrcuItously,totheInjury,thIsrequIrementIsmet.
TherearetwocommontestsemployedtoestablIshcausatIon.ThefIrstIsthebut fortest,
andthesecondIsthesubstantial factortest.ftheInjurywouldnothaveoccurredbutfor
theactIonofthedefendantanesthesIologIst,orIftheactoftheanesthesIologIstwasa
substantIalfactorIntheInjurydespIteothercauses,thenproxImatecauseIsestablIshed.
AlthoughtheburdenofproofofcausatIonordInarIlyfallsonthepatIentplaIntIff,Itmay,
underspecIalcIrcumstances,beshIftedtothephysIcIandefendantunderthedoctrIneof
res ipsa loquitur(lIterally,thethIngspeaksforItself).ApplyIngthIsdoctrInerequIres
provIngthat:
1. theInjuryIsofakIndthattypIcallywouldnotoccurIntheabsenceofneglIgence,
2. theInjurymustbecausedbysomethIngundertheexclusIvecontrolofthe
anesthesIologIst,
J. theInjurymustnotbeattrIbutabletoanycontrIbutIononthepartofthepatIent,and
4. theevIdencefortheexplanatIonofeventsmustbemoreaccessIbletothe
anesthesIologIstthantothepatIent.
8ecauseanesthesIologIstsrenderpatIentsInsensIbletotheIrsurroundIngsandunableto
protectthemselvesfromInjury,thedoctrIneofres ipsa loquiturmaybeInvokedIn
anesthesIamalpractIcecases.WhIlethIsargumentwascommonlyusedInthepastIn
lawsuItsfornerveInjurIes,ItIslesscommonlyusedsuccessfullytoday.
Damages
ThelawallowsforthreedIfferenttypesofdamages.General damagesarethosesuchas
paInandsufferIngthatdIrectlyresultfromtheInjury.Special damagesarethoseactual
damagesthatareaconsequenceoftheInjury,suchasmedIcalexpenses,lostIncome,and
funeralexpenses.Punitive damagesareIntendedtopunIshthephysIcIanforneglIgence
thatwasreckless,wanton,fraudulent,orwIllful.PunItIvedamagesareexceedInglyrareIn
medIcalmalpractIcecases.|orelIkelyInthecaseofgrossneglIgenceIsalossofthe
lIcensetopractIceanesthesIa.nextremecases,crImInalchargesmaybebroughtagaInst
thephysIcIan,althoughthIsIsrare.0etermInatIonofthedollaramountIsusuallybasedon
someassessmentoftheplaIntIff'scondItIonversusthecondItIonheorshewouldhavebeen
InhadtherebeennoneglIgence.PlaIntIffs'attorneysgenerallychargeapercentageofthe
damagesandwIll,therefore,seektomaxImIzetheawardgIven.
Standard of Care
8ecausemedIcalmalpractIceusuallyInvolvesIssuesbeyondthecomprehensIonoflay
jurorsandjudges,thecourtestablIshesthestandardofcareInapartIcularcasebythe
testImonyofexpert witnesses.ThesewItnessesdIfferfromfactualwItnessesmaInlyInthat
theymaygIveopInIons.ThetrIalcourtjudgehassoledIscretIonIndetermInIngwhethera
wItnessmaybequalIfIedasanexpert.AlthoughanylIcensedphysIcIanmaybeanexpert,
InformatIonwIllbesoughtregardIngthewItness'seducatIonandtraInIng,thenatureand
scopeoftheperson'spractIce,membershIpsandaffIlIatIons,andpublIcatIons.Thepurpose
IngatherIngthIsInformatIonIsnotonlytoestablIshthequalIfIcatIonsofthewItnessto
provIdeexperttestImony,butalsotodetermInetheweIghttobegIventothattestImony
bythejury.nmanycasesthesuccessofalawsuItdependsprImarIlyonthestatureand
belIevabIlItyoftheexpertwItnesses.
Unfortunately,thereIsatendencyforexpertstolInksevereInjurywIthInapproprIatecare
(I.e.,abIasthatbadoutcomesmeanbadcare).ToInvestIgatetheInfluenceofthe
severItyoftheInjuryontheassessmentofstandardofcare,agroupof112practIcIng
anesthesIologIstsjudgedapproprIatenessofcareIn21casesInvolvIngadverseanesthetIc
outcomes.
40
TheorIgInaloutcomeIneachcasewaseIthertemporaryorpermanent.For
eachorIgInalcase,amatchIngalternatecasewascreatedthatwasIdentIcaltothe
orIgInalIneveryrespect,exceptthataplausIbleoutcomeoftheopposIteseverItywas
substItuted.FevIewersjudgedthestandardofcareIneachcase.KnowledgeoftheseverIty
ofInjuryproducedasIgnIfIcantInverseeffectonthejudgmentofapproprIatenessofcare
(FIg.41).
40
TheproportIonofratIngsforapproprIatecaredecreasedwhentheoutcome
waschangedfromtemporarytopermanent,andIncreasedwhentheoutcomewaschanged
frompermanenttotemporary.TheseresultssuggestthatoutcomebIasIntheassessment
ofstandardofcaremaycontrIbutetothefrequencyandsIzeofpayments.
Figure 4-1.EffectofoutcomeonphysIcIanjudgmentsofapproprIatenessofcare.
(AdaptedfromCaplanetal.EffectofoutcomeonphysIcIanjudgementsof
approprIatenessofcare.JA|A1991;265:19571960.)
P.90
ncertaIncIrcumstances,thestandardofcaremayalsobedetermInedfrompublIshed
socIetalguIdelInes,wrIttenpolIcIesofahospItalordepartment,ortextbooksand
monographs.SomemedIcalspecIaltysocIetIeshavecarefullyavoIdedapplyIngtheterm
standardstotheIrguIdelInesInthehopethatnobIndIngbehavIorormandatorypractIces
havebeencreated.TheessentIaldIfferencebetweenstandardsandguIdelInesIsthat
guIdelInesshouldbeadheredtoandstandardsmustbeadheredto.TheASApublIshes
standardsandguIdelInesforavarIetyofanesthesIarelatedactIvItIes.
Causes of Anesthesia-Related Lawsuits
FelatIvelyfewadverseoutcomesendupInamalpractIcesuIt.thasbeenestImatedthat
lessthan1of25patIentInjurIesresultInmalpractIcelItIgatIon.
41
TheASACommItteeon
ProfessIonalLIabIlItyhasconductedanatIonwIdeanalysIsofmalpractIceclaImsagaInst
anesthesIologIsts,excludIngdentaldamage,sInce1985(I.e.,theClosed Claims
Project).
42,4J
TheleadIngInjurIesInmalpractIceclaImsInthe1990sweredeath(24),
nervedamage(22),permanentbraIndamage(8),andaIrwayInjury(7;FIg.42).The
causesofdeathandpermanentbraIndamagewerepredomInantlyproblemsInaIrway
management(e.g.,InadequateventIlatIon,dIffIcultIntubatIon,prematureextubatIon)and
othercomplIcatIonssuchaspulmonaryembolIsm,InadequatefluIdtherapy,stroke,
hemorrhage,andmyocardIalInfarctIon.
44
Nervedamage,especIallytotheulnarnerve,
oftenoccursdespIteapparentlyadequateposItIonIng.
14,16
SpInalcordInjurywasthemost
commoncauseofnervedamageclaImsagaInstanesthesIologIstsInthe1990s.
14
ChronIc
paInmanagementIsanIncreasIngsourceofmalpractIceclaImsagaInstanesthesIologIsts.
45
TheanesthesIologIstIslIkelytobethetargetofalawsuItIfanuntowardoutcomeoccurs
becausethephysIcIanpatIentrelatIonshIpIsusuallytenuousatbest.ThepatIentrarely
choosestheanesthesIologIst,thepreoperatIvevIsItIsbrIef,andtheanesthesIologIstwho
seesthepatIentpreoperatIvelymaynotactuallyanesthetIzethepatIent.CommunIcatIon
betweenanesthesIologIstsandsurgeonsaboutcomplIcatIonsIsoftenlackIngandthe
tendencyIsforthesurgeontoblameanesthesIa.naddItIon,anesthesIologIstsareoften
suedalongwIththesurgeonInthecaseofanadverseoutcome.ThIsmayoccurevenIfthe
outcomewasInnowayrelatedtotheanesthetIccare.
Figure 4-2.|ostcommonInjurIesleadIngtoanesthesIamalpractIceclaIms.Dther
categoryIncludesJeachfornewbornInjury,pneumothorax,myocardIalInfarctIon,
stroke,burns,headache,andbackpaIn;and1.5forawareness/recall.0amageto
teethanddenturesexcluded.AmerIcanSocIetyofAnesthesIologIsts'ClosedClaIms
Project(N=7,J28).
What to Do When Sued
AlawsuItbegInswhenthepatIentplaIntIff'sattorneyfIlesacomplaintanddemandforjury
trIalwIththecourt.TheanesthesIologIstIsthenservedwIththecomplaIntandasummons
requIrIngananswertothecomplaInt.UntIlthIshappens,nolawsuIthasbeenfIled.
nsurancecarrIersmustbenotIfIedImmedIatelyafterthereceIptofthecomplaInt.The
anesthesIologIstwIllneedassIstanceInanswerIngthecomplaInt,andthereIsatImelImIt
placedontheresponse.
SpecIfIcactIonsatthIspoIntIncludethefollowIng:
1. 0onotdIscussthecasewIthanyone,IncludIngcolleagueswhomayhavebeenInvolved,
operatIngroompersonnel,orfrIends.
2. Neveralteranyrecords.
J. CathertogetherallpertInentrecords,IncludIngacopyoftheanesthetIcrecord,bIllIng
statements,andcorrespondenceconcernIngthecase.
4. |akenotesrecordIngalleventsrecalledaboutthecase.
5. CooperatefullywIththeattorneyprovIdedbytheInsurer.
ThefIrsttasktheanesthesIologIstmustperformwIthanattorneyIstoprepareananswer
tothecomplaInt.ThecomplaIntcontaInscertaInfactsandallegatIonswIthwhIchthe
defensemayeItheragreeordIsagree.0efenseattorneysrelyonthefrankandtotally
candIdobservatIonsofthephysIcIanInpreparIngananswertothecomplaInt.PhysIcIans
shouldbewIllIngtoeducatetheIrattorneysaboutthemedIcalfactsofthecase,although
mostmedIcalmalpractIceattorneyswIllbeknowledgeableandmedIcallysophIstIcated.
ThenextphaseofthemalpractIcesuItIscalleddiscovery.ThepurposeofdIscoveryIsthe
gatherIngoffactsandclarIfIcatIonofIssuesInadvanceofthetrIal.nalllIkelIhoodthe
anesthesIologIstwIllInItIallyreceIveawrIttenInterrogatory,whIchwIllrequestfactual
InformatIon.nconsultatIonwIththedefenseattorney,theInterrogatoryshouldbe
answeredInwrItIngbecausecarelesslyorInadvertentlymIsstatedfactscanbecome
troublesomelater.
0eposItIonsareasecondmechanIsmofdIscovery.ThedefendantanesthesIologIstwIllbe
deposedasafactwItness,anddeposItIonswIllbeobtaInedfromotheranesthesIologIsts
whowIllactasexpertwItnesses.AnatIonallyrecognIzedexpertIntheareaInquestIon,
recommendedbythedefendantbutwhoIsnotapersonalfrIend,andwhoagreeswIththe
defenseposItIon,maybeveryvaluable.
TheplaIntIff'sattorney,notthedefenseattorney,wIlldeposetheanesthesIologIst.0espIte
theapparentInformalItyofthedeposItIon,theanesthesIologIstmustbeconstantlyaware
thatwhatIssaIddurIngthedeposItIoncarrIesasmuchweIghtaswhatwouldbesaIdIn
court.tIsImportanttobefactuallypreparedforthedeposItIonbyrevIewofpersonal
notes,theanesthetIcrecord,andthemedIcalrecord.ThephysIcIanshoulddress
conservatIvelyandprofessIonallybecauseappearanceandImageareveryImportant.The
opposItIonIsassessIngthephysIcIantoseehowheorshewIllappeartoajury.Answeronly
thequestIonasked,anddonotvolunteerInformatIon.Felyonone'sattorneyforassIstance
whenpreparIngforadeposItIon.
TherewIllbedeposItIonsfromexpertwItnesses,bothfortheplaIntIffandforthedefense.
TheanesthesIologIstshouldworkwIthhIsorherattorneytosuggestquestIonsand
rebuttals.ThebettereducatedtheattorneyIsaboutthemedIcalfacts,thereasonsthe
anesthesIologIstdIdwhatwasdone,and
P.91
thealternatIveapproaches,thebetterabletheattorneywIllbetoconducttheseexpert
deposItIons.
fthereIssomemerItInthecasebutthedamagesaremInImal,orIfproofofInnocence
wIllbedIffIcult,therewIllprobablybeasettlementoffer.ThereIsahIghcostIncurredby
bothplaIntIffsanddefendantsInpursuIngamalpractIceclaImupthroughajurytrIal.
UnlessthereIsastrongprobabIlItyofalargedollaraward,reputableplaIntIffs'attorneys
arenotlIkelytopursuetheclaIm.Thus,evenIfphysIcIansbelIevethattheyaretotally
InnocentofanywrongdoIng,theyshouldnotbeoffendedorangeredaboutsettlIngofthe
case:thIsIssolelyamatterofmoney,notmedIcIne.
fasettlementIsnotreacheddurIngthedIscoveryphase,atrIalwIlloccur.Dnlyabout1In
20malpractIcecaseseverreachthepoIntofajurytrIal.DnlythosecasesInwhIchboth
sIdesthInktheycanwIn,andwhIcharelIkelytohavesIgnIfIcantfInancIalImpact,wIll
proceedtotrIal.
ThedIscussIonofdeposItIontestImonyalsoapplIestotestImonyIncourt,buttherearea
fewaddItIonalpoIntstoconsIderdurIngthetrIal.ThemembersofthejurywIllnotbeas
sophIstIcatedmedIcallyastheattorneyswhodeposedtheanesthesIologIstdurIng
dIscovery.However,donotunderestImatetheIntellIgenceofthejury.TalkIngdownto
themwIllcreateanunfavorableImpressIon.ftheanswertoaquestIonIsnotknown,
avoIdguessIng.fspecIfIcfactscannotberemembered,sayso.Nobodyexpectstotalrecall
ofeventsthatmayhaveoccurredyearsbefore.
ThedefendantphysIcIanshouldbepresentdurIngtheentIretrIal,evenwhennot
testIfyIng,andshoulddressprofessIonally.0Isplaysofanger,remorse,relIef,orhostIlIty
wIllhurtthephysIcIanIncourt.ThephysIcIanshouldbeabletogIvehIsorhertestImony
wIthoutusIngnotesordocuments.WhenItIsnecessarytorefertothemedIcalrecord,It
wIllbeadmIttedIntoevIdence.TheanesthesIologIst'sgoalIstoconvIncethejurythathe
orshebehavedInthIscaseasanyothercompetentandprudentanesthesIologIstwould
havebehaved.
tIsImportanttokeepInmIndthatproofInamalpractIcecasemeansonlymorelIkely
thannot.ThepatIentplaIntIffmustprovethefourelementsofneglIgence,notto
absolutecertaInty,butonlytoaprobabIlItygreaterthan50.DntheposItIvesIde,thIs
meansthatthedefendantanesthesIologIstmustonlyshowthathIsorheractIonswere,
morelIkelythannot,wIthInanacceptablestandardofcare.
Acknowledgments
TheauthorswIshtothankF.W.Cheney,|0,and0.A.Kroll,|0,whosematerIalfrom
prevIousedItIonsofthIschapterhasbeenretaInedInthecurrentedItIon.Theauthorsalso
thankCenePeterson,|0,Ph0forhIshelpfulsuggestIonsonthIsrevIsIon.
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Editors: Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.;
Stock, M. Christine
Title: Clinical Anesthesia, 6th Edition
CopyrIght2009LIppIncottWIllIamsEWIlkIns
TableofContentsSectIonScIentIfIcFoundatIonsofAnesthesIaChapter5|echanIsmsofAnesthesIaand
ConscIousness
Chapter5
Mechanisms of Anesthesia and Consciousness
Alex S. Evers
C. Michael Crowder
Key Points
1. The components of the anesthetic state include unconsciousness,
amnesia, analgesia, immobility, and attenuation of autonomic
responses to noxious stimulation.
2. Minimum alveolar concentration (MAC) remains the most robust
measurement and the standard for determining the potency of
volatile anesthetics.
3. Anesthetic actions on the spinal cord cannot produce either amnesia
or unconsciousness. However, several lines of evidence indicate that
the spinal cord is probably the site at which anesthetics act to inhibit
purposeful responses to noxious stimulation.
4. A developing body of evidence indicates that inhalational anesthetics
can depress the excitability of thalamic neurons, thus blocking
thalamocortical communication and potentially resulting in loss of
consciousness.
5. Whereas certain anesthetic effects may be attributable to specific
anatomic locations (e.g., purposeful response to noxious stimulation
maps to the spinal cord), existing evidence provides no basis for a
single anatomic site responsible for anesthesia.
6. While current data still support the prevailing view that neuronal
excitability is only slightly affected by general anesthetics, this small
effect may nevertheless contribute significantly to the clinical actions
of volatile anesthetics.
