The Practice of Anesthesiology

INTRODUCTION

The Greek philosopher Dioscorides is said to have first used the term anesthesia in
the first century AD to describe the narcotic-like effects of the plant mandragora. The term
subsequently was defined in Bailey’s An Universal Etymological English Dictionary (1721)
as “a defect of sensation” and again in the Encyclopedia Britannica (1771) as “privation of
the senses.” The present use of the term to denote the sleeplike state thet makes possible
painless surgery is credited to Oliver Wendell Holmes in 1846. In the United States, use of
the term anesthesiology to denote the practice of anesthesia was first proposed in the second
decade of this century to emphasize the growing ascientific basis of the speciality. Although
the speciality now rests on ascientific foundation thet rivals any other, ansthesia remains very
much a mixture of both science and art. Moreover, the practice of anesthesiology has
expanded beyond rendering patients insensible to pain during surgery or obstetric delivery.
Causing the American Board Of Anesthesiology to revise its definition in 1989 (Table 1-1).
The specialty is unique in thet it requires a working familiarity with most other specialties,
inclunding surgery and its subspecialities, internal medicine, pediatrics, and obstetrics as well
as clinical pharmacology, applied physiology, and biomedical technology. The application of
recent advances ini biomedical technology in clinical anesthesia continues to make anesthesia
an exciting and rapidly evolving specialty. A significant number of physicians appliying for
residency positions in anesthesiology already have training and certification in other
specialties.
This chapter reviews the history of anesthesia, its British and American roots, and the
current scope of the specialty and present the general approach to the preoperative evaluation
of patients and documentation of the patient’s anesthetic experience, the Case Discussion at
the end of the chapter considers medicolegal aspects of the specialty.

THE HISTORY OF ANESTHESIA

Anesthetic practices date from ancient times, yet the evolution of the specialty began
only in the mid nineteenth century and only became firmly established less than six decades
ago. Ancient civilizations had used opium poppy, coca leaves, mandrake root, alcohol, and
even phlebotomy (to the point of unconsciousness) to allow surgeous to operate. It is
interesting that the ancient Egyptians used the combination of opium poppy (morphine) and
hyoscyamus (hyopscyamine and scopolamine); a similar combination, morphine and
scopolamine, is still used parenterally for premedication. Regional anesthesia in accients
times consisted of compression of nerve trunks (nerveischemia) or the application of cold
(cryoanalgedia) The Incas may have practiced local anesthesia as theis surgeos chewed coca
leaves and spat saliva (presume ably containing cocaine) into the operative wound. Surgical
procedures were for the most part limited to caring for fractures, traumatic wounds,
amputation, ans the remoral of bladder calculi. Amazingly, some civilizations were also able
to perform trephination of the skull,. A major qualification for a successful surgeon was
speed.
The evolution of modern surgery was hampered not only by a poor understanding of
disease processes, anatomy, and surgical asepsis but also by the lask of reliable and safe
anesthetic techniques. These techniques evolved first with inhalation anesthesia, followed by
local and regional anesthesia, and finally intravenous anesthesia.
INHALATION ANESTHESIA
The first general anesthetics were inhalation agents; ether, nitrous oxide, and
chloroform. Ether (really diethyl athe) was originally prepared by Valarius

Table 1-1. definition of the practice of anesthesiology.*

Aswsessing. Consulting and preparing patients for anes
thesia.
Renderind patients insensible to pain during surgical ob
Stetric. Therapeutic, and diagnostic procedures
Monitoring and restoring homeostasis in perioperative and
Critically ill patients
Diagnosing and treating painfull syndromes
Managing and teaching of cardiac and pulmonary resusci
Tation
Evaluating respiratory fuction and applying anf pulmonary respiratory
Therapy
Teaching, supervising, and evaluating the performance of
Medical and paramedical personnel involved in anesthesia,
respiratory care, and critical care
Conducing research at the bacsic and clinical science
levels to explain and improve the care of patients in the terms
of physiologis fuction and drug response
Involvement in the administration of hospitals, medical
Schools, and outpatient facilities as necessary to imple
Ment these responsibilities

*Adapted from the revised definition of the American Board

Of Anesthesiology, 1989.

