ANESTHESIA

Anesthesia, or anaesthesia (see spelling differences; from Greek αν-, an-, "without"; and αἲσθησις, aisthēsis, "sensation"), has

traditionally meant the condition of having sensation (including the feeling of pain) blocked or temporarily taken away. This allows

patients to undergosurgery and other procedures without the distress and pain they would otherwise experience. The word was coined

by Oliver Wendell Holmes, Sr. in 1846.[1] Another definition is a "reversible lack of awareness," whether this is a total lack of awareness

(e.g. a general anesthetic) or a lack of awareness of a part of the body such as a spinal anesthetic or another nerve block would cause.

Anesthesia is a pharmacologically induced reversible state of amnesia, analgesia, loss of responsiveness, loss of skeletal muscle

reflexes and decreased stress response.

Contents

[hide]

• 1 Terms

• 2 History

o 2.1 Herbal derivatives

o 2.2 Non-pharmacological methods

o 2.3 Early gases and vapors

o 2.4 Early local anesthetics

• 3 Anaesthesia providers

o 3.1 Anaesthesiologists/Anaesthetists (medically-

trained physicians)

o 3.2 Nurse anaesthetists

o 3.3 Anaesthesiologist assistants

o 3.4 Anaesthesia technicians

o 3.5 Operating Department Practitioners

o 3.6 Veterinary anaesthetists/anaesthesiologists

• 4 Anaesthetic agents

• 5 Anaesthetic equipment

• 6 Anaesthetic monitoring

• 7 Anaesthesia record

• 8 Anaesthesia information management system (AIMS)

• 9 See also

• 10 Notes

• 11 External links

[edit]Terms
Today, the term general anaesthesia in its most general form can include:[2]

 Analgesia: blocking the conscious sensation of pain;

 Hypnosis produces unconsciousness but not necessarily freedom from pain registration;

 Amnesia: preventing memory formation; if you are unconscious, by definition you will be unable to recall events.

 Paralysis: preventing unwanted movement or muscle tone;

 Obtundation of reflexes, preventing exaggerated autonomic reflexes.

Patients undergoing anaesthesia usually undergo preoperative evaluation. It includes gathering history of previous anesthetics, and any

other medical problems, physical examination, ordering required blood work and consultations prior to surgery.

There are several forms of anaesthesia. The following forms refer to states achieved by anesthetics working on the brain:

 General anaesthesia: "Drug-induced loss of consciousness during which patients are not arousable, even by painful

stimulation." Patients undergoing general anesthesia can often neither maintain their own airway nor breathe on their own. While

usually administered with inhalational agents, general anesthesia can be achieved with intravenous agents, such as propofol.[3]

 Deep sedation/analgesia: "Drug-induced depression of consciousness during which patients cannot be easily aroused but

respond purposefully following repeated or painful stimulation." Patients may sometimes be unable to maintain their airway and

breathe on their own.[3]

 Moderate sedation/analgesia or conscious sedation: "Drug-induced depression of consciousness during which patients

respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation." In this state, patients can

breathe on their own and need no help maintaining an airway.[3]

 Minimal sedation or anxiolysis: "Drug-induced state during which patients respond normally to verbal commands." Though

concentration, memory, and coordination may be impaired, patients need no help breathing or maintaining an airway.[3]

The level of anesthesia achieved ranges on a continuum of depth of consciousness from minimal sedation to general anesthesia. The

depth of consciousness of a patient may change from one minute to the next.

The following refer to the states achieved by anesthetics working outside of the brain:

 Regional anaesthesia: Loss of pain sensation, with varying degrees of muscle relaxation, in certain regions of the body.

Administered with local anesthesia to peripheral nerve bundles, such as the brachial plexus in the neck. Examples include the

interscalene block for shoulder surgery, axillary block for wrist surgery, and femoral nerve block for leg surgery. While traditionally

administered as a single injection, newer techniques involve placement of indwelling catheters for continuous or intermittent

administration of local anesthetics.

 Spinal anaesthesia: also known as subarachnoid block. Refers to a Regional block resulting from a small volume of

local anesthetics being injected into the spinal canal. The spinal canal is covered by the dura mater, through which the spinal
 needle enters. The spinal canal contains cerebrospinal fluid and the spinal cord. The sub arachnoid block is usually injected

between the 4th and 5th lumbarvertebrae, because the spinal cord usually stops at the 1st lumbar vertebra, while the canal

continues to the sacral vertebrae. It results in a loss of pain sensation and muscle strength, usually up to the level of the chest

(nipple line or 4th thoracic dermatome).

 Epidural anesthesia: Regional block resulting from an injection of a large volume of local anesthetic into the epidural

space. The epidural space is a potential space that lies underneath the ligamenta flava, and outside the dura mater (outside

layer of the spinal canal). This is basically an injection around the spinal canal.

 Local anesthesia is similar to regional anaesthesia, but exerts its effect on a smaller area of the body.

