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Key Points

  • image The discovery of anesthesia was one of the most important advances and has enabled surgery to occupy its fundamental place in medicine.

  • image Advances in anesthetic monitoring have made the administration of anesthesia safer than ever. Types of cardiovascular monitors include arterial catheters, central venous and pulmonary artery catheters, and transesophageal echocardiography.

  • image A detailed preoperative evaluation should be performed on each patient when circumstances allow, with special attention devoted to functional status. The American College of Cardiology/American Heart Association guidelines for preoperative evaluation can guide workup.

  • image The American Society of Anesthesiologists has developed specific guidelines for preoperative fasting to mitigate the risk of aspiration of gastric contents; individual patients may need more stringent preoperative fasting periods and/or rapid sequence inductions.

  • image The American Society of Anesthesiologists has developed an algorithm for management of the difficult airway. Notably, in patients in whom both intubation and ventilation are impossible, the algorithm calls for placement of a laryngeal mask airway as the next step.


The discovery of anesthesia is one of the seminal American contributions to the world. Along with infection control and blood image transfusion, anesthesia has enabled surgery to occupy its fundamental place in medicine. Before the advent of anesthesia in the 1840s, many substances and methods had been tried in the search for pain relief and better operating conditions. Patients were typically restrained by several attendants, and only the most stoic could tolerate the screams heard in the operating theater.


Horace Wells (1815–1848), a dentist, first pursued using nitrous oxide for the relief of pain in surgical procedures in 1844.1 After experimenting on himself, Wells attempted to demonstrate the analgesic effects of nitrous oxide for a dental procedure at Harvard Medical School in 1845. The public demonstration was a failure, at least partially, due to improper administration of the gas. Wells never recovered from his humiliating experience and eventually committed suicide. However, he does hold a place in history as the first person to recognize and use the only anesthetic from the 1800s that is still in use today—nitrous oxide.

Ether Day

William Morton (1819–1868) was a dentist and partner of Horace Wells. After taking a course in anesthesia from Wells, Morton left the partnership in Hartford, Connecticut, and established himself in Boston. He continued his interest in anesthesia, but using diethyl ether instead of nitrous oxide. Ether proved a good choice. He practiced the administration of ether on a dog and then used it when extracting teeth from patients in his office. On October 16, 1846, Morton gave the first public demonstration of ether as an anesthetic for Johns Collins Warren, a distinguished surgeon and one of the founders of Massachusetts General Hospital. In attendance in the surgical amphitheater were several surgeons, medical students, and a newspaper reporter. After induction ...

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