Anaesthesia in austere environments: literature review and considerations for future space exploration missions

Matthieu Komorowski; Sarah Fleming; Mala Mawkin; Jochen Hinkelbein

doi:10.1038/s41526-018-0039-y

Anaesthesia in austere environments: literature review and considerations for future space exploration missions

Komorowski, Matthieu; Fleming, Sarah; Mawkin, Mala; Hinkelbein, Jochen 2018-02-23 00:00:00 www.nature.com/npjmgrav REVIEW ARTICLE OPEN Anaesthesia in austere environments: literature review and considerations for future space exploration missions 1,2,3 4 1 5 Matthieu Komorowski , Sarah Fleming , Mala Mawkin and Jochen Hinkelbein Future space exploration missions will take humans far beyond low Earth orbit and require complete crew autonomy. The ability to provide anaesthesia will be important given the expected risk of severe medical events requiring surgery. Knowledge and experience of such procedures during space missions is currently extremely limited. Austere and isolated environments (such as polar bases or submarines) have been used extensively as test beds for spaceﬂight to probe hazards, train crews, develop clinical protocols and countermeasures for prospective space missions. We have conducted a literature review on anaesthesia in austere environments relevant to distant space missions. In each setting, we assessed how the problems related to the provision of anaesthesia (e.g., medical kit and skills) are dealt with or prepared for. We analysed how these factors could be applied to the unique environment of a space exploration mission. The delivery of anaesthesia will be complicated by many factors including space-induced physiological changes and limitations in skills and equipment. The basic principles of a safe anaesthesia in an austere environment (appropriate training, presence of minimal safety and monitoring equipment, etc.) can be extended to the context of a space exploration mission. Skills redundancy is an important safety factor, and basic competency in anaesthesia should be part of the skillset of several crewmembers. The literature suggests that safe and effective anaesthesia could be achieved by a physician during future space exploration missions. In a life-or-limb situation, non-physicians may be able to conduct anaesthetic procedures, including simpliﬁed general anaesthesia. npj Microgravity (2018) 4:5 ; doi:10.1038/s41526-018-0039-y INTRODUCTION contingency plan for any severe illness occurring in LEO includes 2,17,18 rapid stabilisation in orbit and station evacuation. Therefore, Signiﬁcant plans have been drawn by government space agencies it is likely that the ﬁrst extra-terrestrial anaesthesia will be and private companies for manned spaceﬂights beyond low Earth conducted during a SEM. orbit (LEO) in the coming years, with a focus on missions to Mars. Researchers have extensively used space analogue environ- Such ﬂights have been termed space exploration missions (SEM). ments (such as polar bases or submarines) to probe hazards, The latest National Aeronautics and Space Administration (NASA) develop crew proﬁciency, validate medical technologies and mission design called for a 900-day mission for a crew of 6, with 2,3,5,19–21 countermeasures for prospective space missions. Study- around 6 months spent in transit, each way, and 500 days on the ing medical care in these space analogue environments can Mars surface. provide predictive insight into the many factors that will impact These interplanetary missions will present great challenges to 3,5,22 2,3 healthcare delivery during future SEM. the ﬁeld of space medicine. During the exploration of frontiers Our objective is therefore to conduct a literature review about on Earth, human physiologic maladaptation, illness, and injury anaesthesia in space analogue environments, to further our have accounted for more failures than technical or environmental 4–6 understanding of the challenges at stake and propose factors. Beyond the immediate vicinity of Earth, there will be no some possible solutions. We will present how various problems possibility for the crew to return swiftly to the ground or to be 3,7 have been addressed in relevant settings, and discuss how assisted in real-time from Earth. Such space exploration will 2,4 this information could be applied to the unique environment of a entail extreme isolation and therefore total crew autonomy. SEM. The question of surgical preparedness, and the extent of Among the expected severe medical conditions, surgical 4,8–13 problems are of central concern, and will require anaesthesia, the surgical procedures that the crew will be able to carry out which currently represents a gap in space medicine knowl- are outside the scope of this work. This literature review will 12,14,15 edge. No human has ever required an anaesthetic aim to provide important information for the design of the on- procedure in space or shortly after returning to Earth. It is not board healthcare system and protocols for future SEM, as well appropriate to test protocols on healthy astronauts in space, and as clues for future research pathways to help close remaining 12,14,16 efﬁcient ground models do not exist. The current gaps. 1 2 Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Exhibition road, London SW7 2AZ, UK; Space Medicine Team, ISS Operations and Astronauts Group, European Astronaut Centre, European Space Agency, Linder Hoehe, Köln 51147, Germany; Institute for Space Medicine and Physiology (MEDES), 1 Avenue du Professeur 4 5 Jean Poulhes, Toulouse 31400, France; Maidstone Hospital, Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Maidstone ME16 9QQ, UK and Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln, Kerpener Straße 62, Köln 50937, Germany Correspondence: Matthieu Komorowski (m.komorowski14@imperial.ac.uk) Received: 30 April 2017 Revised: 30 January 2018 Accepted: 31 January 2018 Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA Anaesthesia in austere environments... M Komorowski et al. Fig. 1 PRISMA ﬂow diagram of publications reporting on anaesthesia in austere environments relevant to a future space exploration mission, published from January 2000 to December 2016 RESULTS