Anesthesiology: History and Basic

Concepts
Anesthesiology is the field of medicine that focuses on interventions that bring a state
of anesthesia upon an individual. General anesthesia is characterized by a reversible
loss of consciousness along with analgesia, amnesia, and muscle relaxation. General
anesthesia is induced via the administration of gaseous or injectable agents before
surgical procedures or other medical interventions. On the other end of the spectrum is
local anesthesia, which is achieved via the use of topical agents or the local
administration of injectable anesthetics to the area of concern. The use of anesthetics
has been well documented in history, but the practice of modern anesthesiology only
began by the end of the 18th century.

Last updated: March 29, 2023

CONTENTS

Introduction
History
Preoperative Evaluation
Types of Anesthesia
Perioperative Monitoring
Postoperative Care
References
Introduction
Definition
Anesthesiology is the field of medicine focusing on interventions that bring about a
state of anesthesia, which is characterized by a reversible loss of consciousness,
as well as analgesia, amnesia, and muscle relaxation.

State of anesthesia
Induced via the administration of gaseous or injectable agents before surgical
procedures or other medical interventions
Effects:
Analgesia: relief from pain or the prevention of pain
Amnesia: loss of awareness and/or memory of pain/experience
Hypnosis: temporary unconsciousness or the absence of anxiety
Paralysis: adequate muscle relaxation

Certified personnel who perform and manage anesthesia

Anesthesiologists
Certified registered nurse anesthetists
Anesthesia assistants

Settings where anesthesia is performed

ORs
EDs
Endoscopy suites
Interventional radiology suites
Interventional cardiology laboratories
Ambulatory surgical centers (centers for “day surgery”)
Post-anesthesia care units (PACUs)
ICUs

History
The practice of medicine was transformed in the middle of the 19th century with
the discovery of general anesthesia.
In previous centuries, surgery was performed as a last resort and desperate
measure due to the unbearable pain it caused.
The use of chemical compounds to induce a state of anesthesia in modern
medicine dates back to the 18th century with the introduction of
inhaled anesthetics.
Historical landmarks in the development of anesthesia

Years Events

4000 The use of opium poppy; herbal remedies using Hyoscyamus niger,
BCE–0 Mandragora, and aconitum; and acupuncture performed with bones,
CE cannabis vapors, and carotid compression is documented in records from
ancient China, Greece, and Egypt.

1799– 1799: Humphry Davy observes that nitrous oxide (N2O) relieves physical
1850 pain.
CE 1805: Friedrich Sertürner isolates morphine from opium.
1845: Horace Wells inhales N2O as anesthesia for his own dental
extraction at Massachusetts General Hospital.
1845: William Morton is the 1st to publicly and successfully demonstrate
the use of ether anesthesia for surgery.
1847: James Simpson administers chloroform to relieve pain during
childbirth.

1850– 1853: Charles Pravaz and Alexander Wood invent the hollow hypodermic
1900 needle and create the syringe.
CE 1853 & 1857: John Snow popularizes obstetric anesthesia by using
chloroform during Queen Victoria’s births.
1863: Quincy Colton reintroduces N2O as an inhalation anesthetic.
1884: Karl Koller introduces cocaine as an ophthalmic anesthetic.
1898: August Bier conducts the 1st spinal block using cocaine.

1900– 1901: Caudal epidural analgesia is described.

1925 1902: The words "anesthesiology" and "anesthesiologist” are coined.
CE 1923: Isabella Herb administers the ethylene-oxygen surgical anesthetic.

1925– 1929: John S. Lundy popularizes the use of the IV anesthetic thiopental
1950 (Pentothal).
CE 1942: The 1st successful use of a muscle relaxant as an anesthetic is
recorded.
1944: Lidocaine is introduced as a local anesthetic.
 Years Events

1950– 1954: Perioperative mortality related to anesthesia begins to be

1975 recorded.
CE 1956: Michael Johnstone clinically introduces halothane, the 1st modern-
day brominated general anesthetic.
1960: Joseph Artusio begins human trials of the inhalational anesthetic
methoxyflurane.
1964: Günter Corssen begins human trials of the dissociative IV
anesthetic ketamine.
1966: Robert Virtue begins human trials of the inhalational anesthetic
enflurane.
1972: The inhalational anesthetic isoflurane is introduced into clinical
practice.

1975– 1992: The inhalational anesthetic desflurane is introduced into clinical

2000 practice.
CE 1993: A safe and systematic approach to ventilation during general
anesthesia is established.
1994: The inhalational anesthetic sevoflurane is introduced into clinical
practice.

2000 The American Society of Anesthesiologists establishes a Simulation

CE– Education Network (SEN) to continue educating and certifying
present anesthesiologists.