7. The synapse is generally thought to be the most likely relevant site
of anesthetic action. Existing evidence indicates that even at this one
site, anesthetics produce various effects, including presynaptic
inhibition of neurotransmitter release, inhibition of excitatory
neurotransmitter effect, and enhancement of inhibitory
neurotransmitter effect. Furthermore, the effects of anesthetics on
synaptic function differ among various anesthetic agents,
neurotransmitters, and neuronal preparations.
8. Existing evidence suggests that most voltage-dependent calcium
channels (VDCCs) are modestly sensitive or insensitive to
anesthetics. However, some sodium channels subtypes are inhibited
by volatile anesthetics and this effect may be responsible in part for a
reduction in neurotransmitter release at some synapses.
9. A large body of evidence shows that clinical concentrations of many
anesthetics potentiate GABA-activated currents in the central
nervous system. Other members of the ligand-activated ion channel
family, including glycine receptors, neuronal nicotinic receptors, and
5-HT
3
receptors, are also affected by clinical concentrations of
anesthetics and remain plausible anesthetic targets.
10. Activation of background K
+
channels in mammalian vertebrates
could be an important and general mechanism through which
inhalational and gaseous anesthetics regulate neuronal resting
membrane potential and thereby excitability.
11. Direct interactions of anesthetic molecules with proteins would not
only satisfy the Meyer-Overton rule, but would also provide the
simplest explanation for compounds that deviate from this rule.
12. Current evidence strongly indicates protein rather than lipid as the
molecular target for anesthetic action.
P.96
14. All anesthetic actions cannot be localized to a specific anatomic site in
the central nervous system; indeed, some evidence suggests that
different components of the anesthetic state may be mediated by
actions at disparate anatomic sites.
15. At a molecular level, volatile anesthetics show some selectivity, but
still affect the function of multiple ion channels and synaptic proteins.
The intravenous anesthetics, etomidate, propofol, and barbiturates,
are more specific with the GABA
A
receptor as their major target.
TheIntroductIonofgeneralanesthetIcsIntoclInIcalpractIceover150yearsagostandsas
oneofthesemInalInnovatIonsofmedIcIne.ThIssIngledIscoveryfacIlItatedthe
developmentofmodernsurgeryandspawnedthespecIaltyofanesthesIology.0espItethe
ImportanceofgeneralanesthetIcsanddespItemorethan100yearsofactIveresearch,the
molecularmechanIsmsresponsIbleforanesthetIcactIonremaInoneoftheunsolved
mysterIesofpharmacology.
WhyhavemechanIsmsofanesthesIabeensodIffIculttoelucIdate:AnesthetIcs,asaclass
ofdrugs,arechallengIngtostudyforthreemajorreasons:
1. AnesthesIa,bydefInItIon,IsachangeIntheresponsesofanintact animaltoexternal
stImulI.|akIngadefInItIvelInkbetweenanesthetIceffectsobservedInvItroandthe
anesthetIcstateobservedanddefInedin vivohasprovendIffIcult.
2. NostructureactIvItyrelatIonshIpsareapparentamonganesthetIcs;awIdevarIetyof
structurallyunrelatedcompounds,rangIngfromsteroIdstoelementalxenon,arecapable
ofproducIngclInIcalanesthesIa.ThIssuggeststhattherearemultIplemolecular
mechanIsmsthatcanproduceclInIcalanesthesIa.
J. AnesthetIcsworkatveryhIghconcentratIonsIncomparIsontodrugs,neurotransmItters,
andhormonesthatactatspecIfIcreceptors.ThIsImplIesthatIfanesthetIcsdoactby
bIndIngtospecIfIcreceptorsItes,theymustbIndwIthverylowaffInItyandprobablystay
boundtothereceptorforveryshortperIodsoftIme.LowaffInItybIndIngIsmuchmore
dIffIculttoobserveandcharacterIzethanhIghaffInItybIndIng.
0espItethesedIffIcultIes,molecularandgenetIctoolsarenowavaIlablethatshouldallow
formajorInsIghtsIntoanesthetIcmechanIsmsInthenextdecade.TheaImofthIschapter
IstoprovIdeaconceptualframeworkforthereadertocatalogcurrentknowledgeand
IntegratefuturedevelopmentsaboutmechanIsmsofanesthesIa.FIvespecIfIcquestIonswIll
beaddressedInthIschapter:
1. WhatIsanesthesIaandhowdowemeasureIt:
2. WhatIstheanatomIcsIteofanesthetIcactIonInthecentralnervoussystem:
J. WhatarethecellularneurophysIologIcmechanIsmsofanesthesIa(e.g.,effectson
synaptIcfunctIonvs.effectsonactIonpotentIalgeneratIon)andwhatanesthetIceffects
onIonchannelsandotherneuronalproteInsunderlIethesemechanIsms:
4. WhatarethemoleculartargetsofanesthetIcs:
5. HowarethemolecularandcellulareffectsofanesthetIcslInkedtothebehavIoraleffects
ofanesthetIcsobservedInvIvo:
What is Anesthesia?
CeneralanesthesIacanbroadlybedefInedasadrugInducedreversIbledepressIonofthe
centralnervoussystem(CNS)resultIngInthelossofresponsetoandperceptIonofall
externalstImulI.Unfortunately,suchabroaddefInItIonIsInadequatefortworeasons.
FIrst,thedefInItIonIsnotactuallybroadenough.AnesthesIaIsnotsImplyadeafferented
state;amnesIaandunconscIousnessareImportantaspectsoftheanesthetIcstate.Second,
thedefInItIonIstoobroad,asallgeneralanesthetIcsdonotproduceequaldepressIonofall
sensorymodalItIes.Forexample,barbIturatesareconsIderedtobeanesthetIcs,butthey
arenotpartIcularlyeffectIveanalgesIcs.TheseconflIctIngproblemswIthdefInItIoncanbe
bypassedbyamorepractIcaldescrIptIonoftheanesthetIcstateasacollectIonof
componentchangesInbehavIororperceptIon.ThecomponentsoftheanesthetIcstate
IncludeunconscIousness,amnesIa,analgesIa,ImmobIlIty,andattenuatIonofautonomIc
responsestonoxIousstImulatIon.
FegardlessofwhIchdefInItIonofanesthesIaIsused,essentIaltoanesthesIaarerapIdand
reversIbledrugInducedchangesInbehavIororperceptIon.Assuch,anesthesIacanonlybe
defInedandmeasuredIntheIntactorganIsm.ChangesInbehavIorsuchasunconscIousness
oramnesIacanbeIntuItIvelyunderstoodInhIgherorganIsmssuchasmammals,but
becomeIncreasInglydIffIculttodefIneasonedescendsthephylogenetIctree.Thus,whIle
anesthetIcshaveeffectsonorganIsmsrangIngfromwormstoman,ItIsdIffIculttomap
wIthcertaIntytheeffectsofanesthetIcsobservedInlowerorganIsmstoanyofour
behavIoraldefInItIonsofanesthesIa.ThIscontrIbutestothedIffIcultyofusIngsImple
organIsmsasmodelsInwhIchtostudythemolecularmechanIsmsofanesthesIa.SImIlarly,
anycellularormoleculareffectsofanesthetIcsobservedInhIgherorganIsmscanbe
extremelydIffIculttolInkwIththeconstellatIonofbehavIorsthatconstItutethe
anesthetIcstate.TheabsenceofasImpleandconcIsedefInItIonofanesthesIaIsclearly
oneofthestumblIngblockstoelucIdatIngthemechanIsmsofanesthesIaatamolecular
andcellularlevel.
AnaddItIonaldIffIcultyIndefInInganesthesIaIsthatourunderstandIngofthemechanIsms
ofconscIousnessIsratheramorphousatpresent.DnecannoteasIlydefIneanesthesIawhen
theneurobIologIcalphenomenaablatedbyanesthesIaarenotwellunderstood.
Nevertheless,recentadvancesInthestudyofsleepandattentIonhaveIdentIfIedwhat
mayformtheanatomIcandneurophysIologIcalbasIsforsleepandperhapsotherformsof
unconscIousness.
1
CentraltothemechanIsmofsleepIsasetofhypothalamIcnucleIthat
appeartoformanawake/sleepswItchmechanIsm(FIg.51).TheventrolateralpreoptIc
nucleus(7LPD)IntheanterIorhypothalamuspromotessleepwhIlethetuberomammIllary
nucleus(T|N)IntheposterIorhypothalamuspromoteswakefulness.mportantly,the7LPD
andtheT|NaremutuallyInhIbItory.Thus.forexample,IfbyInfluenceofother
modulatorysleeppromotIngnucleItheactIvItyofthe7LPDgaInsgroundrelatIvetothe
T|N,the7LPDwIllultImatelyshutdowntheoutputoftheT|NandsleepwIllbefavored.
DntheotherhanddurIngwakefulness,theT|NIsdomInantandsIlencesthe7LPD.
|odulatoryInfluencesontheT|Nand7LPDIncludeorexInergIcneuronsInthelateral
hypothalamus,thecIrcadIanclock,whIchIsdIrectlymodulatedbylIghtandcontaIned
wIthInthehypothalamIcsuprachIasmatIcnucleus,andmultIplebraInstemnucleI,In
partIcularthelocuscoeruleusanddorsalraphe.ThesebraInstemnucleIasawhole
promotearousalandareapartoftheretIcularactIvatIngformatIon.naddItIonto
synaptIcmodulators,adenosInehasbeenproposedasaneurohumoralfactorthatpromotes
sleepbydIsInhIbItIngthe7LPD.TheT|Nandthe7LPDarethoughttopromotetheawake
orsleepstatebyactIngonthalamIcandcortIcalcIrcuIts,eItherdIrectlyorthroughthe
retIcularactIvatIngformatIon.ThethalamusandcortexmaIntaInwakefulnessand
conscIousnessthroughcomplexInteractIonsthatmayInvolve
P.97
IntrInsIcoscIllatorsandwIdespreadsynaptIccommunIcatIon.AwarenessandconscIousness
IsthoughttoemergefromcommunIcatIonbetweentheprefrontalcortexandmultIple
cortIcalandsubcortIcalareasthathavedIstrIbutedrepresentatIonsofaperceptIon.AgaIn,
theprecIsemechanIsmsoftheemergentpropertIesofconscIousnessareunclear.As
dIscussedlater,somerecentevIdenceImplIcatescomponentsofthesleepswItchas
anatomIctargetsofcertaIngeneralanesthetIcs.
Figure 5-1.SImplIfIedsleep/wakecontrolcIrcuIt.Thewake/sleepswItchIscomposed
ofthemutuallyInhIbItoryventrolateralpreoptIcnucleus(7LPD)andthe
tuberomammIllarynucleus(T|N)hypothalamIcneurons.ThedIrectIonofthIsswItchIs
InfluencedbyhumoralfactorssuchasadenosIne,thecIrcadIanclock,other
hypothalamIcneuronsreleasIngorexIn(notshown),andbraInstemarousalnucleIsuch
asthedorsalraphe(0F)andthelocuscoeruleus(LC).8oththewake/sleepswItchand
thebraInstemarousalsystemactonhIgherordercIrcuItsInthethalamusandcerebral
cortex.CeneralanesthetIcsappeartoactonmultIplecomponentsofthesleep/wake
controlsystem.5HT,5hydroxytryptamIne/serotonIn;Cal,galanIn;NE,
norepInephrIne;HIs,hIstamIne;CA8A,amInobutyrIcacId.
How is Anesthesia Measured?
nordertostudythepharmacologyofanesthetIcactIon,quantItatIvemeasurementsof
anesthetIcpotencyareabsolutelyessentIal.TothIsend,Quashaandcolleagues
2
have
defInedtheconceptof|AC,ormInImumalveolarconcentratIon.|ACIsdefInedasthe
alveolarpartIalpressureofagasatwhIch50ofhumansdonotrespondtoasurgIcal
IncIsIon.nanImals,|ACIsdefInedasthealveolarpartIalpressureofagasatwhIch50of
anImalsdonotrespondtoanoxIousstImulus,suchastaIlclamp,
J
oratwhIchtheylose
theIrrIghtIngreflex.Theuseof|ACasameasureofanesthetIcpotencyhastwomajor
advantages.FIrst,ItIsanextremelyreproducIblemeasurementthatIsremarkably
constantoverawIderangeofspecIes.
2
Second,theuseofendtIdalgasconcentratIon
provIdesanIndexofthefreeconcentratIonofdrugrequIredtoproduceanesthesIasInce
theendtIdalgasconcentratIonIsInequIlIbrIumwIththefreeconcentratIonInplasma.
The|ACconcepthasseveralImportantlImItatIons,partIcularlywhentryIngtorelate|AC
valuestoanesthetIcpotencyobservedInvItro.FIrst,theendpoIntIna|ACdetermInatIon
Isquantal:asubjectIseItheranesthetIzedorunanesthetIzed;ItcannotbepartIally
anesthetIzed.Furthermore,|ACrepresentstheaverageresponseofawholepopulatIonof
subjectsratherthantheresponseofasInglesubject.Thequantalnatureofthe|AC
measurementmakesItverydIffIculttocompare|ACmeasurementstoconcentratIon
responsecurvesobtaInedInvItro,wherethegradedresponseofasInglepreparatIonIs
measuredasafunctIonofanesthetIcconcentratIon.ThesecondlImItatIonof|AC
measurementsIsthattheycanonlybedIrectlyapplIedtoanesthetIcgases.Parenteral
anesthetIcs(barbIturates,neurosteroIds,propofol)cannotbeassIgneda|ACvalue,makIng
ItdIffIculttocomparethepotencyofparenteralandvolatIleanesthetIcs.A|AC
equIvalentforparentalanesthetIcsIsthefreeconcentratIonofthedrugInplasmarequIred
topreventresponsetoanoxIousstImulusIn50ofsubjects;thIsvaluehasbeenestImated
forseveralparenteralanesthetIcs.
4
AthIrdlImItatIonof|ACIsthatItIshIghlydependent
ontheanesthetIcendpoIntusedtodefIneIt.Forexample,Iflossofresponsetoaverbal
commandIsusedasananesthetIcendpoInt,the|ACvaluesobtaIned(|AC
awake
)wIllbe
muchlowerthanclassIc|ACvaluesbasedonresponsetoanoxIousstImulus.ndeed,each
behavIoralcomponentoftheanesthetIcstatewIlllIkelyhaveadIfferent|ACvalue.
0espIteItslImItatIons,|ACremaInsthemostrobustmeasurementandthestandardfor
determInIngthepotencyofvolatIleanesthetIcs.
8ecauseofthelImItatIonsof|AC,monItorsthatmeasuresomecorrelateofanesthetIc
depthhavebeenIntroducedIntoclInIcalpractIce.
5
ThemostpopularofthesemonItors
convertsspontaneouselectroencephalogramwaveformsIntoasInglevaluethatcorrelates
wIthanesthetIcdepthforsomegeneralanesthetIcs.AnesthetIcdepthmonItorshavegreat
potentIal.TheymayreducetheIncIdenceofawarenessdurInganesthesIa,whIchIs
estImatedtobeapproxImately0.1to0.2.
6
Theymayalsoreducetheamountof
anesthetIcusedandmayhastenemergenceandrecoveryroomdIscharge.However,atthIs
tImewhetheranyoftheavaIlableanesthetIcdepthmonItorsIssuperIorto|AC,to
standardIzeddosIngofIntravenousanesthetIcs,ortoclInIcalIndIcatorsofanesthetIcdepth
IscontroversIalandIsstIllanactIveareaofInvestIgatIon.
Where in the Central Nervous System do Anesthetics Work?
nprIncIple,generalanesthesIacouldresultfromInterruptIonofnervoussystemactIvItyat
myrIadlevels.PlausIbletargetsIncludeperIpheralsensoryreceptors,spInalcord,
braInstem,andcerebralcortex.DfthesepotentIalsItes,onlyperIpheralsensoryreceptors
canbeelImInatedasanImportantsIteofanesthetIcactIon.AnImalstudIeshaveshown
thatfluorInatedvolatIleanesthetIcshavenoeffectoncutaneousmechanosensorsIncats
7
andcanevensensItIzenocIceptorsInmonkeys.
8
Furthermore,selectIveperfusIonstudIes
Indogshaveshownthat|ACforIsofluraneIsunaffectedbythepresenceorabsenceof
IsofluraneatthesIteofnoxIousstImulatIon,provIdedthattheCNSIsperfusedwIthblood
contaInIngIsoflurane.
9
Spinal Cord
Clearly,anesthetIcactIonsonthespInalcordcannotproduceeItheramnesIaor
unconscIousness.However,severallInesofevIdenceIndIcatethatthespInalcordIs
probablythesIteat
P.98
whIchanesthetIcsacttoInhIbItpurposefulresponsestonoxIousstImulatIon.ThIsIs,of
course,theendpoIntusedInmostmeasurementsofanesthetIcpotency.FampIland
colleagues
10,11
haveshownthat|ACvaluesforfluorInatedvolatIleanesthetIcsare
unaffectedIntheratbyeItherdecerebratIon
10
orcervIcalspInalcordtransectIon.
11
AntognInIandSchwartz
12
haveusedthestrategyofIsolatIngthecerebralcIrculatIonof
goatstoexplorethecontrIbutIonofbraInandspInalcordtothedetermInatIonof|AC.