Cordus I 1540 but was not used as an anesthetic agent in humans until 1842, whwn Crawfors
W. long and William F. Clark used it indenpendently on patients. Four years later, in Boston,
on October 16, 1856, Willian T.FG. Morton conducted on the first publicized demonstration
of general anesthesia using ether. Nitrous oxide was produced by Joseph Priestley in 1772,
but its analgesic properties were first noted by Humphry Davy in 1800. Gardner Colton and
Horace wells are credited for having first used nitrous oxide as an anesthetic in humans in
1844. Cloroforrm was indenpendently in 1831. Although it was first used clinically as an
general anesthetic by Holmes Coote in 1847, chlostetrician James Simpson, who
administered it ti his patients to relieve the pain of labor.
Nitrous oxide was the leasts popular of the three early inhalation anesthetics
because of its relatively low potency and its tendency tocause asphyxia when used alone (see
Chapter 7). Interest in nitrous oxide was not revived until Edmund Andrews administrated it
in 20% oxygen in the only one og these agents still in common use today. Chloroform
initially superseded ether in popularity in many areas, but reports of chloroform relatef
cardiac arrhythmias and hepatotoxicity eventually cause more and more practitioners to
abandon it in favor of ether. Even with introduction of other inhalationanesthetics (ethyl
chloride, ethylene, divinyl ether, clopropane, trichloroethylene, and fluroxene), ether
remained the standard general anesthetic until the early 1960S. The only inhalational agents
that rivaled ether’s safety and popularity was cyslopropane. Unfortunately, both are highly
combustible and have since been replaced by the nonflammable potent fluorinated
hydrocarbon; halothane (developed in 1951; released 1956), methoxyflurane (developed in
1963;released, 1973), and isoflurance (developed in 1965; released 1981). New agents
continue to be developed. One such agent. Desflurance (released 1992), has many of the
desirable properties of isoflurance charateristis of nitrous oxide, savolflurane also has a low
bloos solubility, but concern about potentially toxic degradation product delayed its lease in
the United State until 1955 (see Chapter 7).

LOCAL & REGIONAL ANESTHESIA

The origin or modern local anesthesia is credited to Carl Koller, an
ophthalmologist, who demonstrated the use of tiopical cocaine for surgical anesthesia of the
eye in 1884. Cocaine had beeb isolated from the coca plant in 1855 by Gaedicke abd later
purified in 1860 by Albert Neimann. The surgeon Willian Halsted demonstrated in 1844 the
useof cocaine for intradermal in filtration and nerve blocks (including the facial nerves, the
brachial plexus, and the pudendal and posterior tibial nerves). August Bier is credited with
administering the first spinal anesthetic in 1898; heused 3 mLof 0,5 % cocaine intrathecally,.
He was also the first to describe intravenous regional anesthesia (Bier block) in 1908.
Procaine was synthesized in 1904 by Alfred Einhorn, and within a year found clinical use as a
local anesthetic by Heinrich Braun. Braun was also the first to thetics. Caudal spidural
anesthesia was introduced in 1901 by Ferdinant Cahtelin and Jean Sicard. Lumbar epidural;
anesthesia was described first in 1921 by Fidel Pages and again 1931 by Achille Dogliotti.
Additionally local dibucaine (1930), tetracaine (1932), lidocaine (1947), chloroprocaine
(1955), mepivacaine(1957), prilocaine (1960), bupivacaine(1963), and etidocaine(1972),
ropivacaine, a new agent with the same duration of action as bupivacaine but perhaps with
the same duration of action as bupivacaine but perhaps less toxicity, may soon be available
for clinical use (see Chapter 14)

