Category: Uncategorized

Globalization has connected people, markets and governments all over the world; thus, health policy has become an international issue.¹ This includes promoting health across borders and assisting countries in assessing and acting on international public health risks.¹ Global health initiatives range from non-governmental organizations² to governmental institutions³ to humanitarian programs such as Médecins Sans Frontières (Doctors Without Borders).⁴ As clinicians who are crucial to pain management and surgical procedures, anesthesia providers should be familiar with global health issues and associated organizations, types of global health efforts and anesthesiology professionals’ roles in global health care. 

Global health issues change constantly depending on patterns of infectious diseases, humanitarian crises or environmental factors.⁵ According to the World Health Organization (WHO), ten of the main global health issues in 2019 were air pollution and climate change, noncommunicable diseases such as diabetes and cancer, the global influenza pandemic, places with little access to health care, antimicrobial resistance from medication overuse, Ebola and other high-threat pathogens, weak primary health care, vaccine refusal, dengue fever and HIV.⁵ The WHO has a five-year plan with three main “billion” targets: one billion more people to benefit from universal health coverage, one billion more people better protected from health emergencies and one billion more people enjoying better health and well-being.⁶ Nongovernmental organizations (NGOs) working in global health include international organizations, such as the Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Bank and the World Health Organization; scientific organizations such as the American Society of Tropical Medicine and Hygiene (ASTMH), the Consortium of Universities for Global Health (CUGH), the International Society for Infectious Diseases (ISID) and the International Diabetes Federation (IDF); advocacy/policy organizations such as the Earth Institute or the Global Alliance for Chronic Diseases (GACD); foundations such as the Bill and Melinda Gates Foundation and UN Foundation (UNF); and resources such as the Institute for Health Metrics and Evaluation (IMHE) and Worldmapper.⁷ 

Global health efforts often aim to improve health outcomes in low- and middle-income countries (LMICs) by strengthening health systems, which entails global investment and national intervention.⁸ At the national level, health systems improvement involves increasing capacity to manage and deliver services, situating interventions firmly within national strategies, ensuring effective implementation and coordinating external support with local resources.⁸ Countries have been collaborating to tackle health issues with specific interventions for centuries.⁹ For example, in the mid-1800s, several countries negotiated international agreements on how to combat cross-border outbreaks of diseases such as cholera and yellow fever.⁹ Among other historical milestones, the WHO was founded in 1948, the Alma-Ata Declaration of 1978 brought the focus of global health to primary care and the Global Fund to Fight AIDS, Tuberculosis and Malaria was established in 2002.¹⁰ Noncommunicable diseases, injuries and mental health have required more attention in contemporary global health efforts,¹¹ which include medical and non-medical work in the field for expatriates¹² and in-country policy changes.¹¹ 

Anesthesia providers play a crucial role in global health efforts.¹³ Surgical disease is an important cause of death and disability in LMICs; however, there remains a shortage of trained anesthesia providers in LMICs who can respond to the need for surgical care.¹³ In today’s highly connected world, application- and technology-based health solutions may expand surgical services, improve patient care and increase patient education within anesthesiology.¹⁴ Anesthesiology practitioners may focus on teaching and providing anesthesia care in a country’s teaching hospitals¹⁵ or contribute to life-supporting care during disaster management.¹⁶ Though improvements in anesthesiology are vital to global health efforts, the relationship between global health and anesthesia care remains ill-defined and unappreciated.¹⁷ Global health education in anesthesiology residency is inconsistent in program structure, goals, curricula and funding.¹⁸ In the future, outreach programs for anesthesiology residents or fellows may allow them to explore global health work and reduce the work-related barriers associated with global health care participation.¹⁹ 

As people all over the world connect through technology and travel, international health systems improvement becomes a main focus of health care efforts. Global health challenges cross borders and are constantly changing, with organizations targeting a variety of diseases and environmental issues throughout different regions. As the need for surgery rises, anesthesia providers become more vital to global health efforts. In the future, anesthesiology professionals should investigate global health curricula and opportunities for anesthesia providers to participate in global health work. 

1.Drager N, Beaglehole R. Globalization: Changing the public health landscape. Bulletin of the World Health Organization. 2001;79(9):803. 

2.Delisle H, Roberts JH, Munro M, Jones L, Gyorkos TW. The role of NGOs in global health research for development. Health Research Policy and Systems. 2005;3(1):3. 

3.National Institutes of Health (NIH) Fogarty International Center. Global Health at NIH. Global Health Resources March 2020; https://www.fic.nih.gov/Global/Global-Health-NIH/Pages/default.aspx. 

4.Médecins Sans Frontières/Doctors Without Borders. 2020; https://www.doctorswithoutborders.org/. 

5.World Health Organization. Ten threats to global health in 2019. Feature stories 2019; https://www.who.int/news-room/feature-stories/ten-threats-to-global-health-in-2019. 

6.Thirteenth general programme of work 2019−2023. Geneva, Switzerland: World Health Organization; May 16, 2018. 

7.National Institutes of Health (NIH) Fogarty International Center. Nongovernmental Organizations (NGOs) Working in Global Health Research. Global Health Resources August 2019; https://www.fic.nih.gov/Global/Global-Health-NIH/Pages/default.aspx. 

