History Reflected in the Evolving Approaches to Anesthesia for a Patient Undergoing Cholecystectomy

Fig. 7.1.
Ether, chloroform and nitrous oxide served most of the world’s needs for general anesthesia for a century. The increasing importance of anesthesia was associated with the development of inhaled anesthetics (e.g., cyclopropane) that competed with these original anesthetics in the 1920s and 1930s. Advances in fluorine chemistry resulting from the need to purify uranium in the 1940s for the atomic bomb led to the development of modern anesthetics (anesthetics containing fluorine; agents noted to the left of the cumulative graph.)

In the early 1950s, Europe was recovering from the physical and economic devastation of World War II, and Great Britain was essentially broke. The British Commonwealth, including Australia, New Zealand, Canada, and South Africa, all endured delayed economic recovery. Asia and Japan were similarly affected, and other countries depended on Britain, Europe or the US for experience and training in anesthesia. In the immediate post war period, only the US had the financial resources to make major investments in health care. There was another confounding factor. Clinical anesthesia in the US greatly depended on nurse anesthetists, and they followed protocols, unlike physicians, who were more inclined to do it “their way”.

Thus, developments in anesthesia tended to occur first in the US, where they could be afforded, and subsequently were adopted elsewhere. The following descriptions of practice, discuss US practice, noting differences from practice in other parts of the world.

As we approached the 1950s, the anesthesia for a cholecystectomy might have been similar in many parts of the world. Events flowing from World War II were about to shape anesthesia in different ways, in different countries, but they hadn’t done so yet. Ether, even after 100 years, was still the mainstay of anesthesia care (Fig. 7.1). The male patient, who at this time was almost certainly a smoker with a chronic cough, would have his preoperative care managed entirely by the surgeon, and might not see the anesthetist until he reached the operating room. Anesthesia would be induced, thankfully, by an intravenous (IV) injection of thiopental, after premedication with morphine and scopolamine. It is unlikely that IV fluids would have been administered, and in the unlikely event that the new muscle relaxant, Intocostrin, had been available, it probably would not have been used. Ether was still the usual anesthetic, perhaps assisted by some additional morphine. It likely would be given by mask, but in a few patients the trachea would have been intubated with a red rubber tracheal tube. In some cases cyclopropane might be used, with a circle absorption circuit to limit its escape and minimize the risk of explosion.

Postoperatively, the patient returned to their hospital room, and would likely spend two weeks recuperating. Pain would be managed by intramuscular or subcutaneous injections of morphine, administered sparingly by nurses according to a routine prescribed by the surgeon. Vomiting would be managed by the provision of a bowl. The diet would consist of weak tea, graduating to thin soup, and eventually something more substantial. The risk of dying was about 1:1000, a risk that would decrease by two orders of magnitude by the 2000s.

The 1950s Anesthetic

The patient requiring a cholecystectomy was still a smoker, and, reflecting the diet of the time, was lean. The anesthesiologist visited the patient in hospital the evening before surgery, reviewed the laboratory and chest X-ray results, took a rudimentary history, examined the chest, and described the likely anesthetic course to the patient. Pentobarbital was given to encourage sleep the night before surgery. As before, morphine and scopolamine were injected intramuscularly, an hour before surgery. A nasogastric tube was inserted before the patient left for the operating room (OR).

In the OR, 5% dextrose in water was infused IV via a steel needle inserted into a vein on the back of the hand, which was carefully padded to avoid infiltration. In the UK, no IV infusion was initiated preoperatively, only as necessary once the surgery had begun. Induction began with an injection made directly through a standard hypodermic needle taped in place. In the US, blood pressures were obtained manually using Riva Rocci’s method and palpation of the superficial temporal artery allowed monitoring of heart rate. The US anesthetist manually recorded these vital signs every 5 minutes on a chart devised a half century earlier by Codman and Cushing [3]. Elsewhere, the anesthetist might neither measure nor record such details. Oxford’s Macintosh famously argued that “The pulse is of little value as a guide to nitrous oxide anaesthesia [4].” The anesthetist injected thiopental from a glass syringe to induce anesthesia which was then sustained with nitrous oxide plus diethyl ether vaporized from an in-circuit Ohio 8 bottle in the US or a Goldman bottle elsewhere. In Great Britain and the Commonwealth, a Boyle’s machine might be used, with ether vaporized into a Mapleson “A” circuit from a Boyle bottle. As always, the anesthetist judged the amount of ether to give by the patient’s responses to the ether given [5]. Small doses of d-tubocurarine (Intocostrin) facilitated relaxation yet permitted continuing spontaneous, manually-assisted, ventilation via a hard conductive-rubber mask. Others might have given open drop ether via a Schimmelbusch mask just as in 1882 or provided anesthesia with cyclopropane.

The surgeon made a right subcostal incision. No antibiotics were given, nor was temperature monitored. The surgeon’s satisfaction and the anesthesiologist’s observation of the abdomen defined relaxation. OR personnel wore cotton clothing and shoes having conductive soles, and anesthetic circuits were conductive to reduce the likelihood of static electricity igniting the ether, or more importantly, the cyclopropane. The flammability of ether and cyclopropane usually precluded the use of electrocautery. As the fascia was closed, the anesthetist augmented relaxation by controlling ventilation (still by mask) and increasing the ether concentration, and then with fascial closure complete ceased ether delivery and control of ventilation. The UK anesthetist antagonized residual effects of curare, but the US anesthetist might not give neostigmine for fear of stopping the heart.

No supplemental oxygen was given during transport to the hospital room unless cyanosis was evident. Blood pressure and pulse rate might be monitored. The surgeon prescribed intramuscular injections of morphine to manage postoperative pain. Postanesthetic visits were rarely performed and notes documenting complications were written into the chart. A junior surgical house officer visited the patient twice daily to provide postoperative care. Recovery in hospital might exceed a week with no prophylaxis for deep vein thrombosis.

The 1960s Anesthetic

In the 1960s, the work of surgeon Thomas Shires prompted the use of salt-containing IV fluids [6]. Succinylcholine followed induction of anesthesia with thiopental, and the trachea was intubated with a cuffed red rubber tracheal tube cleansed with soap and water after its use in a prior patient.

Anesthesia was established and maintained with halothane in 70% nitrous oxide, and might but usually did not include intermittent IV doses of morphine or meperidine. Small doses of d-tubocurarine sustained relaxation. Later in the 1960s, (the 1970s in many countries) these changed to disposable polyvinylchloride tracheal tubes, enflurane, fentanyl, and pancuronium. Given the conversion to halothane or enflurane, the surgeon now used the electrocautery. OR personnel still wore shoes having conductive soles to reduce the likelihood of static electricity igniting cyclopropane or ether if they were used’an increasingly rare occasion. Ventilation was controlled either manually or with the aid of a mechanical ventilator. The effects of curare were empirically antagonized using neostigmine and atropine (toward the end of the decade, twitch height might be monitored). Once spontaneous ventilation and patient movement began, the tracheal tube was removed. The patient was transported to the Post Anesthesia Care Unit (PACU) rather than immediately to their room. Recovery took several days with no prophylaxis for deep vein thrombosis. Pain was controlled by intramuscular injection of opioid at prescribed intervals with allowance for additional doses at the patient’s request. Persistent vomiting, now much less common with the demise of ether, might invite an intramuscular injection of prochlorperazine.

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Mar 21, 2017 | Posted by in ANESTHESIA | Comments Off on History Reflected in the Evolving Approaches to Anesthesia for a Patient Undergoing Cholecystectomy

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