INTRAVENOUS ANESTHESIA
Induction Agents
Intravenous anesthesia followed the invention of the hypodermic syringe and
needle by Alexander Wood in 1855. Early attempts at intravenous anesthesia in cluded the
use of chloral hydrate (by Ore in 1872), chloroform and ether (Burkhardt in 1909), and the
combination of morphine and scopolamine (Bredem combination of morphine and
scoplolamine (Bredenfelid in 1916). Barbiturates were synthesized in 1903 by Fischer and
von Mering. The first barbiturate used for induction of anesthesia was diethyl barbituric acid
(barbital), but it was not until in introduction of hexo barbital in 1927 thet barbiturate
induction became a popular technique, thiopental, synthesized in 1932 by Volwiler and
Tabern, was first used cklinically by john Lundy and Ralph Waters in 1934 and remains the
most common induction agents for anesthesia. Methothexital was first used clinically in 1957
by V.K. Stoelting and is the only onther barbiturate currently used for induction. Since the
synthesis of chlorodiazepoxide in 1957 the benzodiazepines-diazepam (1959), lorazepam
(1971), and midazolam ?(1976)- have been extensively used premedication. Inductin,
Supplementation of anesthesia, and intravenous sedation. Ketamine was synthesized in 1962
by Stevens and first used clinically in 1965 by Corssen and Domino; it was released in 1970.
Ketamine was the first intravenous agent associated with minimal cardiac and respiratory
depression. Etomidate was synthesized in 1964 and released in 1972; enthusiasm over its
relative lack of circulatory and respiratory effects has been tempered by reports of adrenal
suppression after even a single dose. The release of propofol, didisopropylphenol, in 989 was
a major advance in outpatient anesthesia because of its short duration of action (see Chapters
8 and 46).
Musccle Relaxants
The use of curate by Harold griffinth and Enid Johnson in 1942 was a milestone in
anesthesia. Curraregreatly facilitates endiotracheal intubation and provided excellent
abdominal relaxation fot surgery. For the first time, surgery could be performed of patients
without having to administer relatively large doses often resulted in excessive circulatory and
respiratory depression as well prolonged emergence;moreover, they were often not tolerated
by frail patients.
Other muscle relaxants-gallamine, decamethonium, metocurine, alcuronium, and
pancuranium-were soon introduced clinically. Because these agents were often associated
with significant side effects (Chapter 9), the search for the ideal muscle relaxant continued.
Recently introduced agents that come close to this goal include vecuronium, atracurium,
pipecuronium, and doxacurium. Succinyicholine was synthesized by Bovet in 1949 and
released in 1951 ; it has become at standad agent for facilitating andotracheal intubation.
Although it remains unparalleled in its rapis onset of profound muscle relaxation, its
occasional side effects have continued to fuel the search for a comparable substitute.
Mivacurium, a new short-acting nondepolarizing muscle relaxant. Has minimal side effects,
but it still has a slower onset ang longer duration of action that succinylcholine relaxant with
a rapid onset approaching that of succnylcholine.

Opioids
Morphine was isolated from opium in 1805 by Sertuner and subsequently trien as
an intravenous anesthetic (see above) the morbidity and mortality initially associated with
high doses of opioids in early report caused many anesthetists to avoid opioids and favor pure
inhalation anesthesia. Interest in opioids in anesthesia returned folloeing the synthesia of
meperidine in 1939. The concept of Balanced anesthesia was introduced by lundy and others
and evolved to consist of thiopental for induction, nitrous oxide for amnesia, me[peridine (or
any nacrotic) for analgesia , and curate for muscle relaxation, in 1969, lowenstein rekindled
interest in opioid anesthesia by reintroducing the concept og high doses of narcotics as ployed
, but fentanyl, sufentanil, and alfetantanil were all subsequently used as sole agents. As
experience grew with this technique, its suppressing autionomic responses during surgery
were realized. Remifentabil is a new rapidly-metabolized opioid that is broken down by
nonspecific plasma and tissue esterases.

EVOLUTION OF THE SPECIALITY

British Origins
Following its first public demonstration in the United States, the use of ether
quickly spread to England. HjHON Snow, generally considered the father of anesthesia,
became the first physician to take a fulltime interest in this new anesthetic, for which he
invented an inhaler. He was the first to scientifically inventigate ether and physiology of
general anesthesia. (Snow was also a pioneer in epidemiology who helped stop a cholera
epidemic in London by proving that the causative agent was transmitted by ingestion rather
than inhalation) in 1847, snow published the first book on general anesthesia, on the
inhalation of ether. When the anesthetic properties of chloroform and other Anaesthetics, was
published posthumously in 1858.
After Snow’s death, Joseph T. Clover took his place as England’s leading
physician anesthetist. Cover emphasized continuosly monitoring the patient’s pulsecepted at
the time. He was the first to use the jaw-thrust maneuver for airway obstruction, first to have
resuscitation equipment always available during anesthesia, and first to use a cricotyproid
cannula (to save a patient with an oral tumor who developed complete airway obstruction) .
sir Frederick Hewitt became England’s foremost anesthetist at the turn of the century. He was
responsible formany inventions. Inclunding the oral airways. Hewitt also wrote what many
consider to be the first true textbook of anesthesia, which went through five editions. Snow.
Clover, and Hewitt established a tradition of physician anesthetists that still exists in England
in 1891, the first organization of physician specialist in anesthesia, the Society of
Anesthetists, was formed in England by J.F.Silk.