Combat anaesthesia refers to the provision of anaesthesia by trained professionals or non-medics to soldiers and civilians in Publications inclusion ﬂow diagram armed conﬂict environments. This setting is characterised by little The Fig. 1 shows the results of the review process. We screened to no infrastructure, limited logistical support, in remote or 2448 search results by title and abstract for possible inclusion. The 34–39 dangerous areas. full texts of 241 publications were assessed for eligibility. In total, Isolated and conﬁned environments (ICEs) include a broad 134 publications were included in the review, represented by 55 variety of places that present hostile and harsh physical conditions research articles, 31 reviews, 17 book chapters, 9 books, 9 reports, 5,23,40 posing threats to human health and life. ICEs encompass a 5 clinical guidelines, 5 editorials and 3 case reports. wide range of environments and medical specialties such as expedition, wilderness, mountain, diving, underwater, polar, 20,23,40–43 Characteristics of the selected austere environments sailing, aviation, jungle, desert, among others. In ICEs, A summary of the characteristics and limitations of the four micro-societies of scientists and explorers expose themselves selected environments is shown in Table 1. willingly to such environments. In general, the teams include LEO can be used as an 'in-space' analogue for interplanetary trained physicians or paramedics carrying a limited medical kit. travel research. Orbital ﬂights represent the closest analogue to Their ability to perform advanced medical care is sometimes so SEM in terms of environmental exposure, but lacks experience of limited that ICEs have been described as 'fourth world' medicine. invasive medical procedures and isolation. Indeed, crews can communicate in real-time with the ground, beneﬁt from Expected medical and surgical conditions telemedical support and can be readily evacuated in case of In austere environments, the precise anticipation of likely medical 2,7,23,24 serious illness. conditions is important because it inﬂuences the design of the Low and middle income countries (LMICs) are deﬁned as those 9,40,44 health system (equipment, personnel and skills). In these with a gross national income per capita, calculated using the environments, most surgical conditions are traumatic or infec- World Bank Atlas method, of $12,235 or less. These countries are 2,21,26,28,32,34,35,38–41,45–48 tious. Several sources have listed the invariably afﬂicted by severe limitations in healthcare resources surgical procedures which should be available anywhere at any 26–31 32,39,49–51 and skilled personnel. Several signiﬁcant international endea- time, as they are deemed essential. vours such as the WHO Emergency and Essential Surgical Care No human surgery has ever happened in space, and indeed programme, the Lancet Commission on Global surgery and the astronauts have experienced very few events that could have World Bank publication Essential Surgery in Disease Control required surgery. Station evacuations have occurred on three Priorities in Developing Countries—3rd Edition (DCP3) have instances in the 1970’s and 1980’s for suspected appendicitis and released guidelines and tools to improve safety and cost- dysrhythmias but were also hastened by psychological issues and 4,22,52,53 effectiveness of surgery and anaesthesia in resource-poor crew conﬂicts. 28,32,33 settings. They have been deﬁning 'the lowest common The likelihood of events requiring anaesthesia during SEM can anaesthesia denominator', which is an appealing concept for be estimated to some extent from large case series from ground- future SEM where facilities and skills may be reduced to the bare analogue populations, military and civilian populations, and data minimum. gathered throughout the 140 person-years of cumulated npj Microgravity (2018) 5 Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA 1234567890():,; Anaesthesia in austere environments... M Komorowski et al. 8–10,13 spaceﬂight experience. For example, the risk of acute appendicitis has been estimated as 1–2 per 100,000 person-days, which would be equivalent to 1–2 cases every 45 years for a 6- person space crew. The cumulated risk of severe event requiring surgery may add up to one or more during a 900-day Mars 4,8,9,19 mission. However, owing to the duration, remoteness, activities (more extra-vehicular activities—EVAs) of SEM, the exposure to the hazards of space will be different than in LEO and lead to various types of medical conditions. Overall, experts have estimated that the most signiﬁcant risks for SEM are trauma, 9,11 54,55 haemorrhagic shock and infections. Indeed, a loss of bone mineral density of 1–2% per month has been measured and increases the risk of renal stones and possibly of osteoporotic 2,3,56 fractures after a few months into the ﬂight. Although the risk of severe trauma is low in weightlessness, objects conserve their mass and therefore still carry kinetic energy when in move- 11,15 ment. The vast number of EVAs planned during surface exploration will expose the astronauts to a high cumulated risk of 9,13,57 traumatic accidents and hypobaric decompression sickness. The risk of infection is increased in space, due to space-induced immunosuppression and possible increase in bacterial viru- 54,55 lence. The full list of expected conditions is summarised in Table 2, along with non-surgical illnesses, provided for 9,13,57 reference. The provision of anaesthesia under these circumstances will be restricted to procedures which are absolutely essential for the 29,31,58 saving of life or limb. Non-operative treatment may also be 4,10 chosen, for example for uncomplicated appendicitis. Of note, prophylactic removal of the appendix and/or gall bladder is being considered. Causes of death The analysis of the root causes of death in austere environments provides some insight into the most critical aspects of healthcare safety, and helps identify potential strategies for improving 35,59 outcomes. Perioperative mortality is usually due to a combination of factors related to patients, surgery, anaesthesia and general 31,48,59 management. In