Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XV: Anesthesia and Analgesia
United States Department of Defense
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In order to achieve the best results in emergency surgery for battle wounds, anesthetic management must be provided by thoroughly trained and proficient anesthesiologists and nurse anesthetists. Therefore, it is imperative that the most experienced anesthetists available be assigned to forward surgical units in which lifesaving procedures are accomplished. In these instances, the choice and application of anesthesia carry the greatest risks land can be the most dangerous factors in that individual's total care.
The most experienced anesthetists, however, may be assisted by anesthetists of more limited training and experience, who can work under qualified supervision. Nurse anesthetists are employed throughout the U.S. armed forces and frequently outnumber anesthesiologists, as they do in many civilian hospitals in this country. Under emergency conditions when qualified anesthesia providers are scarce, other medical and dental officers without special training in anesthesiology may be employed for this purpose if instructed and supervised. In past conflicts, only a small portion of anesthesiologists deployed to combat areas were fully trained and/or board certified. With the progressive increase in the total number of physicians and with a different conceptual application toward anesthesia care, anesthesia will be delivered or directed by anesthesiologists who are fully trained and have attained expertise in trauma care as well as intensive care.
Enlisted paraprofessionals should be used only as technical assistants to maintain equipment, prepare patients, take vital signs, etc. Throughout the remainder of this chapter, the term "anesthetist" will refer to either physician anesthesiologists or nurse anesthetists.
In wartime, anesthetists in forward surgical units may be called upon to perform resuscitative measures, direct respiratory therapy, and manage other aspects of perioperative care in addition to the administration of anesthetics. The success of surgical treatment of the severely injured largely depends on the effectiveness of these efforts.
It is equally important that the quality of anesthesia care be evaluated on a regular basis to record morbidity and mortality as it relates to that care. Periodic evaluations of ongoing policies, drugs, and equipment are essential to assure appropriate care of the wounded.
The most significant alterations in the physiology of the trauma patient usually involve the circulatory and respiratory systems. Since basic resuscitative treatment will frequently have been initiated soon after wounding, the anesthetist should, before instituting additional measures, have a record of the events which occurred from wounding until arrival at the hospital. The patient's field medical card will usually provide this information. In particular, the anesthetist should know what fluids have been administered, what other resuscitative measures have been necessary, and the dosages and routes of administration of narcotics, sedatives, and other drugs.
Intraoperative management includes monitoring and restoration of homeostasis, maintenance of an operating environment, and measures to relieve pain and block noxious autonomic reflexes. It must also be ensured that an effective airway is maintained, secretions are evacuated, and supplemental oxygen is provided. The anesthetist is responsible for the anesthetic drugs, blood and blood products, plasma volume expanders, and electrolyte solutions during the surgical procedure. He institutes all other required supportive measures and directs the immediate postoperative care.
Prior to the patient's transfer to an intermediate or minimal care ward, the anesthetist must be certain that the vital signs have stabilized, that essential reflexes have returned, and that drug depression has abated satisfactorily.
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