American Origins
In the United States, Few Pysicians had specialized in anesthesia by the turn of the
century. The task of giving anesthesia was usually delegated to junior surgical house officer
or medical students, who tended to be more interested in the surgical procedure then in
monitoring the patient. Because of the shortage of physicians interested in the speciality in
the United states, surgeons at both the Mayo Clinic and Cleveland Clinic trained and
employed nurses as anesthetists. The first organization of physician anesthetists in the United
States was the long Island Society of Anesthesia in 1911. That societywas eventually renamed
the American Society of Anesthetists and later, in 1945, the American Society of
Anesthesiologists (ASA).
Three physicians stand out in the early development of anesthesia in the United States
after the turn of century: Arthur E. Guedel, Ralph M. Waters and John S. Lundy . Guedel was
the first to elaborate obn te signs of general anesthesia after Snow’s original description. He
advocated cuffed endotracheal tubes and introduced artificial ventilation during ether
anesthesia (later called controlled respiration by waters). The first elective endoracheal
intubation during anesthesia were performed in the late nineteenth century by surgeos: Sir
William MacEwen in Scotland, Joseph O’Dwyer in the United States, and Franz Kuhn in
Germany. Endotracheal inland by Sir Ivan Magill and Stanley Rowbotham in the 1920s.
Ralph Waters added a long list of contributions to the these was insistence on the proper
training of Specialists in anesthesia.

Official Recognition
Widespread specialization in anesthesia did not take place until just before World War
II. Ralph Waters was appointed the first professor of anesthesia in United States in 1933 AT
THE University of Wisconsin;the American Board of Anesthesiology was established in
1937. In England. The first examination for the Diploma in Anaethetics took place in 1935,
and the first Chair in Anaesthetics was awarded to Sir Robert Macintosh in 1937 at Oxford
University, Anesthesia became an officially recognized specialty in England only in 1947,
when the Faculry of Anaethetists og the royal College of Surgeons was established.

THE SCOPE OF ANESTHESIA

The practice of anesthesia has changed dramatically since the days of Jhon Snow. The
modern anesthesiologist is now both a consultant and a primary care provider. The consultant
role is appropriate because safely and comfortably through surgey-generally takes only a
short time (minutes to hours). Howevewer, because anesthesiologists manage akll
“noncutting” aspects of the patient’s care in the immediate perioperative period, they are also
primary care providers. The “captain of the ship” doctrine, which held the surgeon
responsible for every aspect of the patient’s perioperative care (including anesthesia), is no
longer valid. The surgeon and anesthesiologist must fuction together effectively, but both are
ultimately answerable to the patient rather than to each other. Patients can select their own
anesthesiologists, but their choices are usually limited by who is on the medical staff at a
particular hospital, the surgeon’s preference (if any), or the on-call schedule for
anesthesiologists on a given day.
 The practive of anesthesia is no longer limited to the operating room nor even
confined to rendering patients insensible to pain (Table 1-10. Anesthesiologiss are now
routinely asked to monitor, sedate, and provide general or regional anesthesia outside the
operating room-for lithotripsy, magnetic resonance imaging, computerized tomography,
fluoroscopy, electroconvulsive therapy, and cardiac catheterization. Anesthesiologists have
traditionally been pioneers in cardiopulmonary resuscitation teams. An increasing number of
practitioners have subspecialized in cardiac anesthesia (Chapter 21), critical care (Chapter
50), neuroanesthesia (Chapter 26), obstetric anesthesia (Chapter 43), pediatric anesthesia
(Chapter 44), and pain management (Chapter 18). Certification requirements for special
competence in critical care and paibnthesiologists are actively involved in the administration
and medical direction of many operating room, intensive care units, and respiratory therapy
departments. They have also assumed administractive and leadership position on the medical
staffs of many hospitals and ambulatory care facilities.

PREOPERATIVE EVALUATION
OF PATIENTS
As will become clear in later chapters, these is no one standard anesthetic. Rather, an
anesthetic plan (Table 1-2) should be formulated that will optimally accommodate the
patient’s baseline physiologic state. Inclunding any medical and surgical illnesses, the
planned procedure, drug sensitivities. Previous anesthetic experiences, and psychological
makeup. To help formulate the anesthetic plan, a general outline for assessing patients
preoperatively is an important starting point (table 1-3). This assessment is completed by
classifying the patient according to the ASA physical status scale. Assessing complicated
patients may require consultation with other specialists to help determine whether the patient
is optimally ready for the procedure and to have his or her assistance, if necessary, in
perioperative care. Following the assessment, the anesthesiologist must discuss with the
patient realistic options available for anesthetis management. The final anesthetic plan is
based on that discussion and the patient’s wishes (reflected in theinformed consent; see
below).

