Basics of Anesthesia PDF
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Basics of ANESTHESIA SEVENTH EDITION Manuel C. Pardo, Jr., MD Professor of Anesthesia and Perioperative Care, Residency Program Director, University of California, San Francisco, School of Medicine, San Francisco, California Ronald D. Miller, MD, MS Professor Emeritus of Anesthesia, Department of Anesthesia and Perioperative Care, University of California, San Francisco, School of Medicine, San Francisco, California 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 BASICS OF ANESTHESIA, SEVENTH EDITION ISBN: 978-0-323-40115-9 Copyright © 2018 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the Publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluat- ing and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administra- tion, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted in 2011, 2007, 2000, 1994, 1989, 1984. Library of Congress Cataloging-in-Publication Data Names: Pardo, Manuel, Jr., 1965- editor. | Miller, Ronald D., 1939- editor. | Preceded by (work): Miller, Ronald D., 1939- Basics of anesthesia. Title: Basics of anesthesia / [edited by] Manuel C. Pardo, Jr., Ronald D. Miller. Description: Seventh edition. | Philadelphia, PA : Elsevier, [2018] | Preceded by Basics of anesthesia / Ronald D. Miller, Manuel C. Pardo Jr. 6th ed. c2011. | Includes bibliographical references and index. Identifiers: LCCN 2017001280 | ISBN 9780323401159 (hardcover : alk. paper) Subjects: | MESH: Anesthesia Classification: LCC RD81 | NLM WO 200 | DDC 617.9/6--dc23 LC record available at https://lccn.loc.gov/2017001280 Executive Content Strategist: Dolores Meloni Senior Content Development Specialist: Ann R. Anderson Publishing Services Manager: Patricia Tannian Senior Project Manager: Sharon Corell Book Designer: Ryan Cook Printed in Canada. Last digit is the print number: 9 8 7 6 5 4 3 2 1 v CONTRIBUTORS Amr E. Abouleish, MD, MBA Professor Department of Anesthesiology The University of Texas Medical Branch Galveston, Texas Meredith C.B. Adams, MD, MS Assistant Professor Department of Anesthesiology Director Pain Medicine Fellowship Medical College of Wisconsin Milwaukee, Wisconsin Dean B. Andropoulos, MD, MHCM Professor Department of Anesthesiology and Pediatrics Vice Chair Department of Anesthesiology Baylor College of Medicine Houston, Texas Jeffrey L. Apfelbaum, MD Professor and Chair Department of Anesthesia and Critical Care University of Chicago Medicine Chicago, Illinois Sheila R. Barnett, MD Associate Professor of Anaesthesia Harvard Medical School Vice Chair Perioperative Medicine Department of Anesthesiology, Critical Care, and Pain Medicine Beth Israel Deaconess Medical Center Boston, Massachusetts Charles B. Berde, MD, PhD Professor of Anaesthesia (Pediatrics) Harvard Medical School Chief Division of Pain Medicine Department of Anesthesiology, Perioperative and Pain Medicine Boston Children’s Hospital Boston, Massachusetts Michael P. Bokoch, MD, PhD Clinical Insructor and Liver Transplant Anesthesia Fellow Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Kristine E. W. Breyer, MD Assistant Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Richard Brull, MD, FRCPC Professor Department of Anesthesia University of Toronto Toronto, Ontario, Canada Vincent W.S. Chan, MD, FRCPC, FRCA Professor Department of Anesthesia University of Toronto Toronto, Ontario, Canada Contributors vi Tony Chang, MD Staff Anesthesiologist Swedish Medical Center Seattle, Washington Frances Chung, MBBS, FRCPC Professor Department of Anesthesiology University Health Network Toronto Western Hospital Toronto, Ontario, Canada Neal H. Cohen, MD, MPH, MS Vice Dean School of Medicine Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Daniel J. Cole, MD Professor of Clinical Anesthesiology Department of Anesthesiology Ronald Reagan UCLA Medical Center Los Angeles, California Wilson Cui, MD, PhD Assistant Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Andrew J. Deacon, B Biomed Sci (Hons), MBBS, FANZCA Staff Specialist Department of Anaesthesia and Pain Medicine The Canberra Hospital Garran, ACT, Australia David M. Dickerson, MD Assistant Professor Department of Anesthesia and Critical Care University of Chicago Medicine Chicago, Illinois Karen B. Domino, MD, MPH Professor and Vice Chair for Clinical Research Department of Anesthesiology and Pain Medicine University of Washington Seattle, Washington Kenneth Drasner, MD Professor Emeritus Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Talmage