Anesthesia

From Wikipedia, the free encyclopedia

Not to be confused with Paresthesia.
For other uses, see Anesthesia (disambiguation).
Anesthesia
Intervention

A 6 year old is prepared to go under anaesthesia

MeSH E03.155
MedlinePlus anesthesia
eMedicine 1271543

Anesthesia, or anaesthesia (from Greek ἀν-, an-, "without"; and αἴσθησις, aisthēsis,
"sensation"),[1] is a temporary state that causes unconsciousness, loss of memory, lack of pain
and relaxes muscles.

Anesthesia is a unique intervention, in that it does not offer any particular benefit, rather it allows
others to do things that might be beneficial. The best anesthetic, therefore is the one with the
lowest risk to the patient that still achieves the end points required to complete the procedure. A
general anesthetic will cause a person to sleep but the body can still mount a fight-or-flight
(stress) response to surgical stimulation leading to a harmful condition called shock. Muscles
will also contract under anesthetic making surgical procedures impossible. Since the needs of
anesthesia are multifaceted, so are the end points which are traditionally described as hypnosis
(medically meaning unconsciousness and amnesia), analgesia and muscle relaxation. To reach
multiple end points one or more drugs are commonly used (such as general anesthetics,
hypnotics, sedatives, paralytics, narcotics and analgesics) each of which serves a specific
purpose in creating a safe anesthetic.

The types of anesthesia are broadly classified into general anesthesia, sedation and regional
anesthesia. General anesthesia refers to the suppression of activity in the central nervous system,
resulting in unconsciousness and total lack of sensation. Sedation (or dissociative anesthesia)
uses agents that inhibit transmission of nerve impulses between higher and lower centers of the
brain inhibiting anxiety and the creation of long-term memories. Regional anesthesia renders a
larger area of the body insensate by blocking transmission of nerve impulses between a part of
the body and the spinal cord. It is divided into peripheral and central blockades. Peripheral
blockade inhibits sensory perception within a specific location on the body, such as when a tooth
is "numbed" or when a nerve block is given to stop sensation from an entire limb. Central
blockades place the local anesthetic around the spinal cord (such as with spinal and epidural
anesthesia) removing sensation to any area below the level of the block.

There are both major and minor risks of anesthesia. Examples of major risks include death, heart
attack and pulmonary embolism whereas minor risks can include postoperative nausea and
vomiting and readmission to hospital. The likelihood of a complication occurring is proportional
to the relative risk of a variety of factors related to the patient's health, the complexity of the
surgery being performed and the type of anesthetic. Of these factors, the person's health prior to
surgery (stratified by the ASA physical status classification system) has the greatest bearing on
the probability of a complication occurring. Patient's typically wake within minutes of an
anesthetic being terminated and regain their senses within hours. An exception being a condition
called long-term post-operative cognitive dysfunction. It is characterized by persistent confusion
lasting weeks or months and is more common in those undergoing cardiac surgery and in the
elderly.

The first public demonstration of general anesthesia was in 1842 by a Boston dentist named
William T.G. Morton at the Massachusetts General Hospital. Dr. Morton gave an ether
anesthetic for the removal of a neck tumor by surgeon John Collins Warren (the first editor of the
New England Journal of Medicine and dean of Harvard Medical School). About a decade later,
cocaine was introduced as the first viable local anesthetic. It wasn't until the the 1930's that Dr.
Harvey Cushing tied the stress response to higher mortality rates and began using local
anesthetic for hernia repairs in addition to general anesthesia.

Contents
 1 Medical uses
 2 Techniques
o 2.1 General anesthesia
 2.1.1 Equipment
 2.1.2 Monitoring
o 2.2 Sedation
o 2.3 Regional anesthesia
 2.3.1 Nerve blocks
 2.3.2 Spinal, epidural and caudal anesthesia
o 2.4 Acute pain management
 3 Risks and Complications
 4 Recovery
 5 History
 6 Society and culture
 7 Special populations
 8 References
  9 External links

Medical uses
The purpose of anesthesia can be distilled down to three basic goals or end points:[2]:236

 hypnosis (a temporary loss of consciousness and with it a loss of memory)

 analgesia (lack of sensation which also blunts autonomic reflexes)
 muscle relaxation

Different types of anesthesia (which are discussed in the following sections) affect the endpoints
in different ways. Regional anesthesia, for instance affects analgesia, benzodiazepine type
sedatives (used in twilight sleep) favor amnesia and general anesthetics can affect all of the
endpoints. The goal of anesthesia is to achieve the necessary endpoints with the least amount of
risk possible to the patient.