The Preoperative History

The preoperative history should clearly establish the patient’s present problem as well
as the planned surgi-
Table 1-2 The anesthetic plan
Premedication
Type of anesthesia
General
Airway management
Induction
Maintenance
Muscle relaxation
Local or regional anesthesia
Technique
Agents
Monitored anesthesia care
Supplemental oxygen
Sedation
Intraoperative management
Monitoring
Positioning
 Fluid management
Special management
Postoperave management
Pain control
Intensive ventilation
Postoperative ventilation
Hemodynamic monitoring

Table 1-3 Routine preoperative anesthetic evaluation

I. History
1. Current problem
2. Other known problems
3. Medication history
Allergies
Present therapy
Prescription
Nonprescription
Nontherapeutic
Alcohol
Tobacco
Llicit
4. Previous anesthetics, surgery, and obstetric
Deliveries
5. Family history
6. Review of organ systems
General (Including activity level)
Respiratory
Cardiovascular
Renal
Gastrointestinal
Hematologic
Neurologic
Endocrine
Psychiatric
Orthopedic
Dermatologic
7. Last oral intake
II. Physical examination
1. Vital signs
2. Airway
3. Heart
4. Lungs
5. Extremities
6. Neurologic examination
III. Laboratory evaluations: See Table 1-4
IV. ASA classification : See Table 1-5
Cal. Therapeutic, or diagnostic procedure. The presence and severity as well as the past and
present treatments for known underlying medical. Problems must also investigated. Because
of the potential for drug interaction with anesthesia, a complete from every patient. This
shouls include the use of tobacco and alcohol as well as illcit drugs such as marijuana,
cocaine, and heroin. An attempt must alsio be made to distinguish between true drug allergies
(often manifested as dyspnea or skin rashes ) and drug intolerances (usually gastrointestinal
upset). Detailed questioning about previous operations and anesthetics may uncover prior
anesthetic complication. A family history of anesthetic problem such as malignant
hyperthermia (see Case Dicussion in Chapter 44). A general review of organ system is
important in identifying undiagnosed medical problem. Question shouls emphasize
cardiovascular, pulmonary, endocrine, hepatic, renal ang neurologic function. A positive
response to any of these question should prompt more detailed inquiries to determine to
extent of any organ impairment.

Physical Examination
The history ang physical examination complement one another. The examination
helpsb detect abnormalities not apparent from the history, while the history heps focus the
examination on the organ system that should be examines closely. Examination of healthy
asymptomatic patients minimally consist of measurement of vital sign (blood pressure, heart
rate, respiratory rate, and temperature) and examination of the airways, heart, lugs, and
extremities; using standard techniques of inspection, auscultation, palpation, and percussion.
An abbreviated neurologic examination is important whwn regional anesthesia is being
considered and serves to document any subtle preexisting neurologic deficits. The patient’s
anatomy should be specifically evaluated when procedures such as a nerve block, regional
anesthesia, or invasive monitoring procedure are planned; evidence of infection over or close
to he site or significant anatomic abnormalities may contraindicate such procedures (see
Chapter 6 and 16)
The importance of examining the airways cannot be overemphasized. The patient’s
dentition should be inspected for loose or chipped teeth and the presence of caps, bridges, or
dentures. A poor anesthesia mask fit should be expected in some edentulous patients and
those with significant facial abnormalities. Micrognathia (a short distance between the chin
and the hyoid bone), prominent upper incicisors, a large tongue, limited range of motion of
the temporamandiblaur joint or cervical spine, or a short neck temporamandibular joint or
cervival spine, or a short neck suggest that difficultry may be ancountered in endotracheal
intubation (Chapter 5)