8.Balabanova D, McKee M, Mills A, Walt G, Haines A. What can global health institutions do to help strengthen health systems in low income countries? Health Research Policy and Systems. 2010;8(1):22. 

9.Fidler DP. The globalization of public health: The first 100 years of international health diplomacy. Bulletin of the World Health Organization. 2001;79:842–849. 

10.The U.S. Government Engagement in Global Health: A Primer. San Francisco: Kaiser Family Foundation; February 5, 2019. 

11.De Cock KM, Simone PM, Davison V, Slutsker L. The new global health. Emerging Infectious Diseases. 2013;19(8):1192–1197. 

12.Work in the field. Médecins Sans Frontières/Doctors Without Borders 2020; https://www.doctorswithoutborders.org/careers/work-field. 

13.Klar G. The Role of Anesthesiology in Global Health: A Comprehensive Guide. Canadian Journal of Anesthesia/Journal canadien d’anesthésie. 2015;62(8):941. 

14.Atcheson CLH. The Future of Anesthesiology and Global Health in a Connected World. In: Roth R, Frost EAM, Gevirtz C, Atcheson CLH, eds. The Role of Anesthesiology in Global Health: A Comprehensive Guide. Cham: Springer International Publishing; 2015:403–416. 

15.Bridenbaugh PO. Role of Anesthesiologists in Global Health: Can One Volunteer Make a Difference? International Anesthesiology Clinics. 2010;48(2):165–175. 

16.Chandler D, Keflemariam Y, Fox CJ, Kaye AD. Anesthesiologists’ Role in Disaster Management. In: Roth R, Frost EAM, Gevirtz C, Atcheson CLH, eds. The Role of Anesthesiology in Global Health: A Comprehensive Guide. Cham: Springer International Publishing; 2015:305–321. 

17.Harris MJ. We Need More Reports of Global Health Anesthesia Articles. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2016;124(2):267–269. 

18.Kaur G, Tabaie S, Brar J, Tangel V, Pryor KO. Global health education in United States anesthesiology residency programs: A survey of resident opportunities and program director attitudes. BMC Medical Education. 2017;17(1):215. 

19.McCunn M, Speck RM, Chung I, Atkins JH, Raiten JM, Fleisher LA. Global health outreach during anesthesiology residency in the United States: A survey of interest, barriers to participation, and proposed solutions. Journal of Clinical Anesthesia. 2012;24(1):38–43. 

Pregnancy termination can be a complicated procedure for both the patient and the provider. Patients may have different preferences for anesthesia or sedation,¹ and providers may have to alter the procedure depending on the patient’s gestational age.² During the first trimester, an abortion procedure can be completed with manual vacuum aspiration (MVA) or electric vacuum aspiration.³ Later procedures may require dilation and evacuation (D&E) or dilation and extraction (D&X), which involve hours to days of cervical preparation and widening.^2,4 The pre-abortion process entails counseling, paperwork, a thorough medical history, physical examination, blood test, screening for sexually transmitted infections and an ultrasound to confirm the age of the pregnancy.² During the procedure, anesthesia and analgesia may consist of local anesthesia and analgesic or sedative medications.⁵ Anesthesiology professionals and abortion providers should be aware of the variety of medications used for pregnancy termination procedures, as well as the efficacy of certain medications and practices.

Because pregnancy termination is a relatively routine procedure, most abortions can be performed on an outpatient basis.⁶ Thus, an anesthesiologist may not always be necessary. Instead, nurses and nurse practitioners who have special training in abortion procedures may administer local anesthesia and moderate sedation.⁶ The type of provider who administers anesthesia or sedation and the type of medication used may differ across clinics and based on gestational age.⁷ For example, most providers give patients oral pain medication, such as ibuprofen, before the procedure in order to prevent pain.^5-7 In some practices, oral medication may include a sedative, such as a benzodiazepine (e.g., Valium) or a stronger pain medication, such as an opioid (e.g., Vicodin).⁶ Also, some patients may request intravenous mild, moderate or heavy sedation to reduce anxiety and pain during the procedure.⁸ Moderate sedation will allow the patient to stay awake but very relaxed, while heavy sedation means complete loss of consciousness.⁷ In addition to these anesthetic and analgesic medications, the patient will receive antibiotics to reduce risk of infection, as well as medications to soften the cervix depending on gestational age.⁸ Guidelines for eating or drinking before a procedure vary based on gestational age and clinic practices, including use of anesthetics. While some procedures do not require fasting before the appointment,^6,7 others may entail foregoing food for several hours in preparation for heavy sedation.⁸ Overall, anesthetic practices for pregnancy termination depend on procedure type, gestational age and the preferences of both the patient and provider.

