A Comprehensive Curriculum of the History of Regional Anesthesia

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Journal of Clinical Anesthesia and Pain Medicine

Research Article A Comprehensive Curriculum of The History of Regional Anesthesia

This article was published in the following Scient Open Access Journal: Journal of Clinical Anesthesia and Pain Medicine Received August 30, 2019; Accepted September 12, 2019; Published September 18, 2019

1 Gustavo Angaramo , James Savage, Abstract David Arcella and Manisha S. Desai1* Department of Anesthesiology and Perioperative The study of the past with regards to medical history has been an underemphasized Medicine, University of Massachusetts Medical component of the medical school curriculum for several reasons. School, Worcester, Massachusetts. 1 Associate Professor of Anesthesiology These have included the lack of direct or immediate clinical impact, the emergence of new disciplines such as medical ethics, expansion of the existing knowledge base, as well as a lack of research grants and funding. The curriculum in graduate medical education struggles to cope with the explosion of new information related to basic and applied sciences. The elimination of questions related to history in certifying examinations could be considered a fatal blow. This study explored the teaching of history of regional anesthesia (HORA) and proposes a curriculum for such education. A formal curriculum has not been described in published literature, even the latest guidelines for fellowship training in regional anesthesiology and acute pain medicine published by ASRA in 2015 did not include a curriculum to teach HORA. We propose a curriculum related to a variety of topics that would provide useful information and enrich the educational experience of trainees. It is suggested that this briefly formatted review of HORA could be used as a starting point for teaching and research to place major events of this specialty in an historical context.

Introduction Anesthesiology is one of the few major medical specialties where discoveries are clearly documented, by the introduction of general anesthesia, and local anesthesia (1,2). The last century has witnessed many developments in the practice of regional anesthesia. What began as a simple method of numbing body parts of the body during surgery has expanded to creating a neural blockade during the perioperative period, either as the sole anesthetic or in combination with general anesthesia. Local anesthetic agents are also increasingly being used in the treatment of chronic pain syndromes.

blockade of nerves and plexuses, neuraxial blocks, and the use of ultrasonography toTechniques identify neural have evolvedstructures. from The topical purpose application of this review and local is to infiltrationoffer a comprehensive to selective curriculum in HORA (history of regional anesthesia) that could be implemented in training programs. During a brief online survey conducted regarding the teaching of regional anesthesia in acute pain programs across the country we realized that much needed to be done in that matter.

constrains and most of all the absence of a curriculum to teach HORA. Even the latest guidelinesSome offor the fellowship barriers training identified in regional were lack anesthesiology of trained faculty and acute in the pain topic, medicine time published by ASRA in 2015 did not include a curriculum to teach HORA. Discussion and Proposed HORA Curriculum This review of the history of regional anesthesia puts forward the following topics as recommendations to be included in the core curriculum for the teaching of HORA: the emergence of ASRA; local anesthetic agents; spinal and epidural anesthesia; brachial *Corresponding Author: Manisha Desai, plexus block; ultrasonography and the recognition that regional anesthesia reduces Department of Anesthesiology, UMass Memorial morbidity and shorter recovery room stays when compared with general anesthesia in Health Care, 55 Lake Avenue North, Worcester, MA ambulatory surgery. 01655, USA. Tel: 5088563266. The origin of American Society of Regional Anesthesia and Pain Medicine (ASRA)

Volume 3 • Issue 1 • 026 www.scientonline.org J Clin Anesth Pain Med Citation: Gustavo Angaramo, James Savage, David Arcella, Manisha S. Desai (2019). A Comprehensive Curriculum of The History of Regional Anesthesia.