TheyfoundthatwhenIsofluraneIsadmInIsteredonlytothebraIn,|ACIs2.9,whereas
whenItIsadmInIsteredtotheentIrebody,|ACIs1.2.SurprIsIngly,whenIsofluranewas
preferentIallyadmInIsteredtothebodyandnottothebraIn,Isoflurane|ACwasreduced
to0.8.
1J
TheactIonsofvolatIleanesthetIcsInthespInalcordaremedIated,atleastIn
part,bydIrecteffectsontheexcItabIlItyofspInalmotorneurons.ThIsconclusIonhasbeen
substantIatedbyexperImentsInrats,
14
goats,
15
andhumans
16
showIngthatvolatIle
anesthetIcsdepresstheamplItudeoftheFwaveInevokedpotentIalmeasurements(F
waveamplItudecorrelateswIthmotorneuronexcItabIlIty).TheseprovocatIveresults
suggestnotonlythatanesthetIcactIonatthespInalcordunderlIes|AC,butalsothat
anesthetIcactIononthebraInmayactuallysensItIzethecordtonoxIousstImulI.The
plausIbIlItyofthespInalcordasalocusforanesthetIcImmobIlIzatIonIsalsosupportedby
severalelectrophysIologIcalstudIesshowIngInhIbItIonofexcItatorysynaptIctransmIssIon
InthespInalcord.
17,18,19,20
Brainstem, Hypothalamic, and Thalamic Arousal Systems
TheretIcularactIvatIngsystem,adIffusecollectIonofbraInstemneuronsInvolvedIn
arousalbehavIor,haslongbeenspeculatedtobeasIteofgeneralanesthetIcactIonon
conscIousness.EvIdencetosupportthIsnotIoncamefromearlywholeanImalexperIments
showIngthatelectrIcalstImulatIonoftheretIcularactIvatIngsystemcouldInducearousal
behavIorInanesthetIzedanImals.
21
AroleforthebraInstemInanesthetIcactIonIsalso
supportedbystudIesexamInIngsomatosensoryevokedpotentIals.Cenerally,thesestudIes
showthatanesthetIcsproduceIncreasedlatencyanddecreasedamplItudeofcortIcal
potentIals,IndIcatIngthatanesthetIcsInhIbItInformatIontransferthroughthebraInstem.
22
ncontrast,studIesusIngbraInstemaudItoryevokedpotentIalshaveshownvarIableeffects
rangIngfromdepressIontoenhancementofInformatIontransferthroughtheretIcular
formatIon.
2J,24,25
WhIlethereIsevIdencethattheretIcularformatIonofthebraInstemIsa
locusforanesthetIceffects,ItcannotbetheonlyanatomIcsIteofanesthetIcactIonfor
tworeasons.FIrst,asdIscussed,thebraInstemIsnotevenrequIredforanesthetIcsto
InhIbItresponsIvenesstonoxIousstImulI.Second,theretIcularformatIoncanbelargely
ablatedwIthoutelImInatIngawareness.
26
WIthIntheretIcularformatIonIsasetofpontInenoradrenergIcneuronscalledthelocus
coeruleus.ThelocuscoeruleuswIdelyInnervatestargetsInthecortex,thalamus,and
hypothalamusIncludIngthesleeppromotIng7LPD.AsdIscussedprevIously,themutually
InhIbItory7LPDandT|Nmayformasleep/awakeswItchcIrcuIt.ThIsswItchwasdIrectly
ImplIcatedInanesthetIcactIonbyasetofelegantexperImentsfromNelsonetal.
27
They
showedthattheapplIcatIonofaCA8AergIcantagonIstdIrectlyontotheT|NdImInIshed
theeffIcacyoftheanesthetIcspropofolandpentobarbItal.ndeed,dIscreteapplIcatIonof
theCA8AergIcantagonIstgabazIneontotheT|NmarkedlyreducedtheduratIonof
sedatIonproducedbysystemIcallyadmInIsteredpropofolorpentobarbItal.ThIseffectIs
unlIkelytobeaconsequenceofanonspecIfIcIncreaseInarousalstatebecause
systemIcallyadmInIsteredgabazInedIdnotantagonIzethepotencyofketamInewhereasIt
dIdantagonIzepropofolandpentobarbItalInamannersImIlartoapplIcatIondIrectlyonto
theT|N.ThIsresultstronglyImplIcatesthe7LPD/T|NsleepswItchasasIteforthe
sedatIveactIonofCA8AergIcanesthetIcslIkepropofolandbarbIturates.However,general
anesthesIaIsclearlynotequIvalenttosleep.8ydefInItIon,onecannotbearousedfrom
generalanesthesIa.Thus,addItIonalneuroanatomIcallocIbesIdesthosemedIatIngsleep
arelIkelytobetargeted.DneareaofthebraInthathasbeenpostulatedasapotentIalsIte
ofanesthetIcactIonIsthethalamus.ThethalamusIsImportantInrelayIngsensory
modalItIesandmotorInformatIontothecortexvIathalamocortIcalpathways.A
developIngbodyofevIdenceIndIcatesthatInhalatIonalanesthetIcscandepressthe
excItabIlItyofthalamIcneurons,thusblockIngthalamocortIcalcommunIcatIonand
potentIallyresultIngInlossofconscIousness.
Cerebral Cortex
ThecerebralcortexIsthemajorsIteforIntegratIon,storage,andretrIevalofInformatIon.
Assuch,ItIsalIkelysIteatwhIchanesthetIcsmIghtInterferewIthcomplexfunctIonslIke
memoryandawareness.AnesthetIcsclearlyaltercortIcalelectrIcalactIvIty,asevIdenced
bythechangesInsurfaceelectroencephalogrampatternsrecordeddurInganesthesIa.
AnesthetIceffectsonpatternsofcortIcalelectrIcalactIvItyvarywIdelyamong
anesthetIcs,
28
provIdInganInItIalsuggestIonthatallanesthetIcsarenotlIkelytoact
throughIdentIcalmechanIsms.|oredetaIledInvItroelectrophysIologIcalstudIes
examInInganesthetIceffectsondIfferentcortIcalregIonssupportthenotIonthat
anesthetIcscandIfferentIallyalterneuronalfunctIonInvarIouscortIcalpreparatIons.For
example,volatIleanesthetIcshavebeenshowntoInhIbItexcItatorytransmIssIonatsome
synapsesIntheolfactorycortex
29
butnotatothers.
J0
SImIlarly,whereasvolatIle
anesthetIcsInhIbItexcItatorytransmIssIonInthedentategyrusofthehIppocampus,
J1
thesesamedrugscanactuallyenhanceexcItatorytransmIssIonatothersynapsesInthe
hIppocampus.
J2
AnesthetIcsalsoproduceavarIetyofeffectsonInhIbItorytransmIssIonIn
thecortex.AvarIetyofparenteralandInhalatIonanesthetIcshavebeenshowntoenhance
InhIbItorytransmIssIonInolfactorycortex
J0
andInthehIppocampus.
JJ
Conversely,volatIle
anesthetIcshavealsobeenreportedtodepressInhIbItorytransmIssIonInhIppocampus.
J4
Summary
AnesthetIcsproduceeffectsonavarIetyofanatomIcstructuresIntheCNS,IncludIngspInal
cord,braInstem,hypothalamus,andcerebralcortex.WhereascertaInanesthetIceffects
maybeattrIbutabletospecIfIcanatomIclocatIons(e.g.,purposefulresponsetonoxIous
stImulatIonmapstothespInalcord),exIstIngevIdenceprovIdesnobasIsforasIngle
anatomIcsIteresponsIbleforanesthesIa.ThIsdIffIcultyInIdentIfyIngasIteforanesthesIa
mIghtplausIblyresultfromthevarIouscomponentsoftheanesthetIcstatebeIngproduced
byanesthetIceffectsondIfferentregIonsoftheCNS.Nevertheless,despItethedIffIcultyIn
IdentIfyIngacommonanatomIcsIteforanesthesIa,InvestIgatorshavecontInuedtolook
forotherunIfyIngprIncIplesInanesthetIcactIon.SpecIfIcally,attentIonhasbeenfocused
onIdentIfyIngcommoncellularormolecularanesthetIctargetsthatmayhaveawIde
anatomIcdIstrIbutIon,explaInIngtheabIlItyofanesthetIctoaffectnervoussystem
functIonInananatomIcallydIffusemanner.
P.99
How do Anesthetics Interfere with the Electrophysiologic
Function of the Nervous System?
nthesImplesttermsanesthetIcsInhIbItorturnoffvItalCNSfunctIons.Theymustdo
thIsbyactIngatspecIfIcphysIologIcswItches.AgreatdealofInvestIgatIveefforthas
beendevotedtoIdentIfyIngtheseswItches.nprIncIple,theCNScouldbeswItchedoffby
severalmeans:
1. 8ydepressIngthoseneuronsorpatterngeneratorsthatsubserveapacemakerfunctIonIn
theCNS.
2. 8yreducIngoverallneuronalexcItabIlIty,eItherbychangIngrestIngmembranepotentIal
orbyInterferIngwIththeprocessesInvolvedIngeneratInganactIonpotentIal.
J. 8yreducIngcommunIcatIonbetweenneurons;specIfIcally,byeItherInhIbItIngexcItatory
synaptIctransmIssIonorenhancIngInhIbItorysynaptIctransmIssIon.
Pattern Generators
nformatIonconcernIngtheeffectsofanesthetIcsonpatterngeneratIngneuronalcIrcuIts
IntheCNSIslImIted,butclInIcalconcentratIonsofanesthetIcsarelIkelytohave
sIgnIfIcanteffectsonthesecIrcuIts.ThesImplestevIdenceforthIsIstheobservatIonthat
mostanesthetIcsexertprofoundeffectsonrespIratoryrateandrhythm,stronglysuggestIng
aneffectonrespIratorypatterngeneratorsInthebraInstem.nvertebratestudIessuggest
thatvolatIleanesthetIcscanselectIvelyInhIbItthespontaneous(pacemaker)fIrIngof
specIfIcneurons.AsshownInFIgure52,halothane(1|AC)completelyInhIbIts
spontaneousactIonpotentIalgeneratIonbyoneneuronIntherIghtparIetalganglIonofthe
greatpondsnaIlwhIleproducIngnoobservableeffectonthefIrIngfrequencyofadjacent
neurons.
J5
Neuronal Excitability
TheabIlItyofaneurontogenerateanactIonpotentIalIsdetermInedbythreeparameters:
restIngmembranepotentIal,thethresholdpotentIalforactIonpotentIalgeneratIon,and
thefunctIonofvoltagegatedsodIumchannels.AnesthetIcscanhyperpolarIze(createa
morenegatIverestIngmembranepotentIal)bothspInalmotorneuronsandcortIcal
neurons,
J6,J7
andthIsabIlItytohyperpolarIzeneuronscorrelateswIthanesthetIcpotency.
ngeneral,theIncreaseInrestIngmembranepotentIalproducedbyanesthetIcsIssmallIn
magnItudeandIsunlIkelytohaveaneffectonaxonalpropagationofanactIonpotentIal.
SmallchangesInrestIngpotentIalmay,however,InhIbIttheinitiationofanactIon
potentIaleItheratapostsynaptIcsIteorInaspontaneouslyfIrIngneuron.ndeed,
hyperpolarIzatIonIsresponsIblefortheInhIbItIonofspontaneousactIonpotentIal
generatIonshownInFIgure52.FecentevIdencealsoIndIcatesthatIsoflurane
hyperpolarIzesthalamIcneurons,leadIngtoanInhIbItIonoftonIcfIrIngofactIon
potentIals.
J8
ThereIsnoevIdenceIndIcatIngthatanesthetIcsalterthethresholdpotentIal
ofaneuronforactIonpotentIalgeneratIon.However,thedataareconflIctIngonwhether
thesIzeoftheactIonpotentIal,onceInItIated,IsdImInIshedbygeneralanesthetIcs.A
classIcartIclebyLarabeeandPosternak
J9
demonstratedthatconcentratIonsofetherand
chloroformthatcompletelyblocksynaptIctransmIssIonInmammalIansympathetIcganglIa
havenoeffectonpresynaptIcactIonpotentIalamplItude.SImIlarresultshavebeen
obtaInedwIthfluorInatedvolatIleanesthetIcsInmammalIanbraInpreparatIons.
29,J1
ThIs
dogmathattheactIonpotentIalIsrelatIvelyresIstanttogeneralanesthetIcshasbeen
challengedbymorerecentreportsthatvolatIleanesthetIcsatclInIcalconcentratIons
produceasmallbutsIgnIfIcantreductIonInthesIzeoftheactIonpotentIalInmammalIan
neurons.
40,41
nonecase,thereductIonIntheactIonpotentIalwasshowntobeamplIfIed
atthepresynaptIctermInalresultIngInalargereductIonInneurotransmItterrelease.
41
Thus,whIlecurrentdatastIllsupporttheprevaIlIngvIewthatneuronalexcItabIlItyIsonly
slIghtlyaffectedbygeneralanesthetIcs,thIssmalleffectmayneverthelesscontrIbute
sIgnIfIcantlytotheclInIcalactIonsofvolatIleanesthetIcs.
Figure 5-2.SelectIvItyofvolatIleanesthetIcInhIbItIonofneuronalautomatIcIty.A:
Halothane(1|AC)reversIblyInhIbItsthespontaneousfIrIngactIvItyofaneuronfrom
theparIetalganglIonofLymnaea stagnalis).B:ThesameconcentratIonofhalothane
hasnoeffectonthefIrIngactIvItyofanadjacent,andapparentlyIdentIcal,neuron).
NotethatInA,halothanemarkedlyreducesrestIngmembranepotentIalInaddItIonto
InhIbItIngfIrIng.(FeprIntedwIthpermIssIonfromFranksNP,LIebWF:|echanIsmsof
generalanesthesIa.EnvIronHealthPerspect87:204,1990.)
Synaptic Function
SynaptIcfunctIonIswIdelyconsIderedtobethemostlIkelysubcellularsIteofgeneral
anesthetIcactIon.NeurotransmIssIonacrossbothexcItatoryandInhIbItorysynapsesIs
markedlyalteredbygeneralanesthetIcs.CeneralanesthetIcsInhIbItexcItatorysynaptIc
transmIssIonInavarIetyofpreparatIons,IncludIngsympathetIcganglIa,
J9
olfactory
cortex,
29
P.100
hIppocampus,
J1
andspInalcord.
19
However,notallexcItatorysynapsesappeartobe
equallysensItIvetoanesthetIcs;Indeed,transmIssIonacrosssomehIppocampalexcItatory
synapsesIsenhancedbyInhalatIonalanesthetIcs.
J2
nasImIlarfashIon,generalanesthetIcs
bothenhanceanddepressInhIbItorysynaptIctransmIssIonInvarIouspreparatIons.na
classIcartIcleIn1975,NIcolletal
42
showedthatbarbIturatesenhancedInhIbItorysynaptIc
transmIssIonbyprolongIngthedecayoftheCA8AergIcInhIbItorypostsynaptIccurrent.
EnhancementofInhIbItorytransmIssIonhasalsobeenobservedwIthmanyothergeneral
anesthetIcsIncludIngetomIdate,
4J
propofol,
44
InhalatIonalanesthetIcs,
J0
and
neurosteroIds.
45
AlthoughanesthetIcenhancementofInhIbItorycurrentshasreceIveda
greatdealofattentIonasapotentIalmechanIsmofanesthesIa,
4
ItIsImportanttonote
thatthereIsalsoalargebodyofexperImentatIonshowIngthatclInIcalconcentratIonsof
generalanesthetIcscandepressInhIbItorypostsynaptIcpotentIalsInhIppocampus
J4,46,47
andInspInalcord.
20
AnesthetIcsdoappeartohavepreferentIaleffectsonsynapses,but
thereIsagreatdealofheterogeneItyInthemannerInwhIchanesthetIcagentsaffect
dIfferentsynapses.ThIsIsnotsurprIsInggIventhelargevarIatIonInsynaptIcstructure,
functIon(I.e.,effIcacy),andchemIstry(neurotransmItters,modulators)extantInthe
nervoussystem.
Presynaptic Effects
CeneralanesthetIcsaffectsynaptIctransmIssIonbothpreandpostsynaptIcally.However,
themagnItudeandeventhetypeofeffectvaryaccordIngtothetypeofsynapseandthe
partIcularanesthetIc.PresynaptIcally,neurotransmItterreleasefromglutamatergIc
synapseshasconsIstentlybeenfoundtobeInhIbItedbyclInIcalconcentratIonsofvolatIle
anesthetIcs.Forexample,astudybyPerouanskyandcolleagues
48
conductedInmouse
hIppocampalslIcesshowedthathalothaneInhIbItedexcItatorypostsynaptIcpotentIals
elIcItedbypresynaptIcelectrIcalstImulatIon,butnotthoseelIcItedbydIrectapplIcatIon
ofglutamate.ThIsIndIcatesthathalothanemustbeactIngtopreventthereleaseof
glutamate,themajorexcItatoryneurotransmItterInthebraIn.|acverandcolleagues
extendedtheseobservatIonsbyfIndIngthattheInhIbItIonofglutamatereleasefrom
hIppocampalneuronsIsnotduetoeffectsatCA8AergIcsynapsesthatcouldIndIrectly
decreasetransmItterreleasefromglutamatergIcneurons.