LMICs, shortages and misdistribution in the anaesthetic workforce, as well as deﬁcits in health infrastructure 28,30,31,60–63 have been consistently correlated to mortality. Most often, perioperative deaths in LMICs are related to acute anaemia or septic shock, frequently hastened by pre-existing morbid 31,48,59,61,64 conditions. In the combat environment, haemorrhage 35,36,45 remains the most common cause of death. In these circumstances, the prevention and prompt correction of major blood loss is critical and requires the availability of blood 31,36,49,64,65 products. Postoperative infections are usually pre- vented with antibiotic prophylaxis and sterilization of instru- 31,66 ments, although the risk of post-operative infection persists in situations such as trauma with contamination, hollow viscus perforation or intra-abdominal abscess and will require full course of antibiotics. Less often, deaths occur as a direct consequence of anaesthesia. In LMICs and elsewhere, preventable anaesthesia mortality stems from two main factors: hypoxemia and hypotension, which are primarily related to failed intubation and induction of anaesthesia 29,31,60,64 in the presence of hypovolaemia. Anaphylaxis, aspiration, cardiac events and medication interactions are also potentially 31,60 life-threatening problems. The safety objective for a mission to Mars has been deﬁned by some experts at 3% of individual risk of death per year. A signiﬁcant portion of this risk is related to spacecraft failure, the rest being represented by death from trauma and medical illness, which amounts to approximately 0.24% per individual and per mission. Trauma, infections, haemorrhage, radiation sickness and cardiovascular events represent the most likely causes of Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA npj Microgravity (2018) 5 Table 1. Summary of the characteristics and limitations of the selected analogue environments LEO LMIC/humanitarian Combat ICE Description Use of LEO as analogue for interplanetary Resource-poor setting with lack of Out of hospital austere setting, high Expeditions in environments such travel research equipment and medical expertise prevalence of severe trauma and blast as: mountain, high altitude, polar, injuries jungle, desert Volume of surgical Nil High High Low procedures Technological and ++ +++ ++ ++ equipment constraints Human constraints ++ +++ ++ ++ Patient physiological ++ secondary to exposure to ± Soldiers are healthy individuals before ± (possible hypoxia, hypo/ alterations microgravity injury hyperthermia) Limitations for No experience of surgery or anaesthesia. Does not provide microgravity and/or Does not provide microgravity and/or Does not provide microgravity applicability to SEM Lacks total isolation (option to evacuate, radiation exposures. Anaesthesia providers radiation exposures. Pathology nearly and/or radiation exposures real-time telemedicine) very different from astronaut population exclusively traumatic. Well trained providers LEO low earth orbit, LMIC low and middle income country, ICE isolated and conﬁned environment +: present; ++: important; +++: major skill erosion is not expected in environments with a high caseload Anaesthesia in austere environments... M Komorowski et al. Table 2. List of expected surgical conditions, recommended procedures and medical illnesses during SEM, not including pregnancy-related conditions 1- Surgical conditions and procedures 2-Non-surgical conditions 1.1- Trauma 2.1- General medical conditions Suturing laceration Minor trauma, sprains and strains Tube thoracostomy Infections: pneumonia, cellulitis, gastroenteritis, urinary tract infection, corneal infection, Fracture reduction latent viral reactivation Irrigation and debridement of open fractures Cardiovascular diseases: myocardial infarction, cardiac dysrhythmias Fractures: external and internal ﬁxation; use of traction Renal stones Trauma laparotomy Psychiatric: depression, anxiety, sleep disorders or Eescharotomy/fasciotomy Cancer Trauma-related amputations Skin grafting Burr hole Surgical airway 1.2- General surgical 2.2- Space-speciﬁc conditions Drainage of superﬁcial abscess Cardiovascular deconditioning, orthostatic intolerance Dental extraction, drainage of dental abscess Radiation exposure Repair of perforations: for example, perforated peptic Visual impairment and intracranial pressure syndrome ulcer Space motion sickness Appendectomy Environmental exposure including hypobaric decompression sickness, toxic atmosphere, Bowel obstruction, colostomy hypothermia/heat stroke, planetary dust Gall bladder disease, including emergency surgery Relief of urinary obstruction: catheterisation, suprapubic cystostomy Treatment of renal stone including nephrostomy Hernia, including incarceration Drainage of septic arthritis Biopsy 13,32,50,51,57 Adapted from. 9,11,55,67–70 death. The risk of infection appears increased in space, due difference with future SEMs is represented by the high number of 27,29,30,77 to several factors related to immunosuppression, possible increase in patients treated by anaesthetic providers in LMICs. bacterial virulence, and presence of particles in suspension. The Consequently, skill retention is less an issue in LMICs, while haemodynamic tolerance to blood loss or sepsis is expected to be representing a huge challenge in future long-term SEMs. poor due to changes in volaemia and cardiovascular performance Simulation plays an important role in the acquisition of 67,71 experienced after exposure to microgravity. anaesthetic and non-technical skills, both for doctors and non- In LMICs, surgeries with a low probability of success and a high doctors, as demonstrated in many studies looking at patient 31,32,48,60,72,73 78,79 probability of death are often not attempted. outcomes. Models for simulation in low-resources settings and 76,78–81 Similarly, during a SEM, the crew must prepare for non- distance learning of anaesthetic skills have been proposed. survivable illnesses or injuries that will exceed the local treatment 'Just-in-time' training allows practitioners to gain or refresh skills capability. on-the-spot, for example in case of unexpected scenarios. We retrieved the