Due to these various factors, the efficacy of anesthetic techniques varies widely between patients. For abortion procedures without intravenous medications, Allen and Singh recommend a multimodal approach to pain management, such as premedication with a non-steroidal anti-inflammatory drug (NSAID), emotional support person, visual or auditory distraction and local anesthesia to the cervix with lidocaine.⁹ According to their review, oral opioids did not reduce procedural pain and oral anxiolytics decreased anxiety (but not pain) in patients who did not use intravenous anesthesia.⁹ In their study, Hamoda et al. found that MVA under local anesthesia was effective and acceptable to patients.¹⁰ Meanwhile, a study by Xia and Chen found that local anesthesia combined with psychological intervention was more effective in pain relief and patient satisfaction than local anesthesia alone, suggesting that nonpharmacological interventions may be useful in cases without intravenous sedation.¹¹ Other research has approached intravenous medications for patients who necessitate or request it. Rawling and Wiebe’s study found that intravenous fentanyl was not significantly effective in pain reduction compared to placebo.¹² Zhang et al. showed that intravenous propofol and dezocine led to more pain reduction and shorter recovery time than propofol alone.¹³ In regards to complications, Clare et al. found that inhaled sevoflurane or desflurane led to greater intraoperative blood loss than intravenous propofol.¹⁴ Another study by Gokhale et al. found that intravenous sedation with fentanyl without tracheal intubation did not increase risk of complications in obese patients compared to non-obese patients.¹⁵ Evidently, a variety of intravenous, inhaled and oral medications can be used to induce different levels of anesthesia.

Anesthesia provision for pregnancy termination is complex, as it depends on gestational age, patient and provider preferences and institutional practices. Analgesia and anesthesia in abortion can range from no sedation to complete loss of consciousness, and can be provided through oral, intravenous or inhaled routes. Future research is needed to evaluate the best forms of pharmacologic and nonpharmacologic pain control in patients who do not use moderate or heavy sedation.⁹ Additionally, policies should aim to standardize care across clinics in order to effectively assess different anesthetic practices for pregnancy termination.

1.         Singh R. Patient Preferences in Anesthesia for Abortion Care (PAC). ClinicalTrials.gov October 26, 2017.

2.         Johnson TC. What Are the Types of Abortion Procedures? Women’s Health March 30, 2019; https://www.webmd.com/women/abortion-procedures.

3.         Goldberg AB, Dean G, Kang MS, Youssof S, Darney PD. Manual versus electric vacuum aspiration for early first-trimester abortion: A controlled study of complication rates. Obstetrics & Gynecology. 2004;103(1):101–107.

4.         Blanchard K, Fried MG, Issokson D, et al. Dilation and Evacuation Abortion. Abortion April 2, 2014; https://www.ourbodiesourselves.org/book-excerpts/health-article/dilation-and-evacuation-abortion/.

5.         Sharma M. Manual vacuum aspiration: An outpatient alternative for surgical management of miscarriage. The Obstetrician & Gynaecologist. 2015;17(3):157–161.

6.         UCSF Health. Surgical Abortion (First Trimester). In: The Regents of the University of California, ed. Treatments A–Z. Web 2020.

7.         Planned Parenthood Federation of America. What happens during an in-clinic abortion? In-Clinic Abortion 2020; https://www.plannedparenthood.org/learn/abortion/in-clinic-abortion-procedures/what-happens-during-an-in-clinic-abortion.

8.         UCSF Health. Surgical Abortion (Second Trimester). In: The Regents of the University of California, ed. Treatments A–Z. Web 2020.

9.         Allen RH, Singh R. Society of Family Planning clinical guidelines pain control in surgical abortion part 1—Local anesthesia and minimal sedation. Contraception. 2018;97(6):471–477.

10.       Hamoda H, Flett GM, Ashok PW, Templeton A. Surgical abortion using manual vacuum aspiration under local anaesthesia: A pilot study of feasibility and women’s acceptability. The Journal of Family Planning and Reproductive Health Care. 2005;31(3):185–188.

11.       Xia L, Chen Y. Effect of lidocaine combined with local anesthesia and psychological intervention on induced abortion. Chinese Journal of Biochemical Pharmaceutics. 2017;37(6):351–352.

12.       Rawling MJ, Wiebe ER. A randomized controlled trial of fentanyl for abortion pain. American Journal of Obstetrics & Gynecology. 2001;185(1):103–107.

13.       Zhang M, Ying C, Wei H. Evaluation of different doses dezocine combined with propofol intravenous anesthesia for artificial abortion. Chinese Journal of Primary Medicine and Pharmacy. 2016;23(12):1824–1827.

14.       Clare CA, Hatton GE, Shrestha N, et al. Intraoperative Blood Loss during Induced Abortion: A Comparison of Anesthetics. Anesthesiology Research and Practice. December 2, 2018;2018:5.

15.       Gokhale P, Lappen JR, Waters JH, Perriera LK. Intravenous Sedation Without Intubation and the Risk of Anesthesia Complications for Obese and Non-Obese Women Undergoing Surgical Abortion: A Retrospective Cohort Study. Anesthesia & Analgesia. 2016;122(6):1957–1962.