Page 2 of 7 The original ASRA was founded in 1923. It was created to he was awarded the Nobel Prize in Chemistry in honor Gaston Labat, who has been called the “father” of regional 1915 [5,6]. Cocaine’s most notable advocate anesthesia and pain medicine in the United States. Labat was a chemistry, psychoanalyst, who French surgeon and came to America with Mayo Clinic founder believed it could be used to cure depression, asat well that as timeaddiction was Charles Mayo. Labat worked in several hospitals in the U.S. toSigmund morphine Freud or alcohol. [1856-1939], He self-experimented the famous with cocaine and and created a course in regional anesthesia through New York described many of its properties but failed to University at Bellevue Hospital. The original ASRA grew out of this work with focus on the development of local, notice1944], its localwho regional, and spinal anesthesia. observedanesthetic the properties tongue-numbing [7,8]. That properties distinction of the went drug to and Freud’s his a colleague,team continued a rising with ophthalmologist self-experimentation Carl Koller feeling [1857- no pain In 1930, Philip Woodbridge presented at an ASRA meeting on debuted at the German Ophthalmological Society Conferenceas they in shift in focus to also include pain management in the Society’s Heidelbergtouched their and own the eyes international with needles. medical In 1884 community his work quickly the use of therapeutic blocks for chronic pain, which signified a purview. The association was no longer focused solely on surgical learned about the local anesthetic properties of cocaine [9]. anesthesia, with pain management becoming increasingly emphasized in papers and meetings [3]. As with the discovery of general anesthesia, controversy arose about the individual[s] who deserved credit for the discovery Despite numerous advances in regional anesthesia and pain of the local anesthetic properties of cocaine. Two other medicine throughout the 1930s, ASRA as an organization began practitioners to lose steam by the end of the decade. Meetings were held less claimed to have discovered these properties frequently, and fewer members were paying their dues. In 1940, before' Koller’s', Vassily von Anrep [1852-1927] and Theodor the group was dissolved, and members were invited to join the Aschenbrandt Vienna caused them to reliquish their American Society of Anesthesiology, which had been established claims and acknowledge1884 presentation, Koller’s contribution but pressure [10,11]. from Later, the early in the 20th century. othermedical physicians community used in cocaine In 1973 Alon Winnie had a vision of an organization that used cocaine for a would be devoted to teaching regional anesthesia. He shared his mandibular nerve block during dentalto obtainsurgery analgesia[12] and also during for vision with Harold Carron, Jordan Katz, Donald Bridenbaugh, asurgery. brachial William plexus blockHalsted [13], [1852-1922] while August Bier and P. Prithvi Raj, who reestablished the society in 1975 [4]. experimentation Interestingly, the reinvented ASRA originally focused on regional resulted in many physicians, including Freud and[1861-1949] Halsted, anesthesia but later added pain medicine in the 1990s. becomingused it intrathecally dependent as on an drugs anesthetic such [14].as morphine Self- and cocaine. Procaine, synthesized in 1905, replaced cocaine due the society had more than 300 members more adrenaline [15]. Even more important, procaine didto not its thanAt 6500 the time physician of the society’s and scientist first meeting members on andMarch the 18, journal 1978, possessefficacy the and addictive longer property lasting properties of cocaine. whenRarely combinedused these days with Regional Anesthesia and Pain Medicine, is . readToday byit over has 9000 as a local anesthetic, mostly secluded to ENT [ear nose subscribers internationally. throat] procedures, the story of the cocaine how a gateway drug laid the foundation for local , anesthetic, and Today, ASRA is one of the largest subspecialty medical techniques and a search for improved agents. illustrates regional anesthesia and pain medicine as new discoveries are Lidocaine: made,societies changes in anesthesiology. occur in healthcare Change administration is constant inand the insurance, field of In 1929 two chemists; Hans von Euler [1873- and demographic shifts occur in the patient population. Although Nobel Prize for their work n fermentation. Von Euler then 1964] and Sir Arthur Harden [1865-1940] were awarded the many organizations and companies provide offerings to address focused his efforts on developing barley strains that were o the needs of