Charles T. Jackson and William T.G. Morton Patented the "Ethereal Solution of Opium" of Elton Romeo Smilie.

The Jackson-Morton 1846 patent for surgical insensibility by means of sulphuric ether states that opiates can be added to the ether and co-administered by inhalation. The erroneous concept that ether could carry opiates in its vapor phase at room temperature was proposed in Boston in 1846 by Elton Romeo Smilie (1819-1889), who believed that the opiates were more important than the ether vehicle.

Use, applicability and reliability of depth of hypnosis monitors in children - a survey among members of the European Society for Paediatric Anaesthesiology.

BACKGROUND: To assess the thoughts of practicing anaesthesiologists about the use of depth of hypnosis monitors in children. METHODS: Members of the European Society for Paediatric Anaesthesiology were invited to participate in an online survey about their thoughts regarding the use, applicability and reliability of hypnosis monitoring in children. RESULTS: The survey achieved a response rate of 30% (N = 168). A total of 138 completed surveys were included for further analysis. Sixty-eight respondents used hypnosis monitoring in children (Users) and 70 did not (Non-users). Sixty-five percent of the Users reported prevention of intra-operative awareness as their main reason to apply hypnosis monitoring. Among the Non-users, the most frequently given reason (43%) not to use hypnosis monitoring in children was the perceived lack or reliability of the devices in children. Hypnosis monitoring is used with a higher frequency during propofol anaesthesia than during inhalation anaesthesia. Hypnosis monitoring is furthermore used more frequently in children > 4 years than in younger children. An ideal hypnosis monitor should be reliable for all age groups and any (combination of) anaesthetic drug. We found no agreement in the interpretation of monitor index values and subsequent anaesthetic interventions following from it. CONCLUSIONS: Prevention of intraoperative awareness appears to be the most important reason to use hypnosis monitoring in children. The perceived lack of reliability of hypnosis monitoring in children is the most important reasons not to use it. No consensus currently exists on how to adjust anaesthesia according to hypnosis monitor index values in children.

Perioperative Considerations of Herbal Medications.

BACKGROUND: A considerable portion of the US population uses herbal supplements on a daily basis for their various proposed beneficial effects. However, the over-the-counter nature of these medications and lack of knowledge of adverse effect profiles can have unexpected serious impact on the perioperative course. The growing list of supplements presents a pharmacologic conundrum to the anesthesiologist. OBJECTIVE: The study aimed to compile a comprehensive list of vitamins, herbals, and supplements used commonly by patients, describe the risks associated with them, and identify recommendations for perioperative management. METHOD: The current literature on PubMed and Medline was reviewed for the years 2000 through 2016. The reference lists of each selected article were also reviewed for additional sources of information. RESULTS: The review identified 23 herbals and supplements that are commonly used and their perioperative considerations. CONCLUSION: The management of herbals and supplements is an issue for the anesthesiologist. Although it would be prudent to stop the use of most substances a week or more preoperatively, the perioperative physician must be wary of the potential for withdrawal.

Simulation-based Assessment of the Management of Critical Events by Board-certified Anesthesiologists.

BACKGROUND: We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods. METHODS: A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant's technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist. RESULTS: Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance. CONCLUSIONS: Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.

Little Black Boxes: Noncardiac Implantable Electronic Medical Devices and Their Anesthetic and Surgical Implications.

Implanted electronic medical devices. or stimulators such as pacemakers and nerve stimulators have grown enormously in diversity and complexity over recent decades. The function and potential interaction of these devices with the perioperative environment is of increasing concern for anesthesiologists and surgeons. Because of the innate electromagnetic environment of the hospital (operating room, gastrointestinal procedure suite, and imaging suite), implanted device malfunction, reprogramming, or destruction may occur and cause physical harm (including nerve injury, blindness, deafness, burn, stroke, paralysis, or coma) to the patient. It is critical for the anesthesiologist and surgeon to be aware of the function and interaction of implanted devices, both with other implanted devices and procedures (such as magnetic resonance imaging and cardioversion) in the hospital environment. Because of these interactions, it is imperative that proper device function is assessed when the surgical procedure is complete. This review article will discuss these important issues for 12 different types of "little black boxes," or noncardiac implantable electronic medical devices.

A delayed functional observer/predictor with bounded-error for depth of hypnosis monitoring.

With the motivation of providing safety for a patient under anesthesia, this paper suggests conditions for evaluating the correctness of an available user interface for systems under shared control based on observability and predictability requirements. Situation awareness is necessary for the user to make correct decisions about the inputs. In this article, we develop a technique to investigate the conditions under which an anesthetists can attain situation awareness about a limited but important aspect of anesthesia, namely depth of hypnosis (DOH). Furthermore, we consider that, in practice, to attain situation awareness, the estimation of the task states does not necessarily need to be precise but can be bounded within certain margins. Hence, attaining situation awareness about DOH is modeled as a bounded-error delayed functional observation/prediction. Unless such an observer/predictor exists for a system with a given user-interface, the safety of the operation may be compromised. The suggested technique proves that, in order to provide safety for the patient under anesthesia, it is necessary for the anesthetist to have access to the predictive information from a clinical decision support system.