Oxycodone is a semisynthetic opioid drug with analgesic properties.¹ Oxycodone is manufactured by modifying the chemical thebaine, an organic chemical found in opium.² It is the active ingredient in prescription pain medications such as Percocet, Percodan, Tylox and OxyContin, which are formulated through combinations with other pain relievers such as aspirin.¹ Oxycodone was first developed in Germany in 1916, and it first came to the United States in 1939.³ In 1996, when Purdue Pharma began manufacturing OxyContin in the U.S., oxycodone became more widely used (and abused).³ Because oxycodone is an active ingredient in several pain medications, anesthesia providers should have thorough knowledge of its biological mechanisms, clinical applications and side effects.

The molecular formula for oxycodone is C₁₈H₂₁NO₄.⁴ Oxycodone is a μ-opioid and κ-opioid receptor agonist.⁵ Through binding at both of these receptors, oxycodone inhibits neuronal activity⁴ and exhibits antinociceptive (i.e., pain-relieving) effects.⁵ It binds to areas in the cortex and other regions that have effects not relating to analgesia, such as the respiratory center in the brainstem, cough center in the medulla oblongata, muscles of the pupils, gastrointestinal tract, cardiovascular system, endocrine system and immune system.⁴ The lipid solubility of oxycodone is similar to that of morphine, and protein binding is low (i.e., 38 percent to 45 percent).⁵ Oxycodone’s duration of action depends on its formulation, ranging from three to four hours to 12 hours.⁶ Because it undergoes low first-pass metabolism, the oral bioavailability of oxycodone is better than morphine, ranging from 60 to 87 percent.⁷ Thus, it is almost twice as potent as morphine.⁸ It is metabolized mainly in the liver by CYP3A4 and CYP2D6 enzymes to the active metabolite oxymorphone, which is three times more potent than morphine.⁷ Another metabolite of oxycodone is noroxycodone, which has weak µ-opioid receptor activity compared with oxycodone or oxymorphone.⁷ Oxycodone and its metabolites are excreted in the urine, with less than 10 percent of oxycodone excreted unchanged.⁷ Women eliminate oxycodone 25 percent more slowly than do men.⁵ Overall, oxycodone and its metabolites exert analgesic effects through actions on opioid receptors.

Oxycodone can be used in a variety of clinical settings. Oxycodone products can be administered intramuscularly, intravenously, subcutaneously, rectally or orally through pills and tablets.⁹ Parenteral (i.e., not oral) oxycodone is not available in the United States.¹⁰ In the U.S., oxycodone is currently used in a controlled-release preparation for cancer-related and chronic non-malignant pain, as well as in an immediate-release preparation for acute or breakthrough pain.¹¹ Its immediate and sustained-release formulations make it useful for moderate to severe postoperative pain.¹² In other countries, intravenous oxycodone can be administered during the preoperative period to induce sedation and prevent perioperative pain.¹³ Oxycodone has clinical uses that are similar to those of other opioid drugs; however, its parenteral applications are not available in the U.S.

The side effects of oxycodone are similar to those of other opioids.⁵ Oxycodone may cause drowsiness, confusion, lightheadedness, nausea, vomiting, pruritus (itching), sweating, urinary retention and constipation.¹⁴ The incidence of constipation is more than with morphine, but there is a relatively decreased incidence of nausea.⁵ More severe consequences of oxycodone use may include changes in pulse, respiration and blood pressure; seizures; pupil constriction; loss of consciousness; or coma and/or death.^14,15 Compared to other opioid drugs, oxycodone has an increased potential for abuse and dependence.¹⁶ Drugs made from oxycodone, such as OxyContin, can be crushed up and used intranasally or intravenously to achieve a “high.”¹⁷ Providers should be careful when prescribing oxycodone given the addictive properties, adverse effects and overdose potential of oxycodone-containing formulations.

Oxycodone is a semisynthetic analgesic drug that acts as a μ-opioid and κ-opioid receptor agonist, thus inhibiting the body’s sense of pain. The metabolism of oxycodone in the liver creates active metabolites, which have an additional analgesic effect. Oxycodone is available in immediate-release and long-acting formulations, giving it clinical applications that include both acute and chronic pain. The side effects of oxycodone, such as drowsiness, nausea, vomiting, itching, sweating and constipation, are similar to those of other opioid drugs. Oxycodone overdose can have severe consequences such as respiratory depression and death. Due to the widespread abuse of oxycodone-based drugs such as OxyContin, anesthesia providers should carefully consider prescribing oxycodone.

1.         Center for Substance Abuse Research. Oxycodone. University of Maryland October 29, 2013; http://www.cesar.umd.edu/cesar/drugs/oxycodone.asp.

2.         Lipp A, Ferenc D, Gütz C, et al. A Regio- and Diastereoselective Anodic Aryl–Aryl Coupling in the Biomimetic Total Synthesis of (−)-Thebaine. Angewandte Chemie International Edition. 2018;57(34):11055–11059.

3.         Winkel B. The History of OxyContin. Treatment Solutions January 9, 2010; https://www.treatmentsolutions.com/blog/the-history-of-oxycontin/.

4.         Oxycodone. DrugBank February 17, 2020; https://www.drugbank.ca/drugs/DB00497.

5.         Koyyalagunta D. Chapter 113—Opioid Analgesics. In: Waldman SD, Bloch JI, eds. Pain Management. Philadelphia: W.B. Saunders; 2007:939–964.