D. Egan, MD Professor and Chair Department of Anesthesiology University of Utah School of Medicine Salt Lake City, Utah Helge Eilers, MD Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California John Feiner, MD Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Alana Flexman, MD Clinical Assistant Professor Anesthesia, Pharmacology, and Therapeutics The University of British Columbia Vancouver, British Columbia, Canada Elizabeth A.M. Frost, MD Professor Department of Anesthesiology, Perioperative and Pain Medicine Icahn School of Medicine at Mount Sinai New York, New York Contributors vii vii William R. Furman, MD, MMHC Professor and Acting Chair Department of Anesthesiology Dartmouth College Geisel School of Medicine Vice President Regional Perioperative Service Line Dartmouth Hitchcock Medical Center Lebanon, New Hampshire Steven Gayer, MD, MBA Professor of Anesthesiology and Ophthalmology Department of Anesthesiology University of Miami Miller School of Medicine Miami, Florida Sarah Gebauer, MD, BA Assistant Professor Department of Anesthesiology and Critical Care Medicine and Department of Internal Medicine Division of Palliative Care University of New Mexico Albuquerque, New Mexico Rebecca M. Gerlach, MD FRCPC Assistant Professor Department of Anesthesia and Critical Care Interim Director for Anesthesia Perioperative Medicine Clinic University of Chicago Medicine Chicago, Illinois David B. Glick, MD, MBA Professor Department of Anesthesia and Critical Care Medical Director Post-Anesthesia Care Unit University of Chicago Medicine Chicago, Illinois Erin A. Gottlieb, MD Assistant Professor Department of Anesthesiology Baylor College of Medicine Director of Clinical Operations Division of Pediatric Cardiovascular Anesthesiology Texas Children’s Hospital Houston, Texas Andrew T. Gray, MD, PhD Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Melissa Haehn, MD Assistant Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Jin J. Huang, MD Assistant Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Lindsey L. Huddleston, MD Assistant Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Robert W. Hurley, MD, PhD Professor and Vice Chairman Department of Anesthesiology Director F&MCW Comprehensive Pain Program Medical College of Wisconsin Milwaukee, Wisconsin Contributors viii Omar Hyder, MD, MS Staff Anesthesiologist Department of Anesthesia, Critical Care, and Pain Medicine Massachusetts General Hospital Boston, Massachusetts Andrew Infosino, MD Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Ken B. Johnson, MD Professor Department of Anesthesiology University of Utah School of Medicine Salt Lake City, Utah Tae Kyun Kim, MD, PhD Associate Professor Department of Anesthesia and Pain Medicine Pusan National University School of Medicine Busan, Korea Kerry Klinger, MD Assistant Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Anjali Koka, MD Instructor in Anaesthesia Harvard Medical School Department of Anesthesiology, Perioperative and Pain Medicine Boston Children’s Hospital Boston, Massachusetts Catherine Kuza, MD Assistant Professor Department of Anesthesiology and Critical Care Medicine Keck School of Medicine of the University of Southern California Los Angeles, California Benn Lancman, MBBS, MHumFac, FANZCA Visiting Clinical Instructor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Associate Clinical Instructor School of Medicine University of Sydney Sydney, NSW, Australia Chanhung Z. Lee, MD, PhD Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Linda L. Liu, MD Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Jennifer M. Lucero, MD Assistant Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Alan J.R. Macfarlane, BSc (Hons), MBChB (Hons), MRCP, FRCA Consultant Anaesthetist Department of Anaesthesia Glasgow Royal Infirmary and Stobhill Ambulatory Hospital Honorary Senior Clinical Lecturer Department of Anaesthesia, Critical Care, and Pain Medicine University of Glasgow, Great Britain Contributors ix ix Vinod Malhotra, MD Professor and Vice-Chair for Clinical Affairs Department of Anesthesiology Professor of Anesthesiology in Clinical Urology Weill Cornell Medical College Clinical Director of the Operating Rooms New York-Presbyterian Hospital Weill-Cornell Medical Center New York, New York Mitchell H. Marshall, MD Clinical Professor and Chief of Anesthesiology Service New York University Langone Hospital for Joint Diseases Department of Anesthesiology, Perioperative Care, and Pain Medicine