case of a spinal anaesthesia delivered in Antarctica by a non-anaesthetist with remote support. Medical skills of anaesthesia provider(s) In combat environments, personnel with various levels of To achieve the minimum standard in patient safety, models for medical skills deal with trauma casualties, often severe and in surgical and anaesthesia training have been devel- 38,39,45,49,72 29,31,32,39,48,49,60,74 large numbers. Nurse anaesthetists have been and oped. These models are organised in several remain the main providers of anaesthesia care to military layers of complexity, with successive strata allowing increasingly 36,49 personnel. The observation that over 90% of deaths happen complex procedures. In these models, the core components before the wounded reach a medical facility has led to efforts to provide basic resuscitative and primary trauma capacity that do 30,31,39,60,75 broaden medical training to non-medical personnel on the ﬁeld, not require extensive equipment or skills. The second including for advanced procedures such as thoracocentesis and level allows treatment of most life-threatening conditions and 39,45,84 surgical airway. includes spinal and ketamine-based anaesthesia, laparotomy, 31,49 The current International Space Station (ISS) programme amputation, closed and open orthopaedic surgery. This requires the presence on-board of a crew medical ofﬁcer, who is requires physician-level skills but not necessarily that of an 2,18,85 not necessarily a physician. The ideal proﬁle for the crew anaesthetist, to provide full resuscitation and general and spinal physician on future SEM is still debated, due to the uniqueness of anaesthesia. The third level requires specialist-level skills to 13,86 31,60 the operation. The best physician proﬁle for a SEM could be an deliver prolonged multi-organ support. In these models, emergency medicine doctor with additional training in surgery medical services in scarce environments focus on primary care 13,86 rather than on more advanced medical and surgical care, which and wilderness medicine. Importantly, the crew doctor will 28,31 likely saves more lives. spend most of his time on non-medical tasks, which increases In LMICs, the shortage of physicians is such that it is common further the complexity of his training during mission for non-doctors (nurses, anaesthetic ofﬁcers, clinical assistants…) preparation. to carry out anaesthesia and surgery, many of whom have little The crew physician will need to have a broad knowledge base, 26,28,29,47,76 medical background and are trained 'on the job'. Their to be competent in basic surgical skills and in the management of 27–29 13,85,86 ability to deal with complex cases remains limited. A key the critically ill and injured. One of the most important npj Microgravity (2018) 5 Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA Anaesthesia in austere environments... M Komorowski et al. qualities will be ﬂexibility and thus the ability to improvise in The care of a surgical patient requires a range of support 13,40 medical scenarios that may have been unseen before. services and equipment that extend well beyond anaesthesia, Most likely, a single physician will oversee both the surgery and such as running water, electricity, surgical equipment and the anaesthesia. Skills redundancy will be critical to enhance sterilization means, personal protective equipment, laboratory crew safety, especially if the physician himself becomes ill, injured, work, imaging equipment, ideally continuous oxygen and blood 18,85,87 26,28,30,31,45,49,51 incapacitated or dies. In this situation, it has been suggested products. Sterilization of surgical instruments in 12,87 that non-physicians could perform advanced medical care. It austere environments is challenging, but simple dry heat or 31,66 appears advisable to train several crewmembers to manage the antiseptic methods are acceptable. most common emergencies, for example matching the ﬁrst level Checklists are a simple and cost-effective way to improve 31,32,77 29,94,95 of competency of the WHO or DCP3 models. patient safety. They are particularly useful where expertise is Signiﬁcant advances have occurred in recent years in the ﬁeld limited, because they help with memory recall and clarify the of artiﬁcial intelligence in medicine, that offers the promises of minimum expected critical safety steps in a complex process. more effective monitoring, improved disease detection and The current ISS medical kit does not allow for general 2,88 development of efﬁcient decisions support systems. Autono- anaesthesia (GA) or prolonged organ support and will need to 8,18,87 mous diagnostic systems, closed-loop automated anaesthesia or be profoundly updated for a SEM. The design of the medical other decision support systems could simplify training require- kit must balance crew skills with constraints in volume, weight, 88–90 ments and improve patient safety. power requirements against the load of expected medical conditions, which partly depends on the mission proﬁle (e.g., 9,44,87 mission duration, number of EVAs…) and crew size. Non-clinical skills, behavioural health and performance During SEM, restrictions in storage and up-mass and the Prolonged exposure to factors such as stress, workload, fatigue, impossibility to re-supply may lead to shortages in tools and social isolation, altered lighting conditions and circadian cues all consumables. On-demand 3D printing of equipment is promis- contribute to degraded performance, both on ICEs and in ing. Methods to ensure drug stability during the mission must 82,91,92 space. The negative psychological response to living in ICEs be developed and validated. The expected lack of blood include mild cognitive impairment, time-sense disturbances, products could be mitigated using fresh whole blood transfusion, motivational decline, sleep disorders, psychosomatic symptoms, similar to the concept of 'walking blood bank' in combat 5,6,22,52,91,92 anxiety, depression and social conﬂicts. Maintaining medicine. This would imply that blood compatibility could crew behavioural health and performance has arose as one of the 45,49,65 become a selection criteria. Ultrasonography