Preoperative Evaluation
Focused evaluation and planning for anesthesia should be completed in advance
for all surgeries, interventions, and procedures.
 Risk stratification is an important part of preoperative planning.
Low-risk individuals can be evaluated immediately before anesthesia on the day of
the procedure.
Low-risk individuals are those who are:
< 65 years of age
Having stable and adequately controlled medical conditions
Undergoing low-risk procedures
Risk increase with:
Age
Complexity of comorbid medical conditions
Complexity of planned anesthesia and/or medical/surgical procedures
Duration of planned anesthesia and/or medical/surgical procedures
Intermediate-to-high risk may need stabilization and/or optimization of comorbid
medical conditions prior to anesthesia and/or planned procedures.
Emergency anesthesia and/or planned procedure necessitate the initiation of
measures with minimal preparation time and are, by their very nature, high risk.

Goals
Assessing medical status and readiness for the planned procedure
Reducing the risks of anesthesia and surgery
Creating an anesthetic plan and preparing the individual

Components of preoperative evaluation

Clinical evaluation:
Medical history
Current medications
History of prior anesthesia and surgeries
Physical examination
Risk assessment:
Evaluation of factors that increase the likelihood of perioperative morbidity
and mortality
An objective observation commonly used by the anesthesiology team to
create ventilation and intubation plans
Assessment of the anatomy of the head and neck to determine the difficulty
of intubation:
Mallampati classification is used to assess ease of airway access for
intubation.
Graded I–IV based on the difficulty associated with oropharyngeal
characteristics
Inclusion of the individual's underlying health problems
Identification of medication allergies
Response to prior anesthesia methods
Other aids in risk assessment include:
Prognostic biomarkers (e.g., B-type natriuretic peptide)
CBC (to rule out anemia, infection, thrombocytopenia)
Electrolyte panel (to evaluate electrolyte imbalance and metabolic
disturbance)
Coagulation studies (to evaluate for coagulopathy)
Creatinine, GFR
CRP
Functional status/ability to engage in daily activities as reported
subjectively by the individual
Optimization of diseases and comorbidities:
Optimally managing and treating comorbidities before surgery and
anesthesia to decrease morbidity and mortality
Common examples include:
Hypertension
Ischemic heart disease
Heart failure
Obstructive sleep apnea
Diabetes mellitus
Thyroid disease
Anemia
Smoking cessation at least 2 weeks before surgery
 Preoperative testing:
Diagnostic testing for preexisting conditions and comorbidities should be
obtained preoperatively to monitor conditions postoperatively.
Patient-specific testing, for example:
If blood transfusion is anticipated, blood typing and crossmatching are
imperative before surgery and anesthesia.
If a woman of childbearing age is to undergo surgery and anesthesia, a
pregnancy test is indicated to avoid fetal loss.

Summary of high-risk conditions that warrant preoperative assessment and

perioperative planning

Preexisting Diagnostic testing

disease/condition

Age > 65 years Albumin, creatinine, hemoglobin

Alcohol use ECG, electrolytes, hemoglobin, liver function test, platelet

disorder count, PT/INR

Anemia CBC, creatinine, ferritin, iron, transferrin saturation, TSH, T3, T4,
vitamin B12, blood typing, screening

Cardiac disease BNP, ECG, +/- stress testing

Diabetes Creatinine, HbA1c, glucose

Liver disease Albumin, BUN, creatinine, electrolytes, hemoglobin, liver

function test, platelet count, PT/INR

Pulmonary Chest X-ray

disease

Thyroid disease T3, T4, TSH

T3: triiodothyronine
T4: thyroxine
TSH: thyroid-stimulating hormone
Table: Risk-stratification categories used to classify perioperative risk based on
subject characteristics (preoperative risk classification by the American Society of
Anesthesiologists)

American Society of Definition Examples

Anesthesiologists
physical status
classification

I A normal, healthy Healthy, nonsmoker, minimal

individual without known alcohol use
diseases

II An individual with mild Current smoker, mild

systemic disease hypertension, mild lung
disease

III An individual with severe Poorly controlled

systemic disease hypertension or diabetes
mellitus, chronic obstructive
pulmonary disease

IV An individual with severe Recent MI, severely reduced

systemic disease that is ejection fraction, sepsis, ARDS
a constant threat to life