Procedures for Evaluating the Adequacy of Anesthesia.

Assessing adequacy of anesthesia requires evaluation of its components: hypnosis, analgesia, and neuromuscular transmission. In order to do this, many methods have been developed that process signals representing different modalities. Assessment of hypnosis requires cortical measures of the central nervous system (CNS); methods that assess analgesia concentrate on subcortical and spinal levels of the CNS; and neuromuscular transmission is a peripheral phenomenon. This article presents an overview of the current state of methods available for measuring each of these components. We conclude that, whereas important gains have been made in the area of assessment of hypnosis, mainly owing to the advancement of methods using EEG and auditory evoked potentials, and whereas neuromuscular transmission can be objectively monitored using motor nerve stimulation, assessment of analgesia still contains many challenges.

Are Anesthesia Providers Ready for Hypnosis? Anesthesia Providers' Attitudes Toward Hypnotherapy.

This study sought to measure current attitudes toward hypnosis among anesthesia providers using an in-person survey distributed at a single grand rounds at a single academic teaching hospital. One hundred twenty-six anesthesia providers (anesthesiologists and nurse anesthetists) were included in this study. A 10-question Institutional Review Board (IRB)-approved questionnaire was developed. One hundred twenty-six (73% of providers at the meeting) anesthesia providers completed the survey. Of the respondents, 54 (43%) were anesthesiologists, 42 (33%) were trainees (interns/residents/fellows) in anesthesia, and 30 (24%) were nurse anesthetists. Over 70% of providers, at each level of training, rated their knowledge of hypnosis as either below average or having no knowledge. Fifty-two (42%) providers agreed or strongly agreed that hypnotherapy has a place in the clinical practice of anesthesia, while 103 (83%) believed that positive suggestion has a place in the clinical practice of anesthesia (p < .0001). Common reasons cited against using hypnosis were that it is too time consuming (41%) and requires special training (34%). Only three respondents (2%) believed that there were no reasons for using hypnosis in their practice. These data suggest that there is a self-reported lack of knowledge about hypnosis among anesthesia providers, although many anesthesia providers are open to the use of hypnosis in their clinical practice. Anesthesia providers are more likely to support the use of positive suggestion in their practice than hypnosis. Practical concerns should be addressed if hypnosis and therapeutic verbal techniques are to gain more widespread use.

Radiation exposure of an anaesthesiologist in catheterisation and electrophysiological cardiac procedures.

Sometimes, cardiac catheterisation and electrophysiological procedures, diagnostic and interventional, require an anaesthesiological support. The anaesthesiologist receives radiation doses depending on various factors, such as type of procedure and exposure modality, anaesthesiological technique, individual protective devices and operator experience. The aim of this study was to investigate the dose per procedure, the exposure inhomogeneity and the effective dose, E, of a senior anaesthesiologist in the haemodynamic laboratory of Ospedali Riuniti, Bergamo. The dose monitoring was routinely performed with sets of several thermoluminescent dosemeters and an electronic personal dosemeter. The study covered 300 consecutive procedures over 1 y. The anaesthesiologist wore a protective apron, a thyroid collar and glasses (0.5 mm lead-equivalent).

Obesity and normal birth: A qualitative study of clinician's management of obese pregnant women during labour.

BACKGROUND: Currently one-fifth of women in the UK are obese. Obese, pregnant woman are at an increased risk of experiencing complications of labour and serious morbidity. However, they are also more likely to undergo medical interventions such as induction of labour and caesarean section which in themselves confer additional health risks for obese women such as wound infection and deep vein thrombosis. Reducing unnecessary interventions and increasing normal birth rates for obese women would substantially improve their postnatal health and wellbeing and reduce the burden of NHS resources required to care for them post operatively. This research aimed to explore practitioners' experiences of and strategies for providing intrapartum care to obese women. METHOD: A qualitative methodology was adopted, focus groups and individual interviews were conducted with health professionals. Audio recordings were transcribed verbatim and data analysed using a framework approach. RESULTS: Twenty-four health professionals participated; Six Consultant Obstetricians two Consultant Anaesthetists and 16 midwives. Three key themes emerged from the data: medicalisation of obese birth; promotion of normal obese birth; and the complexities and contradictions in staff attitudes and behaviours. The overall interpretation is that positive approaches to obese birth offer opportunities to promote normal birth. However, many health professionals find the provision of intrapartum care to obese women challenging, and attitudes and behaviours towards the promotion of normal birth are heterogeneous, complex and contradictory. CONCLUSION: The care of obese women during labour is generally medicalised and focussed on the associated risks. However, although there are conflicting views on how to care for obese women, some practitioners do strive to promote normality and optimise the potential for normal birth by challenging current practices and utilise some 'interventions' in order to facilitate normality and mobility during childbirth. Obesity is a major and growing health problem and a major cause of morbidity and mortality for pregnant women. It is essential that more positive proactive guidelines are available to maximise normal birth if the postnatal health of obese women is to be improved.

