e neuroanesthesiologists are to be given credit for introducing techniques into the laboratory and into clinical practice for monitoring basic physiology and, in clinical practice, facilitating the safe delivery of anesthesia for neurosurgical and neurologically impaired patients. When one evaluates our half-century of contributions to the cutting edge of medicine, however, it is easy to appreciate that, while we have been extremely creative in developing and introducing hypotheses and theories, we have been lacking in our follow-through. Accordingly, we have all too often accepted unproven or underevaluated theories and applied them to clinical practice. Additionally, much of the critical testing of our ideas in humans has come not at the hands of neuroanesthesiologists, but by others.

If we, as a discipline, are to make appropriate progress, I suggest several ideas for improvement:

We must realize that, in the current era, the gold standard for biomedical research is the improvement in patient outcomes or patient safety. As such, our research must be conducted with this endpoint as the ideal conclusion.

We must disabuse ourselves of comfortably assuming that “the whole is equal to the sum of the parts.” Indeed there is ample evidence — in studies of glucose, corticosteroids, cyanide and elsewhere — that results from laboratory test tube and culture plate experiments do not predict outcome in whole animal models, and outcome studies in whole animals do not ideally predict outcomes in complex human physiology. If we want to most accurately improve outcomes and safety in humans, we must study specific human situations. And we have to use appropriate end-points in those studies, not convenient surrogate end-points, if our research is to have optimal validity and clinical utility.

We must embrace the idea that modern research is exceedingly complex, with single research projects typically requiring the input of experts from many disciplines, coordinated by leaders with considerable organizational and communications skills. As such, when recruiting our next generation of neuroanesthesiologists, we need to think not predominantly in terms of which training program candidates have the personality to sit with a single patient during a prolonged (and sometimes monotonous) neuroanesthetic, but also in terms of candidates who have the communication skills and leadership potential to engage in — and hopefully lead — team research. Then, we as mentors, department administrators and supporters need to encourage these individuals to acquire skills in logistics, statistics, epidemiology, pharmacology, genomics and the like so that they can bring fresh insights into solving age-old and modern problems.

We must accept the fact that the provision of neuroanesthesia is increasingly migrating out of the operating rooms and intensive care units into diagnostic and therapeutic radiology suites and other locations. These areas are associated with some of modern medicine’s greatest advances in the care of neurologically at-risk or impaired patients (e.g., as is seen with the rapid use of thrombolyic therapy after embolic or thrombotic stroke). We neuroanesthesiologists have the potential for some of our greatest contributions in these expanding venues, but only to the extent that we are comfortable working in teams with other experts, often in a role other than that of the principal leader. We should embrace these opportunities while realizing that, in the end, the patients benefit.

Finally we must look for opportunities to work with our fellow anesthesiologists in other disciplines to solve important problems. The understanding and prevention of neurologic injury in cardiac anesthesia has, in my opinion, been hindered by unacceptably poor communication and exchange of ideas between neuroanesthesiologists and cardiac anesthesiologists. (One need look no further than the management of cerebral perfusion pressures and the use of corticosteroids to see that this is the case.) Elsewhere, greater contributions from neuroanesthesiologists would be of substantial value in research related to peripheral nerve injury, ischemic optic neuropathy, intraoperative awareness and other conditions. Despite these opportunities, we neuroanesthesiologists have not taken optimal advantage of applying our expertise.

In summary, some five decades’ worth of neuroanesthesiologists can take pride in the intellectual and practice advances that we have contributed to modern medicine. If we are to maintain and advance the professional respect that we have long enjoyed, however, we must: 1) be more disciplined in our investigational follow-through, 2) interact more effectively with experts from other disciplines, and 3) re-evaluate the type of individuals we recruit to our discipline and the type of training we provide them. If we adhere to these three simple rules, neuroanesthesia can expect considerable advances for many more decades..

William L. Lanier, Jr., M.D., is Professor of Anesthesiology, Mayo Clinic, Rochester, Minnesota. He was President of the Society of Neurosurgical Anesthesia and Critical Care in 1993-94.

return to top