Elizabeth A. M. Frost

A History of Neuroanesthesia

Many countries practiced trephination from 10,000 BCE. Cocaine spat in the wound may have minimized pain in Peru. Alcohol, laudanum, henbane, opium or lettuces may have been used in other countries. The 1,700 BCE Edwin Smith Papyrus described the effects of central nervous system trauma.

Nitrous Oxide in Neuroanesthesia: Does It Have a Place?

You had rather hoped that you would be assigned to the aneurysm clipping this morning. After all, operative aneurysms are becoming increasingly rare now that the interventionalists are getting so good at coiling. However, the case has been given to one of the older members of the department, who has more experience with craniotomies. And here you are with the short eye cases. So between cases you decide to wander into the neuro room, just to see how things are going. To your horror you realize that your colleague has dialed in nitrous oxide 60 % with the isoflurane!

Surgery Before and After the Discovery of Anesthesia

Long before the advent of anesthesia, operations relied on a detailed knowledge of anatomy gained by dissection of the dead. Morton’s demonstration of ether anesthesia on 16 Oct 1846 made planned surgery possible, that is surgery in a silent motionless patient. Thus began the era of the great surgeons of Europe (Billroth, Kocher, Torek) and the US (Sims, Halsted, Cushing). Supporting discoveries added to the advances: Lister used antisepsis with carbolic acid spray (1867); Macewen intubated the trachea (1870s); Roentgen discovered X-rays (1895); Landsteiner identified blood groups (1900) and Domagk synthesized sulfonamides (1932).

Preoperative Evaluation of Patients Undergoing Non-cardiac Surgery

Traditionally, routine tests have been considered important elements of preanesthetic evaluation to determine fitness for surgery. Over the past three decades this practice has been scrutinized due to a low yield and high cost. In fact, routine tests such as complete blood count (CBC), chest X-ray, electrocardiogram (EKG), urinalysis, and electrolyte panel are of little value in detecting disease or changing management. Rather multiple investigations detect minor irrelevant abnormalities, increase patient risk, cause delay, and increases liability. Over the past three decades, many reviews and studies have confirmed these findings that routine testing does little or nothing to aid in effective preanesthetic assessment. Rather, postoperative complications were linked to higher ASA classification, longer duration of anesthesia, more complex surgery, and poor nutritional status.

The Tumor Is Inoperable: Tell the Patient or Punt to the Surgeon?

You were somewhat acquainted with the lady. After all you had met her several times at the nail salon. She was probably in her early 40s and she had children about the same age as yours. You talked about them. They were only a couple of grades apart in the same school. In fact, after you told her you were an anesthesiologist and sometimes your cases ran late, she offered to pick up your children and bring them to her house until you got home. So perhaps it was not surprising that she asked you about the indigestion she was getting, and the bloating feelings, and the vague pains. You suggested that she should try some antacids and some nonsteroidal anti-inflammatories. When that did not work, you gave her the name of a gastroenterologist friend of yours.

Do not Resuscitate: What Does that Mean Perioperatively?

You are running a little late this morning. That could be a problem as today’s surgeon is not known for his patience. Glancing at the schedule you see it is a “redo” heart. You meet your patient in the holding area and review his chart, and the preanesthetic assessment completed by a colleague a few days ago. He is a 69-year-old man who has undergone several stent placements over the past 5 years, an aortic valve replacement 3 years ago, and a coronary artery bypass 2 years ago. He still has severe angina and is very limited in his daily activities. He has several comorbidities including diabetes, retinopathy, and end-stage renal disease, requiring dialysis.

A History of Fluid Management

A history of fluid management is discussed focusing on the following key points. Bloodletting has been performed for more than 2000 years and is still used today, albeit for different reasons. While bloodletting was ordered by physicians, it was usually carried out by barber surgeons, thus dividing the two. Circulation of blood was not appreciated until William Harvey in the first century, and it was not immediately accepted as it was contrary to the teachings of Galen and others. The concept of the need for fluid replacement rather than bloodletting grew out of the worldwide cholera epidemic of the nineteenth century. Only over the past 60 years have fluids routinely been given intraoperatively.

Brain Injuries: Perianesthetic Management

Traumatic brain injury and its treatment or better still prevention has concerned man for centuries. While many of the pathways that result in neuronal damage are recognized, means to prevent or decrease impairment are less well understood. Many scores and more recently biomarkers have been used successfully to prognosticate survival. Early control of raised intracranial pressure is essential as is also normalization of systemic blood pressure and prevention of hypoxia and hypocarbia. Fluid resuscitation should be carefully balanced against output and sugar-containing solutions should be avoided.

Mentorship in Anesthesia

Selecting an appropriate mentor is essential to academic achievement and should be a core component of training in anesthesiology. Mentorship develops leaders as a talent pool as part of succession and diversity and enables a balance between professional and personal life. There are multiple benefits to both mentors and mentees. Such a program facilitates the growth of academic departments through research, career satisfaction and often faculty retention, recruitment, and educational success. However, careful planning is essential in determining which individuals are most suited for both mentoring and being mentored, the relevance to individual needs, and the best means to evaluate and reevaluate the program. Both barriers to a successful program and opportunities exist

Medicolegal Considerations in Urologic Anesthesia

Extreme position changes, electrolyte changes, presence of comorbidities such as obstructive sleep apnea, long and complex surgeries, bleeding risks, and an elderly population combine together to increase the risk of perioperative complications during urologic procedures. Not uncommonly these complications may be rightly or wrongly interpreted as malpractice, and the case becomes entrenched in the medicolegal system. Understanding this system and developing strategies to avoid poor or even catastrophic outcomes are essential to the entire urologic team.