[edit]History

[edit]Herbal derivatives

The first anesthesia (an herbal remedy) was administered in prehistory. Opium poppy capsules were collected in 4200 BC, and opium

poppies were farmed in Sumeria and succeeding empires. The use of opium-like preparations in anesthesia is recorded in the Ebers

Papyrus of 1500 BC. By 1100 BC poppies were scored for opium collection in Cyprus by methods similar to those used in the present

day, and simple apparatus for smoking of opium were found in a Minoan temple. Opium was not introduced to India and China until 330

BC and 600–1200 AD respectively, but these nations pioneered the use of cannabis incense and aconitum. Sushruta Samhita, a 3rd

century B.C Indian text, advocates the use of wine with incense of cannabis for anaesthasia[4]. In the second century, according to

the Book of the Later Han andRecords of Three Kingdoms, the physician Hua Tuo performed abdominal surgery using an unknown

anesthetic called mafeisan ( 麻 沸散 "cannabis boil powder") dissolved in liquor. Throughout Europe, Asia, and the Americas a variety

of Solanum species containing potent tropane alkaloids were used, such as mandrake, henbane, Datura metel, and Datura inoxia.

Classic Greek and Roman medical texts by Hippocrates,Theophrastus, Aulus Cornelius Celsus, Pedanius Dioscorides, and Pliny the

Elder discussed the use of opium and Solanum species. In 13th century Italy Theodoric Borgognoni used similar mixtures along with

opiates to induce unconsciousness, and treatment with the combined alkaloids proved a mainstay of anesthesia until the nineteenth

century. In the Americas coca was also an important anesthetic used intrephining operations. Incan shamans chewed coca leaves and

performed operations on the skull while spitting into the wounds they had inflicted to anesthetize the site.[citation needed] Alcohol was also

used, its vasodilatory properties being unknown. Ancient herbal anesthetics have variously been called soporifics, anodynes,

and narcotics, depending on whether the emphasis is on producing unconsciousness or relieving pain.

In the famous 10th century Persian work, the Shahnameh, the author, Ferdowsi, describes a cesarean section performed

on Rudabeh when giving birth, in which a special wine agent was prepared as an anesthetic[5] by a Zoroastrian priest in Persia, and

used to produce unconsciousness for the operation. Although largely mythical in content, the passage does at least illustrate knowledge

of anesthesia in ancient Persia. Arabic and Iranian anesthesiologists were the first to utilize oral as well as inhalant anesthetics.

In Islamic Spain, Abulcasis andIbn Zuhr (Avenzoar), among other Muslim surgeons, performed hundreds of surgeries under inhalant

anesthesia with the use of narcotic-soakedsponges. Abulcasis and Avicenna wrote about anesthesia in their influential medical

encyclopedias, the Al-Tasrif and The Canon of Medicine.[6][7]

The use of herbal anesthesia had a crucial drawback compared to modern practice—as lamented by Fallopius, "When soporifics are

weak, they are useless, and when strong, they kill." To overcome this, production was typically standardized as much as feasible, with

production occurring from specific famous locations (such as opium from the fields of Thebes in ancient Egypt). Anesthetics were

sometimes administered in the spongia somnifera, a sponge into which a large quantity of drug was allowed to dry, from which a

saturated solution could be trickled into the nose of the patient. At least in more recent centuries, trade was often highly standardized,

with the drying and packing of opium in standard chests, for example. In the 19th century, varying aconitum alkaloids from a variety of

species were standardized by testing with guinea pigs. Despite these refinements, the discovery of morphine, a purified alkaloid that

soon afterward could be injected by hypodermic for a consistent dosage, was enthusiastically received and led to the foundation of the

modern pharmaceutical industry.

Another factor affecting ancient anesthesia is that drugs used systemically in modern times were often administered locally, reducing the

risk to the patient. Opium used directly in a wound acts on peripheral opioid receptors to serve as an analgesic[citation needed]
, and a

medicine containing willow leaves (salicylate, the predecessor of aspirin) would then be applied directly to the source of

inflammation[citation needed].

In 1804, the Japanese surgeon Seishū Hanaoka performed general anesthesia for the operation of a breast cancer (mastectomy), by

combining Chinese herbal medicine know-how and Western surgery techniques learned through "Rangaku", or "Dutch studies". His

patient was a 60-year-old woman named Kan Aiya.[8] He used a compound he called Tsusensan, based on the plants Datura

metel, Aconitum and others.

[edit]Non-pharmacological methods

Hypnotism have a long history of use as anesthetic techniques. Chilling tissue (e.g. with ice) can temporarily cause nerve fibers (axons)

to stop conducting sensation, while hyperventilation can cause brief alteration in conscious perception of stimuli including pain

(see Lamaze).

In modern anesthetic practice, these techniques are seldom employed.