is likely to 5,6,22,82,91,92 most challenging aspects of prolonged stays in ICEs. remain the leading imaging modality in future SEM. It can be Practical concepts aimed at improving operational performance used for a variety of tasks related to anaesthesia and surgery, such both in austere environments and in space have been proposed. as nerve localisation, assessment of volaemia and cardiac function, Schematically, they revolve around three aspects of performance, 13,99,100 line placement, and assisting external ﬁxation of fractures. all non-speciﬁc but directly applicable to medical skills: correct Acquisition of several critical skills appears shorter with ultra- crew selection, training prior to the mission, and skills acquisition sound, even in novices. For example, with a standardised teaching 82,91 and maintenance during the mission. Identifying 'the right program, ultrasound-guided central venous catheter insertion can stuff' for an unprecedented challenge such as a SEM, both at the be learnt by non-experts after less than ten procedures individual and the team level, and then maintaining mental health and crew cohesion during the entire ﬂight will be a key 5,22,52,91 Telemedicine component of mission success. Medical and psychological standards for crewmember selection are likely to be extremely Telemedicine relies on remote communication technologies to 22,52,91 restrictive owing to limitations in medical care and support. allow experts to provide diagnosis and/or therapeutic advice for 2,20,21,24,41,43,78,102 In austere environments, many non-clinical skills of the physician patients situated in an isolated place. Real-time 31,36,49,73 contribute to healthcare safety. These can be divided into communication is not mandatory for telemedicine. For example, personnel skills (e.g., team coordination, communication, or augmenting remote consultation by transmitting X-rays, ultra- logistics) and technical skills (e.g., troubleshooting equipment, sound images and digital photographs by email has proven very 5,40,82,91 40,41 use of safety equipment, or orientation). valuable. The proof of concept of a remotely administered general and spinal anaesthesia in real-time have been demon- 83,103 strated. Telemedicine is already extensively used in space- Medical kits ﬂight for remote diagnosis and treatment, monitoring and training In austere environments, a desirable situation for medical support 7,18,23,24 of astronauts. Real time telecommunication will not be is to match the equipment and personnel competencies to deal available during a mission to Mars, with delays ranging from 5 to 40,44 with the most likely medical conditions. 20 min each way, depending on the relative position of the The basic equipment required for safe anaesthesia need not be 4,21 planets. Concepts of delayed asynchronous tele-guidance for elaborate: a basic mechanical ventilator, monitoring including a surgery on Mars have been proposed. pulse oximeter and capnography, airway equipment and a 30,31,51,58,60,93 restricted range of drugs. In the most deprived Preoperative assessment settings, limited kit, even though not ideal, can be adapted to maximise patient care. It has been suggested that the The preoperative assessment of a patient in difﬁcult environments monitoring setup could even be reduced further to continuous should insist on the assessment of the risk of aspiration and clinical monitoring and a pulse oximeter, for a solution that is truly difﬁcult airway, and estimation of the recent ﬂuid loss from 29 31,60 achievable in the poorest settings. This is less relevant to future bleeding, vomiting, diarrhoea, anorexia or other. Most patients SEM since acquisition cost may be less important than the mass of are hypovolaemic due the ongoing pathological process requiring 38,40 the equipment. Oxygen is desirable but unavailable in most surgery (trauma or infection) or secondary to dehydration. 29,30,58 71,104 LMICs. In the absence of a mechanical ventilator, manual In space, microgravity affects most physiological systems. ventilation can be handled by a non-physician, who has usually The loss of the gravitational stimuli profoundly alters the 60,75 been trained on-the-job. The equipment for local and regional cardiovascular system, which rapidly becomes unable to respond 67,71,105 anaesthesia (RA) is much more limited, which makes it very efﬁciently to challenges such as orthostatism or blood loss. desirable in resource-poor environments, but only when anaes- The cardiovascular proﬁle of a microgravity-exposed individual 15,34,61–63 thesia providers are competent. is marked by a 15–20% hypovolemia, altered baroreﬂex and Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA npj Microgravity (2018) 5 Anaesthesia in austere environments... M Komorowski et al. Fig. 2 Fluid shift in space, and its involvement in post-ﬂight orthostatic intolerance. Immediately after entering weightlessness, a portion of the blood volume shifts towards the upper body, leading to the 'puffy face' and 'chicken legs' syndrome. Post-ﬂight, the combination of hypovolaemia and hypo-reactivity of the cardiovascular system commonly leads to orthostatic hypotension. Reproduced with permission from Gunga 26,47 systemic vascular resistances, changes in adrenergic receptors, to 90%) are carried out under GA without intubation. Oro- 110–112 mixed systolic-diastolic cardiac dysfunction, all leading to up to tracheal intubation requires extensive training. It has been 12,67,71,104,106 20% decrease in exercise tolerance. These factors estimated that over 50–60 conventional oro-tracheal procedures 110,113 expose the astronaut to a signiﬁcant risk of cardiovascular collapse were necessary for a novice to reach a 90% success rate. 12,14,107 during induction of GA and mechanical ventilation. The With videolaryngoscopy, this number may drop to less than ten 112,114 cardiovascular system faces its biggest challenges of spaceﬂight procedures. Even if the majority of the literature identiﬁed upon return (Fig. 2). Orthostatic intolerance affects over 80% of ISS steeper learning curves and shorter intubation time with crewmembers and is regarded as one of the most serious