6.         Ordóñez Gallego A, González Barón M, Espinosa Arranz E. Oxycodone: A pharmacological and clinical review. Clinical & Translational Oncology. 2007;9(5):298–307.

7.         Sindt JE, Jenkinson RH. Nonintravenous Opioids. In: Hemmings HC, Egan TD, eds. Pharmacology and Physiology for Anesthesia (Second Edition). Philadelphia: Elsevier; 2019:354–368.

8.         Cortazzo MH, Copenhaver D, Fishman SM. Major Opioids and Chronic Opioid Therapy. In: Benzon HT, Rathmell JP, Wu CL, Turk DC, Argoff CE, Hurley RW, eds. Practical Management of Pain (Fifth Edition). Philadelphia: Mosby; 2014:495–507.e493.

9.         Pöyhiä R, Vainio A, Kalso E. A review of oxycodone’s clinical pharmacokinetics and pharmacodynamics. Journal of Pain and Symptom Management. 1993;8(2):63–67.

10.       Stoops WW, Hatton KW, Lofwall MR, Nuzzo PA, Walsh SL. Intravenous oxycodone, hydrocodone, and morphine in recreational opioid users: Abuse potential and relative potencies. Psychopharmacology. 2010;212(2):193–203.

11.       Lee MC, Abrahams M. Chapter 18—Pain and analgesics. In: Bennett PN, Brown MJ, Sharma P, eds. Clinical Pharmacology (Eleventh Edition). Oxford: Churchill Livingstone; 2012:278–294.

12.       Sharav Y, Benoliel R. Pharmacotherapy of acute orofacial pain. In: Sharav Y, Benoliel R, eds. Orofacial Pain and Headache. Edinburgh: Mosby; 2008:349–376.

13.       Wang J, Fu Y, Ma H, Wang N. Effect of Preoperative Intravenous Oxycodone After Transurethral Resection of Prostate Under General Anesthesia. International Surgery. 2018;102(7–8):377–381.

14.       Mayo Clinic. Oxycodone (Oral Route). Drugs & Supplements February 1, 2020; https://www.mayoclinic.org/drugs-supplements/oxycodone-oral-route/side-effects/drg-20074193.

15.       Oxycodone. PubChem Database. Web: National Center for Biotechnology Information; 2020.

16.       Resnik RR. Postoperative Complications. In: Resnik RR, Misch CE, eds. Misch’s Avoiding Complications in Oral Implantology: Mosby; 2018:364–401.

17.       Lofwall MR, Moody DE, Fang WB, Nuzzo PA, Walsh SL. Pharmacokinetics of intranasal crushed OxyContin and intravenous oxycodone in nondependent prescription opioid abusers. Journal of Clinical Pharmacology. 2012;52(4):600–606.

Fentanyl is a synthetic opioid drug that is 50 to 100 times more potent than morphine and exhibits vastly different properties and pharmacokinetics.¹ The Belgian pharmaceutical company Janssen Pharmaceutica first developed fentanyl in 1959.² In the 1960s, fentanyl was introduced into medical practice as an anesthetic agent, and is now used for both anesthesia and analgesia.² Fentanyl is classified as a United States Drug Enforcement Administration (DEA) Schedule II drug, which means that it has “a high potential for abuse, with use potentially leading to severe psychological or physical dependence.”³ In December 2018, the Centers for Disease Control and Prevention (CDC) pronounced fentanyl the deadliest drug in America due to its potency, addictive properties and role in the opioid crisis.⁴ Because of fentanyl’s potential to cause rapid death, anesthesia providers should understand its biological mechanisms, surgical applications and side effects.⁴

The molecular formula for fentanyl, also known as fentanyl citrate, is C₂₂H₂₈N₂O.⁵ Fentanyl is lipophilic, meaning that it tends to spread to fatty tissues and thus has greater bioavailability than hydrophilic (water-soluble) drugs.⁵ Like other opioids, fentanyl binds to the m-opioid receptor in the central nervous system (CNS), thus reducing neuronal excitability.⁵ However, fentanyl also serves as an agonist for other opioid receptors such as the delta and kappa receptors.¹ Activation of these opioid receptors produces analgesia, while increases in the release of dopamine elicits exhilaration and relaxation effects.¹ Fentanyl is metabolized extensively in the liver and intestines via the enzyme CYP3A4.⁵ Less than 11 percent of the dose is excreted through urine and feces as inactive metabolites or as unchanged drug.⁵ Fentanyl metabolism, elimination and duration of effects may be affected by medications or substances that inhibit the CYP3A4 enzyme.⁶

Fentanyl comes in several forms, which allow it to serve a variety of purposes.⁷ When used to treat breakthrough pain for patients who use opioids on a long-term basis, fentanyl comes as a lozenge on a handle, a sublingual tablet, a film and a buccal tablet.⁷ Fentanyl is also administered intravenously, intramuscularly, transdermally as skin patches, intranasally via a nasal spray and intrathecally.¹ In contrast to other opioid drugs, fentanyl is less common as an oral tablet or powder.¹ For surgical procedures, fentanyl can be used preoperatively, during surgery and in the immediate postoperative period.⁵ Before surgery, fentanyl provides anxiolysis and relaxation.⁵ In combination with other anesthetic drugs, fentanyl is useful for procedures that require patients to be lightly anesthetized or awake.⁵ However, it may be administered with oxygen and a muscle relaxant to provide anesthesia without the use of additional anesthetic agents.⁵ Fentanyl can prevent or relieve postoperative emergence delirium.⁵ Clearly, fentanyl has various uses as an analgesic and anesthetic drug.

