Clinical IT Congress

Anesthesia or anaesthesia has traditionally meant the condition of having the feeling of pain and other sensations blocked. This allows patients to undergo surgery and other procedures without the distress and pain they would otherwise experience. The word was coined by Oliver Wendell Holmes, Sr. in 1846. Another definition is a “reversible lack of awareness”, whether this is a total lack of awareness (e.g. a general anaesthestic) or a lack of awareness of a part of a the body such as a spinal anaesthetic or another nerve block would cause.

Today, the term general anesthesia in its most general form can include:

* Analgesia: blocking the conscious sensation of pain;
* Hypnosis: producing unconsciousness;
* Amnesia: preventing memory formation;
* Relaxation: preventing unwanted movement or muscle tone;
* Obtundation of reflexes, preventing exaggerated autonomic reflexes.

Patients undergoing surgery usually undergo preoperative evaluation. It includes gathering history of previous anesthetics, and any other medical problems, physical examination, ordering required blood work and consultations prior to surgery.

There are several forms of anesthesia. The following forms refer to states achieved by anesthetics working on the brain:

* General anesthesia: “Drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.” Patients undergoing general anesthesia often cannot maintain their own airway and breathe on their own. While usually administered with inhalational agents, general anesthesia can be achieved with intravenous agents, such as propofol.[1]
* Deep sedation/analgesia: “Drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.” Patients may sometimes be unable to maintain their airway and breathe on their own.[1]
* Moderate sedation/analgesia or conscious sedation: “Drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.” In this state, patients can breathe on their own and need no help maintaining an airway.[1]
* Minimal sedation or anxiolysis: “Drug-induced state during which patients respond normally to verbal commands.” Though concentration, memory, and coordination may be impaired, patients need no help breathing or maintaining an airway.[1]

The level of anesthesia achieved ranges on a continuum of depth of consciousness from minimal sedation to general anesthesia. The depth of consciousness of a patient may change from one minute to the next.

The following refer to states achieved by anesthetics working outside of the brain:

* Regional anesthesia: Loss of pain sensation, with varying degrees of muscle relaxation, in certain regions of the body. Administered with local anesthesia to peripheral nerve bundles, such as the brachial plexus in the neck. Examples include the interscalene block for shoulder surgery, axillary block for wrist surgery, and femoral nerve block for leg surgery. While traditionally administered as a single injection, newer techniques involve placement of indwelling catheters for continuous or intermittent administration of local anesthetics.
o Spinal anesthesia: also known as subarachnoid block. Refers to a Regional block resulting from a small volume of local anesthetics being injected into the spinal canal. The spinal canal is covered by the dura mater, through which the spinal needle enters. The spinal canal contains cerebrospinal fluid and the spinal cord. The sub arachnoid block is usually injected between the 4th and 5th lumbar vertebrae, because the spinal cord usually stops at the 1st lumbar vertebra, while the canal continues to the sacral vertebrae. It results in a loss of pain sensation and muscle strength, usually up to the level of the chest (nipple line or 4th thoracic dermatome).
o Epidural anesthesia: Regional block resulting from an injection of a large volume of local anesthetic into the epidural space. The epidural space is a potential space that lies underneath the ligamenta flava, and outside the dura mater (outside layer of the spinal canal). This is basically an injection around the spinal canal.
* Local anesthesia is similar to regional anesthesia, but exerts its effect on a smaller area of the body.

Modern surgery developed rapidly with the scientific era. Ambroise Paré pioneered the treatment of gunshot wounds, and the first modern surgeons were battlefield doctors in the Napoleonic Wars. Naval surgeons were often barber surgeons, who combined surgery with their main jobs as barbers. Three main developments permitted the transition to modern surgical approaches - control of bleeding, control of infection and control of pain (anaesthesia).

Bleeding
Before modern surgical developments, there was a very real threat that a patient would bleed to death before treatment, or during the operation. cauterization (fusing a wound closed with extreme heat) was successful but limited - it was destructive, painful and in the long term had very poor outcomes. Ligatures, or material used to tie off severed blood vessels, are believed to have originated with Ambroise Pare (sometimes spelled “Ambrose”[5]) during the 16th century, but were highly dangerous until infection risk was brought under control - at the time of its discovery, the concept of infection did not exist. Finally, early 20th century research into blood groups allowed the first effective blood transfusions.
Infection
The concept of infection was unknown until relatively modern times. The first progress in combating infection was made in 1847 by the Hungarian doctor Ignaz Semmelweis who noticed that medical students fresh from the dissecting room were causing excess maternal death compared to midwives. Semmelweis, despite ridicule and opposition, introduced compulsory handwashing for everyone entering the maternal wards and was rewarded with a plunge in maternal and fetal deaths, however the Royal Society in the UK still dismissed his advice. Significant progress came following the work of Pasteur, when the British surgeon Joseph Lister began experimenting with using phenol during surgery to prevent infections. Lister was able to quickly reduce infection rates, a reduction that was further helped by his subsequent introduction of techniques to sterilize equipment, have rigorous hand washing and a later implementation of rubber gloves. Lister published his work as a series of articles in The Lancet (March 1867) under the title Antiseptic Principle of the Practice of Surgery. The work was groundbreaking and laid the foundations for a rapid advance in infection control that saw modern aseptic operating theatres widely used within 50 years (Lister himself went on to make further strides in antisepsis and asepsis throughout his lifetime).
Pain
Modern pain control (anesthesia) was discovered by two American dentists, Horace Wells (1815-1848) and William Morton. Before the advent of anesthesia, surgery was a traumatically painful procedure and surgeons were encouraged to be as swift as possible to minimize patient suffering. This also meant that operations were largely restricted to amputations and external growth removals. Beginning in the 1840s, surgery began to change dramatically in character with the discovery of effective and practical anaesthetic chemicals such as ether and chloroform, later pioneered in Britain by John Snow. In addition to relieving patient suffering, anaesthesia allowed more intricate operations in the internal regions of the human body. In addition, the discovery of muscle relaxants such as curare allowed for safer applications.