videolaryngoscopy, negative studies exist and this technique still 2,67,71,104 111,112 cardiovascular problems upon return to Earth. The extent requires appropriate training. Capnography should be used of the cardiovascular alterations in partial gravity (such as on Mars) to conﬁrm successful airway insertion. In one study, novices and the level of gravity required to prevent these effects are could achieve a 80% success rate in bag-and-mask ventilation 71 116 currently unknown. after a median of 25 procedures. The patient’s volaemic status and cardiac function should be Ketamine is the drug of choice for non-anaesthetic trained 31,38,60,77,117 assessed with physical examination and ultrasound, and if doctors, because it is cost-effective and relatively safe. possible optimised before induction. The expected volume of It is used extensively in adult and paediatric populations in military 26,38,46,47,77,117–120 ultrasound procedures required to train a non-expert at these anaesthesia, LMICs and during disaster relief. techniques can be estimated from the literature. Several days of Properly trained individuals can use propofol, although it is a poor training and 25 supervised procedures were necessary to train choice for induction in patients with shock, even after ﬂuid nurses to perform ultrasound measurement of the aorta and resuscitation. inferior vena cava diameters in a resource-limited setting. At In 2002, a NASA working group stated that the safe delivery of least 10 h of mixed didactic and scanning training and 45 anaesthesia in space could be achievable. Inhaled anaesthesia is procedures may be required for emergency physicians to become not an option in the closed environment of a spacecraft, because proﬁcient in focused cardiac ultrasound. In the microgravity- of issues of cabin pollution and because vaporisers would be 12,15,107 exposed patient, it may be advisable to administer a low dose of unreliable in reduced gravity. Among intravenous agents, 12,14,57 vasopressors (alpha-agonists) preventively before induction, ketamine appears to be the safest choice. Of note, 12,14,87 especially if GA or mechanical ventilation are anticipated. ketamine-based anaesthesia has been performed on 22 monkeys shortly after spaceﬂight. Hallucinations and emergence phe- nomena can be mitigated with premedication and overall are a General and regional anaesthesia lesser concern in a life-or-death situation. Gastric motility is slower General anaesthesia. In LMICs, where medical expertise and in space, at least during the ﬁrst days, possibly for longer, so airway equipment is lacking, a vast proportion of procedures (up npj Microgravity (2018) 5 Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA Anaesthesia in austere environments... M Komorowski et al. Table 3. Summary of ﬁndings and recommendations 1. The equipment, protocols and training programme for anaesthesia need to be developed and designed alongside all related medical sub- specialties, in particular surgery. 2. The basic principles of safe surgery (safety checklist, prevention of surgical site infection, conﬁrmation of site and procedure, etc.) must be guaranteed. Checklists should be provided for all the essential steps, including general surgical safety (following the WHO model), preoperative assessment and anaesthetic procedures. 3. The personnel in charge of delivering anaesthesia require speciﬁc training. 4. Skills redundancy will be an important safety parameter. Several crewmembers must be trained to achieve at least a basic level of competency (similar to WHO level 1). 5. Most expected conditions requiring anaesthesia are traumatic and infectious. The availability of blood products or substitutes is expected to improve the survivability of severe bleeding. 6. Non-anaesthetists can perform anaesthesia. Physicians are preferred, but as a last resort (life-or-limb situation), non-physicians could attempt to perform advanced medical care including surgery and anaesthesia. 7. A restricted set of equipment can be sufﬁcient. The strict minimum set of required equipment for anaesthesia is small, but caring for a surgical patient requires extensive equipment and consumables that spans well beyond. 8. The number of available anaesthesia protocols should be minimised, and efforts should be made to simplify them. 9. Ketamine appears to be the most suitable intravenous anaesthetic agent for general anaesthesia and procedural sedation. Videolaryngoscopes could be the preferred equipment for endotracheal intubation. 10. Regional anaesthesia is an appealing option for limb surgery. A limited number of blocks are sufﬁcient. Ultrasound guidance accelerates training and improves success rate. systematic rapid sequence induction is advisable. Succinylcholine condition, training and experience of the anaesthetist and is contraindicated after exposure to microgravity because of surgeon, availability of drugs and equipment, degree of urgency, 12,14,107 60 changes in the neuromuscular junction. Both operator and presence of a full stomach, and ﬁnally patient’s preference. patient must be restrained if conventional laryngoscopy is to be Anaesthesia providers with limited experience should limit attempted in weightlessness, otherwise supraglottic devices are themselves to a small number of safe, widely applicable 122–124 an option. Videolaryngoscopes have been tested in a Mars techniques, to improve familiarity and conﬁdence through regular analogue simulation. practice. Dobson suggested that because of limited skills and 75,94 supplies, GA use should be minimised whenever possible. Regional and perimedullar anaesthesia. The use of RA in difﬁcult During SEMs, in the absence of strong evidence, it appears environments is appealing, because it requires fewer preoperative, sensible to formulate choices based on a worst-case scenario 15,34,38,62,94 intraoperative and postoperative resources. Indeed, approach and consider that astronauts requiring surgery will be regional and perimedullar anaesthesia (spinal anaesthesia in severely deconditioned, hypovolemic, at risk for arrhythmias, particular) are often the preferred choice where expertise is difﬁcult to intubate, intolerant to succinylcholine, have