Regional anesthesia has played a pivotal role in the development of anesthesiology as a medical specialty since the discovery of the local anesthetic properties of cocaine by Carl Köller in 1884. In the decades since this landmark discovery, surgeons and anesthesia providers have appreciated the advantages of regional anesthesia in their patients, particularly in surgical situations complicated by limited resources and austere environmental conditions. War, more than any other human endeavor, has driven the need to provide effective anesthesia for surgery in austere environments. Indeed, the development of anesthesiology as a distinct specialty has been attributed to the medical experience obtained in World War II.1 The physician-anesthetists of that era quickly recognized that regional anesthesia imparted the least physiologic insult to the wounded soldier and allowed a more awake patient to be returned to the recovery ward, thus reducing the burden on limited wartime medical resources.1 As anesthesiology matured as a medical specialty and departments of anesthesiology began to break away from departments of surgery in academic centers, regional anesthesia continued to evolve. During the Vietnam War, the value of regional anesthesia in harsh medical conditions was reestablished. In one series of 1000 battle casualties, nerve block, spinal, or local anesthesia was used in 49% of cases: “This allowed increased anesthesia coverage of more surgical procedures at any one time as well as decreasing the demands on postoperative ward personnel in a multiple casualty situation.”2 The role of regional anesthesia in combat casualty care continues to expand in modern conflicts. Consequently, military medical planners are understandably interested in austere environment anesthesia due to the realities of military wartime missions. Civilian anesthesiologists are also interested in the advantages of regional anesthesia in austere environments for disasters, civil defense, and missions to medically underserved regions of the world.
In the last 20 years, regional anesthesia has undergone a renaissance. New equipment, such as peripheral nerve stimulators and ultrasound technology, has facilitated block placement and enhanced resident training in regional anesthesia. Continuous peripheral nerve block (CPNB) catheters and peripheral nerve infusion pumps have extended the benefits of regional block techniques beyond the immediate perioperative period to days after an operation and even into the home.3 Additionally, the practice of regional anesthesia has evolved into an important subspecialty of anesthesiology termed acute or perioperative pain medicine. Acute pain services are now an integral component of quality healthcare in the United States.4 In this chapter, the advantages and application of advanced regional anesthesia in austere environment medicine will be examined. The role of recent advances in regional anesthesia equipment and techniques for facilitating anesthesia in less-than-ideal conditions will also be discussed.
AUSTERE ENVIRONMENT ANESTHESIOLOGY
The practice of medicine in an austere environment requires a significantly different approach than that used for medicine practiced in major medical centers and in developed countries in general. This is especially true for the practice of ...