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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 undergo surgery 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

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 lumbar vertebrae, 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.

History

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 and Records 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 in trephining 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 and Ibn Zuhr (Avenzoar), among other Muslim surgeons, performed hundreds of surgeries under inhalant anesthesia with the use of narcotic-soaked sponges. 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.

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.

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 Listerian techniques, 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.

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.

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]

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 anaesthetist in 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]

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]

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]

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].

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.

Veterinary anaesthetists/anaesthesiologists

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.

Anaesthetic agents

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 anesthesia and a loss of nociception.

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 various medical 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.

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 include temperature, 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 exhaled inhalational anesthetics which might impair the health of operating room personnel.

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).

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.

See also

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 hi wat up, ASA, 2004-10-27, http://www.asahq.org/publicationsAndServices/standards/20.pdf 
  4. ^ Raju VK (2003). "Sushruta of ancient India". http://www.ijo.in/article.asp?issn=0301-4738;year=2003;volume=51;issue=2;spage=119;epage=122;aulast=Raju. 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. http://ifna-int.org/ifna/e107_files/downloads/Practice.pdf. Retrieved 2007-02-08. 
  11. ^ "Is Physician Anesthesia Cost-Effective?". Anesth Analg. 2007-02-01. http://www.anesthesia-analgesia.org/cgi/content/full/98/3/750#R7-138848. Retrieved 2007-02-15. 
  12. ^ "When do anesthesiologists delegate?". Med Care. 2007-02-01. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=2725080&dopt=Abstract. Retrieved 2007-02-15. 
  13. ^ "Nurse anestheisa worldwide: practice, education and regulation" (PDF). International Federation of Nurse Anesthetists. http://ifna-int.org/ifna/e107_files/downloads/Practice.pdf. Retrieved 2007-02-08. 
  14. ^ "Surgical mortality and type of anesthesia provider". AANA. 2007-02-25. http://www.aana.com/news.aspx?ucNavMenu_TSMenuTargetID=171&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=1606&terms=medical+direction+percent&searchtype=1&fragment=True. Retrieved 2007-02-25. 
  15. ^ "Anesthesia Providers, Patient Outcomes, and Cost" (pdf). Anesth Analg. 2007-02-25. http://nursing.fiu.edu/anesthesiology/COURSES/Semester%203/NGR%206760%20ANE%20Prof%20Aspects/PROF%20Readings/Abenstein.pdf. Retrieved 2007-02-25. 
  16. ^ "ASA Fast Facts: Anesthesiologists Provide Or Participate In 90 Percent Of All Annual Anesthetics". ASA. http://www.asahq.org/PressRoom/homepage.html. 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. http://www.anesthetist.org/content/view/14/38/. Retrieved 2007-02-08. 
  26. ^ New Zealand Anaesthetic Technicians Society
  27. ^ Stoelting RK, Miller RD: Basics of Anesthesia, 3rd edition, 1994.

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