a full available, but are otherwise virtually non- stomach, and be managed by non-medical personnel with limited 26,28,34,38,47,48,62,64 12,57 existent. They are regularly delivered by non- training, if the crew medical doctor is incapacitated or dead. anaesthetists, demonstrating that they can successfully be trained Overall, we argue that RA should be attempted whenever 38,62,83,125–127 12,15 to RA techniques in austere environments. Most limb possible. When not suitable or in case of failure, GA will be surgery is feasible with only 3 blocks (axillary brachial plexus, necessary. We recommend to implement a limited number of 12,15,57,128 femoral and sciatic blocks). The use of ultrasound for RA simpliﬁed intravenous anaesthesia protocols that could be has accelerated the training of anaesthesia residents and narrowed down to two options only: conscious sedation (for 12,57,128 improved success rates. In ultrasound-guided nerve blocks, procedural anaesthesia, peripheral surgery and superﬁcial trunk anaesthesia residents commonly require a minimum of 10–15 surgery) and GA with endotracheal intubation (for head, face and 12,57,87 procedures per block to achieve a 90% success rate. Many deep trunk surgery). additional techniques such as intravenous RA or haematoma 12,38,120 blocks can be of value in difﬁcult environments. In LMICs, Postoperative care intra-abdominal surgery such as caesarean section are commonly The most important aspects of postoperative monitoring do not performed under RA alone, after inﬁltration of the abdominal wall rely on complex equipment: airway patency, haemodynamic and by large volumes of lidocaine. respiratory stability, urine output, warmth of peripheries and pain For future SEM, RA is an extremely interesting and safe option 31,60 control. Following surgery, the most severe patients will despite its limitations, and efforts should be made to integrate RA 12,15,57 require sustained invasive support, which occurs typically in an into the crew physician’s skillset. The absence of sedation intensive care unit. In LMICs, such facilities are excessively and shorter recovery times will enable a faster return to full limited. operations and minimise the impact on the mission, in an A key focus of the postoperative period involves pain control, environment where everyone will have a unique and valuable which is more difﬁcult and inconsistent in austere environ- skillset. The safety and efﬁcacy of perimedullar anaesthesia in ments. The Wilderness Medical Society guidelines propose a weightlessness or in partial gravity is unknown but concerns have pyramidal approach to pain management in austere environ- been expressed about the effect of the sympathetic block on a ments, with simple physical and comfort measures representing microgravity-exposed patient. the basis of the management, before any escalation of care. The ideal medication for austere environments (compact, non-sedat- Choice of anaesthetic technique ing, long shelf-life, with multiple routes of administration, minimal 36,120 The general approach for choosing an anaesthetic technique in a side effects and a wide spectrum of use) does not exist. difﬁcult environment depends on several factors: patient’s Potent drugs with harmful side effects (narcotics, ketamine) are Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA npj Microgravity (2018) 5 Anaesthesia in austere environments... M Komorowski et al. Table 4. List of questions used in the literature review Category Questions Usefulness of analogues 1. What characteristics of each selected austere environment are relevant to a SEM? Expected conditions 2. What medical and surgical conditions are encountered in austere environments and expected during a SEM? 3. What factors contribute to patient death in austere environments and a SEM? Medical skills 4. What is the proﬁle and medical skills of anaesthesia providers in austere environments? What medical skills are recommended for a SEM? 5. What non-clinical skills are important for healthcare delivery in austere environments? How can human behaviour and performance be optimised? Medical kits 6. What equipment is necessary or optional for anaesthesia in austere environments and during a SEM? 7. How is telemedicine used for healthcare in remote environments? How could it be used during future SEM? Pre, per and postoperative 8. How is the patient assessed and resuscitated before receiving an anaesthetic procedure? What are the management speciﬁcities of the physiology of the microgravity-exposed patient? 9. How is general anaesthesia administered in austere environments? How is the airway managed? 10. What is the role of regional and perimedullar anaesthesia in austere environments? What blocks are recommended? 11. What considerations are important for choosing the most appropriate anaesthetic technique in austere environments? 12. How is the patient managed in the post-operative period in austere environments? What are the guidelines for pain control? They explore various aspects of anaesthesia in austere environments and during a future SEM, and correspond to potential current gaps in space medicine knowledge and/or technology. Refer to text for explanations on how the list was established. reserved for the most severe pain, only after safer and less- cognitive aptitudes and ability to deal with extreme stress, are invasive therapies have been considered. Local and regional among the best candidates to overcome such a challenge. Besides anaesthesia are valid choices for pain relief, provided the caregiver the very unique context of a spaceﬂight, the ﬁndings of this 34,120,130 is accustomed to these techniques. research could also beneﬁt Earth-based initiatives and the general Postoperative care and pain control during SEM should follow public, by improving anaesthesia delivery and safety in remote general Earth-based guidance, with the necessary adjustments and resource-poor settings. aiming at improving crew recovery and limiting resource While the analysis of space analogue environments is important 57,120,131 utilisation. The provision of critical care during SEM is given the restricted access to space, no substitute can fully