Laboratory Evaluation
The usefulness of routine laboratory testing for healthy asymptomatic patients is
doubtful when the history ang physical examination fail to detect any abnormalities. Such
routine testing is expensive ang rarely alters perioperative management; moreover,
abnormalities often are ignored –or result in unnecessary delays. Nonetheless, because of the
current litigious environment in the United States, many pyysicians continue to order a
hematocrit or hemoglobin concentration, urinalysis, serum electrolyte measurements,
coagulation studies, an electrocardiogram, and a chest x-ray on all patients.
To be valuabe,a preoperative test implies an increased perioperative risk when it is
abnormal and a reduced risk when the abnormality is corrected. The usefulness of a test in
screening for disease depends on its sensitivity and specificity as well the prevalence of the
disease. Sensitive tests have a low rate of false neative result, while specific tests have a low
rate of false-positive result. The prevalence of a disease varies with the population tested and
often depends on sex, age, genetic background, and lifestyle practices. Testing is therefore
most effective when sensitive and
Table 1-4. , routine preoperative laboratory evaluation of asymptomatic, apparently
healthy patients.
Hematocrit or hemoglobin concentration :
All menstruating women
All patients over 60 years of age
All patients who are likely to experience significant blood
Loss and many require transfuction
Serum glucose and creatinine (or blood urea nitrogen)
Concerntration: all patients over 60 years of age
Electrocardiogram : all patients over 40 years of age
Chest radiograph : all patients

Specific test are used in patients in whom the abnormality might be expected. Accordingly,
laboratory testing should be based on the presence or absence of underlying diseases and drug
therapy as suggested by the history ang physical examination. The nature of the procedure
should also be taken into consideration. Thus, a baseline hematocrit is desirable in any patient
about to undrgo a procedure that may result in extensive bloos loss qng require transfusion.
General guidelines for preoperative testing of asymptomatic and seemingly healthy patients
are given in Table 1-4.
Testing fertile women for an undiagnosed early pregnancy may be justified by the
potentially teratogenic effents of anesthetic agents on the fetus (Chapter 43); pregnancy
testing involves detection of chorionic gonadotropin in urine or serum. Routine testing for
AIDS (detection of the HIV antibody) is highly controversial. Routine coagulation studies
and healthy patients.

ASA Physical
Status Classification
In 1961 the ASA adopten a five-category physical status classification (Table 1-5) for
use in as-
Table 1-5 Preoperative physical status classification of patients according to the American
Society or anesthesiologists
Class Definition
1 A normal healthy patient
2 A patient with mild systemic disease and no functional limitations
3 A patient with moderate to severe systemic disease that results in some
fuctional limitation
4 A patient with severe systemic disease that is a constant threat to life ang
functionally incapacitating
5 A moribund patient who is not expected to survive 24 hours with or without
surgery
6 A brain-dead patient whosw organs are being harvested
E If the procedure is an emergency, the physical status is followed by “E” (for
example,*2E*).
 Table 1-6, American, Society of Anesthesiologists
Classification and perioperative mortality rates
Class Mortality Rate
1 0.06-0.08%
2 0.27-0.4%
3 1.8-4.3%
4 7.8-23%
5 9.4-51%

Sessing a patient preoperatively. Although this system was not intended as such, the ASA
physical status generally correlates with the perioperative mortality rate (Table 1-6). Because
underlying disease is only one of many factors contributing to perioperative complications
(see Chapter 47), it is not suprising that this correlation is not perect. Nonetheless, the ASA
physical status classification remains useful in planning anesthetic management, especially
monitoring techniques (Chapter 6)

Informed Consent
the preoperative assessment culminates in giving the patient a reasonable explanation
of the options available for anesthetic management : general, regional. Local, or topical
anesthesia or intravenous sedation. The term monitored anesthesia care (previously referred
to as local standby) is now commonly used and refers to monitoring the patient during a
procedure performed with intravenous sedation or local anesthesia administered by the
surgeon. Regardless of the technique chosen, consent must always be obtained for general
anesthesia in case other techniques prove inadequate
if any procedure is performed without the patient’s consent, the physician may be
liable for assault and battery. When the patient is a minor or otherwise not competent to
consent, the consent must be obtained from someone legally authorized to give it, such as
apparent, guardian, or close relative. Although oral conseth may be medicolegal, written
consent is usually advisable for medicolegal purpose. Moreover, consent must be infrormed
to ensure that the patient (or guardian) has sufficient information about the procedures ang
their risks to make a reasonable ang prudent decisions whether to conset. It is generally
accepted that not all risk need be detailed but only those tht are realistic risks in similar
patients with similar problems. It is generally advisable to inform the patint that some
complications may be life-threatening.
The purpose of the preoperative visit is not to gather importat information ang obtain
informed consent-it also helps establish a healthy doctor-patient relationship. Moreover, an
empathically conducted interview that answer important question ang lats the patient know to
expect has been shown to be at least as effective in relieving anxiety as some premedication
drug regimens (Chapter 8).

DOCUMENTATION

Documentation is important for both quality assurance ang medicolegal purposes.