New York University School of Medicine New York, New York Mary Ellen McCann, MD, MPH Senior Associate in Perioperative Anesthesia Associate Professor of Anaesthesia Harvard Medical School Department of Anesthesiology Perioperative and Pain Medicine Boston Children’s Hospital Boston, Massachusetts Joseph H. McIsaac, III, MD, MS Associate Clinical Professor Department of Anesthesiology University of Connecticut School of Medicine Farmington, Connecticut Chief of Trauma Anesthesia Department of Anesthesiology Hartford Hospital Hartford, Connecticut Rachel Eshima McKay, MD Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Lingzhong Meng, MD Professor of Anesthesiology and Neurosurgery Chief Division of Neuro Anesthesia Department of Anesthesiology Yale University School of Medicine New Haven, Connecticut Ronald D. Miller, MD, MS Professor Emeritus of Anesthesia Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Cynthia Newberry, MD Assistant Professor Department of Anesthesiology University of Utah School of Medicine Salt Lake City, Utah Dorre Nicholau, MD, PhD Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Shinju Obara, MD Associate Professor Surgical Operation Department Anesthesiology and Pain Medicine Fukushima Medical University Hospital Fukushima, Japan Howard D. Palte, MBChB, FCA(SA) Assistant Professor Department of Anesthesiology University of Miami Miami, Florida Contributors x Anup Pamnani, MD Assistant Professor of Anesthesiology Department of Anesthesiology Weill Cornell Medical College New York, New York Manuel C. Pardo, Jr., MD Professor and Vice Chair Residency Program Director Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Krishna Parekh, MD Assistant Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California James P. Rathmell, MD Professor of Anaesthesia Harvard Medical School Chair Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Women’s Health Care Boston, Massachusetts Amy C. Robertson, MD, MMHC Assistant Professor Department of Anesthesiology Vanderbilt University Medical Center Nashville, Tennessee David Robinowitz, MD, MHS, MS Associate Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Mark D. Rollins, MD, PhD Professor Department of Anesthesia and Perioperative Care Director Obstetric and Fetal Anesthesia University of California, San Francisco, School of Medicine San Francisco, California Andrew D. Rosenberg, MD Professor and Chair and Dorothy Reaves Spatz, MD, Chair Department of Anesthesiology, Perioperative Care, and Pain Medicine New York University School of Medicine New York, New York Patricia Roth, MD Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Scott R. Schulman, MD, MHS Professor of Anesthesia, Surgery, and Pediatrics Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California David Shimabukuro, MDCM Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Mandeep Singh, MBBS, MD, MSc, FRCPC Assistant Professor Department of Anesthesiology Toronto Western Hospital University Health Network Toronto, Ontario, Canada Contributors xi xi Peter D. Slinger, MD, FRCPC Professor and Staff Anesthesiologist Department of Anesthesia University of Toronto Toronto General Hospital Toronto, Ontario, Canada Sulpicio G. Soriano, II, MD Professor Department of Anesthesia, Critical Care, and Pain Medicine Harvard Medical School Endowed Chair in Pediatric Neuroanesthesia Boston Children’s Hospital Boston, Massachusetts Scott Springman, MD Professor Department of Anesthesiology Medical Director Outpatient Surgical Services University of Wisconsin School of Medicine and Public Health Madison, Wisconsin Randolph H. Steadman, MD, MS Professor and Vice Chair of Education Director Liver Transplant Anesthesiology Department of Anesthesiology and Perioperative Medicine University of California, Los Angeles David Geffen School of Medicine Los Angeles, California Erica J. Stein, MD Associate Professor Department of Anesthesiology Wexner Medical Center at The Ohio State University Columbus, Ohio Marc Steurer, MD, DESA Associate Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine Vice Chief Department of Anesthesia and Perioperative Care Zuckerberg San Francisco General Hospital and Trauma Care San Francisco, California Bobbie Jean Sweitzer, MD, FACP Professor of Anesthesiology Director Perioperative Medicine Northwestern University Feinberg School of Medicine Chicago, Illinois James Szocik, MD Clinical Associate Professor Department of Anesthesiology University of Michigan Ann Arbor, Michigan Magnus