J2
EffectsofIntravenous
anesthetIcsonglutamatereleasehavealsobeendemonstrated,buttheevIdenceIsmore
lImItedandtheeffectspotentIallyIndIrect.
49,50
ThedataforanesthetIceffectson
InhIbItoryneurotransmItterreleaseIsmIxed.nhIbItIon,
51
stImulatIon,
52,5J
andnoeffect
54
havebeenreportedforvolatIleanesthetIcandIntravenousanesthetIcactIononCA8A(
amInobutyrIcacId)release.nabraInsynaptosomalpreparatIonwhereeffectsonboth
CA8AandglutamatereleasecouldbestudIedsImultaneously,WestphalenandHemmIngs
55
foundthatglutamateand,toalesserdegree,CA8AreleasewereInhIbItedbyclInIcal
concentratIonsofIsoflurane.ThemechanIsmunderlyInganesthetIceffectsontransmItter
releasehasnotbeenestablIshed.TheeffectsofanesthetIcsonneurotransmItterreleasedo
notappeartobemedIatedbyreducedneurotransmIttersynthesIsorstorage,butratherby
adIrecteffectontheprocessofneurosecretIon.AvarIetyofevIdencearguesthatatsome
synapsesasubstantIalportIonoftheanesthetIceffectIsupstreamofthetransmItter
releasemachInery,perhapsonpresynaptIcsodIumchannelsorpotassIumleakchannels
(seelaterdIscussIon).However,genetIcdataInCaenorhabditis elegansshowsthatthe
transmItterreleasemachInerystronglyInfluencesvolatIleanesthetIcsensItIvIty
56
;at
present,ItIsunclearwhetherthesefIndIngsrepresentspecIesdIfferencesordIfferent
aspectsofthesamemechanIsm.
Postsynaptic Effects
AnesthetIcsalterthepostsynaptIcresponsetoreleasedneurotransmItter.Theeffectsof
generalanesthetIcsonexcItatoryneurotransmItterreceptorfunctIonvarydependIngon
neurotransmIttertype,anesthetIcagent,andpreparatIon.FIchardsandSmaje
57
examIned
theeffectsofseveralanesthetIcagentsontheresponseofolfactorycortIcalneuronsto
applIcatIonofglutamate,themajorexcItatoryneurotransmItterIntheCNS.Theyfound
thatwhIlepentobarbItal,dIethylether,methoxyflurane,andalphaxalonedepressedthe
electrIcalresponsetoglutamate,halothanewaswIthouteffect.ncontrast,when
acetylcholInewasapplIedtothesameolfactorycortIcalpreparatIon,halothaneand
methoxyfluranestImulatedtheelectrIcalresponsewhereaspentobarbItalhadnoeffect;
onlyalphaxalonedepressedtheelectrIcalresponsetoacetylcholIne.
58
Theeffectsof
anesthetIcsonneuronalresponsestoInhIbItoryneurotransmIttersaremoreconsIstent.A
wIdevarIetyofanesthetIcs,IncludIngbarbIturates,etomIdate,neurosteroIds,propofol,
andthefluorInatedvolatIleanesthetIcs,havebeenshowntoenhancetheelectrIcal
responsetoexogenouslyapplIedCA8A(forarevIew,seeref.59).Forexample,FIgure5J
IllustratestheabIlItyofenfluranetoIncreaseboththeamplItudeandtheduratIonofthe
currentelIcItedbyapplIcatIonofCA8AtohIppocampalneurons.
60
Summary
AttemptstoIdentIfyaphysIologIcswItchatwhIchanesthetIcsacthavesufferedfromtheIr
ownsuccess.AnesthetIcsproduceavarIetyofeffectsonmanyphysIologIcprocessesthat
mIghtlogIcallycontrIbutetotheanesthetIcstate,IncludIngneuronalautomatIcIty,
neuronalexcItabIlIty,andsynaptIcfunctIon.ThesynapseIsgenerallythoughttobethe
mostlIkelyrelevantsIteofanesthetIcactIon.ExIstIngevIdenceIndIcatesthatevenatthIs
onesIte,anesthetIcsproducevarIouseffects,IncludIngpresynaptIcInhIbItIonof
neurotransmItterrelease,InhIbItIonofexcItatoryneurotransmIttereffect,and
enhancementofInhIbItoryneurotransmIttereffect.Furthermore,theeffectsofanesthetIcs
onsynaptIcfunctIondIfferamongvarIousanesthetIcagents,neurotransmItters,and
neuronalpreparatIons.
Anesthetic Actions on Ion Channels
onchannelsareonelIkelytargetofanesthetIcactIon.Theadventofpatchclamp
technIquesIntheearly1980smadeItpossIbletodIrectlymeasurethecurrentsfromsIngle
IonchannelproteIns.twasattractIvetothInkthatanesthetIceffectsonasmallnumber
ofIonchannelsmIghthelptoexplaInthecomplexphysIologIceffectsofanesthetIcsthat
wehavealreadydescrIbed.AccordIngly,durIngthe1980sand1990samajoreffortwas
dIrectedatdescrIbIngtheeffectsofanesthetIcsonthevarIouskIndsofIonchannels.The
followIngsectIonsummarIzesanddIstIllsthIseffort.ForthepurposesofthIsdIscussIon,Ion
channelsarecatalogedaccordIngtothestImulItowhIchtheyrespondbyopenIngor
closIng(I.e.,theIrmechanIsmofgatIng).
Anesthetic Effects on Voltage-Dependent Ion Channels
AvarIetyofIonchannelscansenseachangeInmembranepotentIalandrespondbyeIther
openIngorclosIngtheIrpore.ThesechannelsIncludevoltagedependentsodIum,
potassIum,
P.101
andcalcIumchannels,allofwhIchsharesIgnIfIcantstructuralhomologIes.7oltage
dependentsodIumandpotassIumchannelsarelargelyInvolvedIngeneratIngandshapIng
actIonpotentIals.TheeffectsofanesthetIcsonthesechannelshavebeenextensIvely
studIedbyHaydonandUrban
61
InthesquIdgIantaxon.ThesestudIesshowthatthese
InvertebratesodIumchannelsandpotassIumchannelsareremarkablyInsensItIveto
volatIleanesthetIcs.Forexample,50InhIbItIonofthepeaksodIumchannelcurrent
requIredhalothaneconcentratIons8tImesthoserequIredtoproduce
P.102
anesthesIa.ThedelayedrectIfIerpotassIumchannelwasevenlesssensItIve,requIrIng
halothaneconcentratIonsmorethan20tImesthoserequIredtoproduceanesthesIa.SImIlar
resultshavebeenobtaInedInamammalIancelllIne(CH
J
pItuItarycells)whereboth
sodIumandpotassIumcurrentswereInhIbItedbyhalothaneonlyatconcentratIonsgreater
than5tImesthoserequIredtoproduceanesthesIa.
62
However,anumberofrecentstudIes
wIthvolatIleanesthetIcshavechallengedthenotIonthatvoltagedependentsodIum
channelsareInsensItIvetoanesthetIcs.Fehbergandcolleagues
6J
expressedratbraInA
sodIumchannelsInamammalIancelllIne,andshowedthatclInIcallyrelevant
concentratIonsofavarIetyofInhalatIonalanesthetIcssuppressedvoltageelIcItedsodIum
currents.FatnakumarIandHemmIngs
64
showedthatsodIumfluxmedIatedbyratbraIn
sodIumchannelswassIgnIfIcantlyInhIbItedbyclInIcalconcentratIonsofhalothane.
ShIraIshIandHarrIs
65
documentedtheeffectsofIsofluraneonavarIetyofsodIumchannel
subtypesandfoundthatseveralbutnotallsubtypesaresensItIvetoclInIcal
concentratIons.FInally,asprevIouslydescrIbed,InaratbraInstemneuron,Wuand
colleagues
41
foundthatasmallInhIbItIonofsodIumcurrentsbyIsofluraneresultedIna
largeInhIbItIonofsynaptIcactIvIty.Thus,sodIumchannelactIvItynotonlyappearstobe
InhIbItedbyvolatIleanesthetIcs,butthIsInhIbItIonresultsInasIgnIfIcantreductIonIn
synaptIcfunctIon,atleastatsomemammalIansynapses.ntravenousanesthetIcshavealso
beenshowntoInhIbItsodIumchannels,buttheconcentratIonsforthIseffectaresupra
clInIcal.
66,67
Figure 5-3.EnfluranepotentIatestheabIlItyofCA8A(amInobutyrIcacId)toactIvate
achlorIdecurrentInculturedrathIppocampalcells.ThIspotentIatIonIsrapIdly
reversedbyremovalofenflurane(wash;A).EnfluraneIncreasesboththeamplItudeof
thecurrent(B)andthetIme(
1/2
)Ittakesforthecurrenttodecay(C).(Feproduced
wIthpermIssIonfromJones|7,8rooksPA,HarrIsonL:EnhancementofamInobutyrIc
acIdactIvatedCl

currentsInculturedrathIppocampalneuronesbythreevolatIle
anaesthetIcs.JPhysIol449:289,1992.)
Voltage-dependent calcium channels(70CCs)servetocoupleelectrIcalactIvItytospecIfIc
cellularfunctIons.nthenervoussystem,70CCslocatedatpresynaptIctermInalsrespond
toactIonpotentIalsbyopenIng.ThIsallowscalcIumtoenterthecell,actIvatIngcalcIum
dependentsecretIonofneurotransmItterIntothesynaptIccleft.AtleastsIxtypesof
calcIumchannels(desIgnatedL,N,P,Q,F,andT)havebeenIdentIfIedonthebasIsof
electrophysIologIcalpropertIesandalargernumberbasedonamInoacIdsequence
sImIlarItIes.N,P,Q,andFtypechannels,aswellassomeoftheuntItledchannels,are
preferentIallyexpressedInthenervoussystemandarethoughttoplayamajorroleIn
synaptIctransmIssIon.LtypecalcIumchannels,althoughexpressedInbraIn,havebeen
beststudIedIntheIrroleInexcItatIoncontractIoncouplIngIncardIac,skeletal,and
smoothmuscleandarethoughttobelessImportantInsynaptIctransmIssIon.Theeffects
ofanesthetIcsonLandTtypecurrentshavebeenwellcharacterIzed,
62,68,69
andthereare
somereportsconcernIngtheeffectsofanesthetIcsonNandPtypecurrents.
70,71,72
Asa
generalrule,thesestudIeshaveshownthatvolatIleanesthetIcsInhIbIt70CCs(50
reductIonIncurrent)atconcentratIons2to5tImesthoserequIredtoproduceanesthesIaIn
humans,wIthlessthana20InhIbItIonofcalcIumcurrentatclInIcalconcentratIonsof
anesthetIcs.However,somestudIeshavefound70CCsthatareextremelysensItIveto
anesthetIcs.TakenoshItaandSteInbach
7J
reportedaTtypecalcIumcurrentIndorsalroot
ganglIonneuronsthatwasInhIbItedbysubanesthetIcconcentratIonsofhalothane.
AddItIonally,ffrench|ullenandcolleagues
74
havereporteda70CCofunspecIfIedtypeIn
guIneapIghIppocampusthatIsInhIbItedbypentobarbItalatconcentratIonsIdentIcalto
thoserequIredtoproduceanesthesIa.Thus,70CCscouldwellmedIatesomeactIonsof
generalanesthetIcs,buttheIrgeneralInsensItIvItymakesthemunlIkelytobemajor
targets.
Potassium channelsarethemostdIverseoftheIonchannelstypesandIncludevoltage
gated,backgroundorleakchannelsthatopenoverawIderangeofvoltagesIncludIngat
therestIngmembranepotentIalofneurons,secondmessengerandlIgandactIvated,and
socalledInwardrectIfyIngchannels;somechannelsfallIntomorethanonecategory.HIgh
concentratIonsofbothvolatIleanesthetIcsandIntravenousanesthetIcsarerequIredto
affectsIgnIfIcantlythefunctIonofvoltagegatedK
+
channels.
61,75,76
SImIlarly,classIc
InwardrectIfyIngK
+
channelsarerelatIvelyInsensItIvetosevofluraneand
barbIturates.
77,78,79
However,somebackgroundK
+
channelsarequItesensItIvetovolatIle
anesthetIcs.
Summary
ExIstIngevIdencesuggeststhatmost70CCsaremodestlysensItIveorInsensItIveto
anesthetIcs.However,somesodIumchannelssubtypesareInhIbItedbyvolatIleanesthetIcs
andthIseffectmayberesponsIbleInpartforareductIonInneurotransmItterreleaseat
somesynapses.AddItIonalexperImentaldatawIllberequIredtoestablIshwhether
anesthetIcsensItIve70CCsarelocalIzedtospecIfIcsynapsesatwhIchanesthetIcshave
beenshowntoInhIbItneurotransmItterrelease.
Anesthetic Effects on Ligand-Gated Ion Channels
FastexcItatoryandInhIbItoryneurotransmIssIonIsmedIatedbytheactIonsoflIgandgated
Ionchannels.SynaptIcallyreleasedglutamateorCA8AdIffuseacrossthesynaptIccleftand
bIndtochannelproteInsthatopenasaconsequenceofneurotransmItterrelease.The
channelproteInsthatbIndCA8A(CA8A
A
receptors)aremembersofasuperfamIlyof
structurallyrelatedlIgandgatedIonchannelproteInsthatIncludenIcotInIcacetylcholIne
receptors,glycInereceptors,and5HT
J
receptors.8asedonthestructureofthenIcotInIc
acetylcholInereceptor,eachlIgandgatedchannelIsthoughttobecomposedoffIve
nonIdentIcalsubunIts.TheglutamatereceptorsalsocomprIseafamIly,eachreceptor
thoughttobeatetramerIcproteIncomposedofstructurallyrelatedsubunIts.ThelIgand
gatedIonchannelsprovIdealogIcaltargetforanesthetIcactIonbecauseselectIveeffects
onthesechannelscouldInhIbItfastexcItatorysynaptIctransmIssIonand/orfacIlItatefast
InhIbItorysynaptIctransmIssIon.TheeffectsofanesthetIcagentsonlIgandgatedIon
channelsarethoroughlycatalogedInarevIewbyKrasowskIandHarrIson.
59
ThefollowIng
sectIonprovIdesabrIefsummaryofthIslargebodyofwork.
Glutamate-Activated Ion Channels
ClutamateactIvatedIonchannelshavebeenclassIfIed,basedonselectIveagonIsts,Into
threecategorIes:A|PAreceptors,kaInatereceptors,andN|0Areceptors.A|PAand
kaInatereceptorsarerelatIvelynonselectIvemonovalentcatIonchannelsInvolvedInfast
excItatorysynaptIctransmIssIon,whereasN|0AchannelsconductnotonlyNa
+
andK
+
but
alsoCa
++
andareInvolvedInlongtermmodulatIonofsynaptIcresponses(longterm
potentIatIon).StudIesfromtheearly1980sInmouseandratbraInpreparatIonsshowed
thatA|PAandkaInateactIvatedcurrentsareInsensItIvetoclInIcalconcentratIonsof
halothane,
80
enflurane,
81
andtheneurosteroIdallopregnanolone.
82
ncontrast,kaInate
andA|PAactIvatedcurrentswereshowntobesensItIvetobarbIturates;Inrat
hIppocampalneurons,50|pentobarbItal(pentobarbItalproducesanesthesIaat
approxImately50|)InhIbItedkaInateandA|PAresponsesby50.
82
|orerecentstudIes
usIngclonedandexpressedglutamatereceptorsubunItsshowthatsubmaxImalagonIst
responsesofCluFJ(A|PAtype)receptorsareInhIbItedbyfluorInatedvolatIleanesthetIcs
whereasagonIstresponsesofCluF6(kaInatetype)receptorsareenhanced.
8J
ncontrast
bothCluFJandCluF6receptorsareInhIbItedbypentobarbItal.ThedIrectIonallyopposIte
effectsofthevolatIleanesthetIcsondIfferentglutamatereceptorsubtypesmayexplaIn
theearlIerInconclusIveeffectsobservedIntIssue,wheremultIplesubunIttypesare
expressed.TheseopposIteeffectshavealsobeenusedasastrategytoIdentIfycrItIcalsItes
onthemoleculesInvolvedInanesthetIceffect.8yproducIngCluFJ/CluF6receptor
chImeras(receptorsmadeupofvarIouscombInatIonsofsectIonsoftheCluFJandCluF6
receptors)andscreenIngforvolatIleanesthetIceffect,specIfIcareasoftheproteIn
requIredforvolatIleanesthetIcpotentIatIonofCluF6havebeenIdentIfIed.Subsequent
sItedIrectedmutagenesIsstudIeshaveIdentIfIedaspecIfIcglycIneresIdue(Cly819)as
crItIcalforvolatIleanesthetIcactIononCluF6contaInIngreceptors.
84
N|0AactIvatedcurrentsalsoappeartobesensItIvetoasubsetofanesthetIcs.