Adequate documentation is essential for the defense of a malpractice action (see case
Dicussion, below)

The Preoperative Note

The preoperative note should be written in the patientt’s chart ang should describe all
aspects of the preoperative assessment, including the medical history, the physical
examination, laboratory result, ASA classification, and the recommendations of any
consultants. It also describes the anesthetic plan and includes the informed consent. The plan
should be as detailed as possible and should include the use of specific procedures such as
endotracheal intubation, invasive monitors (Chapter 6), and regional or hypontensive
techniques. Documentation of informed consent usually takes the form of a narrative in the
chart indicating that the plan, alternative plans, their advantages ang disadvantages (including
the risk of compication) were presented and understood and agreed to by the patient.
Alternatively, the patient signs a special anesthesia consent form that contains the same
information. A sample preanesthetic report form is illustrated in Figure 1-1. Although a
completely handwritten note in the chart is acceptable, the use of a printes form lessens the
likelihood of omitting important information

The Intraoperative
Anesthesia Record
The intraoperative anesthesia record (Figure 1-2) serves many purposes. It Fuctons as
a useful intraoperative monitor, anreferences for future anesthetics for that patient, and a toll
for quality assurance. This record should be as pertinent and accurate as possible. It should
document all aspects of anesthetic care in the operating room, including the following.
 A. preoperativecheck of the anesthesia machine and other equipment.
 A review or reevaluation of the patient immediately prior to induction of anesthesia
 A review of the chart for new laboratory result or consultations.
 A review of the anesthesia ang surgical consents
 The time of administration, dosage, and route of intraoperative drugs,
 All intraoperative monitoring (including laboratory measurements, blood loss, and urine
output)
 Intravenous fluid administration and transfuction
 All procedures (such as intubation, placement of a nasogastric tube, or placement of
invasive monitors)
 Routine and special techniques such as mechanical ventilation, hypotensive anesthesia,
one-lug ventilation, high-frequency jet ventilation, or cardiopulmonary bypass
 The timing and course of important events such as induction, positioning, surgical
incision, and extubation.
 Unusual events or complication.
 The condition of the patient at the end the procedure.

Vitals signs are recorded graphically at leasr every 5 minutes. Other monitoring data are also
usually entered graphically, while descriptions of techniques or complication are handwritten.
Auromates record keeping systems are available, but their use is still not widespread,.
Unfortunately, the intraoperative anesthetic record is often inadequate for documenting
critical incidents such as a cardiac arrest. In such cases, a separate note in the patient’s chart
may benecessary. Careful recording of the course of events, actions taken, and their timing is
necessary to avoid discrepancies between multiple simultaneous record (anesthesia record,
nurses’, note, cardiopulmonary resuscitation record and other physicians’ entries in the
medical record). Such disrepansies are frequently taergeteg as evidence of incompetence or
dissembling by malpractice attoneys. Incomlete, inaccurate, or illegible record may subject
physicians to unjustified legal liability.
Postoperative Notes
The anesthesiologist’s immediate responsibility to the patient does not end until the patient
has completely recovered from the effects of the anesthetic. After accompanying the patient
to the postanesthesia care unit (PACU), the anesthesiologists should remain with the patient
until normal vital signs have been established and the patient’s condition is deemed stable
(Chapter 49). Prior to discharge from the PACE, a discharge note should be written by the
anesthesiologist to document the patient’s recovery from anesthesia, any apparent anesthesia
–related complication, the immediate postoperative condition of the patient, and the
disposition (discharge to an outpatient, and inpatient ward , an intensive care unit, or home).
Inpatients should be seen again at least once within 48 hours after discharge from the PACU.
Postoparatve notes the presence or absence of any anesthesia –related complications, and any
measures undertaken to treat such complication (Figure 1-3).

CARE DISCUSSION :
MEDICAL MALPRACTICE
A healthy 45-year-old man suffers a cardiac arrest during an elective inguinal hernia
repair. Although cardiopulmonary resuscitatiois successful, the patient is left with permanent
mental status changes that preclude his return to eork, one years later, the patient files a
complain against the anesthesiologist, surgeom, and hospital.

What four elements must beProved by the plaintiff (patient) to Establish

negligence on the part Of the defendant (physician or hospital) ?