individuals working with these challenges, ASRA resistant to loss of agricultural output to insects. He isolated remains committed to a focus on the highest quality of evidence- a new pesticide called gramin. Von Euler and Holger Erdtman based education and research for physicians. This history of attempted to synthesize gramin but ended up synthesizing the ASRA is relevant to today’s anesthesiologist so we don’t forget incorrect isomer isogramin. When placed on the tongue, iso- the heritage of the past to make certain that regional anesthesia gramin resulted in a temporarily loss of sensation. is always available to the patients for whom we care. In von Euler’s laboratory in 1935, Holger Erdtman [1902- anilides with Local Anesthetics: tongue numbing properties and published their results 1989] in Cocaine: Extracts from the coca plant have been consumed by 1937and Nils16 Lӧfgren Although [1913-1967] none of the synthesized agents appeared , different to natives of the Andes region in South America for over 5000 years [3,4]. The active ingredient was separated from the leaves [ ]. be superior to using lime, and used as a stimulant to decrease air hunger and procaine, Lӧfgren continued to work on these compounds until increase 1942 when his student Bengt Lundqvist [1922- 1953] convinced properties of saliva , rich with coca extract., him that these drugs ought to be tested by injection rather than toCenturies endurance. later, The Incas were the first to observe local producing numbness of the tongue. After conducting a series of anesthetic clinicalCompound experiments, LL30 they was found tested that on compound mice at LL30 the showed Karolinska modern chemical processes allowed the elucidated the structure of plant greatInstitute promise as a local anesthetic [17]. alkaloidsextraction, such purification, as atropine and and identification cocaine as part of cocaine. of his doctoral Richard Willstatter [1872-1942] thesis, and later also explored the structure of chlorophyll. [Stockholm, Sweden]and found to have greater efficacy, For his many contributions to the obtainedlonger duration a of action and a less toxic profile than procaine. On July 15, 1943 Lӧfgren and Lundqvist applied for and Volume 3 • Issue 1 • 026 understanding of plantwww.scientonline.org J Clin Anesth Pain Med Citation: Gustavo Angaramo, James Savage, David Arcella, Manisha S. Desai (2019). A Comprehensive Curriculum of The History of Regional Anesthesia.

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patent to protect their intellectual property rights. They licensed the product for a two-week trial and were disappointed when the medical and pharmaceutical community showed little interest A study in animals by Taniguchi showed that intrathecal in their drug. After considering several offers, they injection of sodium bisulfite caused lesscausative neurological agent; transferred ownership of the patent to Astra Pharmaceuticals wasdysfunction it the local compared anesthetic to chloroprocaine or the preservative? alone, bringing[27]. Despite into on November 22, 1943 for 15,000 Swedish Crowns playthis more study, confusion FDA regulations about the identity restrict of Astra, the the current and 4% of all sales for 17 years. Rebranded and tested, Astra manufacturer of chloroprocaine [Nesacaine-MPF] to market marketed[Sweden] the drug in early the chloroprocaine with preservatives is permitted and 1948 as Xylocaine. surveillancedrug without bisulfite. In Europe, epidural administration of Lӧfgren finished his doctorate in 1948 and published his years later, there is a lack of clear evidence thesis,University “Studies on of local Stockholm anesthetics: where Xylocaine: he was precludeda new synthetic from pointing to anystudies single have mechanism not revealed responsible evidence for of neurotoxicity neurological winningdrug” [18]. He stayed on as a professor of organic chemistry at associateddeficit. Thirty with the use of epidural chloroprocaine. the Bupivacaine and its toxicity: Numerous new amino amide researchof stairs. grants He as died a result from ofcerebral his financial hemorrhage success at with the agecompound of 30. LL30. Lundqvist sustained a skull fracture after a fall including nirvaquine, procaine, chloroprocaine, cinchocaine, down a flight locallidocaine, anesthetics mepivacaine, were prilocaine, synthesized efocaine, between articaine, 1898 etidocaine, and 1972 Chloroprocaine: When chloroprocaine was introduced to the market in 1952, lidocaine had already been used for epidural control onset and duration of action, and decrease the likelihood andof drug bupiv dependence.acaine [28]. Attempts were made to decrease toxicity, less likely