ElectrophysIologIcalstudIesshowvIrtuallynoeffectsofclInIcalconcentratIonsofvolatIle
anesthetIcs,
80,81
neurosteroIds,orbarbIturates
82
onN|0AactIvatedcurrents.tshouldbe
notedthatthereIssomeevIdencefromfluxstudIesthatvolatIleanesthetIcsmayInhIbIt
N|0AactIvatedchannels.AstudyInratbraInmIcrovesIclesshowedthatanesthetIc
concentratIons(0.2to0.Jm|)ofhalothaneandenfluraneInhIbItedN|0AactIvated
calcIumfluxby50.
85
ncontrast,ketamIneIsapotentandselectIveInhIbItorofN|0A
actIvatedcurrents.KetamInestereoselectIvelyInhIbItsN|0AcurrentsbybIndIngtothe
phencyclIdInesIteontheN|0AreceptorproteIn.
86,87,88
TheanesthetIceffectsofketamIne
InIntactanImalsshowthesamestereoselectIvItyasthatobservedInvItro,
89
suggestIng
thattheN|0AreceptormaybetheprIncIpalmoleculartargetfortheanesthetIcactIonsof
ketamIne.TwootherrecentfIndIngssuggestthatN|0AreceptorsmaybeanImportant
targetfornItrousoxIdeandxenon.ThesestudIesshowthatN
2
D
90,91
andxenon
92
arepotent
andselectIveInhIbItorsofN|0AactIvatedcurrents.ThIsIsIllustratedInFIgure54,
showIngthatN
2
DInhIbItsN|0AelIcIted,butnotCA8AelIcIted,currentsInhIppocampal
neurons.
GABA-Activated Ion Channels
CA8AIsthemostImportantInhIbItoryneurotransmItterInthemammalIanCNS.CA8A
actIvatedIonchannels(CA8A
A
receptors)medIatethepostsynaptIcresponsetosynaptIcally
releasedCA8AbyselectIvelyallowIngchlorIdeIonstoenterandtherebyhyperpolarIzIng
neurons.CA8A
A
receptorsaremultIsubunItproteInsconsIstIngofvarIouscombInatIonsof
,,andsubunIts,andtherearemanysubtypesofeachofthesesubunIts.ThefunctIon
ofCA8A
A
receptorsIsmodulatedbyawIdevarIetyofpharmacologIcagentsIncludIng
convulsants,antIconvulsants,sedatIves,anxIolytIcs,andanesthetIcs.
9J
Theeffectsofthese
varIousdrugsonCA8A
A
receptorfunctIonvarIesacrossbraInregIonsandcelltypes.The
followIngsectIonbrIeflyrevIewstheeffectsofanesthetIcsonCA8A
A
receptorfunctIon.
8arbIturates,anesthetIcsteroIds,benzodIazepInes,propofol,etomIdate,andthevolatIle
anesthetIcsallmodulateCA8A
A
receptorfunctIon.
60,9J,94,95,96
Thesedrugsproducethree
kIndsofeffectsontheelectrophysIologIcalbehavIoroftheCA8A
A
receptorchannels:
potentIatIon,dIrectgatIng,andInhIbItIon.PotentiationreferstotheabIlItyofanesthetIcs
toIncreasemarkedlythecurrentelIcItedbylowconcentratIonsofCA8A,buttoproduce
P.10J
noIncreaseInthecurrentelIcItedbyamaxImallyeffectIveconcentratIonofCA8A.
PotentIatIonIsIllustratedInFIgure55,showIngtheeffectsofhalothaneoncurrents
elIcItedbyarangeofCA8AconcentratIonsIndIssocIatedcortIcalneurons.AnesthetIc
potentIatIonofCA8A
A
currentsgenerallyoccursatconcentratIonsofanesthetIcswIthInthe
clInIcalrange.Direct gatingreferstotheabIlItyofanesthetIcstoactIvateCA8A
A
channels
IntheabsenceofCA8A.Cenerally,dIrectgatIngofCA8A
A
currentsoccursatanesthetIc
concentratIonshIgherthanthoseusedclInIcally,buttheconcentratIonresponsecurvesfor
potentIatIonandfordIrectgatIngcanoverlap.tIsnotknownwhetherdIrectgatIngof
CA8A
A
channelsIseItherrequIredfororcontrIbutestotheeffectsofanesthetIcsonCA8A
medIatedInhIbItorysynaptIctransmIssIonInvIvo.nthecaseofanesthetIcsteroIds,strong
evIdenceIndIcatesthatpotentIatIon,ratherthandIrectgatIngofCA8A
A
currents,Is
requIredforproducInganesthesIa.
97
AnesthetIcscanalsoInhIbItCA8AactIvatedcurrents.
InhibitionreferstotheabIlItyofanesthetIcstopreventCA8AfromInItIatIngcurrentflow
throughCA8A
A
channels,andhasgenerallybeenobservedathIghconcentratIonsofboth
CA8AandanesthetIc.
98,99
nhIbItIonofCA8A
A
channelsmayhelptoexplaInwhyvolatIle
anesthetIcshave,Insomecases,beenobservedtoInhIbItratherthanfacIlItateInhIbItory
synaptIctransmIssIon.
J4
Figure 5-4.NItrousoxIdeInhIbItsN|0AelIcIted,butnotCA8AelIcIted,currentsInrat
hIppocampalneurons.A:EIghtypercentN
2
DhasnoeffectonholdIngcurrent(upper
trace),butInhIbItsthecurrentelIcItedbyN|0A.B:N
2
DcausesarIghtwardand
downwardshIftoftheN|0AconcentratIonresponsecurve,IndIcatIngamIxed
competItIve/noncompetItIveantagonIsm.C:EIghtypercentN
2
DhaslIttleeffecton
CA8AelIcItedcurrents.ncontrast,anequIpotentanesthetIcconcentratIonof
pentobarbItalmarkedlyenhancestheCA8AelIcItedcurrent.(FeproducedwIth
permIssIonfromJevtovIcTodorovIc7,TodorovIcS|,|ennerIckSet al:NItrousoxIde
(laughInggas)IsanN|0AantagonIst,neuroprotectant,andneurotoxIn.Nat|ed4:460,
1998.)
Figure 5-5.Theeffectsofhalothane(Hal),enflurane(Enf),andfluorothyl(HFE)on
CA8AactIvatedchlorIdecurrentsIndIssocIatedratCNSneurons.A:ClInIcal
concentratIonsofhalothaneandenfluranepotentIatetheabIlItyofCA8AtoelIcIta
chlorIdecurrent.TheconvulsantfluorothylantagonIzestheeffectsofCA8A(
amInobutyrIcacId.B:CA8AcausesaconcentratIondependentactIvatIonofachlorIde
current.HalothaneshIftstheCA8AconcentratIonresponsecurvetotheleft(Increases
theapparentaffInItyofthechannelforCA8A),whereasfluorothylshIftsthecurveto
therIght(decreasestheapparentaffInItyofthechannelforCA8A).(FeproducedwIth
permIssIonfromWakamorI|,kemotoY,AkaIkeN:EffectsoftwovolatIleanesthetIcs
andavolatIleconvulsantontheexcItatoryandInhIbItoryamInoacIdresponsesIn
dIssocIatedCNSneuronsoftherat.JNeurophysIol66:2014,1991.)
EffectsofanesthetIcshavealsobeenobservedonthefunctIonofsIngleCA8A
A
channels.
ThesestudIesshowthatbarbIturates,
94
propofol,
96
andvolatIleanesthetIcs
100
donotalter
theconductance(rateatwhIchIonstraversetheopenchannel)ofthechannel,butthat
theyIncreasethefrequencywIthwhIchthechannelopensand/ortheaveragelengthof
tImethatthechannelremaInsopen.CollectIvely,thewholecellandsInglechanneldata
aremostconsIstentwIththeIdeathatclInIcalconcentratIonsofanesthetIcsproducea
changeIntheconformatIonofCA8A
A
receptorsthatIncreasestheaffInItyofthereceptor
forCA8A.ThIsIsconsIstentwIththeabIlItyofanesthetIcstoIncreasetheduratIonof
InhIbItorypostsynaptIcpotentIals,sIncehIgheraffInItybIndIngofCA8Awouldslowthe
dIssocIatIonofCA8AfrompostsynaptIcCA8A
A
channels.twouldnotbeexpectedthat
anesthetIcswouldIncreasethepeakamplItudeofaCA8AergIcInhIbItorypostsynaptIc
potentIalsIncesynaptIcally
P.104
releasedCA8AprobablyreachesveryhIghconcentratIonsInthesynapse.HIgher
concentratIonsofanesthetIcscanproduceaddItIonaleffects,eItherdIrectlyactIvatIngor
InhIbItIngCA8A
A
channels.ConsIstentwIththeseIdeas,astudyby8anksandPearce
101
showedthatIsofluraneandenfluranesImultaneouslyIncreasedtheduratIonanddecreased
theamplItudeofCA8AergIcInhIbItorypostsynaptIccurrentsInhIppocampalslIces.
0espItethesImIlareffectsofmanyanesthetIcsonCA8A
A
receptorfunctIon,thereIs
sIgnIfIcantevIdencethatthevarIousanesthetIcsdonotactbybIndIngtoasInglecommon
bIndIngsIteonthechannelproteIn.FIrst,evenanesthetIcsthatdIrectlyactIvatethe
channelprobablydonotbIndtotheCA8AbIndIngsIte.ThIsIsmostclearlydemonstrated
bymolecularbIologIcstudIesInwhIchtheCA8AbIndIngsIteIselImInatedfromthechannel
proteInbutpentobarbItalcanstIllactIvatethechannel.
102
0IrectradIolIgandbIndIng
studIeshavedemonstratedthatbenzodIazepInesbIndtotheCA8A
A
receptoratnanomolar
concentratIonsandthatotheranesthetIcscanmodulatebIndIngbutdonotbInddIrectlyto
thebenzodIazepInesIte.
9J,10J
AserIesofmorecomplexstudIesexamInIngtheInteractIons
betweenbarbIturates,anesthetIcsteroIds,andbenzodIazepInesIndIcatesthatthesethree
classesofdrugscannotbeactIngatthesamesItes.
9J
TheactIonsofanesthetIcsonCA8A
A
receptorsarefurthercomplIcatedbytheobservatIonthatsteroIdanesthetIcscanproduce
dIfferenteffectsonCA8A
A
receptorsIndIfferentbraInregIons.
104
ThIssuggeststhe
possIbIlItythatthespecIfIcsubunItcomposItIonofaCA8A
A
receptormayencode
pharmacologIcselectIvIty.ThIsIswellIllustratedbybenzodIazepInesensItIvIty,whIch
requIresthepresenceofthe2subunItsubtype.
105
SImIlarly,sensItIvItytoetomIdatehas
beenshowntorequIrethepresenceofa2orJsubunIt.
106
|orerecently,Ithasbeen
shownthatthepresenceofaorsubunItInaCA8A
A
receptorconfersInsensItIvItytothe
potentIatIngeffectsofsomeanesthetIcs.
107,108
nterestIngly,CA8A
A
receptorscomposedoftypesubunIts(referredtoasGABA
C
receptors)havebeenshowntobeInhIbItedratherthanpotentIatedbyvolatIle
anesthetIcs.
109
ThIspropertyhasbeenexploIted,usIngmolecularbIologIctechnIques,by
constructIngchImerIcreceptorscomposedofpartofthereceptorcoupledtopartofan
,,orglycInereceptorsubunIt.8yscreenIngthesechImerasforanesthetIcsensItIvIty,
regIonsofthe,,andglycInesubunItsresponsIbleforanesthetIcsensItIvItyhavebeen
IdentIfIed.8asedontheresultsofthesechImerIcstudIes,sItedIrectedmutagenesIsstudIes
wereperformedtoIdentIfythespecIfIcamInoacIdsresponsIbleforconferrInganesthetIc
sensItIvIty.ThesestudIesrevealedtwocrItIcalamInoacIds,neartheextracellularregIons
oftransmembranedomaIns2andJ(T|2,T|J)oftheglycIneandCA8A
A
receptorsthatare
requIredforvolatIleanesthetIcpotentIatIonofagonIsteffect.
110
tIsnotyetclearIfthese
amInoacIdsrepresentavolatIleanesthetIcbIndIngsIte,orwhethertheyaresItescrItIcal
totransducInganesthetIcInducedconformatIonalchangesInthereceptormolecule.
nterestIngly,oneoftheamInoacIdsshowntobecrItIcaltovolatIleanesthetIceffect(T|J
sIte)hasalsobeenshowntoberequIred(Inthe
2
/
J
subunIt)forthepotentIatIngeffects
ofetomIdate.
111
ncontrast,theT|2andT|JsItesdonotappeartoberequIredforthe
actIonsofpropofol,barbIturates,orneurosteroIds.
112
nterestIngly,adIstInctamInoacIdIn
theT|JregIonofthe
1
subunItoftheCA8A
A
receptorhasbeenshowntoselectIvely
modulatetheabIlItyofpropofoltopotentIateCA8AagonIsteffects.
112
FecentevIdence
alsoIndIcatesthatneurosteroIdsactIonsonCA8A
A
receptorsoccurvIaInteractIonswIth
specIfIcsIteswIthInthetransmembranespannIngregIonsofthe
1
and
2
subunItsthatare
dIstInctfromthosewIthwhIchbenzodIazepInesandpentobarbItalact.
11J
CollectIvely,
thesemolecularbIologIcdataprovIdestrongevIdencethattherearemultIpleunIque
bIndIngsItesforanesthetIcsontheCA8A
A
receptorproteIn.
Other Ligand-Activated Ion Channels
DthermembersofthelIgandgatedreceptorsuperfamIlyIncludethenIcotInIcacetylcholIne
receptors(muscleandneuronaltypes),glycInereceptors,and5HT
J
receptors.Alarge
bodyofworkhasgoneIntoexamInIngtheeffectsofanesthetIcsonnIcotInIcacetylcholIne
receptors.ThemuscletypeofnIcotInIcreceptorhasbeenshowntobeInhIbItedby
anesthetIcconcentratIonsIntheclInIcalrange
114
andtobedesensItIzedbyhIgher
concentratIonsofanesthetIcs.
115
ThemusclenIcotInIcreceptorIsanInformatIvemodelto
studybecauseofItsabundanceandthewealthofknowledgeaboutItsstructure.tIs,
however,notexpressedIntheCNSandhencenotInvolvedInthemechanIsmofanesthesIa.
However,aneuronaltypeofnIcotInIcreceptor,whIchIswIdelyexpressedInthenervous
system,mIghtplausIblybeInvolvedInanesthetIcmechanIsms.DlderstudIeslookIngat
neuronalnIcotInIcreceptorsInmolluscanneurons
116
andInbovInechromaffIncells
117
IndIcatethatthesechannelsareInhIbItedbyclInIcalconcentratIonsofvolatIle
anesthetIcs.|orerecentstudIesusIngclonedandexpressedneuronalnIcotInIcreceptor
subunItshaveshownahIghdegreeofsubunItandanesthetIcselectIvIty.AcetylcholIne
elIcItedcurrentsareInhIbIted,InreceptorscomposedofvarIouscombInatIonsof
2
,
4
,
2
,
and
4
subunIts,bysubanestheticconcentratIonsofhalothane
118
orIsoflurane.
119
n
contrast,thesereceptorsarerelatIvelyInsensItIvetopropofol.|ostInterestIngly,
receptorscomposedof
7
subunItsarecompletelyInsensItIvetobothIsofluraneand
propofol.
119,120
SubsequentpharmacologIcexperImentsusIngselectIveInhIbItorsof
neuronalnIcotInIcreceptorsledtotheconclusIonthatthesereceptorsareunlIkelytohave
amajorroleInImmobIlIzatIonbyvolatIleanesthetIcs.
121,122
However,theymIghtplaya
roleIntheamnestIcorhypnotIceffectsofvolatIleanesthetIcs.
12J
ClycIneIsanImportantInhIbItoryneurotransmItter,partIcularlyInthespInalcordand
braInstem.TheglycInereceptorIsamemberofthelIgandactIvatedchannelsuperfamIly
that,lIketheCA8A
A
receptor,IsachlorIdeselectIveIonchannel.Alargenumberof
studIeshaveshownthatclInIcalconcentratIonsofvolatIleanesthetIcspotentIateglycIne
actIvatedcurrentsInIntactneurons
80
andInclonedglycInereceptorsexpressedIn
oocytes.
124,125
ThevolatIleanesthetIcsappeartoproducetheIrpotentIatIngeffectby
IncreasIngtheaffInItyofthereceptorforglycIne.
125
Propofol,
96
alphaxalone,and
pentobarbItalalsopotentIateglycIneactIvatedcurrents,whereasetomIdateandketamIne
donot.
124
PotentIatIonofglycInereceptorfunctIonmaycontrIbutetotheanesthetIc
actIonofvolatIleanesthetIcsandsomeparenteralanesthetIcs.The5HT
J
receptorsare
alsomembersofthegenetIcallyrelatedsuperfamIlyoflIgandgatedreceptorchannels.
ClInIcalconcentratIonsofvolatIleanesthetIcspotentIatecurrentsactIvatedby5
hydroxytryptamIneInIntactcells
126
andInclonedreceptorsexpressedInoocytes.
127
n
contrast,thIopentalInhIbIts5HT
J
receptorcurrents
126
andpropofolIswIthouteffecton
thesereceptorchannels.
127
The5HT
J
receptorsmayplaysomeroleIntheanesthetIcstate
producedbyvolatIleanesthetIcsandmayalsocontrIbutetosomeunpleasantanesthetIc
sIdeeffectssuchasnauseaandvomItIng.