The anesthetic area of an operating room

To achieve the goals of anesthesia, drugs act on different but interconnected parts of the nervous
system. Hypnosis, for instance, is generating through actions on the nuclei in the brain and is
similar to the activation of sleep. The effect is to make people less aware and less reactive to
non-noxious stimuli.[2]:245

Loss of memory (amnesia) is created by action of drugs on multiple (but specific) regions of the
brain. Memories are created as either declarative or non-declarative memories in several stages
(short-term, long-term, long-lasting) the strength of which is determined by the strength of
connections between neurons termed synaptic plasticity.[2]:246 Each anesthetic produces amnesia
through unique effects on memory formation at variable doses. Inhalational anesthetics will
reliably produce amnesia through general suppression of the nuclei at doses below those required
for loss of consciousness. Drugs like midazolam, produce amnesia through different pathways by
blocking the formation of long-term memories.[2]:249

Tied closely to the concepts of amnesia and hypnosis is the concept of consciousness.
Consciousness is the higher order process that synthesizes information. For instance, the “sun”
conjurers up feelings, memories and a sensation of warmth rather than a description of a round,
orange warm ball seen in the sky for part of a 24 hour cycle. Likewise, a person can have dreams
(a state of subjective consciousness) during anesthetic or consciousness of the procedure despite
having no indication of it under anesthetic. It’s estimate that 22% of people dream during general
anesthesia and 1 or 2 cases per 1000 have some consciousness termed “awareness during general
anesthesia”.[2]:253

Techniques
Anesthesia is unique, in that it doesn't offer any particular benefit, rather it allows others to do
things that might be beneficial. The best anesthetic, therefore is the one with the lowest risk to
the patient that still achieves the endpoints required to complete the procedure. The first stage of
an anesthetic is the pre-operative risk assessment made up of the medical history, physical
examination and lab tests. Diagnosing a person's pre-operative physical status allows the
clinician to minimize anesthetic risks. A well completed medical history will arrive at the correct
diagnosis 56% of the time which increases to 73% with a physical examination. Lab tests help in
diagnosis but only in 3% of cases, underscoring the need for a full history and physical
examination prior to anesthetics. Incorrect pre-operative assessments or preparations are the root
cause of 11% of all adverse anesthetic events.[2]:1003

ASA physical status classification system[3]

ASA
Physical status
class
ASA 1 Healthy person
ASA 2 Mild systemic disease
ASA 3 Severe systemic disease
Severe systemic disease that is a
ASA 4
constant threat to life
A moribund person who is not
ASA 5 expected to survive without the
operation
A declared brain-dead person whose
ASA 6 organs are being removed for donor
purposes
Suffix added for patients undergoing
E
emergency procedure

One part of the risk assessment is based on the patients' health. The American Society of
Anesthesiologists have developed a six-tier scale which stratifies the pre-operative physical state
of the patient called the ASA physical status. The scale assesses a high-order of risk as the
patients general health relates to an anesthetic.[3]

The more detailed pre-operative medical history aims to discover genetic disorders (such as
malignant hyperthermia or pseudocholinesterase deficiency), habits (tobacco, drug and alcohol
use), physical attributes (such as obesity or a difficult airway) and any coexisting diseases
(especially cardiac and respiratory diseases) that might impact the anesthetic. The physical
examination helps quantify the impact of anything found in the medical history in addition to lab
tests.[2]:1003–1009

Aside from the generalities of the patients health assessment, an evaluation of the specific factors
as they relate to the surgery also need to be considered for anesthesia. For instance, anesthesia
during childbirth must consider not only the mother but the baby. Cancers and tumors that
occupy the lungs or throat create special challenges to general anesthesia. After determining the
health of the person undergoing anesthetic and the endpoints that are required to complete the
procedure, the type of anesthetic can be selected. Choice of surgical method and anaesthetic
technique aims to reduce risk of complications, shorten time needed for recovery and minimise
the surgical stress response.