[New approaches for determination of area of superficial functional and anatomic objects in pediatric anesthesiology and surgery].

A hypothesis concerning expediency for application of a Bezye's curves in anesthesiology while solving the tasks of the images recognition of a functional part hyperalgesia and hemangioma.

Curriculum development for an advanced regional anesthesia education program: one institution's experience from apprenticeship to comprehensive teaching.

Results of recent attitude survey studies suggest that most practicing physicians are inadequately treating postoperative pain. Residents in anesthesia are confident in performing lumbar epidural and spinal anesthesia, but many are not confident in performing the blocks with which they have the least exposure. Changes need to be made in the training processes to a comprehensive model that prepares residents to perform a wider array of blocks in postgraduate practice. Here, we describe one institution's approach to creating a standardized, advanced regional anesthesia curriculum for residents that follows the six core competencies of the ACGME. Residents received training in anatomy dissection, ultrasound-guided regional anesthesia, traditional nerve stimulation techniques, problem-based learning and simulation sessions, oral board presentation sessions, and journal club sessions. Residents kept a detailed log for their use of peripheral nerve block procedures. We have now redesigned and implemented an advanced regional anesthesia program within our institution to provide residents with experience in regional anesthesia at a competent level. Resident's knowledge in regional anesthesia did improve after the first year of implementation as reflected in improvements between the pre- and post-tests. As the advanced regional anesthesia education program continues to improve, we hope to demonstrate levels of validity, reliability, and usability by other programs.

[Weaning--definition and clinical context from the anesthetic point of view]. / Respiratorentwöhnung--Definition und klinischer Kontext aus Sicht der Anästhesie.

Independent from the mode of mechanical ventilation, particularly a quick termination of mechanical ventilation is essential for the weaning progress. Respirator-associated complications need to be early detected and treated. Thus it is important to know correspondent pathomechanisms as they have a crucial influence on the weaning process.To facilitate a holistic treatment approach for patients in prolonged weaning, a tight junction of intensive care within specialized units seems mandatory.

Anesthesia and the Lone Star State.

The field of anesthesiology has changed dramatically from its humble beginnings. Rags of ether and the art of monitoring blood color for oxygenation have been replaced with precise concentrations of inhaled anesthetic and continuous pulse oximetry. It is on the shoulders of our predecessors that we stand today as anesthesiologists. We must constantly evolve to adapt to an ever-changing medical profession. It is this spirit and mind-set that will allow the field of anesthesiology to continue to advance and improve the care of our patients.

A multidisciplinary approach to improve preoperative understanding and reduce anxiety: a randomised study.

BACKGROUND: Emotional factors may influence reception of information provided during informed consent leading to incomplete understanding and reduced satisfaction. OBJECTIVE: This study was designed to test the hypothesis that a multidisciplinary approach could improve understanding of the information provided by the anaesthesiologist and in turn, reduce anxiety. DESIGN: A randomised controlled clinical trial. SETTING: Veneto Oncology Institute, Italian comprehensive cancer centre. Recruitment from December 2008 to June 2010. PATIENTS: Two hundred and fifty-one women requiring anaesthesia for breast cancer surgery. INTERVENTIONS: Women undergoing surgery for primary breast cancer were randomly assigned to either the structured anaesthesiology interview group (SAI) or the integrated multidisciplinary psycho-oncological approach (IPA). In the IPA arm, patients underwent an interview with the psycho-oncologist. Subsequently, and prior to preoperative anaesthesia evaluation, the psycho-oncologist informed the anaesthesiologist of the type of communicative strategy to adopt for each individual. In the SAI arm, patients received only the anaesthesiology interview. MAIN OUTCOME MEASURES: Anxiety as assessed by State-Trait Anxiety Inventory (STAI) questionnaire. RESULTS: Two hundred and fifty-one patients were randomised and 234 analysed: 124 in the IPA arm and 110 in the SAI arm. For both groups, mean anxiety scores, according to the STAI questionnaire, were statistically lower after the anaesthesiology visit than at baseline, with a reduction of 6.5 points for the IPA arm [95% confidence interval (CI) 4.6 to 8.4, P < 0.0001] and 4.7 points for the SAI arm (95% CI 2.6 to 6.7, P < 0.0001). There were no significant differences between the two groups in the mean anxiety score before and after the interview. For highly anxious patients, the STAI score decreased significantly more in the IPA group (10.2 points, 95% CI 7.4 to 13.0) than in the SAI group (6.8 points, 95% CI 3.8 to 9.8), P = 0.024.The information provided during the anaesthesiology visit was correctly understood by more than 80% of patients and was similar in both groups. CONCLUSION: In breast cancer surgical patients with high levels of preoperative anxiety, a multidisciplinary approach with psycho-oncological intervention proved to be useful at the preoperative anaesthesiology interview.