All about anaesthesia

Anaesthesia is a word derived from the Greek, meaning ‘without sensation’. Anaesthesia may be applied to the whole body, when it is known as general anaesthesia, or to part of the body, when it is known as regional or local anaesthesia. All of these techniques involve giving specific drugs that interfere with the transmission of nervous impulses so as to reduce sensation. ‘Anaesthetic’ is the term applied to some or all of the drugs used to produce anaesthesia and is also used to describe the whole process. For example, one might say, ‘Mary had a general anaesthetic.’

If you live in Australia, Canada, New Zealand, South Africa, or the United Kingdom, your anaesthetic will most likely be given by a specialist doctor. Depending on the country, this specialist is known as the anaesthetist or anaesthesiologist or anesthesiologist.

After graduating from medical school, these doctors have undertaken several years’ additional training in anaesthesia. Anaesthetic training is usually under the direction of a professional body, such as the Australian and New Zealand College of Anaesthetists, the Royal College of Physicians and Surgeons of Canada, or the Royal College of Anaesthetists in the United Kingdom. The training varies in content and length, depending on the country in which it is undertaken. In those countries mentioned above, the training is for a minimum of several years and equal in length to that of other specialists, including surgeons. The process to become a specialist anaesthetist includes intensive assessment and written and verbal examinations. If successful in passing the examinations, the anaesthetist becomes a Fellow of the national professional accrediting body, such as one of the Colleges mentioned above.

In Canada and the United States of America, specialist anaesthetists are known as anesthesiologists. American anesthesiologists have always been known by this term, to distinguish these doctors from Certified Registered Nurse Anaesthetists or CRNAs (see below). There are no nurse anaesthetists practising in Canada, Australia, New Zealand or the United Kingdom.

In the United States, at the completion of anaesthetic training, the doctor takes a written examination. The successful candidate must then pass an oral examination to become a Board Certified anesthesiologist. In Europe and many other countries, specialist anaesthetists are known as anaesthesiologists. This again denotes the distinction from ‘nurse anaesthetists’ who practise with specialists in many European countries.

After qualification, anaesthetists are strongly encouraged to continue their education throughout their professional lives. Most Colleges or other regulatory and licensing bodies now require some on-going evidence that the anaesthetist is keeping up to date. The degree of professional regulation depends on the country in which the anaesthetist practises.

In Canada, the Canadian Anesthesiologists’ Society is a professional organisation that has undertaken development of Guidelines to the Practice of Anaesthesia. These provide recommendations as to how anaesthetics are given – for example, which monitors should be used during an anaesthetic. The Royal College of Physicians and Surgeons of Canada (RCPSC), which regulates training and certification of anesthesiologists, plays no further specific role in the regulation of anaesthetic practice. However, the RCPSC does direct a system of continuing medical education, to enable specialists to continue learning and keep up to date.

By way of contrast, in Australia and New Zealand, the College of Anaesthetists (ANZCA) has developed guidelines for anaesthetic practice. In addition, the College directs a Continuing Professional Development (CPD) program in which any anaesthetist can participate.

In some countries, non-specialist doctors may also give anaesthetics, most often in rural areas. Smaller communities depend on non-specialist anaesthetists because the amount of work available is not sufficient to support a full-time specialist. These doctors have not usually had full specialty training, and tend to give anaesthetics for less complex operations; however, they also participate in programs aimed at maintaining skills and knowledge. Many non-specialist anaesthetists also continue to work as Family or General Practitioners.

Non-medical practitioners

In some countries, particularly in Europe, nurse anaesthetists give anaesthetics under the supervision of a specialist anaesthesiologist. Often they will work as a team, with one nurse anaesthetist and one anaesthesiologist for each patient. In other areas, nurse anaesthetists give anaesthetics under the direction of the surgeon, cardiologist or radiologist who may be operating or performing a procedure on a patient at the same time. In a few countries, nurse anaesthetists are legally allowed to practise without any supervision by a doctor.

Other assistants

In the Operating Room, your anaesthetist usually has the help of an assistant. This person could be a nurse, respiratory therapist or an anaesthetic technician. Ideally, the assistant has undergone formal training and examination, although this is not always the case. Anaesthetists value good assistants, who carry out many differing tasks. These tasks include preparing and checking drugs and equipment, and obtaining extra equipment from outside the Operating Room. The assistant may also attach various monitors to patients, such as an automatic blood pressure cuff, and then may record heart rate, blood pressure and other measurements on the anaesthetic record. In addition, the assistant hands drugs or equipment to your anaesthetist, and is generally available to help at all times, particularly at the beginning and end of the anaesthetic.

Depending on where you live and where your hospital is, a number of the people described above may be involved in providing your anaesthesia care. In addition, some hospitals also train other health care workers, such as ambulance attendants and paramedics, who may be present in the Operating Room and help with part of your anaesthetic..