1. Duty : Once a physicians establishes a professional relationship with a patient, the

physician owes that patient certain obligations, such as adhering to the “standard of care”
2. Breach of duty : if these obligations are noy fulfilled, the physician has breached his
duties to the patient
3. Causation : the plaintiff must demonstrate that the breach of duty was causally related to
the injury. This proximate cause I does not have to be the most important or immediate cause
of the injury.
4. Damages : an injury must result. The injury may cause general damages (eg, pain and
suffering) or special damages(eg, loss of income)

How is the standard of care

Defined and established
Individual physicians are expected to perform as any prudent and reasonable physician
would in light of the surrounding circunstances. As a specialist, the anesthesiologist is held to
a higher standard of knowledge and skill with respect to the subject matter of thet specialty in
another specialty. The standard of care is usually established by an expert witness. While
most jurisisdictions have estended the “ locality rule” to encompass a national standard of
care, the specific circumstances pertaining to each individual case are taken into account. The
law recognized that these are differences of opinion and varying schools of thought within the
medical profession.

How is causation determined ?

It is usually the plaintiff who bears the burden of proving that the injury would not have
occurred “but for” the negligence of the physician, or that the physician;s action was a
“substantial factor” in causing the injury. An exception is the doctrine of res ipsa loquitur
(“the thing speaks for itself”). Which permits a finding pf negligence based solely on
circumstantial evidence. For res ipsa to apply in the present case summary. The plaintiff
would have to establish that cardiac arrest does not ordinarily occir in the absence of
negligence and that it could not have been due to something outside the control of the
anesthesiologist. An impotant concept is that causation in civil cases need only be established
by a preponderance of the evidence (“more likely than not”)-as opposed to criminal cases,
where all elements of a charged offense must be proved “beyond a reasonable doubt.”

What factors influence the likelihood of a malpractice suit ?

1. The Physician-Patient Relationship: This is particularly important for the
anesthesiologist. Who usually does not meet the patient until the night before or on the
morning of surgery. Another problem is that the patient is unconscious while under the
anesthesiologist’ care. Thus, the preoperative ang postoperative visits with the patient assume
vital importance. While anesthesiologists have less long –term contact with patients than
other medical specialists do. It is possible and desirable to make this contact meangingful.
Family members should also be considered during these meetings, particular the
postoperative visit if these has been an intraoperative complication.
2. Adequacy of informed Consent : Rendering care to a competent patient who does not
consent constitutes assault and battery. Consent is not enough, however. The patient should
be informed of the comtempated procedure, including its reasonably anticipated risks, its
possible benefits, and the therapeutic alternatives. The physician may be liable for a
complication-even if it is not due to the negligent performance of a procedure-if a jury is
convinced that a reasonable person would have refused trarment if properly informed of the
possibility of the complication. This does not mean, of course, that a documented consent
relieves from liability physicians who violate the standard of care.
3. Quality of Documentation : careful documentation of the perioperative visits. Informed
consent, consultation with other specialists, intraoperative eents, and postoperative care is
absolutely essential. The viewpoint of many courts ang juries is that “if it isn’t written, it
wasn;t done,” it goes without saying that medical records should never be intentionally
destroyed or altered.

SUGGESTED READNING
Cheng EY,Kay J (editors)Manual of Anesthesia and the medisally Compromised Patient. Lippincott,
1990 Blends the perspectives of internal medicine, critical care, and intreoperative anesthesia
into perioperative evaluation and management
Frost AM (editor) : Preanesthetic Assessment, Anesthesiol Clin North An 1990’8.No. Anesthetic
implication and preoperative management
Little DM Jr: Classical Anesthesia Files. Wood Library-Museum of Anesthesiology 1985
Lyons AS. Petrucelli RJ: Medicine : An Illustrated History, Abrams, 1978.
Muravchick S : THE Anesthetic Plaen : From Physiologic principles to Clinical Strategies, Mosby
Year Bokk, 1991 A good introduction to formulating anesthetic strategies that takes into
account organ system dysfunction and emphasizes the role of the anesthesiologist as a
consultant.
Smith WDA : Under the Influence : A History of Nitrous oxide and Oxigen Anesthesia,
Macmillan/WLM,1982.
Sykes WS, Ellis RH: Essays on the first Hundred Years of Anaesthesia, 3 volt. Churchill Livingstone,
1982. This collection and other works of historical interest are available through the Wood
Library-Museum of Anesthesiology, 515 Busse Highway, Park Ridge, IL 60068-3189.
Symposium on complication and medico-legal aspects of anaesthesia. Br J Anaesth 1987;59,813.
British perpective on anesthetic complication and medical malpractice