[edit]Early gases and vapors

Contemporary re-enactment of Morton's October 16, 1846, ether operation;daguerrotype by Southworth & Hawes.
In the West, the development of effective anesthetics in the 19th century was, with Listeriantechniques, one of the keys to successful

surgery. Henry Hill Hickman experimented with carbon dioxide in the 1820s. Nitrous oxide was discovered in 1769 by Joseph

Priestley[9] and its anesthetic qualities were discovered by the British chemist Humphry Davy in 1799,[9] when he was an assistant

to Thomas Beddoes, and reported in a paper in 1800. But initially the medical uses of this so-called "laughing gas" were limited—its

main role was in entertainment. It was used on 30 September 1846 for painless tooth extraction upon patient Eben Frost by

American dentist William Thomas Green Morton. Horace Wells of Connecticut, a traveling dentist, had demonstrated it the previous year

1845 at Massachusetts General Hospital. Wells made a mistake in choosing a particularly sturdy male volunteer, and the patient

suffered considerable pain. This lost the colorful Wells any support. Later the patient told Wells he screamed in shock and not in pain. A

subsequently drunk Wells died in jail, by cutting his femoral artery, after allegedly assaulting a prostitute with sulfuric acid.

Anaesthesia pioneer Crawford W. Long

Another dentist, William E. Clarke, performed an extraction in January 1842 using a different chemical, diethyl ether (discovered

by Valerius Cordus in 1540). In March 1842 in Danielsville, Georgia, Dr.Crawford Long was the first to use anesthesia during an

operation, giving it to his friend, who was also a school teacher (James M. Venable) before excising a cyst from his neck. Long got the

idea to do this from his observations at ether frolics. He noted that participants experienced bumps and bruises but afterward had no

recall of what had happened. He did not publicize this information until 1849.

On October 16, 1846, dentist William Thomas Green Morton, invited to the Massachusetts General Hospital, performed the first public

demonstration of diethyl ether (then called sulfuric ether) as an anesthetic agent, for a patient (Edward Gilbert Abbott) undergoing an

excision of a vascular tumor from his neck. In a letter to Morton shortly thereafter, Oliver Wendell Holmes, Sr. proposed naming the

state produced anæsthesia, and the procedure an anæsthetic.

Despite Morton's efforts to keep "his" compound a secret, which he named "Letheon" and for which he received a US patent, the news

of the discovery and the nature of the compound spread very quickly to Europe in late 1846. Here, respected surgeons—including
Liston, Dieffenbach, Pirogoff, and Syme—undertook numerous operations with ether. An American-born physician, Boott—who had

traveled to London—encouraged a leading dentist, Mr James Robinson, to perform a dental procedure on a Miss Lonsdale. This was

the first case of an operator-anesthetist. On the same day, 19 December 1846 in Dumfries Royal Infirmary, Scotland, a Dr. Scott used

ether for a surgical procedure. The first use of anesthesia in the Southern Hemisphere took place in Launceston, Tasmania, that same

year. Ether has a number of drawbacks, such as its tendency to induce vomiting and its flammability. In England it was quickly replaced

with chloroform.

Discovered in 1831, the use of chloroform in anesthesia is usually linked to James Young Simpson, who, in a wide-ranging study of

organic compounds, found chloroform's efficacy on 4 November 1847. Its use spread quickly and gained royal approval in 1853

when John Snow gave it to Queen Victoria during the birth of Prince Leopold. Unfortunately, chloroform is not as safe an agent as ether,

especially when administered by an untrained practitioner (medical students, nurses, and occasionally members of the public were often

pressed into giving anesthetics at this time). This led to many deaths from the use of chloroform that (with hindsight) might have been

preventable. The first fatality directly attributed to chloroform anesthesia (Hannah Greener) was recorded on 28 January 1848.

John Snow of London published articles from May 1848 onwards 'On Narcotism by the Inhalation of Vapours' in the London Medical

Gazette. Snow also involved himself in the production of equipment needed for inhalational anesthesia.

The surgical amphitheater at Massachusetts General Hospital, or "ether dome," still exists today, although it is used for lectures and not

surgery. The public can visit the amphitheater on weekdays when it is not in use.

[edit]Early local anesthetics

The first effective local anesthetic was cocaine. Isolated in 1859, it was first used by Karl Koller, at the suggestion of Sigmund Freud, in

ophthalmic surgery in 1884.[9] Before that doctors had used a salt and ice mix for the numbing effects of cold, which could only have

limited application. Similar numbing was also induced by a spray of ether or ethyl chloride. A number of cocaine derivatives and safer

replacements were soon produced, including procaine (1905), Eucaine (1900), Stovaine (1904), and lidocaine (1943).

Opioids were first used by Racoviceanu-Piteşti, who reported his work in 1901.

[edit]Anaesthesia providers

Physicians specializing in peri-operative care, development of an anesthetic plan, and the administration of anesthetics are known in the

United States as anesthesiologists and in the UK and Canada as anaesthetists or anaesthesiologists. All anesthetics in the UK,

Australia, New Zealand and Japan are administered by physicians. Nurse anesthetists also administer anesthesia in 109 nations. [10] In

the US, 35% of anesthetics are provided by physicians in solo practice, about 55% are provided by Anesthesia Care Teams (ACTs) with

anesthesiologists medically directing Anesthesiologist Assistants or CRNAs, and about 10% are provided by CRNAs in solo practice.[11]
[12][13]
-[14] -[15]

[edit]Anaesthesiologists/Anaesthetists (medically-trained physicians)

File:Anaesthesia patient simulator.jpg

Anesthesiology students training with a patient simulator.