General anesthesia

Further information: Anesthetic, General anesthetic, and Inhalational anesthetic

A vaporizer holds a liquid anesthetic and converts it to gas for inhalation (in this case
sevoflurane)

Anesthesia is the combination of the endpoints (discussed above) which are reached by drugs
acting on different but overlapping sites in the central nervous system. General anesthesia (as
opposed to sedation or regional anesthesia) has three main goals; (1) lack of movement
(paralysis), (2) unconsciousness, and (3) blunting of the stress response. In the early days of
anesthesia, anesthetics could reliably cause the first two, allowing surgeons to perform necessary
procedures, but many patients died because the extremes of blood pressure and pulse caused by
the surgical insult was ultimately harmful. Eventually, the need for blunting of the surgical stress
response was identified by Harvey Cushing who injected local anesthetic prior to hernia repairs.
[2]:30
This lead to other drugs that could blunt the response leading to lower surgical mortality
rates.
The most common approach to reach the endpoints of general anesthesia is through the use of
inhaled general anesthetics. Each has its own potency which is correlated to its solubility in oil.
This relationship exists, because the drugs bind directly to cavities in proteins of the central
nervous system although several theories of general anaesthetic action have been described.
Inhalational anesthetics are thought to exact their effects on different parts of the central nervous
system. For instance, the immobilizing effect of inhaled anesthetics results from an effect on the
spinal cord whereas sedation, hypnosis and amnesia involve sites in the brain.[2]:515 The potency
of an inhalational anesthetic is quantified by its minimum alveolar concentration or MAC. The
MAC is the percentage dose of anaesthetic that will prevent a response to painful stimulus in
50% of subjects. The higher the MAC, generally, the less potent the anesthetic.

The ideal anesthetic drug would provide hypnosis, amnesia, analgesia, and muscle relaxation
without undesirable changes in the blood pressure, pulse or breathing. In the 1930s, physicians
started to augment inhaled general anesthetics with intravenous general anesthetics. The drugs
used in combination, offered a better risk profile to the person under anesthetic and quicker
recovery. A combination of drugs was later shown to result in lower odds of dying in the first 7
days after anesthetic. For instance, propofol (injection) might be used to start the anesthetic,
fentanyl (injection) used to blunt the stress response, midazolam (injection) given to ensure
amnesia and sevoflurane (inhaled) during the procedure to maintain the effects. More recently,
several intravenous drugs have been developed which, if desired, allow inhaled general
anesthetics to be avoided completely.[2]:720

Equipment

Further information: Instruments used in anesthesiology and Anaesthetic machine

The core instrument in an inhalational anesthetic delivery system is an anesthetic machine. It has
vaporizers, ventilators, an anesthetic breathing circuit, waste gas scavenging system and pressure
gauges. The purpose of the anesthetic machine is to provide anesthetic gas at a constant pressure,
oxygen for breathing and to remove carbon dioxide or other waste anesthetic gases. Since
inhalational aenesthetics are inflammable, various checklists have been developed to confirm
that the machine is ready for use, that the safety features are active and the electrical hazards are
removed.[4] Intravenous anesthetic is delivered either by bolus doses or an infusion pump. There
are also many smaller instruments used in airway management and monitoring the patient. The
common thread to modern machinery in this field is the use of fail-safe systems that decrease the
odds of catastrophic misuse of the machine.[5]

Monitoring
An anesthetic machine with integrated systems for monitoring of several vital parameters.

Patients under general anesthesia must undergo continuous physiological monitoring to ensure
safety. In the US, the American Society of Anesthesiologists (ASA) have established minimum
monitoring guidelines for patients receiving general anesthesia, regional anesthesia, or sedation.
This includes electrocardiography (ECG), heart rate, blood pressure, inspired and expired gases,
oxygen saturation of the blood (pulse oximetry), and temperature.[6] In the UK the Association of
Anaesthetists (AAGBI) have set minimum monitoring guidelines for general and regional
anesthesia. For minor surgery, this generally includes monitoring of heart rate, oxygen
saturation, blood pressure, and inspired and expired concentrations for oxygen, carbon dioxide,
and inhalational anesthetic agents. For more invasive surgery, monitoring may also include
temperature, urine output, blood pressure, central venous pressure, pulmonary artery pressure
and pulmonary artery occlusion pressure, cardiac output, cerebral activity, and neuromuscular
function. In addition, the operating room environment must be monitored for ambient
temperature and humidity, as well as for accumulation of exhaled inhalational anesthetic agents,
which might be deleterious to the health of operating room personnel.[7]