to produce allergic reactions than the amino ester- anestheticsanesthesia as[19]. the In first comparison amino-amide to anesthetic.chloroprocaine, Lidocaine lidocaine was It had already been established that the central nervous provided a longer duration of action and was cleared less quickly system was more susceptible to local anesthetics when compared from the body. Chemically similar to procaine, 2-Chloroprocaine to the cardiovascular system [29]. One pivotal case by Prentiss became popular because of its rapid onset of action and illustrated the danger of etidocaine during caudal anesthesia; metabolism by plasma esterases. It had virtually no effect on causing convulsions and cardiac arrest in a health young male maternal-fetal physiology and was used extensively for pain relief [30]. More examples of the toxic effects of local anesthetics during labor and delivery [20]. lipid-soluble anesthetics and the dangerous effects on the cardiovascularemerged as Albright system addedand the five central other nervous case reports system linked [31]. As to is the case with most established practices, resistance erupted Numerous reports in the 1980s describingpractice long of term regional and against such causative claims. analgesiaeven permanent [21]. neurologicalHalf a dozen deficits cases due reported to local anestheticprolonged Bupivacaine, synthesized in 1957, is of special interest transientagents sent neurological a shockwave sequelae through [TNS] the and suggested because of its long duration of action and history of epidural clinical application. catheter placement [22]. Reports of more cases involvingthat the accidentalcause might be accidentalintrathecal intrathecal injection infiltration with during resulting Several case reports highlighted the. permanent neurological sequelae, in some cases causing Inpotential theory, toxicitythe toxicity of 0.75% was thought bupivacaine. to be Thisrelated resulted to the incardiac much sexual dysfunction sodiuminvestigative channels work to [32]. understand The mechanisms anesthetic ofwas its toxicity further issues by altering the composition of the characterized as “fast-in, slow-out” due to its prolonged preservatives used[23], in forced the manufacturer to find ways to blockade and a potent depressant of the maximum deal with these and marketed a UV light upstroke velocity of cardiac muscle action potential. the manufacturing process. In 1987, protected vial. Nonetheless, fear of causing potentially Awareness of this unique behavior of bupivacaine led to the Astra removed preservatives permanent neurologic complications lead the Food and Drug design of enantiomers, such as levo-bupivacaine and Administration [FDA] to prohibit the use of preservative ropivacaine, each having their own physiological . containing chloroprocaine for lumbar and caudal epidural blocks. These drugs, even in their present state, were stillproperties incredibly valuable to multimodal pain techniques and their use was Several hypotheses were put forward to explain these “rescued” by an astute observation on a patient with carnitine- adverse effects. The high dose and volume of the local anesthetic were blamed initially. However, hundreds of deliberate spinal of fatty acids within the mitochondria enhanced the toxicity of injections with the same doses had not produced adverse bupivacainedeficiency. It [33]. was Therefore,Weinberg infusionwho showed of a lipid that would the accumulation emulsify the results [24]. Several of the early reports involved medications anesthetic and reduce its activity when toxicity was encountered. without preservatives, nonetheless, other studies suggested that This was proven by his series of experiments on dogs and rats preservatives such as methylparaben, ethylene diamine which showed the rescue effect of lipid emulsion therapy on the tetra cardiotoxic effects of bupivacaine. acetateof the [EDTA], drug and sodiuminhibited bisulfite bacterial were growth. to blame Studies [25]. Several years later, Rosenblatt showed its utility Iton wasanimal known models that theseand in-vitro additives neuronal significantly stem prolongedcells showed the shelfproliferative life and architectural changes when exposed to 2- chloroprocaine during cardiac arrest where electrical defibrillation was successful”. only after lipid infusion [34]. The mechanism is with and without sodium bisulfite [26]. believed to be lipophyllic binding which isolates the drug in a 'lipid sink Volume 3 • Issue 1 • 026 www.scientonline.org J Clin Anesth Pain Med Citation: Gustavo Angaramo, James Savage, David Arcella, Manisha S. Desai (2019). A Comprehensive Curriculum of The History of Regional Anesthesia.

