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
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.