In the US and Canada, medical doctors who specialize in anesthesiology are called anaesthesiologists, and dentists who specialize in

anaesthesiology are called dental anesthesiologists. Such physicians in the UK and Australia are

called anaesthetists or anaesthesiologists.

In the US, a physician specializing in anaesthesiology completes 4 years of college, 4 years of medical school, 1 year of internship, and

3 years of residency. According to the American Society of Anesthesiologists, anesthesiologists provide or participate in more than 90

percent of the 40 million anesthetics delivered annually.[16]

In the UK, this training lasts a minimum of seven years after the awarding of a medical degree and two years of basic residency, and

takes place under the supervision of the Royal College of Anaesthetists. In Australia and New Zealand, it lasts five years after the

awarding of a medical degree and two years of basic residency, under the supervision of the Australian and New Zealand College of

Anaesthetists. Other countries have similar systems, including Ireland (the Faculty of Anaesthetists of the Royal College of Surgeons in

Ireland), Canada and South Africa (the College of Anaesthetists of South Africa).

In the UK, Fellowship of the Royal College of Anaesthetists (FRCA), is conferred upon medical doctors following completion of the

written and oral parts of the Royal College's examination. In the US, completion of the written and oral Board examinations by

a physician anesthesiologist allows one to be called "Board Certified" or a "Diplomate" of the American Board of Anesthesiology (or of

the American Osteopathic Board of Anaesthesiology, for osteopathic physicians).

Other specialties within medicine are closely affiliated to anaesthetics. These include intensive care medicine and pain medicine.

Specialists in these disciplines have usually done some training in anesthetics. The role of the anaesthetist is changing. It is no longer

limited to the operation itself. Many anaesthetists perform well as peri-operative physicians, and will involve themselves in optimizing the

patient's health before surgery (colloquially called "work-up"), performing the anesthetic,including specialized intraoperative monitoring

(like[17] transesophageal echocardiography), following up the patient in the post anesthesia care unit and post-operative wards, and

ensuring optimal analgesia throughout.

It is important to note that the term anaesthetist in the United States usually refers to registered nurses who have completed specialized

education and training in nurse anaesthesia to become certified registered nurse anesthetists (CRNAs). As noted above, the

term anaesthetistin the UK refers to medical doctors who specialize in anaesthesiology. Anaesthesia providers are often trained using

full scale human simulators. The field was an early adopter of this technology and has used it to train students and practitioners at all

levels for the past several decades. Notable centers in the United States can be found at Harvard's Center for Medical Simulation,
[18]
Stanford,[19] The Mount Sinai School of Medicine HELPS Center in New York,[20] and Duke University[21]

[edit]Nurse anaesthetists

In the United States, advance practice nurses specializing in the provision of anesthesia care are known as Certified Registered Nurse

Anesthetists (CRNAs). According to the American Association of Nurse Anesthetists, the 39,000 CRNAs in the US administer

approximately 30 million anesthetics each year, roughly two thirds of the US total.[22] Thirty-four percent of nurse anesthetists practice in

communities of less than 50,000. CRNAs start school with a bachelors degree and at least 1 year of acute care nursing experience,
[23]
and gain a masters degree in nurse anesthesia before passing the mandatory Certification Exam. Masters-level CRNA training

programs range in length from 27 to 36 months.

CRNAs may work with podiatrists, dentists, anesthesiologists, surgeons, obstetricians and other professionals requiring their services.

CRNAs administer anesthesia in all types of surgical cases, and are able to apply all the accepted anesthetic techniques—general,

regional, local, or sedation. CRNAs do not require Anesthesiologist supervision in any state and require surgeon/dentist/podiatrists to

sign and approve the chart for medicare billing in all but 16 states. Many states place restrictions on practice, and hospitals often

regulate what CRNAs and other midlevel providers can or can not do based on local laws, provider training and experience, and hospital

and physician preferences.[24]

[edit]Anaesthesiologist assistants

In the United States, anesthesiologist assistants (AAs) are graduate-level trained specialists who have undertaken specialized education

and training to provide anesthesia care under the direction of an Anesthesiologist. AAs typically hold a masters degree and practice

under Anesthesiologist supervision in 18 states through licensing, certification or physician delegation.[25]

In the UK, a similar group of assistants are currently being evaluated. They are named Physician's Assistant (Anaesthesia) (PAAs).

Their background can be nursing, Operating Department Practice, or another profession allied to medicine or a science graduate.

Training is in the form of a post-graduate diploma and takes 27 months to complete. Once finished, a masters degree can be

undertaken.[citation needed]

[edit]Anaesthesia technicians

Anesthesia technicians are specially trained biomedical technicians who assist anesthesiologists, nurse anesthetists, and

anesthesiologist assistants with monitoring equipment, supplies, and patient care procedures in the operating room. Commonly these

services are collectively called Perioperative services, and thus the term Perioperative Service Technician (PST) is used

interchangeably with Anesthesia Technician.

In New Zealand, an anaesthetic technician completes a course of study recognized by the New Zealand Anaesthetic Technicians

Society[26].