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Understanding the history behind the creation of these and hypnotics drugs allow in our daily practice. intraoperatively, and providing effective postoperative pain reducing the need for analgesics Halstead applied the theory of local relief . The Brachiala better Plexus: appreciation anesthesia to peripheral nerves for surgery of the upper extremity, Bier' block [Intravenous Regional Anesthesia]: In August others to discover its possibilities. A pupil of Halstead, Harvey a new method of producing analgesia of a limb which he named defending its use in the scientific community and encouraging ‘vein1908 anesthesia’Karl August [47]. Bier, Professor of Surgery in Berlin, revealed avoiding complications of shock, comparing two surgeries on theCushing, shoulder, published one a without report concerning cocainization its efficacy and the with other regard to anesthesia [IVRA] at the 37th Congress of the German Surgical with Bier first presented this new method of intravenous regional cocaine applied proximal to the division of nerve trunks [36]. ofSociety occluding on 22 the April circulation 1908, only in a 10 segment years after of the other arm significant with two The first percutaneous supraclavicular block was performed tourniquetscommunication and on injecting spinal anesthesia a dilute local[48]. Theanesthetic method through consisted a percutaneousin 1911 by Germanapproach surgeon to the brachial Diedrich plexus Kulenkampff from the [1880– axilla venous cut-down in the isolated segment. Bier used procaine, the 1967] [37]. Later, Georg Hirschel [1875–1963] described a time in 1927, stating ‘On the basis of strict comparison, it Einhorn in 1900 15 cannot[38]. Livingston be said that compiled the untoward a review effects of the from achievements brachial plexus of the first safe injectable local anesthetic that had been synthesized by After initial enthusiasm, the technique fell into obscurity block are of more severity, than those of inhalation narcosis. [ ]. Furthermore, even in the experimental era, complications for >50 years. In 1963, Holmes reintroduced Bier block with the and disagreeable by-effects occurred with only a small novel use of lidocaine [49]. percentage of patients, while the average patient receives the Today, intravenous regional anesthesia of the upper limb brachial plexus anesthesia without unfavorable symptoms [39]. remains popular because it is reliable, cost effective, safe, and the door for regional anesthesia as a less simple to administer. ' harmful technique when compared with general anesthesia. Spinal and epidural anesthesia: The advent of spinal Thus he opened anesthesia cannot be fully accredited to the arrival of cocaine a thousand blocks without apparent major complications. TheIn technique 1928, Kulenkampff applied to and the Persky patient published was described a report in about that ophthalmology, treatment of depression by Sigmund Freud [50], they would be in the sitting position or in the supine position into the medical field. It served many purposes including with a pillow behind the shoulders. The needle was inserted above the midpoint of the clavicle where the pulse of the drugand evento the being spinal added column. to Procedures Coca-Cola inapproximating 1886 [51]. Thethe spinal credit subclavian artery could be felt and it was directed medially should go to the clinicians who first attempted to apply this toward the second or third thoracic spinous process [40]. By as high risks with permanent paralysis being the result. However, the late 1940s, clinical experience with brachial plexus block thesecolumn pioneers were regarded went ahead by theand scientific tested their and hypotheses, medical community changing in both peacetime and wartime surgery was extensive, and new approaches to this technique began to emerge [41]. spinalthe field anesthesia of anesthesiology on the lowerand obstetrics. limbs although James Leonard Karl Gustav Bier [52], is credited with the first use of operative brachial plexus block technique. This was done by a needle being securedIn 1946, in the F. Paul supraclavicular Ansbro was thefossa first with to describe tubing connecteda continuous to Corning was the first to use cocaine in the spinal column in 1885 a syringe through which incremental doses of local anesthetic [53], several years earlier than Bier [48]. A native of Stamford, could be injected [42]. The subclavian perivascular block was CT, his familyUpon fled returning to Germany to the when he wasStates, a young he began boy. The his influencepractice of German Neurology and