At least two prehistoric cultures had developed forms of surgery. The oldest for which we have evidence is trepannation,[1] in which a hole is drilled or scraped into the skull, thus exposing the dura mater in order to treat health problems related to intracranial pressure and other diseases. Evidence has been found in prehistoric human remains from Neolithic times, in cave paintings, and the procedure continued in use well into recorded history. Surprisingly, many prehistoric and premodern patients had signs of their skull structure healing; suggesting that many survived the operation. In modern-day Pakistan, remains from the early Harappan periods of the Indus Valley Civilization (c. 3300 BC) show evidence of teeth having been drilled dating back 9,000 years.[2] A final candidate for prehistoric surgical techniques is ancient Egypt, where a mandible dated to approximately 2650 BC shows two perforations just below the root of the first molar, indicating the draining of an abscessed tooth. Recent excavations of the construction workers of the Egyptian pyramids also led to possible evidence of brain surgery.[citation needed]

The oldest known surgical texts date back to Indian physician Sushruta, the “Father of Surgery”, who taught and practiced surgery on the banks of the Ganges around 600 BC. Much of what is known about Sushruta is contained in a series of volumes he authored, which are collectively known as the Susrutha Samhita. It is the oldest known surgical text and it describes in great detail the examination, diagnosis, treatment, and prognosis of numerous ailments, as well as procedures on performing various forms of plastic surgery, such as cosmetic surgery and rhinoplasty.[3] His technique for the latter, used to reconstruct noses that were amputated as a punishment for crimes, is practiced almost unchanged in technique to this day.

Other ancient cultures to have surgical knowledge include ancient Greece - the Hippocratic Oath was an innovation of the Greek physician Hippocrates - and ancient China. However ancient Greek culture traditionally considered the practice of opening the body to be repulsive and thus left known surgical practices such as lithotomy to such persons as practice [it]. In China, Hua Tuo was a famous Chinese physician during the Eastern Han and Three Kingdoms era. He was the first person to perform surgery with the aid of anesthesia, some 1600 years before the practice was adopted by Europeans.[citation needed]

In the Middle Ages, surgery was developed to a high degree in the Islamic world, with renowned practitioners such as Abulcasis (Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi), an Andalusian-Arab physician and scientist who practised in the Zahra suburb of Córdoba. A great medieval surgeon, whose comprehensive medical texts shaped European surgical procedures up until the Renaissance. He is also often regarded as a Father Of Surgery.[4]

In Europe, the demand grew for surgeons to formally study for many years before practicing; universities such as Montpellier, Padua and Bologna Universities were particularly renowned. By the fifteenth century at the latest, surgery had split away from physics as its own subject, of a lesser status than pure medicine, and initially took the form of a craft tradition until Rogerius Salernitanus composed his Chirurgia, laying the foundation for modern Western surgical manuals up to the modern time.

In the coming decades, pharmacists are expected to become more integral within the health care system. Rather than simply dispensing medication, pharmacists will be paid for their patient care skills.[6]

This paradigm shift has already commenced in some countries; for instance, pharmacists in Australia receive remuneration from the Australian Government for conducting comprehensive Home Medicines Reviews. In the United Kingdom, pharmacists (and nurses) who undertake additional training are obtaining prescribing rights. They are also being paid for by the government for medicine use reviews. In the United States, the Clinical pharmacy movement has had an evolving influence on the practice of pharmacy.[7] Moreover, the Doctor of Pharmacy (Pharm.D.) degree is now required before entering practice and many pharmacists now complete one or two years of residency training following graduation. In addition, consultant pharmacists, who traditionally operated primarily in nursing homes are now expanding into direct consultation with patients, under the banner of “senior care pharmacy.”[8]

In most jurisdictions (such as the United States), pharmacists are regulated separately from physicians. Specifically, the legislation stipulates that the practice of prescribing must be separate from the practice of dispensing.[citation needed] These jurisdictions also usually specify that only pharmacists may supply scheduled pharmaceuticals to the public, and that pharmacists cannot form business partnerships with physicians or give them “kickback” payments. However, the American Medical Association (AMA) Code of Ethics provides that physicians may dispense drugs within their office practices as long as there is no patient exploitation and patients have the right to a written prescription that can be filled elsewhere. 7 to 10 percent of American physician practices reportedly dispense drugs on their own.[5]

In other jurisdictions (particularly in Asian countries such as China, Hong Kong, Malaysia, and Singapore), doctors are allowed to dispense drugs themselves and the practice of pharmacy is sometimes integrated with that of the physician, particularly in traditional Chinese medicine.

In Canada it is common for a medical clinic and a pharmacy to be located together and for the ownership in both enterprises to be common, but licensed separately.

The reason for the majority rule is the high risk of a conflict of interest. Otherwise, the physician has a financial self-interest in “diagnosing” as many conditions as possible, and in exaggerating their seriousness, because he or she can then sell more medications to the patient. Such self-interest directly conflicts with the patient’s interest in obtaining cost-effective medication and avoiding the unnecessary use of medication that may have side-effects.

A campaign for separation has begun in many countries and has already been successful (like in Korea). As many of the remaining nations move towards separation, resistance and lobbying from dispensing doctors who have pecuniary interests may prove a major stumbling block (e.g. in Malaysia).