General principles

Effective general anaesthesia for surgery began in 1846 when WT.G. Morton gave ether for dental extraction in Massachusetts General Hospital, shortly to be followed by the successful use of ether for amputation of the leg in University College Hospital, London. Anaesthesia gained good public repute when Queen Victoria accepted chloroform a Ia reine from Dr john Snow during the birth of Prince Leopold in 1857. Local anaesthesia originated with the use of topical ophthalmic cocaine in Vienna in 1884 (by Kollei; a friend of Freud), to be followed by the gradual development of local infiltration, nerve blocks, intrathecal (colloquially termed spinal anaesthesia) and, eventually, epidural anaesthesia.

In the UK, training and standards in anaesthetic practice have been led predominantly by the Association of Anaesthetists of Great Britain and Ireland and the Faculty of Anaesthetists of the Royal College of Surgeons. The latter achieved autonomy as the College of Anaesthetists, and in 1993 gained its charter as a Royal College.

Together with the specialist societies, they have fostered advances and developments in anaesthesia for all of the surgical subspecialties, and for obstetric and paediatric anaesthesia, intensive care, trauma and resuscitation, and acute and chronic pain relief. Many advances in anaesthesia have facilitated or are driven by changes in surgical practice. Optimal patient care results from the surgeon and anaesthetist working as a team, and requires a working knowledge of each other’s craft. This is especially true in the presence of complex medical and surgical problems, demanding a joint approach to risk—benefit assessment and preoperative medical optimisation.

The importance of multidisciplinary collaborations at national level for successful audit, analysis of performance, and drafting of practice recommendations and policy is exem­plified by the Confidential Enquiries into Maternal Deaths (Triennial Reports) and into Perioperative Deaths (CEPOD) in the UK. Surgical and anaesthetic joint working parties have resulted in influential documents such as Pain after Surgery.

Jntra-operatively, the anaesthetist should provide the general anaesthetic triad of unconsciousness, pain relief and muscular relaxation, while ensuring maintenance of tissue perfusion and oxygenation. Monitoring of vital functions is mandatory, and must include electrocardiography, blood pressure and oxygen saturation.

Throughout, the anaesthetist’s prime duty is to the patient’s safety and welfare, but it is also important to

optimise the operative conditions. A collective duty of care exists to prevent injuries such as cutaneous burns or to vulnerable structures such as nerves and eyes.

An anaesthetist’s care extends into the postoperative period, at least until it has been clearly delegated to another person on the surgical ward or intensive care unit. Indeed, the modern anaesthetist is developing a more defined role as ‘perioperative physician’, with recognition of the continuing care beyond the immediate recovery period. Organizational and individual conduct has been recently outlined in the Guide to Good Practice, published jointly in the UK by the Association of Anaesthetists of Great Britain and Ireland, and the Royal College of Anaesthetists.