Unfortunately, fentanyl’s many uses are accompanied by many side effects. Fentanyl’s side effects are similar to those of heroin, including euphoria, confusion, drowsiness, nausea, visual disturbances or hallucinations, delirium and constipation.¹ Serious adverse effects include addiction, hypotension, coma, respiratory depression and death.¹ Fentanyl and its derivatives can produce rigidity in the diaphragm, chest wall and upper airway—known as “wooden chest syndrome” (WCS)—within a narrow dosing range.⁴ WCS can be fatal and causes rapid death without proper airway management.⁴ Because fentanyl is so potent and overdose is likely, anesthesia providers must be extremely diligent when providing patients with fentanyl.⁸ Patients who have respiratory issues or liver failure or who are using drugs such as alcohol, antibiotics or antifungal agents may not be able to use fentanyl.¹ Fentanyl can be habit forming, so patients should be educated about its proper use and addictive properties.⁷

Fentanyl is an extremely potent synthetic opioid that is used for analgesia and anesthesia. By activating certain opioid receptors, fentanyl inhibits neuronal activity. Fentanyl is primarily used for analgesia in combination with other anesthetics. Fentanyl’s side effects range from drowsiness and nausea to coma, respiratory depression and even death. Because fentanyl is a highly addictive substance, anesthesiology professionals should prescribe it cautiously.

1.         Ramos-Matos CF, Lopez-Ojeda W. Fentanyl. StatPearls. Web: StatPearls Publishing LLC; October 3, 2019.

2.         Dale E, Ashby F, Seelam K. Report of a patient chewing fentanyl patches who was titrated onto methadone. BMJ Case Reports. 2009;2009:bcr01.2009.1454.

3.         United States Drug Enforcement Administration. Drug Scheduling. Drug Information 2020; https://www.dea.gov/drug-scheduling.

4.         Torralva R, Janowsky A. Noradrenergic Mechanisms in Fentanyl-Mediated Rapid Death Explain Failure of Naloxone in the Opioid Crisis. Journal of Pharmacology and Experimental Therapeutics. 2019;371(2):453–475.

5.         Fentanyl. PubChem Database. Web: National Center for Biotechnology Information; 2020.

6.         Kharasch ED, Whittington D, Hoffer C. Influence of hepatic and intestinal cytochrome P4503A activity on the acute disposition and effects of oral transmucosal fentanyl citrate. Anesthesiology. 2004;101(3):729–737.

7.         Fentanyl. MedlinePlus. Bethesda, MD: National Institutes of Health; October 15, 2019.

8.         Simmons B, Kuo A. 40—Analgesics, Tranquilizers, and Sedatives. In: Brown DL, ed. Cardiac Intensive Care (Third Edition). Philadelphia: Elsevier; 2019:421–431.e425.

Humans have used herbs and plants for medicinal purposes since ancient times.¹ The oldest written evidence of medicinal plants’ usage for drug preparation is on a 5000-year-old Sumerian clay slab from Nagpur.¹ It includes 12 recipes for drug preparation with over 250 various plants, including poppy, henbane, and mandrake.¹ These plants contain pharmacologically active components that can treat illness.¹ Today, herbal medicines’ therapeutic potential should not be dismissed, given the long history of their successful use.² Herbal products may also interfere with other contemporary medicines, so medical providers must be aware of their potential effects and mechanisms of action.² Anesthesia providers in particular should be aware of commonly used herbal supplements and their functions, as well as their potential to affect anesthetic drugs.

Herbal products, also known as dietary supplements, alternative therapies, complementary medicine and homeopathic or holistic health care, are common in many societies.³ According to the World Health Organization (WHO), up to 80 percent of the world’s population still depends on herbal medicines.⁴ Patient surveys have reported that 12 percent of Americans, 12 percent of Australians, and 4.8 percent of patients in the UK use herbal remedies.⁴ Commonly used compounds include feverfew, garlic, ginseng, ginkgo, St. John’s wort, hoodia, kava, valerian and echinacea.^3,5 Because the United States Food and Drug Administration (FDA) considers these pharmacologically active agents as foods or supplements, they are not subject to standard drug regulations.² There are limited instructions on proper use, dosage requirements, possible side effects, toxicity and drug interactions.³ Also, a lack of pharmacokinetic and pharmacodynamic data on herbal products makes it difficult to predict a patient’s reaction to the product or know if the product has any therapeutic value.⁴ Due to unstandardized dosage policies and unclear pharmacological effects, herbal supplements can be harmful to patients whether or not they are taking other medications.