V An individual who is not Brain bleed, ruptured

expected to survive aneurysm, massive trauma
without the intended
operation

VI An individual declared
brain dead or whose
organs are being
harvested
 Mallampati classification to assess ease of airway access for intubation:
I: The soft palate, fauces, uvular, and pillars are visible.
II: The soft palate, fauces, and part of the uvula are visible.
III: The soft palate and base of the uvula are visible.
IV: Only the hard palate is visible.
Image (https://openi.nlm.nih.gov/detailedresult?img=PMC3842741_1745-6215-14-347-
3&query=airway%20assessment&it=xg&req=4&npos=2): “Modified Mallampati classification” by Department of
Anaesthesiology, Copenhagen University Hospital, Nordsjælland Hospital, 3400, Hillerø d, Denmark. License:
CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)

Patient education
Essential for the affected individual's satisfaction and safety
Provides information on how to reduce the risks of surgery and anesthesia:
Stop smoking before and after surgery.
Medications that are to be taken or avoided before surgery
Cessation of eating and drinking by midnight prior to the procedure to
prevent aspiration of gastric contents
Sanitary measures prior to the procedure (e.g., antibacterial soap prep)
Involve the individual in the decision-making and planning steps.
Answer all questions.
Address all concerns.

Informed consent
Based on the premise that individuals have the right to receive information and ask
questions about recommended treatments so that they can make well-informed
decisions about their care
Treating physicians should discuss all risks and complications associated with the
procedure and associated anesthesia before asking for informed consent.
Results in the individual's agreement or refusal to undergo a specific medical
intervention
Usually obtained in a written format

Anesthesia plan
The creation of a plan for anesthesia involves the consideration of:
 Surgery requirements
Duration of surgery
Comorbidities
Postoperative considerations
The individual's preference
Preferences of the surgeon and the anesthesiologist

Postoperative care
Considerations include:
Pain management
Hemodynamics
Pulmonary hygiene
Early interventions
Requirement of ICU vs appropriate hospital wing vs outpatient care for recovery

Types of Anesthesia
Several types of anesthesia are used for surgery or other medical
procedures. Choosing the appropriate type depends on:
Procedure to be performed
Procedure requirements
Area that needs to be anesthetized
Duration of surgery
Patient-specific comorbidities
Postoperative anesthesia plans and considerations
Individual's preference
Preferences of the provider and the anesthesiologist
Types of anesthesia:
General
Neuraxial
Peripheral nerve block
IV regional anesthesia
Monitored anesthesia care (MAC)

General anesthesia
 Drug-induced loss of consciousness
Affects the whole body
Appropriate for most major surgical procedures
The goal of general anesthesia is to attain:
Unconsciousness
Analgesia
Muscle relaxation with immobility
Blockage of noxious stimuli during surgery
The 3 stages of general anesthesia are:
1. Induction:
Accomplished via inhalation or IV
Airway management is integral and is initially via a face mask followed by the
transition to endotracheal intubation.
2. Maintenance:
Typically achieved via a primary inhalation technique using IV drugs
Goal is to reduce the total dosage of any 1 agent; thus, anesthetic
combinations are commonly used.
3. Emergence:
Involves removing anesthetic agents and reversing their residual effects for
the return of consciousness and movement
Extubation can be performed when the individual can protect their airway,
follow simple commands, and ventilate without assistance.

Table: Induction agents

Class Commonly used drugs

IV sedative-hypnotics Propofol, etomidate, ketamine

IV adjuvants Opioids, lidocaine, midazolam

Inhalation agents Nitrous oxide, halothane, isoflurane

Neuromuscular blockers Vecuronium, rocuronium, succinylcholine

Neuraxial anesthesia
 A type of anesthesia that involves anesthetizing the nerves of the CNS
Neuraxial anesthesia is commonly used for lower abdominal and lower extremity
surgeries or for pain relief.
2 main types:
Spinal anesthesia: A needle is inserted between the vertebrae and the
anesthetic is injected directly into the subarachnoid space.
Epidural anesthesia: A catheter is inserted between the vertebrae and the
anesthetic is injected directly into the epidural space.

Epidural anesthesia is commonly used during childbirth:

Anesthesiologists place a catheter between the L3 and L4 vertebrae into the epidural space for
the continuous delivery of local anesthetics. Common epidural agents include lidocaine,
bupivacaine, and ropivacaine.
Image (https://www.wikilectures.eu/w/Epidural_Anaesthesia#/media/File:Epidural_blood_patch.svg):
“Localization of epidural” by Gurch. License: Public Domain
(https://creativecommons.org/licenses/publicdomain/)

Peripheral nerve blocks

 A type of regional anesthesia
The anesthetic is injected near a specific nerve or a bundle of nerves to block
sensations of pain from a specific area of the body.
Commonly used for procedures involving the upper and lower extremities
Fluoroscopy or ultrasound guidance is often used for needle or catheter insertion
and placement.
Long-acting local anesthetics provide prolonged postoperative analgesia.