Teig, MB, ChB, MRCP, FRCA Clinical Associate Professor Department of Anesthesiology University of Michigan Ann Arbor, Michigan Kevin K. Tremper, PhD, MD Professor and Chair Department of Anesthesiology University of Michigan Ann Arbor, Michigan Avery Tung, MD, FCCM Professor and Quality Chief for Anesthesia Department of Anesthesia and Critical Care University of Chicago Chicago, Illinois Contributors xii John H. Turnbull, MD Assistant Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Arthur Wallace, MD, PhD Professor Department of Anesthesia and Perioperative Care Chief Anesthesiology Service San Francisco Veterans Affairs Medical Center University of California, San Francisco San Francisco, California Stephen D. Weston, MD Assistant Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Elizabeth L. Whitlock, MD, MSc Clinical Instructor and Postdoctoral Research Fellow Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California Victor W. Xia, MD Clinical Professor Department of Anesthesiology and Perioperative Medicine University of California, Los Angeles David Geffen School of Medicine Los Angeles, California Edward N. Yap, MD Assistant Professor Department of Anesthesia and Perioperative Care University of California, San Francisco, School of Medicine San Francisco, California xiii The first edition of Basics of Anesthesia, edited by Robert K. Stoelting and Ronald D. Miller, was my first textbook of anesthesia. As an anesthesia resident at the University of California, San Francisco (UCSF), I relied on Basics of Anesthesia to provide concise coverage of fundamental principles and developments in our field. Drs. Stoelting’s and Miller’s co-editorship of the book continued through the fifth edition. The sixth edition, published in 2011 by Dr. Miller and new co-editor, Manuel C. Pardo, Jr., fea- tured a companion website, Expert Consult, that presented the complete text and illustrations in an online format. This seventh edition of Basics of Anesthesia represents the culmination of Dr. Miller’s 33-year stewardship of the book. We should admire his determined leadership to publish a textbook that offers the anesthesia community an invaluable educational resource reflecting the ever- evolving practice of anesthesia. This book is symbolic of Dr. Miller’s uncompromising desire for all anesthesia learners and providers to walk in his path, in “the Pur- suit of Excellence,” which was the title of his Rovenstine Lecture at the Annual Meeting of the American Society of Anesthesiology in 2008. Michael A. Gropper, MD, PhD Professor and Chair UCSF Department of Anesthesia and Perioperative Care FOREWORD xv PREFACE TO THE SEVENTH EDITION The Basics of Anesthesia continues its tradition of pro- viding updated and concise information for the entire community of anesthesia learners. In this seventh edition, editors Ronald D. Miller and Manuel C. Pardo, Jr., have added four new chapters and rigorously updated all con- tent to reflect evolving developments in the specialty. The editors are pleased to welcome the contribution of more than 30 new authors, mostly from the United States, but also from Japan, Australia, Canada, South Korea, and the United Kingdom. This edition marks the transition to a new lead edi- tor, Manuel C. Pardo, Jr., Professor of Anesthesia and Perioperative Care and Director of the Anesthesia Resi- dency Program at the University of California, San Fran- cisco. Dr. Pardo has worked alongside retiring lead editor, Dr. Miller, to identify emerging trends and chronicle advances in anesthesia care. In this edition the editors have eliminated the History chapter and added four new chapters: Chapter 12, “Anesthetic Neurotoxicity”; Chap- ter 49, “Palliative Care”; Chapter 50, “Sleep Medicine and Anesthesia”; and Chapter 51, “New Models of Anesthesia Care: Perioperative Medicine, the Perioperative Surgical Home, and Population Health.” The editors elected to pro- vide more in-depth coverage to the prior edition’s chapter on “Trauma, Bioterrorism, and Natural Disasters,” which has been split into two chapters: Chapter 42, “Anesthesia for Trauma,” and Chapter 43, “Human-Induced and Natu- ral Disasters.” Multiple chapters have been restructured to promote clarity and organization of the material. In addition, we have continued to make extensive use of color figures, illustrations, and tables to present concepts in a focused manner. Each chapter has “Questions of the Day,” which are designed to promote reflection on the chapter content. Many questions focus