[edit]Operating Department Practitioners

In the United Kingdom, Operating Department Practitioners provide close assistance and support to the anaesthetist(anaesthesiologist).
[citation needed]
They can also assist with surgical procedures alongside the surgeon and provide Post-Operative Care to patients emerging

from anesthesia. ODPs can be found in the Operating Department, Accident and Emergency (providing advanced airway assistance),

Intensive Care Unit, High Dependency Unit and for specialist MRI scanners which require anesthetic cover. They also work with organ

retrieval teams in transplant surgery and attend pre hospital care to injury victims in the community and will undertake advanced

specialist training to carry out this work. They are state registered in the UK and their title, Operating Department Practitioner is a

protected title. The ODP is not a technician but a practitioner of peri-opertive care. ODPs also work in the field of teaching as lecturers,

resuscitation trainers and work in senior positions in management of operating theatre departments.

[edit]Veterinary anaesthetists/anaesthesiologists
Main article: Veterinary anesthesia

Veterinary anesthetists utilize much the same equipment and drugs as those who provide anesthesia to human patients. In the case of

animals, the anesthesia must be tailored to fit the species ranging from large land animals like horses or elephants to birds to aquatic
animals like fish. For each species there are ideal, or at least less problematic, methods of safely inducing anesthesia. For wild animals,

anesthetic drugs must often be delivered from a distance by means of remote projector systems ("dart guns") before the animal can

even be approached. Large domestic animals, like cattle, can often be anesthetized for standing surgery using only local anesthetics

and sedative drugs. While most clinical veterinarians and veterinary technicians routinely function as anesthetists in the course of their

professional duties, veterinary anesthesiologists in the U.S. are veterinarians who have completed a two-year residency in anesthesia

and have qualified for certification by the American College of Veterinary Anesthesiologists.

[edit]Anaesthetic agents
Main article: Anesthetic

An anesthetic agent is a drug that brings about a state of anesthesia. A wide variety of drugs are used in modern anesthetic practice.

Many are rarely used outside of anesthesia, although others are used commonly by all disciplines. Anesthetics are categorized in to two

categories:general anesthetics cause a reversible loss of consciousness (general anesthesia), while local anesthetics cause

reversible local anesthesiaand a loss of nociception.

[edit]Anaesthetic equipment
Main article: Anaesthetic equipment

In modern anesthesia, a wide variety of medical equipment is desirable depending on the necessity for portable field use, surgical

operations or intensive care support. Anesthesia practitioners must possess a comprehensive and intricate knowledge of the production

and use of variousmedical gases, anesthetic agents and vapors, medical breathing circuits and the variety of anesthetic

machines (including vaporizers, ventilators and pressure gauges) and their corresponding safety features, hazards and limitations of

each piece of equipment, for the safe, clinical competence and practical application for day to day practice.

[edit]Anaesthetic monitoring

Patients being treated under general anesthetics must be monitored continuously to ensure the patient's safety. In the UK the

Association of Anaesthetists (AAGBI) have set minimum monitoring guidelines for General and Regional Anaesthesia. For minor

surgery, this generally includes monitoring of heart rate (via ECG or pulse oximetry), oxygen saturation (via pulse oximetry), non-

invasive blood pressure, inspired and expired gases (for oxygen, carbon dioxide, nitrous oxide, and volatile agents). For moderate to

major surgery, monitoring may also includetemperature, urine output, invasive blood measurements (arterial blood pressure, central

venous pressure), pulmonary artery pressure and pulmonary artery occlusion pressure, cerebral activity (via EEG analysis),

neuromuscular function (via peripheral nerve stimulation monitoring), and cardiac output. In addition, the operating room's environment

must be monitored for temperature and humidity and for buildup of exhaledinhalational anesthetics which might impair the health of

operating room personnel.

[edit]Anaesthesia record

The anesthesia record is the medical and legal documentation of events during an anesthetic.[27] It reflects a detailed and continuous

account of drugs, fluids, and blood products administered and procedures undertaken, and also includes the observation of

cardiovascular responses, estimated blood loss, urinary body fluids and data from physiologic monitors (Anesthetic monitoring, see
above) during the course of an anesthetic. The anesthesia record may be written manually on paper; however, the paper record is

increasingly replaced by an electronic record as part of an Anesthesia Information Management System (AIMS).

[edit]Anaesthesia information management system (AIMS)

An AIMS refers to any information system that is used as an automated electronic anesthesia record keeper (i.e., connection to patient

physiologic monitors and/or the anesthetic machine) and which also may allow the collection and analysis of anesthesia-related

perioperative patient data.

[edit]See also

 Geriatric anaesthesia

 Anaesthesia awareness

 Anesthetic technician

 Allergic reactions during anesthesia

 ASA physical status classification system

 Sedation

 EEG measures during anesthesia

 Patient safety

 Perioperative mortality

 Second gas effect

[edit]Notes

1. ^ Morris Fishbein, M.D., ed (1976). "Anesthesia". The New Illustrated Medical and Health Encyclopedia. 1 (Home Library Edition

ed.). New York, N.Y. 10016: H. S. Stuttman Co. pp. 87.