inFrench New physicians York City, influenced attending Corning’s the became popular due to its lower risk of pneumothorax compared curiosity.Roosevelt Hospital. Corning United tofirst the described traditional by KulenkampffWinnie and Collins approach. in 1964 [43]. This approach Halstead and Richard Hall successfully demonstrated one of theirhad been in the surgical auditorium in 1884 when William spinal anesthesia by in 1973 [44]. In 1977, Selander described a technique for injecting 2 ml of 3% cocaine into theperipheral T11/T12 nerveinterspinous blocks The infraclavicular approach was first developed by Raj continuous brachial plexus block using an intravenous catheter space[54]. A in year a gentleman later he first suffering demonstrated with “spinal weakness” and secured in the axilla [45]. The development of a more practical “seminal incontinence”. Minutes later the patient experienced and portable nerve stimulator [NS] in 1962, led to increased impaired sensitivity in the legs, genitalia and lumbar region as use among practitioners. Reports questioning the safety of well as post-dural puncture headache. The theory the paresthesia technique such as those by Selander in 1979 published by him stated that the mechanism of anesthesia during the was through the infusion of cocaine into the tissues last decade surrounding the spinal column and by diffusion into the venae encouraged clinicians to explore other approaches into clinical practice. Ting and Sivagnanatnam spinosae. Because his procedure did not describe fully of the 20th century. In 1989, another modality was utilized ultrasound penetrating the dura, he was introduced during axillary nerve blocks [46]. to confirm needle placement and observe not creditedinjecting withless of being the localToday anesthetic upper spread extremity plexus blocks have an obvious place as a sole anesthetic technique or as a powerful cocaineresponsible solution for the to first provide spinal the block. anesthetic Bier’s block did this in complement' , 1899, entering the spinal column fully and effects. He never applied his findings in the operating room, but Volume 3 • Issue to 1 general• 026 anesthesia, www.scientonline.org J Clin Anesth Pain Med Citation: Gustavo Angaramo, James Savage, David Arcella, Manisha S. Desai (2019). A Comprehensive Curriculum of The History of Regional Anesthesia.

Page 5 of 7 he may have used this technique to relie forms of paresthesia found that in his own patients. by using continuous infusions via caudal catheter, the need for ve postoperativein newborns withventilation biliary atresiain babies and with subsequently oesophageal atresia Despite the utility of spinal anesthesia, the preference of and other surgical conditions was reduced. His work spinal anesthesia for nerve blockade and lower extremity surgery demonstrated that epidural analgesia can be provided for was secondary to general anesthesia because of the feared neonates undergoing major surgery with a low risk of neurologic sequelae. complication [63]. Further advantages include the reduced One case report detailed paraplegia with two previously need for muscle relaxants, opioids and postoperative healthy middle aged males [55,56]. ventilatory support. In 1956, a study from the Hospital of the University of Pennsylvania by Dripps and Vandam showed that a long term to improvements in Spinal and other local anesthetic techniques in children had follow up of over 10,000 patients who received spinal anesthesia general anesthesia. ups and downs in popularity likely related Ultrasound Guidance: A technology originally used to detect improved the public image of spinal blocks and their use in the submarines during warfare, ultrasound found initial medical use resulted in no long term neurologic sequelae [57].These findings Caudal blocks and epidurals came into use in children much take several decades before it was adopted to identify nerves. operating room and in pain clinics [58,59]. later. In the early years these blocks were performed by surgeons, in fetal monitoring and identification of gallstones, but it would but as other doctors began to give anesthetics the specialty delivering local anesthesia to the brachial plexus using Doppler of anesthesia evolved, and these practitioners gradually took In 1978 La Grange developed a unique approach of This type of ultrasonography only provided spinal anesthesia with cocaine. All of his six patients, including ultrasonography [58]. over this role. On August 16, 1898, August Bier tried to induce and they reported no neurological vomiting and headache, and Bier felt that the technique had little