Ultrasound-guided nerve block:

Ultrasound demonstrating a needle (row of white arrowheads) and an anesthetic solution (dark
area surrounding the ulnar nerve) injected around the ulnar nerve for successful peripheral
nerve block. Anesthetic blockade of a nerve bundle blocks all nerves downstream, providing
adequate analgesia for a procedure. Notice how the anesthesiologist identified the ulnar artery
to avoid puncturing it.
Image (https://openi.nlm.nih.gov/detailedresult?img=PMC4983335_CRIEM2016-
2518596.002&query=peripheral%20nerve%20block&it=xg&req=4&npos=4): “Ultrasound-guided nerve block” by
Richard Amini et al. License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/)

Intravenous regional anesthesia (IVRA)

 Also known as a “Bier block”
Less invasive alternative to peripheral nerve blocks
Suitable for shorter procedures of the hand, forearm, and foot
Estimated blockage time: approximately 1.5 hours
Appropriate for surgeries lasting 1 hour or less
Procedure:
1. Compression and exsanguination of the extremity using an Esmarch bandage
2. A tourniquet is used to keep the blood out of the extremity and retain
anesthesia.
3. An infusion of 0.5% lidocaine via a peripheral vein establishes anesthesia.
4. The surgeon can work in a completely anesthetized and bloodless surgical
field for a limited time.

Basic setup for a Bier block

Image by Lecturio.

Monitored anesthesia care

Involves monitoring an individual's vitals and administering sedatives, anxiolytics,
or analgesics accordingly
Commonly used during outpatient procedures
If needed, anesthesiologists are ready to convert to general anesthesia at any
time.
A common example is administering propofol whenever an anesthesiologist
deems it necessary during an endoscopy based on the individual's vitals and
mobility.
Perioperative Monitoring
Standard monitors
Used by the anesthesiology team during a procedure
Includes:
Pulse oximetry
ECG
Noninvasive blood pressure monitoring device
Thermometers
Integrated monitors with alarms

Monitoring of ventilation
Serialized visual inspection, auscultation, palpation, and O2 saturation
Ventilation monitoring is essential during anesthesia due to the risk of respiratory
depression and hypoxia.
Ventilation is monitored in several ways:
Clinical monitoring:
Visualization of chest excursion
Auscultation of breath sounds
Movement of the reservoir bag
O2 saturation monitor
Capnography: a graph showing the respiratory rate and CO2 concentration
over time
Other measures:
End-tidal CO2 concentration
Inspired O2 concentration
Quantitative volume of expired gas
Normal capnogram reflecting appropriate CO2 levels in an individual receiving general
anesthesia:
Capnography reflects adequate ventilation during surgery.
Image by Lecturio.

Monitoring of hemodynamics
Serialized recording of automated blood pressure, ECG, and HR
More accurate hemodynamic monitoring can be achieved via invasive approaches
such as:
Intra-arterial pressure monitor
Central venous pressure monitor
Pulmonary artery catheter
Transesophageal echocardiography (TEE) probes
Hemodynamics are monitored based on:
Vitals signs
Fluids (IV input and urine output)
Vasoactive drugs can be administered to maintain optimal intravascular
volume status throughout anesthesia.

Monitoring of neurologic status

Neurologic status may be difficult to assess in individuals who are sedated and/or
paralyzed.
EEG may be used for the neuromonitoring of cortical function.
IM paraspinal and/or limb electrodes may be used to monitor nerve stimulation
during neurosurgical, orthopedic, or interventional spinal procedures.
Intracranial pressure may be monitored during neurosurgical procedures.

Depth of anesthesia
 Monitored based on end-tidal concentrations of inhalation anesthetics
The goal of anesthesia is stage II or III, depending on the type of anesthesia
chosen.
Stage III requires endotracheal intubation for airway protection.
If the desired stage III enters stage IV, prompt reversal is necessary.

Table: Stages of anesthesia depth

Stage I Conscious and rational with decreased pain perception

Stage II Unconscious and reflexive with an irregular breathing pattern

Stage III Inability to protect the airway due to increased muscle relaxation

Stage IV Cardiovascular and respiratory depression (medullary)

Postoperative Care
All individuals are monitored postoperatively in a PACU, where standard
procedures are followed:
Antiemetics for postoperative nausea and/or vomiting
Fluid administration and monitoring for the inability to void via strict inputs and
outputs
Respiratory, cardiovascular, and neurological monitoring
Monitoring and control of hypothermia and hyperthermia
Pain control
Reassurance, reorientation, and potential drug reversal for delayed emergence
(failure to return to a conscious state within 60 minutes of anesthesia cessation)
Recovery assessment
Reduction of postoperative adverse events
Streamline discharge
Transferring to an ICU vs appropriate hospital wing vs outpatient care for recovery

References
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