Sedation

Further information: Sedation

Sedation (also referred to as dissociative anesthesia or twilight anesthesia) creates hypnotic,

sedative, anxiolytic, amnesic, anticonvulsant, and centrally produced muscle-relaxing properties.
From the perspective of the person giving the sedation, the patient will appear sleepy, relaxed
and forgetful, allowing unpleasant procedures to be more easily completed. Sedatives such as
benzodiazepines are usually given with pain relievers (such as narcotics, or local anesthetics or
both) because they don't, by themselves, provide significant pain relief.[8]

From the perspective of the person receiving sedative, the effect is a feeling of general
relaxation, forgetfulness and time passing quickly. Many drugs can produce a sedative effect
including benzodiazepines, propofol, thiopental, ketamine and inhaled general anesthetics. The
advantage of sedation over a general anesethetic is that it generally doesn't require support of the
airway or breathing (no tracheal intubation or mechanical ventilation) and can have less of an
effect on the cardiovascular system which may add to a greater margin of safety in some
patients.[2]:736

Regional anesthesia

Further information: Regional anesthesia and Local anesthesia

Sonography guided femoral nerve block

Backflow of cerebrospinal fluid through a spinal needle after puncture of the arachnoid mater
during of spinal anaesthesia

When pain is blocked from a part of the body using local anesthetics, it is generally referred to as
regional anesthesia. There are many types of regional anesthesia either by injecting into the
tissue itself, a vein that feeds the area or around a nerve trunk that supplies sensation to the area.
The later are called nerve blocks and are divided into peripheral or central nerve blocks.

The following are the types of regional anesthesia:[2]:926–931

 Infiltrative anesthesia: a small amount of local anesthetic is injected in a small area to

stop any sensation (such as during the closure of a laceration, as a continuous infusion or
"freezing" a tooth). The effect is almost immediate.
 Peripheral nerve block: local anesthetic is injected near a nerve that provides sensation to
particular portion of the body. There is significant variation in the speed of onset and
duration of anesthesia depending on the potency of the drug (e.g. Mandibular block).
  Intravenous regional anesthesia (also called a Bier block): dilute local anesthetic is
infused to a limb through a vein with a tourniquet placed to prevent the drug from
diffusing out of the limb.
 Central nerve blockade: Local anesthetic is injected or infused in or around a portion of
the central nervous system (discussed in more detail below in Spinal, epidural and caudal
anesthesia).
 Topical anesthesia: local anesthetics that are specially formulated to diffuse through the
mucous membranes or skin to give a thin layer of analgesia to an area (e.g. EMLA
patches).
 Tumescent anesthesia:large amount of very dilute local anesthetics are injected into the
subcutaneous tissues during liposuction.
 Systemic local anesthetics':local anesthetics are given systemically (orally or intravenous)
to relieve neuropathic pain

Nerve blocks

Further information: Nerve block

When local anesthetic is injected around a larger diameter nerve that transmits sensation from an
entire region it is referred to a nerve block. Nerve blocks are commonly used in dentistry, when
the mandibular nerve is blocked for procedures on the lower teeth. With larger diameter nerves
(such as the interscalene block for upper limbs or psoas compartment block for lower limbs) the
nerve and position of the needle is localized with ultrasound or electrical stimulation. The use of
ultrasound, may reduce complication rates and improve quality, performance time, and time to
onset of blocks.[9] Because of the large amount of local anesthetic required to affect the nerve, the
maximum dose of local anesethetic has to be considered. Nerve blocks are also used as a
continuous infusion, following major surgery such as knee, hip and shoulder replacement surgery
and may be associated with lower complications.[10] Nerve blocks are also associated with a
lower risk of neurologic complications when compared to neuraxial blocks.[2]:1639–1641

Spinal, epidural and caudal anesthesia

Further information: Neuraxial blockade and History of neuraxial anesthesia

Central neuraxial anesthesia is the injection of local anesthetic around the spinal cord to provide
analgesia in the abdomen, pelvis or lower extremities. It is divided into either spinal (injection
into the subarachnoid space), epidural (injection outside of the subarachnoid space into the
epidural space) and caudal (injection into the cauda equina or tail end of the spinal cord). Spinal
and epidural are the most commonly used forms of central neuraxial blockade.