Summary
SeverallIgandgatedIonchannelsaremodulatedbyclInIcalconcentratIonsofanesthetIcs.
KetamIne,N
2
D,andxenonInhIbItN|0Atypeglutamatereceptors,andthIseffectmayplay
amajorroleIntheIrmechanIsmofactIon.AlargebodyofevIdenceshowsthatclInIcal
concentratIonsofmanyanesthetIcspotentIateCA8AactIvatedcurrentsIntheCNS.ThIs
suggeststhatCA8A
A
receptorsareaprobablemoleculartargetofanesthetIcs.Dther
membersofthelIgandactIvatedIonchannelfamIly,IncludIngglycInereceptors,neuronal
nIcotInIcreceptors,
P.105
and5HT
J
receptors,arealsoaffectedbyclInIcalconcentratIonsofanesthetIcsandremaIn
plausIbleanesthetIctargets.
Anesthetic Effects on Background Potassium Ion Channels
CertaInpotassIumchannelscalledbackgroundorleak channelsareactIvatedbyboth
volatIleandgaseousanesthetIcs.
128
8ackgroundorleakchannelsaresonamedbecause
theytendtobeopenatallvoltagesIncludIngtherestIngmembranepotentIalofneurons,
producIngaleakcurrent.LeakcurrentscansIgnIfIcantlyregulatetheexcItabIlItyof
neuronsInwhIchtheyareexpressed.AnesthetIcactIvatIonofaleakchannelwasfIrst
observedInaganglIonofthepondsnaIl,Lymnea stagnalis.
129
ClInIcalconcentratIonsof
halothaneactIvatedthIschannelcalled
K(AN)
,resultIngInsIlencIngofthespontaneous
burstIngoftheseneurons(FIg.56A).AsImIlaranesthetIcactIvatedbackgroundpotassIum
channelwassubsequentlyfoundbyWInegarandYost
1J0
InthemarInemolluskAplysia.The
ImportanceofvolatIleanesthetIcactIvatIonoftheseInvertebratepotassIumchannelshas
nowbecomeapparentwIththedIscoveryofalargefamIlyofbackgroundpotassIum
channelsInmammals.ThesemammalIanpotassIumchannelshaveaunIquestructurewIth
twoporeformIngdomaInsIntandemplusfourtransmembranesegments(2P/4T|;FIg.5
6C).
1J1
Pateletal
1J2
havestudIedtheeffectsofvolatIleanesthetIcsonseveralmembersof
themammalIan2P/4T|famIly.TheyhaveshownthatTFEK1channelsareactIvatedby
clInIcalconcentratIonsofchloroform,dIethylether,halothane,andIsoflurane(FIg.568).
ncontrast,closelyrelatedTFAAKchannelsareInsensItIvetoallthevolatIleanesthetIcs,
andTASKchannelsareactIvatedbyhalothaneandIsoflurane,InhIbItedbydIethylether,
andunaffectedbychloroform.TheseauthorswentontoshowthattheCtermInalregIons
ofTASKandTFEK1contaInamInoacIdsessentIalforanesthetIcactIon.
1J2
|orerecently,
TFEK1butnotTASKwasfoundtobeactIvatedbyclInIcalconcentratIonsofthegaseous
anesthetIcs:xenon,nItrousoxIde,andcyclopropane.
1JJ
Thus,actIvatIonofbackgroundK
+
channelsInmammalIanvertebratescouldbeanImportantandgeneralmechanIsmthrough
whIchInhalatIonalandgaseousanesthetIcsregulateneuronalrestIngmembranepotentIal
andtherebyexcItabIlIty.ndeed,genetIcevIdencearguesforaroleofthesechannelsIn
producInganesthesIa(seelaterdIscussIon).
Figure 5-6.7olatIleanesthetIcsactIvatebackgroundK
+
channels.A:Halothane
reversIblyhyperpolarIzesapacemakerneuronfromLymnaea stagnalis(thepondsnaIl)
byactIvatIng
Kan
.B:Halothane(J00|)actIvateshumanrecombInantTFEK1
channelsexpressedInCDScells.ThefIgureshowscurrentvoltagerelatIonshIpswIth
reversalpotentIal(V
rev
)of88m7,IndIcatIveofaK
+
channel.C:PredIctedstructureof
atypIcalsubunItofthemammalIanbackgroundK
+
channels.Notethefour
transmembranespannIngsegments(Inblack)andthetwoporeformIngdomaIns(P1
andP2).Somebutnotallofthese2P/4T|K
+
channelsareactIvatedbyvolatIle
anesthetIcs.D:PhylogenetIctreeforthe2P/4T|famIly.(FeproducedwIthpermIssIon
fromFranksNP,LIebWF:8ackgroundK
+
channels:AnImportanttargetforanesthetIcs:
NatNeuroscI2:J95,1999.)
Summary
FecentevIdencesuggeststhatmembersofthe2P/4T|famIlyofbackgroundpotassIum
channelsmaybeImportantInproducIngsomecomponentsoftheanesthetIcstate.
What is the Chemical Nature of Anesthetic Target Sites?
The Meyer-Overton Rule
|orethan100yearsago,|eyer
1J4
andDverton
1J5
Independentlyobservedthatthepotency
ofgasesasanesthetIcswasstronglycorrelatedwIththeIrsolubIlItyInolIveoIl(FIg.57).
P.106
ThIsobservatIonhassIgnIfIcantlyInfluencedthInkIngaboutanesthetIcmechanIsmsIntwo
ways.FIrst,sInceawIdevarIetyofstructurallyunrelatedcompoundsobeythe|eyer
Dvertonrule,IthasbeenreasonedthatallanesthetIcsarelIkelytoactatthesame
molecularsIte.ThIsIdeaIsreferredtoastheUnitary Theory of Anesthesia.Second,Ithas
beenarguedthatsIncesolubIlItyInaspecIfIcsolventstronglycorrelateswIthanesthetIc
potency,thesolventshowIngthestrongestcorrelatIonbetweenanesthetIcsolubIlItyand
potencyIslIkelytomostcloselymImIcthechemIcalandphysIcalpropertIesofthe
anesthetIctargetsIteIntheCNS.8asedonthIsreasonIng,theanesthetIctargetsItewas
assumedtobehydrophobIcInnature.
Figure 5-7.The|eyerDvertonrule.ThereIsalInearrelatIonshIp(onaloglogscale)
betweentheoIl/gaspartItIoncoeffIcIentandtheanesthetIcpotency(mInImum
alveolarconcentratIon,|AC)ofanumberofgases.ThecorrelatIonbetweenlIpId
solubIlItyand|ACextendsovera70,000folddIfferenceInanesthetIcpotency.
(FeproducedwIthpermIssIonfromTanfIujIY,EgerE,TerrellFC:SomecharacterIstIcs
ofanexceptIonallypotentInhaledanesthetIc:thIomethoxyflurane.AnesthAnalg
56:J87,1977.)
The|eyerDvertoncorrelatIonsuffersfromtwolImItatIons:(1)ItonlyapplIestogasesand
volatIlelIquIdssInceolIveoIl/gaspartItIoncoeffIcIentscannotbedetermInedforlIquId
anesthetIcs,and(2)olIveoIlIsapoorlycharacterIzedmIxtureofoIls.TocIrcumventthese
lImItatIons,attemptshavebeenmadetocorrelateanesthetIcpotencywIthwater/solvent
partItIoncoeffIcIents.Todate,theoctanol/waterpartItIoncoeffIcIentbestcorrelateswIth
anesthetIcpotency.ThIscorrelatIonholdsforavarIetyofclassesofanesthetIcsandspans
a10,000foldrangeofanesthetIcpotencIes.
1J6
ThepropertIesofthesolventoctanol
suggestthattheanesthetIcsIteIslIkelytobeamphIpathIc,havIngbothpolarandnonpolar
characterIstIcs.
Exceptions to the Meyer-Overton Rule
HalogenatedcompoundsexIstthatarestructurallysImIlartotheInhaledanesthetIcsyet
areconvulsantsratherthananesthetIcs.
1J7
TherearealsoconvulsantbarbIturates
1J8
and
neurosteroIds.
1J9
Dneconvulsantcompound,fluorothyl(hexafluorodIethylether)hasbeen
showntocauseseIzuresIn50ofmIceat0.12vol,buttoproduceanesthesIaathIgher
concentratIons(EC
50
=1.22vol).
140
TheconcentratIonoffluorothylrequIredtoproduce
anesthesIaIsapproxImatelypredIctedbythe|eyerDvertonrule.ncontrast,several
polyhalogenatedalkaneshavebeenIdentIfIedthatareconvulsants,butthatdonot
produceanesthesIa.8asedontheolIveoIl/gaspartItIoncoeffIcIentsofthesecompounds,
anesthesIashouldhavebeenachIevedwIthIntherangeofconcentratIonsstudIed.
141
The
endpoIntusedtodetermInetheanesthetIceffectofthesecompoundswasmovementIn
responsetoanoxIousstImulus(|AC).nterestIngly,someofthesepolyhalogenated
compoundsdoproduceamnesIaInanImals.
142
Thesecompoundsarethusreferredtoas
nonimmobilizersratherthanasnonanesthetIcs.Severalpolyhalogenatedalkaneshavealso
beenIdentIfIedthatanesthetIzemIce,butonlyatconcentratIons10tImesthosepredIcted
bytheIroIl/gaspartItIoncoeffIcIents
141
;thesecompoundsarereferredtoastransitional
compounds.ThenonImmobIlIzersandtransItIonalcompoundshavebeenproposedasa
lItmustestfortherelevanceofanesthetIceffectsobservedInvItrotothoseobservedIn
thewholeanImal.
nseveralhomologousserIesofanesthetIcs,anesthetIcpotencyIncreaseswIthIncreasIng
chaInlengthuntIlacertaIncrItIcalchaInlengthIsreached.8eyondthIscrItIcalchaIn
length,compoundsareunabletoproduceanesthesIa,evenatthehIghestattaInable
concentratIons.ntheserIesofnalkanols,forexample,anesthetIcpotencyIncreasesfrom
methanolthroughdodecanol;alllongeralkanolsareunabletoproduceanesthesIa.
14J
ThIs
phenomenonIsreferredtoasthecutoff effect.CutoffeffectshavebeendescrIbedfor
severalhomologousserIesofanesthetIcsIncludIngnalkanes,nalkanols,
cycloalkanemethanols,
144
andperfluoroalkanes.
145
WhIletheanesthetIcpotencyIneachof
thesehomologousserIesofanesthetIcsshowsacutoff,acorrespondIngcutoffIn
octanol/wateroroIl/gaspartItIoncoeffIcIentshasnotbeendemonstrated.Therefore,
compoundsabovethecutoffrepresentadevIatIonfromthe|eyerDvertonrule.
AfInaldevIatIonfromthe|eyerDvertonruleIstheobservatIonthatenantIomersof
anesthetIcsdIfferIntheIrpotencyasanesthetIcs.EnantIomers(mIrrorImagecompounds)
areaclassofstereoIsomersthathaveIdentIcalphysIcalpropertIes,IncludIngIdentIcal
solubIlItyInsolventssuchasoctanolorolIveoIl.AnImalstudIeswIththeenantIomersof
barbIturateanesthetIcs,
146,147
ketamIne,
89
neurosteroIds,
97
etomIdate,
148
andIsoflurane
149
allshowenantIoselectIvedIfferencesInanesthetIcpotency.ThesedIfferencesInpotency
rangeInmagnItudefromamorethantenfolddIfferencebetweentheenantIomersof
etomIdateortheneurosteroIdstoa60dIfferencebetweentheenantIomersofIsoflurane.
tIsarguedthatamajordIfferenceInanesthetIcpotencybetweenapaIrofenantIomers
couldonlybeexplaInedbyaproteInbIndIngsIte(seeProteInTheorIesofAnesthesIa);
thIsappearstobethecaseforetomIdateandtheneurosteroIds.EnantIomerIcpaIrsof
anesthetIcshavealsobeenusedtostudyanesthetIcactIonsonIonchannels.tIsargued
thatIfananesthetIceffectonanIonchannelcontrIbutestotheanesthetIcstate,the
effectontheIonchannelshouldshowthesameenantIoselectIvItyasIsobservedInwhole
anImalanesthetIcpotency.EarlystudIesshowedthatthe(+)IsomerofIsofluraneIs1.5to2
tImesmorepotentthanthe()IsomerInelIcItIngananesthetIcactIvatedpotassIum
current,InpotentIatIngCA8A
A
currents,andInInhIbItIngthecurrentmedIatedbya
neuronalnIcotInIcacetylcholInereceptor.
99,116
ncontrast,thestereoIsomersofIsoflurane
areequIpotentIntheIreffectsonavoltageactIvatedpotassIumcurrentandIntheIr
effectsonlIpIdphasetransItIontemperature.
116
StudIeswIththeneurosteroIds
97
and
etomIdate
148
showthattheseanesthetIcsexertenantIoselectIveeffectsonCA8A
A
currents
thatparalleltheenantIoselectIveeffectsobservedforanesthetIcpotency.
P.107
TheexceptIonstothe|eyerDvertonruledonotobvIatetheImportanceoftherule.They
do,however,IndIcatethatthepropertIesofasolventsuchasoctanoldescrIbesome,but
notall,ofthepropertIesofananesthetIcbIndIngsIte.CompoundsthatdevIatefromthe
|eyerDvertonrulesuggestthatanesthetIctargetsIte(s)arealsodefInedbyother
propertIesIncludIngsIzeandshape.
ndefInIngthemoleculartarget(s)ofanesthetIcmoleculesonemustbeabletoaccount
bothforthe|eyerDvertonruleandforthewelldefInedexceptIonstothIsrule.thas
sometImesbeensuggestedthatacorrectmolecularmechanIsmofanesthesIashouldalso
beabletoaccountforpressurereversal.Pressure reversalIsaphenomenonwherebythe
concentratIonofagIvenanesthetIcneededtoproduceanesthesIaIsgreatlyIncreasedIf
theanesthetIcIsadmInIsteredtoananImalunderhyperbarIccondItIons.TheIdeathat
pressurereversalIsausefultoolforelucIdatIngmechanIsmsofanesthesIaIsbasedonthe
assumptIonthatpressurereversesthespecIfIcphysIcochemIcalactIonsoftheanesthetIc
thatareresponsIbleforproducInganesthesIa;thatIstosay,pressureandanesthetIcsact
onthesamemoleculartargets.However,recentevIdencesuggeststhatpressurereverses
anesthesIabyproducIngexcItatIonthatphysIologIcallycounteractsanesthetIcdepressIon,
ratherthanbyactIngasananesthetIcantagonIstattheanesthetIcsIteofactIon.
150
Therefore,InthefollowIngdIscussIonofmoleculartargetsofanesthesIa,pressurereversal
wIllnotbefurthermentIoned.
Lipid versus Protein Targets
AnesthetIcsmIghtInteractwIthseveralpossIblemoleculartargetstoproducetheIreffects
onthefunctionofIonchannelsandotherproteIns.AnesthetIcsmIghtdIssolveInthelipid
bIlayer,causIngphysIcochemIcalchangesInmembranestructurethataltertheabIlItyof
embeddedmembraneproteInstoundergoconformatIonalchangesImportantfortheIr
functIon.AlternatIvely,anesthetIcscouldbInddIrectlytoproteins(eItherIonchannel
proteInsormodulatoryproteIns),thuseIther(1)InterferIngwIthbIndIngofalIgand(e.g.,a
neurotransmItter,asubstrate,asecondmessengermolecule)or(2)alterIngtheabIlItyof
theproteIntoundergoconformatIonalchangesImportantforItsfunctIon.ThefollowIng
sectIonsummarIzestheargumentsforandagaInstlIpIdtheorIesandproteIntheorIesof
anesthesIa.
Lipid Theories of Anesthesia
TheelucIdatIonofthe|eyerDvertonrulesuggestedthatanesthetIcsInteractwItha
hydrophobIctarget.ToInvestIgatorsIntheearlypartofthe20thcentury,themostlogIcal
hydrophobIctargetwasalIpId.nItssImplestIncarnatIon,thelIpIdtheoryofanesthesIa
postulatesthatanesthetIcsdIssolveInthelIpIdbIlayersofbIologIcalmembranesand
produceanesthesIawhentheyreachacrItIcalconcentratIonInthemembrane.ConsIstent
wIththIshypothesIs,themembrane/gaspartItIoncoeffIcIentsofanesthetIcgasesInpure
lIpIdbIlayerscorrelatestronglywIthanesthetIcpotency.
151
Also,consIstentwIththelIpId
theorIes,varIousmembraneperturbatIonsareproducedbygeneralanesthetIcs;however,
themagnItudeofthesechangesproducedbyclInIcalconcentratIonsofanesthetIcsare
quItesmallandarethoughttobeveryunlIkelytodIsruptnervoussystemfunctIon.
152
WhIle
someofthemoresophIstIcatedlIpIdtheorIescanaccountforthecutoffeffectand
ImpotenceofnonImmobIlIzers,nolIpIdtheorycanplausIblyexplaInallanesthetIc
pharmacology.Thus,mostInvestIgatorsdonotconsIdermembranes/lIpIdsasthemost
lIkelytargetofgeneralanesthetIcs.