sequelae or pneumothorax. It did not become popular due two children – the first to have spinals – had postoperative unidimensionalto images superintendent at the Hospital for Sick Children at Great ultrasonographic visualization of local anesthetic Ormondadvantage Street, over generalLondon, anesthesia. published In three 1909–1910,H. detailed papers Tyrell Gray,each spreadthe during prohibitive brachial cost plexus of thisblock. technology. Instead of InDoppler, 1989 Tingthey based on cases of spinal anesthesia in children. usedescribed a B-mode ultrasound device that provided two- They occupied 14 ½ pages in the Lancet [60].Gray’s patients dimensional visualization. Their conclusions emphasized were not anesthetizedmore than 100 but were comforted by a nurse who knew improved visualization of the them. Some were even allowed to have cake! Six retched and 21 safety. vomited during the anesthetic. The incidence of vomiting brachial plexus but did not comment on improved efficacy and postoperatively was very low, only 2%. In three patients, spinal amount of anesthetic needed to produce clinical analgesia using anesthesia failed, and general anesthesia was instituted. Gray ultrasoundIn 1994, guidance Kapral [64], during reported brachial a significant plexus block. decrease Moreover, in the concluded that the the technique was associated with fewer complications, while surgical shock, the analgesia was patients reported less discomfort. The stage was set for a benefits to the patient were as follows: localized to the area of the block, and postoperative vomiting revolution in techniques used to identify neural structures that absolute anesthesia, no was minimal. The advantages for the surgeon were as could be blocked with local anesthetic agents. Improvements in follows: good operating conditions, easy access to the anesthetic techniques can bring about major changes in surgical abdomen, the bowel was constricted, surgery could be approaches. Ultrasound guided regional anesthetics have enabled completed patients to emerge from minimally invasive day-surgery with . Postoperatively, there was less pain, and almost no pain or side effects. feeding couldquickly, be started and thesooner. anesthetic These couldpapers be illustrate administered how muchby the was surgeon known about spinal anesthesia in children, more Regional vs General Anesthesia: any improvement than 100 years ago. in outcomes?: Caudal blocks now play a major role in pediatric anesthesia, As in all fields of medicine, there hasshowed been an a explosive growth in clinical research related to regional Meredith Campbell when she presented a paper to the American dramatically reduced mortality anesthesia. In 1987, Yeager [59] and colleagues Societybut they of wereRegional first Anesthesia reported for in cystoscopies1933 [61]. By in 1950, children Harry by . In 2000, Rodgers and colleagues in high-risk patients who Curwen in Durban, South Africa, was using caudal blocks in published an extensive meta-analysis showing a reduction received regional anesthesia neonates, he recognized the potential advantages, especially in postoperative mortality and morbidity with neuraxial for the occasional pediatric anesthetists or doctors working in anesthesia with the subsequent recommendation of more the rural areas [61]. Schulte Steinberg, who had trained widespread use of this technique [60]. with Bromage in Montreal, working in the county hospital Spinal anesthesia is the preferred anesthetic method for sub- in Starnberg [Germany] used caudal anesthesia and umbilical surgery, particularly in elderly patients and parturients. undertookPhilip studies on the reached in Parker and colleagues [61], investigated in a Cochrane meta- children, with different volumes of local analysis 22 clinical trials involving 2567 patients where dermatomal levels sabbatical in neuraxial [mainly spinal] anesthesia was compared with Durban, where anesthetic .with He general anesthesia hip fracture surgery. The authors found addedstudied X-ray caudal contrast. catheters Schulte Steinberg went on a and a reduced risk for postoperative deep venous thrombosis found it was possiblecaudal to thread anesthesia them easily was usedto the commonlythorax in small [30% compared withfor 47%] and acute postoperative confusion children [62]. Bosenberg thenin applied piglets the and method human clinically cadavers [9.4% compared