on understanding relevant basic concepts as well as analyzing challenging clinical situations. We are extremely thankful to the authors of the current and previous editions of Basics of Anesthesia for their commitment to the excellence of the book. The editors also gratefully acknowledge the expertise of editorial analyst Tula Gourdin, who managed the communication with the authors, editors, and publisher and ensured that no detail was overlooked throughout the entire publication process. We also wish to acknowledge our publisher, Elsevier, and the dedication of their staff, including executive content strategists William R. Schmitt and Dolores Meloni, senior content development specialist Ann Ruzycka Anderson, and senior project manager Sharon Corell. Ronald D. Miller Manuel C. Pardo, Jr. 3 The specialty of anesthesiology has evolved dramatically since the first public demonstration of ether use in the 19th century. Originally, the emphasis was completely on providing surgical anesthesia. As surgical procedures became more diverse and complex, other associated skills were developed. For example, airway management, including endotracheal intubation, was required to pro- vide controlled ventilation to patients who had respiratory depression and paralysis from neuromuscular blocking drugs. These practices required the development of a “recovery room,” which was later termed a postoperative or postanesthesia care unit (PACU) (Chapter 39). The skills that anesthesiologists used in the recovery room evolved and progressed into intensive care units (ICUs) and the specialty of critical care medicine (Chapter 41). The devel- opment of regional anesthesia created opportunities for treatment of some chronic pain syndromes (Chapters 40 and 44). Anesthesiology also evolved into a recognized medical specialty (as affirmed by the American Medical Association and the American Board of Medical Special- ties), providing continuous improvement in patient care based on the introduction of new drugs and techniques made possible in large part by research in the basic and clinical sciences. DEFINITION OF ANESTHESIOLOGY AS A SPECIALTY A more formal definition of the specialty of anesthesi- ology is provided by The American Board of Anesthe- siology (ABA).1 The ABA defines anesthesiology as a Chapter 1 SCOPE OF ANESTHESIA PRACTICE Ronald D. Miller and Manuel C. Pardo, Jr. DEFINITION OF ANESTHESIOLOGY AS A SPECIALTY EVOLUTION OF ANESTHESIA AS A MULTI- DISCIPLINARY MEDICAL SPECIALTY Pain Management Critical Care Medicine Pediatric Anesthesia Cardiac Anesthesia Obstetric Anesthesia Other Surgical Areas of Anesthesia PERIOPERATIVE PATIENT CARE Preoperative Evaluation Operating Room Theaters Postanesthesia Care Unit TRAINING AND CERTIFICATION IN ANESTHESIOLOGY Postgraduate (Residency) Training in Anesthesiology American Board of Anesthesiology Credentialing and Privileging OTHER ANESTHETIC PROVIDERS Certified Registered Nurse Anesthetists Anesthesiologist Assistants QUALITY OF CARE AND SAFETY IN ANESTHESIA Continuous Quality Improvement ORGANIZATIONS WITH EMPHASIS ON ANESTHESIA QUALITY AND SAFETY Anesthesia Patient Safety Foundation Anesthesia Quality Institute American Society of Anesthesiology Closed Claims Project and Its Registries Foundation for Anesthesia Education and Research PROFESSIONAL LIABILITY Adverse Events RISKS OF ANESTHESIA HAZARDS OF WORKING IN THE OPERAT- ING ROOM SUMMARY AND FUTURE OUTLOOK QUESTIONS OF THE DAY Section I INTRODUCTION 4 discipline within the practice of medicine dealing with but not limited to: 1. Assessment of, consultation for, and preparation of patients for anesthesia. 2. Relief and prevention of pain during and following surgical, obstetric, therapeutic, and diagnostic procedures. 3. Monitoring and maintenance of normal physiology during the perioperative period. 4. Management of critically ill patients including those receiv- ing their care in an intensive care unit. 5. Diagnosis and treatment of acute, chronic, and cancer-related pain. 6. Management of hospice and palliative care. 7. Clinical management and teaching of cardiac, pulmonary, and neurologic resuscitation. 8. Evaluation of respiratory function and application of respira- tory therapy. 9. Conduct of clinical, translational, and basic science research. 10. Supervision, instruction, and evaluation of performance of both medical and allied health personnel involved in periopera- tive or periprocedural care, hospice and palliative care, critical care, and pain management. 