Anaesthetists provide anaesthetic care for surgical operations, before the operation ( preoperative), during the operation ( intraoperative), and after the operation ( postoperative). They also provide anaesthetic care for patients undergoing non-surgical procedures, such a special heart examinations or X-ray treatment, particularly if these procedures are long, complex, or painful. Sometimes this care consists of providing sedation, either for a procedure such as an examination of the bowel ( endoscopy) or in addition to regional or local anaesthesia. (This is often called monitored anaesthesia care.)

Anaesthetists also provide relief of acute pain for women during labour and delivery, and to many patients after operations, as well as treatment of chronic pain for patients with long-term pain problems.

Many anaesthetists are involved in intensive care or in the provision of retrieval services and resuscitation. Retrieval services involve going to a small hospital by air or road ambulance, to fetch accident victims or patients who need specialised care in a major hospital.

Other anaesthetists spend part of their time doing research in diverse fields – studying how the body works, developing new drugs and equipment, and working out how to teach teams of medical workers to minimise human error and patient harm. Many anaesthetists also teach a wide range of health care workers, including medical and nursing students, interns, residents, specialists in training, and other specialists (surgeons, obstetricians, physicians, etc). Anaesthetists are also often asked to give talks of a general nature to interested groups, such as the Scouts, community organisations, and school classes. (If you would like to have an anaesthetist speak to your group, contact your local hospital Department of Anaesthesia or the College or Society.)

No matter which type of anaesthetic care they provide, the responsibilities of anaesthetists are similar. These responsibilities include evaluating the patient before the operation or procedure; forming a plan for the care of the patient during and after the anaesthetic; monitoring and supporting the patient during the procedure; and supervising care after the procedure.

Modern anaesthesia is safe, despite some of the stories you hear. To compare one hour of being anaesthetised with, say, one hour spent in traffic or a one-hour plane trip, the risk of dying is about one in ten thousand in traffic, about one in one million in an aircraft, and one in 100,000 – 500,000 during the anaesthetic. If you compare one hour of having an anaesthetic with an hour of air travel, then the risk of dying is about five to ten times higher during the anaesthetic. In contrast, an hour spent parachute-jumping carries a risk of death about 20 – 100 times that associated with anaesthesia. The safety of anaesthesia has increased over the years, even though much more complicated operations are being performed, for patients with more severe illnesses. For example, in Australia, the risk of death associated with anaesthesia has decreased to one-tenth of what it was thirty years ago. You can be confident that modern anaesthesia is very safe.

A number of factors have contributed to the overall safety of modern anaesthesia. These factors include your anaesthetist, the drugs and equipment used in the Operating Room, and overall medical care. For example, your anaesthetist is responsible for your overall health and safety from the start of your anaesthetic until you leave the recovery room after your operation. Your anaesthetist makes sure that all the anaesthetic equipment is working properly before you undergo anaesthesia. (This is just like the airline pilot who completes a pre-flight check of the aeroplane.) Your anaesthetist knows what to do if a problem occurs with any of the equipment during your anaesthetic. He or she will be with you throughout your operation, watching you and watching your surgeon. Your anaesthetist also continuously watches a number of monitors that measure many of the things happening to you while you are under the effects of the anaesthetic. Should there be any complications, either because of the anaesthetic drugs, or more likely because of the operation, your anaesthetist will respond quickly, having been fully trained in managing emergencies.

There have been major improvements in the drugs used for anaesthesia. Starting in 1846, the first anaesthetics were given with one drug, such as ether or chloroform. Inhaling these drugs was unpleasant, because of the smell and a sensation of choking. induction of anaesthesia was often slow and occasionally patients would struggle and have to be restrained. Because only one drug was used, patients needed heavy doses to make them very deeply anaesthetised. This was to ensure that the patients’ muscles were sufficiently relaxed for the surgeons to be able to operate. After the operation, patients often slept for long periods of time, as they breathed out the large amounts of drug that had been used. Vomiting and severe postoperative pain were very common.

Since the 1940s, anaesthetists have had the benefit of being able to use many new anaesthetic agents. All have contributed to the development of anaesthetic practice as it is today. The newer agents tend to be absorbed less by the body’s fat, which means that they have a shorter duration of action than the older agents. This allows anaesthetists to determine and control the depth of an anaesthetic more precisely for the requirements of each individual patient. However, the principle upon which the use of all of these drugs is based remains common to those of the original agents – ‘sufficient and safe’.

In addition to improvements in anaesthetic agents, there have been major changes in the equipment used to give the anaesthetic and to monitor its effects. As recently as the mid-1970s, anaesthetics were given in modern hospitals in Canada and Australia with only a blood pressure cuff and a stethoscope to monitor the patient. Since then, many new pieces of equipment have been introduced. As a result, anaesthetists are now better able to assess and evaluate what is happening to their patients.

The cost of anaesthetic care is in addition to the cost of surgical care. Fees charged by anaesthetists for their services vary in different countries, and depend on whether or not medical treatment is covered by a public health system. For patients receiving private medical care, the fee varies according to the length and complexity of the anaesthetic. In Australia, fees range from around $200 to $2000 or more. If you live in a country where anaesthetic fees are charged, you should ask your anaesthetist about the fees before the procedure.