2. ^ Miller, Ronald (2005). Miller's Anesthesia. New York: Elsevier/Churchill Livingstone. ISBN 0443066566.

3. ^ a b c d "Continuum Of Depth Of Sedation Definition Of General Anesthesia And Levels Of Sedation/Analgesia", American Society of

Anaesthesiologists, ASA, 2004-10-27

4. ^ Raju VK (2003). "Sushruta of ancient India". Retrieved 2007-05-24.

5. ^ Medicine throughout Antiquity. Benjamin Lee Gordon. 1949. p.306

6. ^ Dr. Kasem Ajram (1992). Miracle of Islamic Science, Appendix B. Knowledge House Publishers. ISBN 0911119434.

7. ^ Sigrid Hunke (1969), Allah Sonne Uber Abendland, Unser Arabische Erbe, Second Edition, pp. 279–280:

"The science of medicine has gained a great and extremely important discovery and that is the use of general anaesthetics for

surgical operations, and how unique, efficient, and merciful for those who tried it the Muslim anaesthetic was. It was quite different

from the drinks the Indians, Romans and Greeks were forcing their patients to have for relief of pain. There had been some

allegations to credit this discovery to an Italian or to an Alexandrian, but the truth is and history proves that, the art of using the
 anaesthetic sponge is a pure Muslim technique, which was not known before. The sponge used to be dipped and left in a mixture

prepared from cannabis, opium, hyoscyamus and a plant called Zoan."

(cf. Prof. Dr. M. Taha Jasser, Anaesthesia in Islamic medicine and its influence on Western civilization, Conference on Islamic Medicine)

8. ^ Utopian surgery: Early arguments against anaesthesiain surgery, dentistry and childbirth

9. ^ a b c Morris Fishbein, M.D., ed (1976). "Anesthesia". The New Illustrated Medical and Health Encyclopedia. 1 (Home Library Edition

ed.). New York, N.Y. 10016: H. S. Stuttman Co. pp. 89.

10. ^ "Nurse anesthesia worldwide: practice, education and regulation" (PDF). International Federation of Nurse Anesthetists. Retrieved

2007-02-08.

11. ^ "Is Physician Anesthesia Cost-Effective?". Anesth Analg. 2007-02-01. Retrieved 2007-02-15.

12. ^ "When do anesthesiologists delegate?". Med Care. 2007-02-01. Retrieved 2007-02-15.

13. ^ "Nurse anestheisa worldwide: practice, education and regulation" (PDF). International Federation of Nurse Anesthetists. Retrieved

2007-02-08.

14. ^ "Surgical mortality and type of anesthesia provider". AANA. 2007-02-25. Retrieved 2007-02-25.

15. ^ "Anesthesia Providers, Patient Outcomes, and Cost" (pdf). Anesth Analg. 2007-02-25. Retrieved 2007-02-25.

16. ^ "ASA Fast Facts: Anesthesiologists Provide Or Participate In 90 Percent Of All Annual Anesthetics". ASA. Retrieved 2007-03-22.

17. ^ http://en.wikipedia.org/wiki/Echocardiography#Transesophageal_echocardiogram

18. ^ www.harvardmedsim.org/

19. ^ med.stanford.edu/VAsimulator/medsim.html

20. ^ http://msmc.affinitymembers.net/simulator/intro2.html

21. ^ simcenter.duke.edu/

22. ^ http://aana.com/aboutaana.aspx?

ucNavMenu_TSMenuTargetID=127&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=38

23. ^ http://aana.com/BecomingCRNA.aspx?

ucNavMenu_TSMenuTargetID=18&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=1018

24. ^ http://www.aana.com/Advocacy.aspx?

ucNavMenu_TSMenuTargetID=49&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=2573

25. ^ "Five facts about AAs". American Academy of Anesthesiologist Assistants. Retrieved 2007-02-08.

26. ^ New Zealand Anaesthetic Technicians Society

27. ^ Stoelting RK, Miller RD: Basics of Anesthesia, 3rd edition, 1994.

[edit]External links

 American Association of Nurse Anesthetists

  American Society of Anesthesiologists

 International Federation of Nurse Anesthetists

 British Anaesthetic & Recovery Nurses Association

 La SFAR Société Française d’Anesthésie et de Réanimation

 DGF Online: Deutsche Gesellschaft Für Fachkrankenpflege E.V

 Schweizerische Interessengemeinschaft für Anästhesiepflege - Fédération Fédération suisse des infirmiers anesthésistes

(Swiss Federation of Nurse Anesthesists)

 Nederlandse Vereniging Van Anesthesie Medewerkers

 Riksföreningen för anestesi och intensivvård (Swedish Association of Nurse Anesthetists and Intensive Care Nurses)

