The evolution of anesthesia: 20 facts, trends and thoughts on the administration and development of anesthesia

Anesthesia has played an integral role in medicine since the first successful surgical procedure was performed with anesthesia in 1846. However, the exact way anesthesia affects the brain is still not fully understood, and the risks associated with it pose serious potential health threats. A series of facts, trends, and thoughts on the administration and development of anesthesia is listed below.

Anesthesia in the U.S.: A general overview

1. Some form of anesthesia is used in more than 100 million surgical procedures performed on Americans every year, but many people are unaware or overlook the seriousness of anesthetics, according to The American Society of Anesthesiologists.

2. Medical experts do not completely understand the way anesthesia affects the brain, and sometimes serious complications can occur. According to a recent article in The Wall Street Journal, as more outpatient centers perform surgical procedures with faster-acting anesthetics, such as propofol, there is an increasing need to better prepare medical staff to prevent and handle anesthesiology emergencies.

3. The overall death rate due to complications with anesthesia during surgery in the U.S. remained constant at three deaths per 10,000 surgeries or procedures involving anesthesia between 2010 and 2013, according to the Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry.

4. There was an improvement in the prevalence of adverse events involving anesthesia, with the percentage of adverse events falling from 11.8 percent in 2010 to 4.8 percent in 2013.

5. About half of people 65 and older will have at least one surgery. Advanced age can increase associated surgical risks, because the aging brain is more vulnerable to anesthesia, according to the ASA. The most common adverse effects for the elderly include postoperative delirium, a temporary condition that may not develop until a few days after the surgery takes place, and postoperative cognitive dysfunction, a potentially serious condition with symptoms including long-term memory loss and decreased capacity for learning, thinking and concentrating.

6. In the words of Dr. David Gaba, a professor of anesthesia at Stanford University School of Medicine and founding director of the simulation center at the Veterans Affairs Palo Alto Health Care System in California, "Evolution didn't intend for patients to be rendered unconscious and impervious to pain so someone could slice them open and close them up again," he told the WSJ. "We don't completely understand the mechanisms of general anesthesia."

7. According to the WSJ and the ASA, while the workings of anesthesia are still somewhat of a mystery, both patients and medical staff can take steps to prevent and respond to anesthesia-related complications during surgical procedures.

Prepare patients before going under

8. It is important for patients to understand the risks involved in surgical procedures involving anesthesia. The WSJ cites Sheridan Healthcare, a national anesthesia services company, for its strategy for educating patients. Sheridan Healthcare provides a patient education portal with explanations of different kinds of anesthesia and outlines a list of questions patients may want to ask their healthcare team before surgery.

9. Before undergoing a surgical procedure that involves anesthesia, patients should give a complete medical history to physicians and nurses. According to the ASA, certain medical conditions, such as obesity, diabetes, sleep apnea, asthma, heart disease and some genetic conditions can put patients at an increased risk for complications. If a patient has a medical problem, they might need clearance from the primary care physician or an anesthesiologist before the surgery.

10. Patients should also notify all physicians involved in the procedure of any medications they are taking or recently took, including herbal remedies, as outside medication can interact with anesthetics and other drugs administered for the procedure.

11. Patients should know who will be monitoring them during surgery. The surgeon, nurse or anesthesiologist may be the one monitoring a patient during the duration of the procedure. Only a medical professional specifically trained to administer anesthesia and monitor patients should care for a patient during a surgical procedure. Nurse anesthetists can provide anesthesia without direct anesthesiologist supervision in some states, according to the ASA.

Ensure proper selection of drugs and dosage, careful patient monitoring

12. Determine proper level, drugs, and doses of anesthesia. Before administering anesthetics, medical professionals must determine the correct level of sedation for the procedure, choose the drugs and calculate the proper dosage based on patient-specific factors, such as the patient's weight and medical condition.

13. It is critical to have teams of anesthesiologists and certified registered nurse anesthetists perform anesthesia and monitor the patient for adverse reactions. Patients can unexpectedly slip from moderate sedation to deep sedation, and if the staff is inexperienced or unaware a problem is occurring, issues can progress very quickly and result in permanent injuries to the patient. If there is a breathing or airway issue, a patient can suffer an oxygen-related brain injury in approximately five minutes. The WSJ stated more operating rooms have begun monitoring patients with tools that detect oxygen and breathing issues.

14. Create a checklist for the operating room. An on-site checklist can be a lifesaving strategy. According to the WSJ, Dr. Gaba and others at Stanford developed a checklist that can be used to train medical residents on how to detect and respond to various anesthesia emergencies.

Take special precautions for high-risk patients, especially at outpatient surgery centers

15. Be aware of genetic predisposition to malignant hyperthermia. About 1 in 2,000 patients has a genetic mutation that makes them susceptible to this condition. Malignant hyperthermia is an inherited disorder that can be triggered by certain inhaled anesthesia drugs, and causes a fast, extreme rise in temperature and muscle contractions that could be fatal, according to the WSJ. Hospitals and outpatient surgery centers can prepare an emergency cart that includes the drug dantrolene, which acts as an antidote for potentially fatal malignant hyperthermia reactions.

16. If at an outpatient surgery center, send high-risk patients to the hospital for surgery. Although it may not be a popular decision, high-risk patients whose pre-surgery screenings raise red flags are better off having surgery in a hospital setting, rather than being transferred to a hospital after surgery at an outpatient center due to complications, Steven Sheinman, MD, wrote in "Patient screening, communication key to avoiding anesthesia complication" published in Becker's Hospital Review. The patient will be in a setting most equipped to handle emergencies, and the surgery center will ultimately benefit reducing complications occurring in the center.

17. According to John Di Capua, MD, CEO of North American Partners in Anesthesia, anesthesiologists can ensure quality of care when patients return home from outpatient procedures by implementing a system of call through which patients can receive additional medical assistance at home. "NAPA has a system of call, where we actually take care of patients at home, whether it's answering their phone calls or visiting them. It takes time and a cultural shift to do that as well, but there is a dramatic increase in patient care and revenue," Dr. Di Capua told Becker's Hospital Review.

Use quality metrics to track and improve outcomes

18. Compare outcomes to other practices. Medical facilities performing surgical procedures can improve anesthesia practices by reporting outcomes to the Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry. This enables hospitals or outpatient centers to compare their outcomes to other practices across the country, "and if you give doctors a scorecard, they will tend to improve," Richard Dutton, MD, executive director of the Anesthesia Quality Institute, told the WSJ.

19. According to Dr. Di Capua, the most important data that is collected is quality data. Anesthesia practices are challenged by quality as well as costs, so efforts should be applied to make hospitals more efficient, while keeping patient recovery the top priority.

20. Dr. Di Capua also suggested anesthesiologist have to carefully watch how downward financial pressures leading to decreased subsidies for academic and private practices will impact medicine. "They must be careful not to scale back the number of practitioners required to manage patients appropriately. Don't fix the budget at the expense of quality," he told Becker's Hospital Review.

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