Protein Theories of Anesthesia
The|eyerDvertonrulecouldalsobeexplaInedbythedIrectInteractIonofanesthetIcs
wIthhydrophobIcsItesonproteIns.ThreetypesofhydrophobIcsItesonproteInsmIght
InteractwIthanesthetIcs:
1. HydrophobIcamInoacIdscomprIsethecoreofwatersolubleproteIns.AnesthetIcscould
bIndInhydrophobIcpocketsthatarefortuItouslypresentIntheproteIncore.
2. HydrophobIcamInoacIdsalsoformthelInIngofbIndIngsItesforhydrophobIclIgands.For
example,therearehydrophobIcpocketsInwhIchfattyacIdstIghtlybIndonproteInssuch
asalbumInandthelowmolecularweIghtfattyacIdbIndIngproteIns.AnesthetIcscould
competewIthendogenouslIgandsforbIndIngtosuchsItesoneItherwatersolubleor
membraneproteIns.
J. HydrophobIcamInoacIdsaremajorconstItuentsofthehelIces,whIchformthe
membranespannIngregIonsofmembraneproteIns;hydrophobIcamInoacIdsIdechaIns
formtheproteInsurfacethatfacesthemembranelIpId.AnesthetIcmoleculescould
InteractwIththehydrophobIcsurfaceofthesemembraneproteIns,dIsruptIngnormal
lIpIdproteInInteractIonsandpossIblydIrectlyaffectIngproteInconformatIon.ThIslast
possIbIlItywouldInvolvetheInteractIonofmanyanesthetIcmoleculeswItheach
membraneproteInmoleculeandwouldprobablybeanonselectIveInteractIonbetween
anesthetIcmoleculesandallmembraneproteIns.
0IrectInteractIonsofanesthetIcmoleculeswIthproteInswouldnotonlysatIsfythe|eyer
Dvertonrule,butwouldalsoprovIdethesImplestexplanatIonforcompoundsthatdevIate
fromthIsrule.AnyproteInbIndIngsIteIslIkelytobedefInedbypropertIessuchassIzeand
shapeInaddItIontoItssolventpropertIes.LImItatIonsInsIzeandshapecouldreducethe
bIndIngaffInItyofcompoundsbeyondthecutoff,thusexplaInIngtheIrlackofanesthetIc
effect.EnantIoselectIvItyIsalsomosteasIlyexplaInedbyadIrectbIndIngofanesthetIc
moleculestodefInedsItesonproteIns;aproteInbIndIngsIteofdefIneddImensIonscould
readIlydIstInguIshbetweenenantIomersonthebasIsoftheIrdIfferentshape.ProteIn
bIndIngsItesforanesthetIcscouldalsoexplaIntheconvulsanteffectsofsome
polyhalogenatedalkanes.0IfferentcompoundsbIndIng(InslIghtlydIfferentways)tothe
samebIndIngpocketcanproducedIfferenteffectsonproteInconformatIonandhenceon
proteInfunctIon.Forexample,therearethreekIndsofcompoundsthatcanbIndatthe
benzodIazepInebIndIngsIteontheCA8A
A
channel:agonists,whIchpotentIateCA8Aeffects
andproducesedatIonandanxIolysIs;inverse agonists,whIchpromotechannelclosureand
produceconvulsanteffects;andantagonists,whIchproducenoeffectontheIrownbutcan
competItIvelyblocktheeffectsofagonIstsandInverseagonIsts.8yanalogy,
polyhalogenatedalkanescouldbeInverseagonIsts,bIndIngatthesameproteInsItesat
whIchhalogenatedalkaneanesthetIcsareagonIsts.TheevIdencefordIrectInteractIons
betweenanesthetIcsandproteInsIsbrIeflyrevIewedInthefollowIngsectIon.
Evidence for Anesthetic Binding to Proteins
AbreakthroughInproteIntheorIesofanesthesIawasthedemonstratIonthatapurIfIed
watersolubleproteIn,fIreflylucIferase,couldbeInhIbItedbygeneralanesthetIcs.ThIs
provIdedtheImportantproofofprIncIplethatanesthetIcscouldbIndtoproteInsInthe
absenceofmembranes.NumerousstudIeshaveextensIvelycharacterIzedanesthetIc
InhIbItIonof
P.108
fIreflylucIferaseactIvItyandhaverevealedthefollowIng
15J,154
:
1. AnesthetIcsInhIbItfIreflylucIferaseactIvItyatconcentratIonsverysImIlartothose
requIredtoproduceclInIcalanesthesIa.
2. ThepotencyofanesthetIcsasInhIbItorsoffIreflylucIferaseactIvItycorrelatesstrongly
wIththeIrpotencyasanesthetIcs,InkeepIngwIththe|eyerDvertonrule.
J. HalothaneInhIbItIonoflucIferaseactIvItyIscompetItIvewIthrespecttothesubstrate0
lucIferIn.
4. nhIbItIonoffIreflylucIferaseactIvItyshowsacutoffInanesthetIcpotencyforbothn
alkanesandnalkanols.
8asedonthesestudIesItcanbeInferredthatawIdevarIetyofanesthetIcscanbIndInthe
lucIferInbIndIngpocketoffIreflylucIferase.ThefactthatanesthetIcInhIbItIonof
lucIferaseactIvItyIsconsIstentwIththe|eyerDvertonrule,occursatclInIcalanesthetIc
concentratIons,andexplaInsthecutoffeffectsuggeststhatthelucIferInbIndIngpocket
mayhavephysIcalandchemIcalcharacterIstIcssImIlartothoseofaputatIveanesthetIc
bIndIngsIteIntheCNS.
|oredIrectapproachestostudyanesthetIcbIndIngtoproteInshaveIncludedN|F
spectroscopyandphotoaffInItylabelIng.8asedonearlystudIesbyWIshnIaand
PInder,
155,156
ItwassuspectedthatanesthetIcscouldbIndtoseveralfattyacIdbIndIng
proteIns,IncludInglactoglobulInandbovIneserumalbumIn(8SA).
19
FN|FspectroscopIc
studIesconfIrmed
157
thIs,anddemonstratedthatIsofluranebIndstoapproxImatelythree
saturablebIndIngsIteson8SA.sofluranebIndIngIselImInatedbycoIncubatIonwItholeIc
acId,suggestIngthatIsofluranebIndstothefattyacIdbIndIngsItesonalbumIn.Dther
anesthetIcs,IncludInghalothane,methoxyflurane,sevoflurane,andoctanol,competewIth
IsofluraneforbIndIngto8SA.
158
ThestudIeswIth8SAprovIdedIrectevIdencethata
varIetyofanesthetIcscancompeteforbIndIngtothesamesIteonaproteIn.UsIngthIs8SA
model,ItwassubsequentlyshownthatanesthetIcbIndIngsItescouldbeIdentIfIedand
characterIzedusIngaphotoaffInItylabelIngtechnIque.TheanesthetIchalothanecontaIns
acarbonbromInebond.ThIsbondcanbebrokenbyultravIoletlIghtgeneratIngafree
radIcal.ThatfreeradIcalallowstheanesthetIctopermanently(covalently)labelthe
anesthetIcbIndIngsIte.EckenhoffandShuman
159
used
14
Clabeledhalothaneto
photoaffInItylabelanesthetIcbIndIngsIteson8SA,andobtaInedresultsvIrtuallyIdentIcal
tothoseobtaInedusIngN|Fspectroscopy.Eckenhoff
160
subsequentlyhasIdentIfIedthe
specIfIcamInoacIdsthatarephotoaffInItylabeledby[
14
C]halothane.N|Fand
photoaffInItylabelIngtechnIqueshavealsobeenapplIedtoseveralotherproteIns.For
example,saturablebIndIngofhalothanetothelucIferInbIndIngsIteonfIreflylucIferase
hasbeendIrectlyconfIrmedusIngN|FandphotoaffInItylabelIngtechnIques.
161
|ost
recently,HusaInandcolleagues
162
havedevelopedageneralanesthetIcthatIsananalogof
octanolandfunctIonsasaphotoaffInItylabel.ThIscompound,JdIazyrInyloctanol,bIndsto
specIfIcsItesonthenIcotInIcacetylcholInereceptor.
AlthoughN|FandphotoaffInItytechnIquescanprovIdeextensIveInformatIonabout
anesthetIcbIndIngsItesonproteIns,theycannotrevealthedetaIlsofthethree
dImensIonalstructureofthesesItes.XFaydIffractIoncrystallographycanprovIdethIskInd
ofthreedImensIonaldetaIlandhasbeenusedtostudyanesthetIcInteractIonswIthasmall
numberofproteIns.Todate,IthasbeendIffIculttocrystallIzemembraneproteIns;thus,
thesestudIeshavebeenlImItedtowatersolubleproteIns.FIreflylucIferasehasbeen
crystallIzedInthepresenceandabsenceoftheanesthetIcbromoform.XFaydIffractIon
studIesofthesecrystalsshowedthattheanesthetIcdoesbIndInthelucIferInbIndIng
pocket,ashadbeenInferredfromfunctIonalstudIes.nterestIngly,twomoleculesof
bromoformbIndInthelucIferInpocketonethatIslIkelytocompetedIrectlywIthlucIferIn
forbIndIngandonethatIsnot.
16J
ThebIndIngdatawIthfIreflylucIferaseIsofpartIcular
InterestbecauseItdemonstratesthatanesthetIcscanbIndtoendogenouslIgandbIndIng
sItesandthatthIsbIndIngstronglycorrelateswIthanesthetIcInhIbItIonofproteInfunctIon.
ThesamegrouphasalsocrystallIzedhumanserumalbumInInthepresenceofeIther
propofolorhalothane.ThexraycrystallographIcdatademonstratebIndIngofboth
anesthetIcstopreformedpocketsthathadbeenshownprevIouslytobIndfattyacIds.
164
CIventhatbothoftheseanesthetIcsbIndtoserumalbumInatclInIcalconcentratIons,
thesedatagIvethebestInsIghtyetIntothestructureofananesthetIcbIndIngpocket.
ArecentapproachtostudyanesthetIcInteractIonswIthproteInshasbeentoemploysIte
dIrectedmutagenesIsofcandIdateanesthetIctargets,coupledwIthmolecularmodelIngto
makepredIctIonsaboutthelocatIonandstructureofanesthetIcbIndIngsItes.Forexample,
WIckandcolleagues
165
haveusedthIsapproachtopredIctthelocatIonandstructureofthe
alcoholbIndIngsIteonCA8A
A
andglycInereceptors.SImIlarly,thelIkelyneurosteroId
bIndIngsItesforactIvatIonandpotentIatIonoftheCA8A
A
receptorwerefoundby
extensIvesItedIrectedmutagenesIsexperIments.
11J
Arelatedapproachhasbeento
developmodelproteInstodefInethestructuralrequIrementsforananesthetIcbIndIng
sIte.UsIngthIsapproach,Johanssonetal
166
haveshownthatafourhelIxbundlewItha
hydrophobIccorecanbIndvolatIleanesthetIcsatconcentratIons(K
0
)sImIlartothose
requIredtoproduceanesthesIa.
166
Summary
UnequIvocalevIdencefromstudIesusIngwatersolubleproteInsdemonstratesthat
anesthetIcscanbIndtohydrophobIcpocketsonproteIns.FunctIonalandbIndIngstudIes
wIthfIreflylucIferasedemonstratethatanesthetIcscanbIndtoaproteInsIteatclInIcally
relevantconcentratIonsInamannerthatcanaccountforthe|eyerDvertonruleand
devIatIonsfromIt.EvIdencethatdIrectanesthetIcproteInbIndIngInteractIonsmaybe
responsIbleforanesthetIceffectsonIonchannelsIntheCNSremaInsIndIrect;
stereoselectIvItycurrentlyoffersthestrongestIndIrectargument.
Dverall,currentevIdencestronglyIndIcatesproteInratherthanlIpIdasthemolecular
targetforanesthetIcactIon.WhIlethelongstandIngcontroversybetweenlIpIdandproteIn
theorIesofanesthesIamaybebehIndus,numerousunansweredquestIonsremaInaboutthe
detaIlsofanesthetIcproteInInteractIons,IncludIng:
1. WhatIsthestoIchIometryofanesthetIcbIndIngtoaproteIn(I.e.,0omanyanesthetIc
moleculesInteractwIthasIngleproteInmoleculeoronlyafew):
2. 0oanesthetIcscompetewIthendogenouslIgandsforbIndIngtohydrophobIcpocketson
proteIntargetsordotheybIndtofortuItouscavItIesIntheproteIn:
J. 0oallanesthetIcsbIndtothesamepocketonaproteInoraretheremultIple
hydrophobIcpocketsfordIfferentanesthetIcs:
4. HowmanyproteInshavehydrophobIcpocketsInwhIchanesthetIcscanbIndatclInIcally
usedconcentratIons:
How Are the Molecular Effects of Anesthetics Linked to
Anesthesia in the Intact Organism?
TheprevIoussectIonshavedescrIbedhowanesthetIcsaffectthefunctIonofanumberof
IonchannelsandsIgnalIngproteIns,probablyvIadIrectanesthetIcproteInInteractIons.t
Is
P.109
unclearwhIch,Ifany,oftheseeffectsofanesthetIcsonproteInfunctIonarenecessary
and/orsuffIcIenttoproduceanesthesIaInanIntactorganIsm.Anumberofapproaches
havebeenemployedtotrytolInkanesthetIceffectsobservedatamolecularlevelto
anesthesIaInIntactanImals.TheseapproachesandtheIrpItfallsarebrIeflyexploredInthe
followIngsectIon.
Pharmacologic Approaches
AnexperImentalparadIgmfrequentlyusedtostudyanesthetIcmechanIsmsIstoadmInIster
adrugthoughttoactspecIfIcallyataputatIveanesthetIctarget(e.g.,areceptoragonIst
orantagonIst,anIonchannelactIvatororantagonIst),thendetermInewhetherthedrug
haseItherIncreasedordecreasedtheanImal'ssensItIvItytoagIvenanesthetIc.The
underlyIngassumptIonIsthatIfachangeInanesthetIcsensItIvItyIsobserved,thenthe
anesthetIcIslIkelytoactvIaanactIononthespecIfIctargetoftheadmInIstereddrug.
ThIsIsalargelyflawedstrategythathasnonethelessproducedahugelIterature.Thedrugs
usedtomodulateanesthetIcsensItIvItyusuallyhavetheIrowndIrecteffectsonCNS
excItabIlItyandthusindirectlyaffectanesthetIcrequIrements.Forexample,whIle
2

adrenergIcagonIstsdecreasehalothane|AC,
167
theyareprofoundCNSdepressantsIntheIr
ownrIghtandproduceanesthesIabymechanIsmsdIstInctfromthoseusedbyvolatIle
anesthetIcs.Thus,the|ACsparIngeffectsof
2
agonIstsprovIdelIttleInsIghtIntohow
halothaneworks.AmoreusefulpharmacologIcstrategywouldbetoIdentIfydrugsthat
havenoeffectonCNSexcItabIlItybutpreventtheeffectsofgIvenanesthetIcs.Currently,
however,therearenosuchanesthetIcantagonIsts.0evelopmentofspecIfIcantagonIstsfor
anesthetIcagentswouldprovIdeamajortoolforlInkInganesthetIceffectsatthe
molecularleveltoanesthesIaIntheIntactorganIsm,andmIghtalsobeofsIgnIfIcant
clInIcalutIlIty.
AnalternatIvepharmacologIcapproachIstodeveloplItmustestsfortherelevanceof
anesthetIceffectsobservedInvItro.Dnesuchtesttakesadvantageofcompoundsthatare
nonanesthetIcdespItethepredIctIonsofthe|eyerDvertonrule.tIsarguedthatasIte
affectedbythesenonanesthetIccompoundsIsunlIkelytoberelevanttotheproductIonof
anesthesIa.
141
AsImIlarargumentusesstereoselectIvItyasthedIscrImInatorandargues
thatasItethatdoesnotshowthesamestereoselectIvItyasthatobservedforwholeanImal
anesthesIaIsunlIkelytoberelevanttotheproductIonofanesthesIa.
168
Althoughthese
testsmaybeuseful,theyareverydependentontheassumptIonthatanesthesIaIs
producedvIadrugactIonatasinglesIte.Forexample,anonanesthetIcmIghtdepressCNS
excItabIlItyvIaItsactIonsonanImportantanesthetIctargetsItewhIlesImultaneously
producIngcounterbalancIngexcItatoryeffectsatasecondsIte.nthIscasethelItmus
testwouldIncorrectlyelImInatetheanesthetIcsIteasIrrelevanttowholeanImal
anesthesIa.ThIsexampleIsquIteplausIblegIventheconvulsanteffectsofmanyofthe
nonanesthetIcpolyhalogenatedhydrocarbons.AnothersortoflItmustestIstoselectIvely
antagonIzetheputatIveanesthetIctargetsothatthIstargetIsnolongerfunctIonal.f
anesthetIceffectsaremedIatedthroughthIstarget,InactIvatIonofthetargetbythe
antagonIstshouldresultInanesthetIcresIstance.UsIngthIslogIc,themodest|ACsparIng
effectsofCA8A
A
andglycInereceptorantagonIstswereusedtoarguethatbothCA8A
A
and
glycInereceptorsmedIatesomebutnotalloftheImmobIlIzIngeffectsofvolatIle
anesthetIcsInrodents.