Spinal anesthesia, is a "one-shot" injection that provides rapid onset and profound sensory
anesthesia with lower doses of anesethetic and is usually associated with neuromuscular
blockade (loss of muscle control). Epidural anesthesia, uses larger doses of anesthetic infused
through an indwelling catheter which allows the anesthetic to be augmented should the effects
begin to dissipate. Epidural anesethesia does not typically affect muscle control.
Because central neuraxial blockade causes arterial and vasodilation a drop in blood pressure is
common. This drop is largely dictated by the venous side of the circulatory system which holds
75% of the circulating blood volume. The physiologic effects are much greater when the block is
placed above the 5th thoracic vertebrae. An ineffective block is most often due to inadequate
anxiolysis or sedation rather than a failure of the block itself.[2]:1611.

Acute pain management

Pain that is well managed during and immediately after surgery improves the health of patients
(by decreasing physiologic stress) and the potential for chronic pain.[11] Nociception (pain
sensation) is not hard-wired into the body. Instead, it is a dynamic process wherein persistent
painful stimuli can sensitize the system and either make pain management difficult or promote
the development of chronic pain. For this reason, preemptive acute pain management may reduce
both acute and chronic pain and is tailored to the surgery, the environment in which it is given
(in-patient/out-patient) and the individual patient.[2]:2757

Pain management is classified into either pre-emptive or on-demand. On-demand pain

medications typically include either opioid or non-steroidal anti-inflammatory drugss but can
also make use of novel approaches such as inhaled nitrous oxide[12] or ketamine.[13] On demand
drugs can be administered by a clinician ("as needed drug orders") or by the patient using
patient-controlled analgesia (PCA). PCA has been shown to provide slightly better pain control
and increased patient satisfaction when compared with conventional methods.[14] Common
preemptive approaches include epidural neuraxial blockade[15] or nerve blocks.[16] One review
which looked at pain control after abdominal aortic surgery found that epidural blockade
provides better pain relief (especially during movement) in the period up to three postoperative
days. It reduces the duration of postoperative tracheal intubation by roughly half. The occurrence
of prolonged postoperative mechanical ventilation and myocardial infarction is also reduced by
epidural analgesia.[17]

Risks and Complications

See also: The Helsinki Declaration for Patient Safety in Anaesthesiology and Patient safety
Risks and complications as they relate to anesthesia are classified as either morbidity (a disease
or disorder that results from anesthesia) or mortality (death that results from anesthesia).
Attempting to quantify how anesthesia contributes to morbidity and mortality can be difficult
because a person's health prior to surgery and the complexity of the surgical procedure can also
contribute to the risks.

Anesthesia-related deaths by ASA status[18]

Prior to anesthetic in the early 19th century, the physiologic stress from surgery caused
significant complications and many deaths from shock. The faster the surgery was, the lower the
rate of complications (leading to reports very quick amputations). The advent of anesthesia,
allowed more complicated and life-saving surgery to be completed, decreased the physiologic
stress of the surgery but added an element of risk. It was 2 years after the introduction of ether
anesthetics that the first death, directly related to anesethetic was reported.[19]

Morbidity can be major (myocardial infarction, pneumonia, pulmonary embolism, renal

failure/insufficiency, postoperative cognitive dysfunction and allergy) or minor (minor nausea,
vomiting, readmission). There is usually overlap in the contributing factors that lead to morbidity
and mortality between the health of the patient, the surgery being performed and the anesthetic.
To understand the relative risk of each contributing factor, consider that the rate of deaths totally
attributed to the patient's health is 1:870. Compare that to the rate of deaths totally attributed to
surgical factors (1:2860) or anesthesia alone (1:185,056) illustrating that the single greatest
factor in anesthetic mortality is the health of the patient. These statistics can also be compared to
the first such study on mortality in anesthesia from 1954, which reported a rate of death from all
causes at 1:75 and a rate attributed to anesthesia alone at 1:2680.[2]:993 Direct comparisons
between mortality statistics cannot reliably be made over time and across countries because of
differences in the stratification of risk factors, however, there is evidence that anesthetics have
made a significant improvement in safety[20] but to what degree is uncertain.[18]