Because of the possible interference with anesthetic medications, the American Society of Anesthesiologists recommends that patients discontinue the use of herbal supplements two to three weeks before surgery.⁴ However, patients are often unaware of this recommendation or in need of emergency surgery, in which case preoperative preparation time is limited.⁴ According to a study by Levy et al., 44 percent of patients hospitalized for surgery reported dietary and herbal supplement use, with 16.5 percent using substances that could potentially interact with anesthesia.⁶ In a separate study, Kaye et al. found that among 1,017 patients surveyed before outpatient anesthetic administration, 482 were using at least one herbal supplement.⁷ Despite some of the benefits of these supplements, they can negatively impact postoperative analgesia, bleeding and level of sedation.² Wong et al.’s review thoroughly describes the medicinal uses, pharmacological effects and potential anesthetic interactions of several common herbal supplements.⁴ Garlic, ginger, gingko and ginseng contribute to intraoperative risk of bleeding; kava, St. John’s wort and valerian have sedative effects and may reduce anesthetic requirements; ephedra causes sympathetic nervous system issues and arrhythmia; and echinacea can cause liver failure when combined with hepatotoxic drugs.⁴ Despite the potential perioperative dangers of these drugs on their own or in combination with anesthetic agents,³ documentation and identification of herbal remedies in medical records remain subpar. For example, in Levy et al.’s study, supplement use was only documented in 11 percent of the medical files of patients who used them.⁶ It is the anesthesia provider’s duty to ask patients open-ended questions about their herbal supplement use during the preoperative assessment.⁸ Adequate reporting of patient use and proper understanding of herbal supplement pharmacology are key to an anesthesia provider’s practice.⁸

Medicinal herbs have been used for thousands of years, and many herbs contribute to the pharmacological effects of modern-day medications. Despite their widespread use, herbal supplements are not heavily regulated and may pose dangers to patients, whether or not they use other medicines. Anesthesia providers should consider the pharmacology and possible perioperative effects of these supplements. Ideally, the anesthesia provider should ensure the patient’s discontinuation of such products well before surgery.⁴ Future research should investigate the possible uses of herbal supplements for anesthesia and analgesia to aim for a more symbiotic relationship between herbal supplements and allopathic medicine.  

1.         Petrovska BB. Historical review of medicinal plants’ usage. Pharmacognosy Reviews. 2012;6(11):1–5.

2.         Abe A, Kaye AD, Gritsenko K, Urman RD, Kaye AM. Perioperative analgesia and the effects of dietary supplements. Best Practice & Research Clinical Anaesthesiology. 2014;28(2):183–189.

3.         American Society of Nurse Anesthetists. Herbal Products and Your Anesthesia. Patients 2019; https://www.aana.com/patients/herbal-products-and-your-anesthesia.

4.         Wong A, Townley SA. Herbal medicines and anaesthesia. Continuing Education in Anaesthesia Critical Care & Pain. 2010;11(1):14–17.

5.         Skinner CM, Rangasami J. Preoperative use of herbal medicines: A patient survey. BJA: British Journal of Anaesthesia. 2002;89(5):792–795.

6.         Levy I, Attias S, Ben-Arye E, et al. Perioperative Risks of Dietary and Herbal Supplements. World Journal of Surgery. 2017;41(4):927–934.

7.         Kaye AD, Clarke RC, Sabar R, et al. Herbal medicines: Current trends in anesthesiology practice—a hospital survey. Journal of Clinical Anesthesia. 2000;12(6):468–471.

8.         Lyons TR. Herbal medicines and possible anesthesia interactions. AANA Journal. 2002;70(1):47–51.

A concussion is a traumatic brain injury caused by a bump, blow or jolt that causes the head and brain to move rapidly back and forth.¹ This sudden movement can make the brain bounce or twist within the skull, creating chemical changes and damaging brain cells.¹ Concussion signs and symptoms include loss of consciousness, amnesia, clumsiness, nausea or vomiting, light or noise sensitivity, headache and confusion.² Concussions are common sports injuries; according to estimates by the Centers for Disease Control and Prevention (CDC), an estimated 1.6 to 3.8 million sports- and recreation-related concussions occur in the United States each year.³ Lack of proper diagnosis or poor management of a concussion can result in long-term consequences, including coma or death.⁴ Some patients may need urgent or elective surgery immediately after a concussion, which can be complicated given the stress associated with any procedure.⁵ Anesthesia providers should be especially cautious with patients who have had a recent concussion diagnosis, as a concussed brain may be particularly vulnerable.⁶ In order to give the best care to their patients, anesthesiology practitioners need to understand the complexities of concussion, the problems surgery might pose to a concussed patient and the anesthesia provider’s role.