169,170
ThIssamegroupusedthelackofeffectofneuronalnIcotInIc
antagonIstsonIsoflurane|ACtoconcludethatthesereceptorshadnoroleInvolatIle
anesthetIcImmobIlIzatIon.
122
AswIthmanypharmacologIcresults,theIssuesofspecIfIcIty
andeffIcacyoftheantagonIstspreventtheseexperImentsfrombeIngdefInItIve.
Nevertheless,theseresultsareconsIstentwIththefIndIngsthatvolatIleanesthetIcsaffect
thefunctIonofalargenumberofImportantneuronalproteInsandnoonetargetIslIkelyto
medIatealloftheeffectsofthesedrugs.
Genetic Approaches
AnalternatIveapproachtostudytherelatIonshIpbetweenanesthetIceffectsobservedIn
vItroandwholeanImalanesthesIaIstoalterthestructureorabundanceofputatIve
anesthetIctargetsanddetermInehowthIsaffectswholeanImalanesthetIcsensItIvIty.
CenetIctechnIquesprovIdethemostrelIableandversatIlemethodsforchangIngthe
structureorabundanceofputatIveanesthetIctargets.ThefIrsttruegenetIcscreenfor
mutantswIthalteredgeneralanesthetIcsensItIvItywasperformedInthenematodeC.
elegansbyPhIl|organand|argaretSedensky.
171
TheyscreenedforalteredsensItIvItyto
supraclInIcalconcentratIonsofhalothane.HIghhalothaneconcentratIonswereused
becausetheyarerequIredtoImmobIlIzeC. elegans.ThefIrstmutantIsolatedhada
threefoldreductIonInItsEC
50
forhalothane.ThemutatIonwasgenetIcallymappedand
foundtobealossoffunctIonalleleoftheunc-79gene,whIchencodesalargeneuronal
proteInverysImIlarInsequencetoahumanproteIn.
172
ThecellularfunctIonofeItherthe
C. elegansorhumanproteInIsunknown.ntheabsenceofanesthetIcs,unc-79mutants
haveanInterestInglocomotIondefectcalledfainting.NormalC. eleganswormscrawl
almostcontInuouslywhereasunc-79mutantsappeartofaIntwheretheyspontaneouslystop
movIngforextendedperIodsoftIme.ntestIngothersuchmutants,Humphreyetal
172
and
|organandSedensky
17J
foundthat,Ingeneral,faInterswerehypersensItIveto
halothane.SubsequentextensIvegenetIcscreensandmappIngoffaIntIngmutantshaveled
toafocusonanovelpresumptIvecatIonchannel,NCA1/NCA2,thatcontrolshalothane
sensItIvItyInbothC. elegansandInthefruItflyDrosophila.
172
ThIsremarkable
conservatIonoftheanesthetIchypersensItIvItyphenotypeacrosssuchdIvergentspecIes
arguesforafundamentalroleofNCA1/NCA2IntheactIonofhalothane.
ClInIcalconcentratIonsofvolatIleanesthetIcsdonotImmobIlIzeC. elegans,buttheydo
producebehavIoraleffectsIncludInglossofcoordInatedmovement.
174
Crowderand
colleagues
174
havescreenedformutantsthatareresIstanttoanesthetIcInduced
uncoordInatIonandfoundthatmutatIonsInasetofgenesencodIngproteInsregulatIng
neurotransmItterreleasecontrolanesthetIcsensItIvIty.ThegenewIththelargesteffect
encodedsyntaxIn1A,aneuronalproteInhIghlyconservedfromC. eleganstohumansand
essentIalforfusIonofneurotransmIttervesIcleswIththepresynaptIcmembrane.
175
mportantly,somesyntaxInmutatIonsproducedhypersensItIvItytovolatIleanesthetIcs
whIleothersconferredresIstance.TheseallelIcdIfferencesInanesthetIcsensItIvItycould
notbeaccountedforbyeffectsontheprocessoftransmItterreleaseItself
56,175
;rather,
thegenetIcdataarguedthatsyntaxInInteractswIthaproteIncrItIcalforvolatIle
anesthetIcactIon,perhapsananesthetIctarget.Fecently,ahIghlyevolutIonarIly
conservedpresynaptIcproteIncalledUNC-13InC. eleganswasImplIcatedInthIs
presynaptIcvolatIleanesthetIcmechanIsm.
176
UNC1JIsrequIredfornormalIsoflurane
sensItIvIty,unc-13mutantsarefullyresIstanttotheeffectsofclInIcalconcentratIonof
Isoflurane,andIsofluranepreventsthenormalsynaptIclocalIzatIonofUNC1J.Whether
UNC1JIsadIrecttargetofvolatIleanesthetIcsIsunknown.ThIssamelaboratoryhasalso
shownbymutantanalysIsthatanN|0AglutamatereceptorsubunItIsessentIalfornItrous
oxIdesensItIvItyInC. elegans
177
andthatanotherglutamatereceptorsubunItIsrequIred
fortheeffectsofXenon.
178
nDrosophila,clInIcalconcentratIonsofvolatIleanesthetIcsdIsruptnegatIvegeotaxIs
behavIorandresponsetoanoxIouslIght
P.110
orheatstImulus.
179,180,181
UsIngoneormoreoftheseanesthetIcseffects,KrIshnanand
Nash
179
performedaforwardgenetIcscreenforhalothaneresIstance.TheresultsofthIs
screenhaveledtoafocusontheDrosophilahomologofnca-1/2.AsprevIouslydIscussed,
mutantsIntheDrosophilahomologofnca-1/2arehypersensItIvetohalothanelIketheC.
elegansmutants.
172
ThesynergyofbothDrosophilaandC. elegansgenetIcsshouldleadto
anunderstandIngofhowthIschannelcontrolsvolatIleanesthetIcsensItIvIty.
nmammals,themostpowerfulgenetIcmodelorganIsmIsmouse,wheretechnIqueshave
beendevelopedtoalterordeleteanygeneofInterest.TheCA8A
A
receptorhasbeen
extensIvelystudIedusIngmousegenetIctechnIques.
182,18J
ThegenesencodIngforvarIous
subunItsoftheCA8A
A
receptorhavebeenmutatedsothattheyareeIthernonfunctIonal
(geneknockouts)orsothattheyhavealteredamInoacIdsthatmIghtproducealtered
functIon(geneknockIns).KnockoutsofthreesubunItsoftheCA8A
A
receptorhavebeen
testedfortheIranesthetIcsensItIvIty.0eletIonofthe1subunItdoesnotaltersensItIvIty
ofmIcetothehypnotIceffectsofpentobarbItal.
184
SImIlarly,6subunItknockoutmIceare
normallysensItIvetohalothaneandenflurane.
185
However,5knockoutmIceareresIstant
tolearnIngImpaIrmentbyetomIdate.
186
KnockInmousestraInshavebeengeneratedfor
severalofthesubunIts,prImarIlyforexamInIngbenzodIazepIneactIon.Thelossof
varIousaspectsofbenzodIazepIneactIonInthesestraInsdemonstratedthatthe1subunIt
medIatesthesedatIveandamnestIcactIons,andIspartIallyrequIredforItsantIconvulsant
propertIes.SImIlarly,the2subunIthasbeenshowntobeessentIalforanxIolysIsby
dIazepam,andJand5knockInstraInsarepartIallyresIstanttoItsmyorelaxanteffects.
FInally,amouseexpressIngadoublemutated1subunIt,1(S270H,L277A),hasrecently
beentestedforItsanesthetIcsensItIvIty.
187,188
The1S270HmutatIonhasbeenshownto
blockCA8ApotentIatIonbyvolatIleanesthetIcs,butthemutatIonalsoIncreasesnatIve
sensItIvItytoCA8A,confoundIngInterpretatIonofthedata.|oreover,1S270HsIngle
mutantmIcearequIteabnormalbehavIorallyandarepronetoanesthetIcInducedseIzure
actIvIty.
189
Thus,asecondmutatIon,L277A,wasIntroducedIntothe1subunItthat
compensatedforthechangeInnatIvegatIngpropertIes.The1(S270H,L277A)mIceare
vIableandbehavIorallynormal.ThesemIcearemIldlyresIstanttotheataxIceffectsof
Isofluraneandenflurane;however,thepotencyofthedrugsIn|ACandfearcondItIonIng
assays(ameasureoflearnIng)arenotalteredbythedoublemutant1subunIt.
nvItroelectrophysIologIcalexperImentsshowthataspecIfIcJsubunItpoIntmutatIon,
J(N265|),blockstheactIonofetomIdateandpropofolontheCA8A
A
receptorwIthout
greatlyalterIngreceptorfunctIonIntheabsenceofdrug.
111,190
AJ(N265|)knockInstraIn
wasgeneratedandfoundtobeInsensItIvetotheImmobIlIzIngeffectsofetomIdate,
propofol,andpentobarbItal.
191,192
However,theJ(N265|)mIcearenotcompletely
resIstanttothelossofrIghtIngreflexbytheseanesthetIcs,IndIcatIngthatothertargets
medIatethIsbehavIoraleffect.nterestIngly,therespIratorydepressanteffectsof
etomIdateandpropofolarealsoblockedbytheJ(N265|)mutatIon,butthe
cardIovascularandhypothermIcactIonsofthedrugsarenot.
19J
TheJ(N265|)mIceshow
aslIghtlyreducedsensItIvItytotheImmobIlIzIngactIonsofvolatIleanesthetIcs,suggestIng
thattheJsubunItmayplayamInorroleInImmobIlIzatIon,butthemutanthasunaltered
sensItIvItytotheamnestIceffectsofIsoflurane.
194
AsImIlarapproachforthe2subunIt
hasshownthatItIscrItIcalforthesedatIngbutnotanesthetIcactIonofetomIdate.
195,196
FInally,straInscarryIngaknockoutmutatIonofthesubunItoftheCA8A
A
receptorhavea
shorterduratIonofneurosteroIdInducedlossofrIghtIngreflexwhereastheIrsensItIvItyto
otherIntravenousandvolatIleanesthetIcsIsunchanged.
197
Thus,thesubunItmayplaya
relatIvelyspecIfIcroleInneurosteroIdactIon.
TherolesInanesthetIcsensItIvItyoftwoofthebackgroundpotassIumchannelshavebeen
testedInlImItedmousegenetIcstudIes.ATFEK1knockoutmousewasfoundtobe
sIgnIfIcantlyresIstanttomultIplevolatIleanesthetIcsfor|ACandlossofrIghtIngreflex
endpoInts.
198
ThevolatIleanesthetIcresIstanceoftheTFEK1knockoutIssubstantIal,
partIcularlyforhalothanewhere|ACwasIncreasedby48.mportantly,theTFEK1
knockoutmIcehaveanormalsensItIvItytopentobarbItal,IndIcatIngspecIfIcItyforvolatIle
anesthetIcsconsIstentwIthprevIouselectrophysIologIcaldata.Fecently,Westphalenet
al
199
oftheHemmIngslaboratoryhasusedtheTFEK1knockoutstraIntotestthe
hypothesIsthatTFEK1medIatessomeofthepresynaptIcInhIbItoryeffectsofvolatIle
anesthetIcs.ndeed,glutamatereleasefromsynaptosomespreparedfromtheTFEK1
knockoutstraInIssIgnIfIcantlyresIstanttoInhIbItIonbyhalothanecomparedtorelease
fromwIldtypecontrolsynaptosomes.TheroleofTASK2,anothertwoporebackground
potassIumchannel,hasbeensImIlarlytestedbymeasurIngthe|ACofaTASK2knockout
mouse.However,unlIkeforTFEK1,theTASK2knockouthas|ACvaluessImIlartowIld
typecontrolsfordesflurane,halothane,andIsoflurane.
77
ThIsresultIssomewhatsurprIsIng
gIventhatTASK2IsstronglyactIvatedbyhalothaneandIsofluraneandmaybeexplaIned
byanoverallreducedexpressIonInthenervoussystemcomparedtoTFEK1.
128
Summary
FesultsfrombothInvertebrateandvertebrategenetIcsIndIcatethatmultIpleproteIns
controlvolatIleanesthetIcsensItIvIty.SomeofthesemaybeanesthetIctargetsandsome
not.CertaInCA8A
A
receptorsubunItsandtheTFEK1backgroundpotassIumchannelare
verylIkelytobetargetsrelevanttogeneralanesthesIa,butareprobablynottheonlyones.
ThemammalIanelectrophysIologIcaldataandthegenetIcevIdenceInC. elegansboth
ImplIcatetheN|0AglutamatereceptorastheprImarytargetofnItrousoxIde.SImIlarly,
elegantelectrophysIologIcalandgenetIcexperImentshaveshownthattheCA8A
A
receptor
IstheprImarymedIatorforImmobIlIzatIonbyetomIdate,propofol,andpentobarbItal.
Conclusions
nthIschapterevIdencehasbeenrevIewedconcernIngtheanatomIc,physIologIc,and
molecularlocIofanesthetIcactIon.tIsclearthatallanesthetIcactIonscannotbe
localIzedtoaspecIfIcanatomIcsIteIntheCNS;Indeed,someevIdencesuggeststhat
dIfferentcomponentsoftheanesthetIcstatemaybemedIatedbyactIonsatdIsparate
anatomIcsItes.TheactIonsofanesthetIcsalsocannotbelocalIzedtoaspecIfIcphysIologIc
process.WhIlethereIsconsensusthatanesthetIcsultImatelyaffectsynaptIcfunctIonas
opposedtoIntrInsIcneuronalexcItabIlIty,theeffectsofanesthetIcsdependontheagent
andsynapsestudIedandcanaffectpresynaptIcand/orpostsynaptIcfunctIon.Ata
molecularlevel,volatIleanesthetIcsshowsomeselectIvIty,butstIllaffectthefunctIonof
multIpleIonchannelsandsynaptIcproteIns.TheIntravenousanesthetIcs,etomIdate,
propofol,andbarbIturates,aremorespecIfIcwIththeCA8A
A
receptorastheIrmajor
target.AlthoughItIslIkelythattheseeffectsaremedIatedvIadIrectproteInanesthetIc
InteractIons,ItappearsthattherearenumerousproteInsthatcandIrectlyInteractwIth
anesthetIcs.CenetIcdataplaInlydemonstratethattheunItarytheoryofanesthesIaIsnot
correct.NosInglemechanIsmIsresponsIblefortheeffectsofallgeneralanesthetIcs,nor
doesasInglemechanIsmaccountforalloftheeffectsofasIngleanesthetIc,atleastwhere
IthasbeenexamIned.FIgure58provIdesasImplemodelofthemolecular
P.111
andcellulareffectsofgeneralanesthetIcs.ThIscartoonIsnotmeanttoIncludeall
potentIaltargetsofgeneralanesthetIcs.Father,onlythosemoleculeswIthstrongevIdence
forImportanceInanesthetIcactIonfrommultIpledIfferentapproachesareshown.
Figure 5-8.AmultIsItemodelforanesthesIa.AnesthetIcsaregroupedaccordIngto
sImIlarItyofmechanIsm.ArrowsIndIcateactIvatIonorpotentIatIonandT'sIndIcate
InhIbItIonorantagonIsm.TheneurophysIologIcaleffectsofgeneralanesthetIcsare
lumpedIntoneuronalexcItabIlIty(theprobabIlItyofaneuronfIrIngandpropagatIng
anaxonpotentIal)andexcItatoryneurotransmIssIon(synaptIcactIvItyatexcItatory
synapsessuchasglutamatergIc).NeuronalexcItabIlItyInthIscontextIsthesumof
bothIntrInsIcandextrInsIcfactors(e.g.,CA8AergIcInhIbItIon).
AlthoughtheprecIsemolecularInteractIonsresponsIbleforproducInganesthesIahavenot
beenfullyelucIdated,IthasbecomeclearthatanesthetIcsdoactvIaselectIveeffectson
specIfIcmoleculartargets.ThetechnologIcrevolutIonsInmolecularbIology,genetIcs,and
cellphysIologymakeItlIkelythatthenextdecadewIllprovIdesomeanswerstothe
centuryoldpharmacologIcpuzzleofthemolecularmechanIsmofanesthesIa.
Acknowledgment
TheauthorsacknowledgegenerousongoIngfundIngsupportfromNatIonalnstItuteof
Ceneral|edIcalScIences,8ethesda,|aryland,forASEP01C|047969andC|CF01
C|59781.
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Editors: Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.;
Stock, M. Christine
Title: Clinical Anesthesia, 6th Edition
CopyrIght2009LIppIncottWIllIamsEWIlkIns
TableofContentsSectIonScIentIfIcFoundatIonsofAnesthesIaChapter6CenomIc8asIsofPerIoperatIve
|edIcIne
Chapter6
Genomic Basis of Perioperative Medicine
Mihai V. Podgoreanu
Joseph P. Mathew
Key Points
1. Genetic variation can significantly modulate risk of adverse
perioperative events.
2. Several methodological approaches are used to study the genetic
architecture of perioperative outcomes.
3. Current perioperative risk profiling has limited ability to explain
individual variability in adverse outcomes.
4. Genetic variants in inflammatory and coagulation pathways are
associated with susceptibility to perioperative myocardial infarction.
5. Biomarkers associated with perioperative atrial fibrillation were
identified through genetic associatio