Rather than stating a flat rate of morbidity or mortality, many factors are reported as contributing
to the relative risk of the procedure and anesthetic combined. For instance, an operation on a
person who is between the ages of 60–79 years old places the patient at 2.32 times greater risk
than someone less than 60 years old. Having an ASA score of 3, 4 or 5 places the person at 10.65
times greater risk than someone with an ASA score of 1 or 2. Other variables include age greater
than 80 (3.29 times risk compared to those under 60), gender (females have a lower risk of 0.77),
urgency of the procedure (emergencies have a 4.44 times greater risk), experience of the person
completing the procedure (less than 8 years experience and/or less than 600 cases have a 1.06
times greater risk) and the type of anesthetic (regional anesthetics are lower risk than general
anesthetics) .[2]:984 Obstetrical, the very young and the very old are all at greater risk of
complication so extra precautions may need to be taken.[2]:969–986

Recovery
The immediate time after anesthesia is called emergence. Emergence from general anesthesia or
sedation requires careful monitoring because there is still a risk of complication.[21] Nausea and
vomiting is reported at 9.8% but will vary with the type of anesthetic and procedure. There is a
need for airway support in 6.8%, there can be urinary retention (more common in those over 50
years of age) and hypotension in 2.7%. Hypothermia, shivering and confusion are also common
in the immediate post-operative period because of the lack of muscle movement (and subsequent
lack of heat production) during the procedure.[2]:2707

Postoperative cognitive dysfunction (also known as POCD and post-anesthetic confusion) is a

disturbance in cognition after surgery. It may also be variably used to describe emergence
delirium (immediate post-operative confusion) and early cognitive dysfunction (diminished
cognitive function in the first post-operative week). Although the three entities (delirium, early
POCD and long-term POCD) are separate, the presence of delirium post-operatively predicts the
presence of early POCD. There does not appear to be an association between delirium or early
POCD and long-term POCD.[22]

Long-term postoperative cognitive dysfunction is a subtle deterioration in cognitive function,

that can last for weeks, months, or longer. Most commonly, relatives of the person report a lack
of attention, memory and loss of interest in activities previously dear to the person (such as
crosswords). In a similar way, people in the workforce may report an inability to complete tasks
at the same speed they could previously.[23] There is good evidence that POCD occurs after
cardiac surgery and the major reason for its occurrence is the formation of microemboli. POCD
also appears to occur in non-cardiac surgery. Its causes in non-cardiac surgery are less clear but
older age is a risk factor for its occurrence.[2]:2805–2816

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

Throughout Europe, Asia, and the Americas a variety of Solanum species containing potent
tropane alkaloids were used for anesthesia. In 13th century Italy, Theodoric Borgognoni used
similar mixtures along with opiates to induce unconsciousness, and treatment with the combined
alkaloids proved a mainstay of anesthesia until the nineteenth century. Local anesthetics were
used in Inca civilization where shamans chewed coca leaves and performed operations on the
skull while spitting into the wounds they had inflicted to anesthetize.[24]Cocaine was later isolated
and became the first effective local anesthetic. It was first used in 1859 by Karl Koller, at the
suggestion of Sigmund Freud, in eye surgery in 1884.[25] German surgeon August Bier (1861–
1949) was the first to use cocaine for intrathecal anesthesia in 1898.[26] Romanian surgeon
Nicolae Racoviceanu-Piteşti (1860–1942) was the first to use opioids for intrathecal analgesia;
he presented his experience in Paris in 1901.[27]
Contemporary re-enactment of Morton's 16 October 1846, ether operation; daguerrotype by
Southworth & Hawes

Early Arab writings mention anesthesia by inhalation. This idea was the basis of the "soporific
sponge" ("sleep sponge"), introduced by the Salerno school of medicine in the late twelfth
century and by Ugo Borgognoni (1180–1258) in the thirteenth century. The sponge was
promoted and described by Ugo's son and fellow surgeon, Theodoric Borgognoni (1205–1298).
In this anesthetic method, a sponge was soaked in a dissolved solution of opium, mandragora,
hemlock juice, and other substances. The sponge was then dried and stored; just before surgery
the sponge was moistened and then held under the patient's nose. When all went well, the fumes
rendered the patient unconscious.

In 1275, Spanish physician Raymond Lullus, while experimenting with chemicals, made a
volatile, flammable liquid he called sweet vitriol. Sweet vitriol, or sweet oil of vitriol, was the
first inhalational anesthetic used for surgical anesthesia. It is no longer used often because of its
flammability. In the 16th century, a Swiss-born physician commonly known as Paracelsus made
chickens breathe sweet vitriol and noted that they not only fell asleep but also felt no pain. Like
Lullus before him, he did not experiment on humans. In 1730, German chemist Frobenius gave
this liquid its present name, ether, which is Greek for “heavenly”. But 112 more years would
pass before ether’s anesthetic powers were fully appreciated.