Concussion refers to the functional issues of a mild traumatic brain injury (mTBI).⁶ The diagnosis of a concussion can be difficult, as brain imaging after mTBI is usually nondiagnostic, nonpredictive and nonspecific for concussion.⁶ Though the majority of concussion symptoms, such as headache, resolve within one week, patients who have suffered a previous concussion may not show such a quick recovery.⁷ Additionally, post-concussive symptoms such as dizziness, fatigue, anxiety and cognitive deficits can result in functional impairment and societal costs extending months after the initial injury.⁷ These extended symptoms may be due to profound brain changes after concussion.⁶ Immediately after the head injury, the brain’s metabolic rate increases.⁶ Then, in the hours, days and weeks following a concussion, the brain enters a state of increased blood flow, reduced metabolism, altered vascular responsiveness and dysfunctional neuronal axon activity.⁶ Evidence suggests that even after signs and symptoms of a concussion subside, cerebral physiology may remain altered for months.⁶

Because the brain is vulnerable right after a concussion, clinicians recommend cognitive and physical rest as part of the treatment regimen.⁶ This includes minimized physical activity; reduction of reading, social visits and video games; and avoidance of significant decision making.⁶ The need for surgery after a concussion may interfere with these requirements.⁵ After all, the perioperative period involves a variety of physical and cognitive demands, including exposure to foreign environments, meeting multiple new people, answering questions, making important decisions, bright lights, physical transfers, pain, medications and altered sleep.⁶ Thus, clinicians may need to balance the time sensitivity of a surgery with the potential dangers of overstimulation after a concussion.^5,8

Anesthesiology practitioners in particular should be cautious when administering anesthesia soon after a patient’s concussion.⁹ A review by Tasker states that the effects of anesthetic agents on the autonomic nervous system and on cerebrovascular reactivity to carbon dioxide could further alter the brain’s post-concussive state.⁹ Abcejo et al. found that anesthesia use is common in patients after a concussion, and clinicians may need to alter their anesthesia practice to avoid potential injury in these patients.¹⁰ Though the data are limited on proper anesthetic practices in patients with altered cerebral physiology,^7,11 a review by King and Collins-Yoder shows that anesthesia providers should pay special attention to mean arterial pressures and partial CO₂ pressure in concussed patients.¹¹ Furthermore, while D’Souza et al. found no differences in intraoperative and postoperative outcomes between patients with recent concussion and control patients,¹² Ferrari et al. and Sheshadri et al. emphasize the lack of literature on long-term outcomes of anesthesia after concussion.^8,13 Until the evidence base is better established, Vavilala et al. recommend deferring anesthesia use in post-concussive patients until physical restrictions are lifted.⁷

Concussion is a serious condition resulting in long-term physiological brain changes. Because surgery can be physically and cognitively stressful, it poses challenges to a patient who was recently concussed. Anesthesia providers need to be especially careful when caring for post-concussive patients, as the cerebral changes from anesthesia may cause further injury to the patient’s vulnerable brain. More research is needed on best practices in anesthesia for concussed patients and the long-term outcomes of anesthesia after concussion.

1.         Centers for Disease Control and Prevention. What Is a Concussion? Heads Up February 12, 2019; https://www.cdc.gov/headsup/basics/concussion_whatis.html.

2.         Centers for Disease Control and Prevention. Concussion Signs and Symptoms. Heads Up February 12, 2019; https://www.cdc.gov/headsup/basics/concussion_symptoms.html.

3.         Daneshvar DH, Nowinski CJ, McKee AC, Cantu RC. The Epidemiology of Sport-Related Concussion. Clinics in Sports Medicine. 2011;30(1):1–17.

4.         Brain Injury Research Institute. What is a Concussion? Information and Research 2020; http://www.protectthebrain.org/Brain-Injury-Research/What-is-a-Concussion-.aspx.

5.         Rasouli MR, Kavin M, Stache S, Mahla ME, Schwenk ES. Anesthesia for the patient with recently diagnosed concussion: Think about the brain! Korean Journal of Anesthesiology. July 1, 2019.

6.         Abcejo AS, Pasternak JJ. Is a Concussed Brain a Vulnerable Brain? Anesthesia after Concussion. Anesthesia Patient Safety Foundation. October 2018;33(2).

7.         Vavilala MS, Ferrari LR, Herring SA. Perioperative Care of the Concussed Patient: Making the Case for Defining Best Anesthesia Care. Anesthesia & Analgesia. 2017;125(3):1053–1055.

8.         Ferrari LR, O’Brien MJ, Taylor AM, et al. Concussion in pediatric surgical patients scheduled for time-sensitive surgical procedures. Journal of Concussion. 2017;1:1–8.

9.         Tasker RC. Anesthesia and concussion. Current Opinion in Anesthesiology. 2017;30(3):343–348.

10.       Abcejo AS, Savica R, Lanier WL, Pasternak JJ. Exposure to Surgery and Anesthesia After Concussion Due to Mild Traumatic Brain Injury. Mayo Clinic Proceedings. 2017;92(7):1042–1052.

11.       King D, Collins-Yoder A. Perioperative Considerations in Patients With Concussion. AANA Journal. 2019;87(2):97–104.

12.       D’Souza RS, Sexton MA, Schulte PJ, Pasternak JJ, Abcejo AS. Recent Preoperative Concussion and Postoperative Complications: A Retrospective Matched-cohort Study. Journal of Neurosurgical Anesthesiology. October 23, 2019.

13.       Sheshadri V, Manninen P, Venkatraghavan L. Anesthesia in Patients With Postconcussion Syndrome: Is There Evidence? Journal of Neurosurgical Anesthesiology. April 2017;29(2):185.