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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, or missions
to medically underserved regions of the world.
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In the last 15 years regional anesthesia has undergone a renaissance.
New equipment, such as peripheral nerve stimulators and ultrasound
technology have facilitated block placement and enhanced resident training
in regional anesthesia. Continuous peripheral nerve block 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 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 in facilitating anesthesia in
less than ideal conditions will also be discussed.
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The practice of medicine in an austere environment requires a
significantly different approach than that used for medicine practiced in
the major medical centers or in developed countries in general. This is
especially true for the practice of anesthesiology. In developed countries,
the anesthesiologist has a tremendous resource base that is readily
available and largely transparent to the production of an anesthetic plan.
The utilities, roads, computers and other wonders of modern infrastructure
common to developed nations are rarely noticed by anesthesiologists, but
they impart ...