11. Administrative involvement in health care facilities and orga- nizations, and medical schools as appropriate to the ABA’s mission. As with other medical specialties, anesthesiology is represented by professional societies (American Society of Anesthesiologists, International Anesthesia Research Society), scientific journals (Anesthesiology, Anesthesia & Analgesia), a residency review committee with delegated authority from the Accreditation Council for Graduate Medical Education (ACGME) to establish and ensure com- pliance of anesthesia residency training programs with published standards, and a medical specialty board, the ABA, that establishes criteria for becoming a certified specialist in anesthesiology. The ABA, in conjunction with other specialty boards, has also developed criteria for maintenance of certification, which includes a pro- gram of continual self-assessment and lifelong learning, along with periodic assessment of professional standing, cognitive expertise in practice performance, and improve- ment.1 This describes the American system. Other coun- tries and societies have their systems to certify specialists in anesthesiology. Some countries work in a collective manner to educate and certify specialists in anesthesiol- ogy (e.g., European Society of Anesthesia). EVOLUTION OF ANESTHESIA AS A MULTIDISCIPLINARY MEDICAL SPECIALTY In the last 50 years, the medical specialty of anesthesiology has progressively extended its influence outside the oper- ating rooms. Initially, the most important non–operating room patient care skills developed by anesthesia provid- ers have been in pain management (Chapters 40 and 44) and adult critical care medicine (Chapter 41). Beginning in the 1980s, anesthesia residency training required rotation experiences in these areas. In 1985, the ABA began issu- ing subspecialty certificates in critical care medicine to candidates who had completed at least a year of specialty training, thus becoming the first recognized subspecialty of anesthesiology. Pain medicine became the second sub- specialty to be formally recognized when the ABA began issuing certificates in 1991. By this time, residency pro- grams required rotations in multiple specialty areas, and fellowship programs in many areas were being developed. This reflected the progressive complexity of health care as well as extensive specialization in all fields of medicine. Pain Management Pain management is required in the perioperative setting (Chapter 40) as well as for chronic pain conditions (Chap- ter 44). The management of perioperative pain has become more complex as the relationship between postoperative pain control and functional outcomes (e.g., mobility after joint replacement surgery) has become more tightly linked. In addition, the increasing use of neuraxial and regional anes- thesia techniques (Chapters 17 and 18) for postoperative pain management has led to increasingly specialized acute pain management services usually managed by anesthesiology. An outpatient-based pain management center typi- cally takes care of patients with chronic pain on an out- patient basis with occasional consultations in the hospital itself (e.g., for patients with chronic pain who require sur- gery that leads to acute and chronic pain). Many special- ties are involved in chronic pain management, including neurology, neurosurgery, medicine, psychiatry, physical medicine, and physical therapy. Critical Care Medicine Critical care medicine has significantly increased in com- plexity over the 30 years it has been recognized as a distinct subspecialty of anesthesiology (see Chapter 41). Increasingly, data from large randomized clinical trials are used to develop patient care protocols.2 The catego- rization of ICU patients is most often arranged by one or more specialties (e.g., medical, surgical, neurosurgical, cardiac). Because so many specialties can or need to be involved, the critical care medicine specialist may have his or her initial residency training in several different specialties, including anesthesiology, medicine, surgery, neurology, pulmonary medicine, nephrology, or emer- gency medicine. In many institutions, anesthesiologists are in local leadership roles in critical care medicine. Pediatric Anesthesia Since the 1980s, anesthesia residency training has included rotations in pediatric anesthesia (see Chapter 34), and sepa- rate pediatric anesthesia fellowships have been offered for
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