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with 19.2%] in patients treated with neuraxial [mainly spinal] cocain. Muriat auf den menschlichen organismus. Dtsch Med Wochenschr. anesthesia compared with general anesthesia. There was no 1883;50:730-732. evidence for reduced perioperative mortality. Peripheral nerve blocks and local anesthesia have very few cardiovascular 12. Raymond EH. Hydrochlorate of cocaine as a local anesthetic in dental surgery. Dental Cosmos. 1885;27:207-226. or pulmonary side-effects. , and peripheral nerve block must be with adequate 13. Halsted WS. Practical comments on the use and abuse of cocaine; Complications do occur suggested by its invariably successful employment in more than a thousand safety precautions by anesthetists with appropriate minor surgical operations. New York Medical Journal. 1885;42:294-295. experience. In experienced hands,performed it seems likely that peripheral nerve block would be safer than general 14. Redman M. Cocaine: What is the Crack? A Brief History of the Use of Cocaine as an Anesthetic. Anesthesiology and Pain Medicine. 2011;1[2]: anesthesia due primarily to the avoidance of airway 95-97. management. However, evidence to prove this assumption will 15. Einhorn A. Ueber neue arzneimittel. Liebig‘s Ann Chemie. 1900;311:26-77. never be available due to the low numbers of severe anesthesia- related complications. At the same time opioid consumption can 16. Erdtman H, Lofgren N. Uber eine neue gruppe von lokalanasthetisch be decreased or even avoided, in consequence, opioid-related wirksamen verbingdungen. Svensk Kemisk Tidskrift. 1937;49:163-174. side-effects can be reduced when perineural block 17. Lofgren N, Lundqvist B. Studies on local anaesthetics II. Svensk Kemisk after surgery Tidskrift. 1946;58:206-217. is a controversial topic, in skilled hands, variousis performed. regional 18. Lofgren N. Studies on local anesthetics. Xylocaine, a new synthetic drug. anestheticWhether regional techniques anesthesia are powerful influences tools outcome providing almost Stockholm: Chemistry, Stockholms Hogskola; 1948. perfect perioperative pain therapy. Using an optimal 19. Eggleston ST, Lush LW. Understanding allergic reactions to local anesthetics. balance between appropriate techniques, application of Annals of Pharmacotherapy. 1996;30[7-8]:851-857. advanced equipment, and optimal doses of drugs, regional 20. Bonica JJ. Obstetric analgesia and anesthesia: A manual for medical anesthesia plays an important role in perioperative medicine. students, physicians in training, midwives, nurses and other health personnel. Amsterdam: World Federation of Societies of Anesthesiologists; Conclusions 1980. Regional anesthesia has a fascinating history, with events following the introduction of general anesthesia by a half- 21. Reisner LS HB, Plumer MH. Persistent neurologic deficit and adhesive arachnoiditis following intrathecal 2-chloroprocaine injection. Anesthesia century. As with general anesthesia, techniques and drugs Analgesia.1980;59[60] :452-454. have evolved over time, and currently many patients receive 22. Ravindran RS BV, Tasch MD, Gupta CD, Luerssen TG. Prolonged neural concurrent care under both techniques. During the late blockade following regional anesthesia with 2-chloroprocaine. Anesthesia 19th and early 20th century regional anesthesia was the Analgesia.1980; 59[6]:447-451. preferred technique because of complications associated 23. Moore D, Spierdik, J., van Kleef, JD., Coleman, RL., Love, GF. with general anesthesia, and a shortage of anesthesia Chloroprocaine neurotoxicity: four additional cases. Anesthesia Analgesia. providers. Ensuing decades showed the use of regional 1982; 61[2]:155-159. anesthetics decreasing as general anesthesia became safer. 24. Gissen A. The Chloroprocaine Controversy: I. A Hypothesis to Explain the However, recent advances in techniques, drugs and Neural Complications of Chloroprocaine. Regional Anesthesia. 1984;124- applications have led to a resurgence in the use of regional 134. anesthesia. We believe historical aspects of regional 25. Gissen A. The Chloroprocaine Controversy: II. Is Chloroprocaine Neurotoxic? anesthesia can and should be taught as part of the Regional Anesthesia. 1984;9:135-145. educational curriculum. 26. Baker M. Cocaine or Sulfite Toxicity? Anesthesiology. 2004:1247. References 27. Taniguchi M. Sodium Bisulfite:Scapegoat for Chloroprocaine Neurotoxicity? Anesthesiology. 2004;85-91. 1. Sim P. The heritage of anesthesia. Park Ridge, Illinois: Wood Library- Museum of Anesthesiology; 2012. 28. Ruetsch Y, Boni, T, Borgeat, A. From cocaine to ropivacaine: the history of local anesthetic drugs. Curr Top Med Chem. 2001;175-182. 2. Eger EI, Saidman LJ, Westhorpe RN. The wondrous story of anesthesi.New York: Springer. 2014. 29. 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