 International Anesthesia Research Society

 The Mount Sinai Simulation HELPS Center

 Articles about anesthesia and mechanical ventilation

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Guidelines Special Needs
Immunisation Sports Medicine
Literature Reviews STD's
Journals - Medical Travel Information
Journals - Other Links to GP's Home Pages
Colleges and Medical Associations
 • American Academy of Family Practice
• American Medical Association
• British Medical Association
• Colleges of Medicine of South Africa
• Irish College of General Practitioners
• North of Scotland Institute of Postgraduate Medical Education
• The Royal College of General Practitioners - UK
• The Royal Australian College of General Practitioners
• Wellington School of Medicine
• University of Auckland Department of General Practice and Primary Health Care
• WONCA - Global Family Doctor
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Cardiology
• The Online Journal of Cardiology
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CME
• Goodfellow Unit - An Auckland region RNZCGP CME provider
• Dermnet for NZ GPs - Gain CME points here
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Dental
• Dental Council of New Zealand
• New Zealand Dental Association
• The Dental Surgeon site
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Dermatology
• American Academy of Dermatology
• Australasian College of Dermatologists
• Dermnet - NZ Dermatological Society
• Archives of Dermatology
• The Australasian Journal of Dermatology
• International Journal of Dermatology
• The British Journal of Dermatology
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Diabetes
• AIDA - glucose insulin diabetes simulator software
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Drug Information
• Mosby's Drug Consult
• Pharmac
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Emergency Medicine
• Emergency Medicine at NCEMI
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Enuresis
• National Enuresis Society
• Enuresis Clinic
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Evidence Based Medicine
• Bandolier
• Cochrane Library
• Evidence-Based Medicine - Evidence-Based Medicine, a co-publication of the BMJ Publishing Group and the American
College of Physicians-American Society of Internal Medicine

• Evidence-Based Medicine Resources - BMJ Publishing Group

• Scharr Introduction to Evidence Based Practice on the Internet
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General
• Medivision
• Centres for Disease Control and Prevention
• Effective Health Care Bulletins
• Global Health Resourses.com
• Global Family Doctor - WONCA Online
• Health Communication Network
• Health on the Net Foundation
• HealthAtoZ.Com
• Healthanswers
• Healthworks
• Health Reform.online
• Housecall
• Martindale's Health Science Guide -'98
• Medical Matrix
• Medicine Net
• Medscape
• Merck Manual
• Primary Health Care Network
• Resident Medical Officers Handbook
• Reuters Health Information Services
• University of Iowa - Family Practice Handbook
• The Virtual Hospital
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Geriatric
• Normal Aging Index
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Guidelines
• Guideline Library - NZ Guidelines Group
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Immunisation
• Immunisation Advisory Centre
• Immunet
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Literature Reviews
 • RNZCGP Early Detection of Breast Cancer - Literature review by Department of Public Health & General Practice
Christchurch School of Medicine, University of Otago
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Journals - Medical
• Medical Education - Abstracts are free of charge.Full Text and PDF articles require a subscription or individual article
purchase
• American Family Physician - Official Journal of the American Academy of Family Physicians. (indexed) (full text)
(ISSN 0002-838X) is published 24 times a year
• Australian Family Physician - Offician Journal od RACGP. (indexed) (abstracts only) (Some full text)
• Archives of Family Medicine - The Archives of Family Medicine is a monthly peer-reviewed scientific journal providing
academically sound, clinically practical information for family and general physicians. Published by the American Medical
Association.
• British Journal of General Practice - The British Journal of General Practice publishes peer-reviewed research papers
on topics related to general practice and primary care.
• Canadian Family Physician - (abstracts only) the only peer-reviewed family medicine journal published in Canada.
• Family Medicine Journal - (indexed) (abstracts only) The Official Journal of the Society of Teachers of Family Medicine
(USA)
• Family Practice Management - (indexed) (full text) American Academy of Family Physicans
• NZFP: New Zealand Family Physician - (indexed) (some full text)Journal of the Royal New Zealand College of General
Practitioners