Meanwhile, in 1772, English scientist Joseph Priestley discovered the gas nitrous oxide. Initially,
people thought this gas to be lethal, even in small doses. However, in 1799, British chemist and
inventor Humphry Davy decided to find out by experimenting on himself. To his astonishment
he found that nitrous oxide made him laugh, so he nicknamed it laughing gas. Davy wrote about
the potential anesthetic properties of nitrous oxide, but nobody at that time pursued the matter
any further.

American physician Crawford W. Long noticed that his friends felt no pain when they injured
themselves while staggering around under the influence of ether. He immediately thought of its
potential in surgery. Conveniently, a participant in one of those “ether frolics", a student named
James Venable, had two small tumors he wanted excised. But fearing the pain of surgery,
Venable kept putting the operation off. Hence, Long suggested that he have his operation while
under the influence of ether. Venable agreed, and on 30 March 1842 he underwent a painless
operation. However, Long did not announce his discovery until 1849.[28]
Morton's Ether inhaler

William Thomas Green Morton, a Boston dentist, conducted the first public demonstration of the
inhalational anesthetic. Morton, who was unaware of Long's previous work, was invited to the
Massachusetts General Hospital to demonstrate his new technique for painless surgery. After
Morton had induced anesthesia, surgeon John Collins Warren removed a tumor from the neck of
Edward Gilbert Abbott. This occurred in the surgical amphitheater now called the Ether Dome.
The previously skeptical Warren was impressed and stated, "Gentlemen, this is no humbug." In a
letter to Morton shortly thereafter, physician and writer Oliver Wendell Holmes, Sr. proposed
naming the state produced "anesthesia", and the procedure an "anesthetic".[29]

Morton at first attempted to hide the actual nature of his anesthetic substance, referring to it as
Letheon. He received a US patent for his substance, but news of the successful anesthetic spread
quickly by late 1846. Respected surgeons in Europe including Liston, Dieffenbach, Pirogov, and
Syme, quickly undertook numerous operations with ether. An American-born physician, Boott,
encouraged London dentist James Robinson to perform a dental procedure on a Miss Lonsdale.
This was the first case of an operator-anesthetist. On the same day, 19 December 1846, in
Dumfries Royal Infirmary, Scotland, a Dr. Scott used ether for a surgical procedure.[30] The first
use of anesthesia in the Southern Hemisphere took place in Launceston, Tasmania, that same
year. Drawbacks with ether such as excessive vomiting and its flammability led to its
replacement in England with chloroform.

Discovered in 1831 by an American physician Samuel Guthrie (1782-1848); and independently a

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

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

Society and culture

Further information: Anesthesia provision in the United States, Anesthesiologist, and Nurse
anesthetist
Almost all healthcare providers use anesthesia to some degree, however most health professions
have their own field of specialists in the field including medicine, nursing and dentistry.

Doctors specializing in perioperative care, development of an anesthetic plan, and the

administration of anesthetics are known in the US asanesthesiologists and in the UK, Canada,
Australia, and NZ as anaesthetists or anaesthesiologists. All anesthetics in the UK, Australia,
New Zealand, Hong Kong and Japan are administered by doctors. Nurse anesthetists also
administer anesthesia in 109 nations.[31] In the US, 35% of anesthetics are provided by physicians
in solo practice, about 55% are provided by anesthesia care teams (ACTs) with anesthesiologists
medically directing anesthesiologist assistants or certified registered nurse anesthetists (CRNAs),
and about 10% are provided by CRNAs in solo practice.[31][32][33] There can also be
anesthesiologist assistants (US) or physician assistant (anaesthesia) (UK) who assistant with
anesthesia[34]

Special populations
There are many circumstances when anesthesia needs to be altered for special circumstances due
to the procedure (such as in cardiac surgery, cardiothoracic anesthesiology or neurosurgery), the
patient (such as in pediatric anesthesia, geriatric, bariatric or obstetrical anesthesia) or special
circumstances (such as in trauma, prehospital care, robotic surgery or extreme environments).

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Archived from the original on 2006-09-26. Retrieved 2010-11-25.

http://en.wikipedia.org/wiki/Anesthesia