• New Zealand Medical Journal - Official Journal of the NZ Medical Association. (full text)
• British Medical Journal - Official Journal of the British Medical Association. (indexed) (full text)
• JAMA - Journal of the American Medical Association. Online full-text articles are available to JAMA and Archives
Journal paid subscribers and to all AMA members.
• Medical Journal of Australia - (indexed) (some full text) Journal of the Australian Medical Association
• NEJM: New England Journal of Medicine - (indexed) (full text)The New England Journal of Medicine On-line now offers
subscribers access to full text plus several additional features. The Journal On-line continues to offer to all users many
selections from the Journal, including abstracts of all scientific articles. The current issue becomes available on the Web
Wednesday at 5 PM
• The Lancet - (indexed) (full text) (abstracts only)The Lancet is a signatory journal to the Uniform Requirements for
Manuscripts Submitted to Biomedical Journals, a document issued by the International ,Committee of Medical Journal Editors
• Quality in Health Care - BMJ Publishing Group. Access to Tables of Contents and Abstracts at no cost. Access
individual articles at a fixed cost
• International Journal for Quality in Health Care - (indexed) (abstracts only) (full text) The International Journal for
Quality in Health Care is the official journal of the International Society for Quality in Health Care (ISQua)
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Journals - Other
• Education for General Practitioners - (indexed) Affiliated to WONCA
• Bandolier - The Internet version of Bandolier started in 1995, accessible from a University of Oxford server at the
John Radcliffe Hospital. Every issue is available, full text, and free of charge.
• Clinical Evidence - (full text)is a compendium of the best available evidence for effective health care. Published by
the BMJ.
• Effective Health Care - University of York. Promoting the use of research-based knowledge in health care
 • Evidence-Based Medicine - (indexed) (full text)Published bi-monthly Evidence-Based Medicine surveys a wide range
of international medical journals to identify the key research papers that are scientifically valid and relevant to practice. BMJ
publishing group
• Family Medical Practice - (full text) The International Journal of Family Medical Practice and Primary Care. ISSN
1360-0176
• Journal of Family Medicine - (indexed) (full text)A Journal of Current Medical Therapeutics for Family Medicine. A one
time charge to view documents
• General Practice Online - (indexed) (abstracts only) We are pleased to accept contributions of news, and review
articles from all over the world.
• Scandinavian Journal of Primary Health Care
• Journal of Medicine - (indexed) (full text) A Journal of Advances in Medicine
• QJM: Monthly Journal of the Assoc of Physicians - (indexed) (abstracts only)QJM is a long-established, leading
general medical journal. It focuses on internal medicine and publishes peer-reviewed articles which promote medical science
and practice
• He@lth Information on the Internet - (full text) A bimonthly newsletter from the Wellcome Trust and the Royal
Society of Medicine. The newsletter aims to meet the growing demand from health professionals for information about health
resources that are available on the Internet.
• International Health News - (indexed) (full text) provides subscribers with useful, authoritative on-line information
about the latest research in health, nutrition and medicine. Review over 50 medical and scientific journals every month.
• Medicine Australia Online - (indexed) (full text) Relies on contributions of health practitioners from around the world
for its material and is dedicated to making all material available free of charge.
• NZ Doctor - (indexed) (some full text) News and information for New Zealand's family doctors
• The Journal of Rural Health - (indexed) (abstracts only) a quarterly journal published by the NRHA, offers original
research encompassing evaluations of model and demonstration projects to improve rural health, statistical comparisons of
rural and urban differences, and mathematical models examining the use of health care services by rural residents.
• Global Family Doctor - Make it easy keeping up to date with the latest literature, join the WONCA Journal Alerts
(free) and get the latest scientific literature relevant to general practice.
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Medical Software
• Houston Medical Software
• MedTech LTD
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Medicine on the Net

• Achoo Health Care Online
• BMA Library Medline Service (Only for BMA members)
• The Medline Database
• PubMed
• US National Library of Medicine
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Mental Health
• Mental Health Foundation of NZ
• Schizophrenia Fellowship of New Zealand
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Neurology
 • Neurological Examination
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New Zealand Health Links
• Accident Compensation Corporation
• ALAC Alcohol Advisory Council of New Zealand
• Cancer Society of NZ
• Diabetes NZ
• Eating Disorder Services
• HealthPages
• Health Promotion Forum of New Zealand
• Maori Medical Practitioners Association
• Mental Health Commission
• Mental Health Foundation of NZ
• Minister of Health's Home page
• National Health Committee
• NZ College of Practice Nurses NZNO
• NZ Drug Foundation
• NZ Health Information Service
• NZ Heart Foundation
• NZ Injury Prevention Strategy
• NZ Medical Council
• Practice Managers & Administrators Association of New Zealand
• Public Health Networking Project
• Schizophrenia Fellowship of New Zealand
• Statistics New Zealand
• Pharmac: Pharmaceutical Schedule
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Nutrition
• U.S. Food And Drug Administration
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Obstetrics
• Antenatal Planner
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Oncology
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Patient Resources
• National Enuresis Society
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Post Graduate Courses

• Post Graduate Courses

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Other Links
• Medivision
• SCHIN - Sowerby Centre for Health Informatics at Newcastle
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Read Codes
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Research
• Malaghan Institute of Research
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Search Engines - Medical
• PubMed - NCBI - National Library of Medicine. PubMed is the US National Library of Medicine's search service that
provides access to over 11 million citations in MEDLINE, PreMEDLINE, and other related databases, with links to participating
online journals.
• MedlinePlus - A service of the US National Library of Medicine
• NLM Locator Plus - The National Library of Medicine Library's catalog of books, journals, and audiovisuals and access
points to other medical research tools.
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Special Needs
• Special Education Services
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Sports Medicine
• Sports Medicine - New Zealand
• Sports Science
• The Gatorade Sports Science Institute
• The Physician and Sports Medicine Online
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STD's
• Australian Herpes Management Forum
• International Herpes Management Forum
• New Zealand Herpes Foundation
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Travel Information
• International Travel and Health - WHO
• MASTA - Medical Advisory Services for Travellers Abroad
• MASTA - New Zealand Service
• Medical Assistance to Travellers
• Travellers Medical and Vacination Centres
• United States National centre for Infectious diseases - Travelers' Health
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Links to GP's home pages
• East Tamaki Healthcare
• Glenfield Medical Centre (Dr Jon Wilcox)
• Hammond Williamson's home page
• High St Medical Centre - Christchurch
• Mornington Health Clinic
• Northern Rural General Practice Consortium
• Otumoetai Doctors
• Redwoodtown Doctors