beyond the strict scope of this review, but if we extrapolate from replicate the uniqueness of a future SEM, where a self-reliant the current ISS capabilities, it is unlikely that the crew will have the restricted crew will be exposed to exceptional challenges and capacity to provide prolonged organ support of one or several risks, some of which are impossible to foresee. Space analogues 12,18,87 critically ill patients following surgery or resuscitation. are only simulations of greater or lesser ﬁdelity along varying 5,23 dimensions of interest. We have not included research carried out in highly controlled simulation centres, because very few DISCUSSION studies have explored the question of anaesthetic care provided Imray (2015) anticipated that future developments in healthcare in by non-medical personnel, but also because the very attributes of difﬁcult environments will be determined by the needs of modern the environment that have the greatest impact on performance day explorers. He argues that travellers will encounter 'environ- are removed in simulation studies (e.g., real danger, uncontrolled ments where physiological and geographical extremes necessitate events, situational ambiguity, or the interaction with the extreme prompt and innovative approaches to rescue, medical care, and transportation'. Future SEMs perfectly illustrate this statement. environment itself). Bishop has argued that the value of this However, medical preparedness for SEM is difﬁcult to achieve as research was very limited once these features were experimentation in space is constrained by access and operational compromised. resources, and because of the small sample size and low incidence While this review provides useful clues regarding some critical of medical conditions. The need to ﬁnd relevant terrestrial aspects of anaesthesia in space, several factors remained substitutes is driven by extraordinary demands for mission unexplored and warrant further research. More research needs success. Among medical procedures, the delivery of anaesthesia to be done to deﬁne the ultimate skillset of the astronaut currently represents a gap in knowledge. Therefore, we have physician, design tools to prevent skills erosion during the ﬂight analysed an extensive set of topics surrounding the practice of 5,13,22 and address the question of skills redundancy. Designing the anaesthesia in environments relevant to SEM, with the objective of on-board medical kit will take place in parallel, and will partly be closing this gap. driven by anaesthetic and surgical capability and engineering The summary of our results is shown in Table 3. The literature 8,18,44 requirements. A return to gravity is increasingly difﬁcult with seems to indicate that non-anaesthetists, and, as a last resort, non- increasing ﬂight duration. More research is needed to investi- physicians, could potentially provide effective and relatively safe gate the synergistic effects of prolonged exposure to space- anaesthetic procedures during future SEM, provided that they derived stressors and partial gravity on human systems, and to receive the appropriate training during the preparatory phase. It 2,71,132 resolve some contradictory ﬁndings. makes little doubt that astronauts, with their extensive skill-set, npj Microgravity (2018) 5 Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA Anaesthesia in austere environments... M Komorowski et al. CONCLUSION AUTHOR CONTRIBUTIONS M.K. and J.H. made substantial contributions to the conception and design of the Future spaceﬂight medical systems must permit a well-trained article. All authors reviewed independently all the selected articles. M.K. was medical ofﬁcer to autonomously provide care for the crew during responsible for drafting the manuscript. S.F. and M.M. were responsible for revising the mission. Many considerations beyond the speciﬁc illness or the draft for wording and important intellectual content. J.H. made substantial injury will inﬂuence the outcome, including environmental factors, contributions to drafting the article and to the tables. All authors revised and communications, supplies, crew preparation, skills redundancy approved the ﬁnal version. and teamwork. Preparation for the management of surgical conditions is only in its infancy, but safe and efﬁcient anaesthesia could theoretically be achievable. ADDITIONAL INFORMATION Supplementary information accompanies the paper on the npj Microgravity website (https://doi.org/10.1038/s41526-018-0039-y). METHODS Competing interests: The authors declare no competing interests. First, we established the list of the relevant questions that the literature review had to address. These questions explore various Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims aspects of anaesthesia in austere environments and represent in published maps and institutional afﬁliations. potential gaps in knowledge and/or technology for delivering anaesthesia during a prospective SEM. The list covers aspects such as medical training, the content of the medical kit, expected REFERENCES scenarios, physiological changes relevant to anaesthesia, etc. It 1. Mars Architecture Steering Group (Mars Design Reference Architecture 5.0, was established from exploring reference anaesthesia text- 2009). 133,134 books, as well as from the authors’ expertise. The Table 4 2. Doarn, C. R, Williams, R. S, Schneider, V. S. & Polk, J. D. Principles of crew health summarizes the ﬁnal list of 12 questions. monitoring and care. in Space Physiology and Medicine (ed. Nicogossian, A. E.). Secondly, we selected space analogue environments, charac- 393–421 (Springer, New York, 2016). terised by the presence of up to four types of constraints that 3. Nicogossian, A. E. The environment of space exploration. in Space 5,12,23,30,40 match those of a SEM: Physiology and Medicine (eds Nicogossian, A. E. et al.) 59–94 (Springer, New York, 2016). 1. Environmental challenges, represented by extreme, hostile or 4. Ball, C. G. et al. Prophylactic surgery prior to extended-duration space ﬂight: Is uncontrolled conditions and physical and social isolation and the beneﬁt worth the risk? Can. J. Surg. 55, 125–131 (2012). conﬁnement. Some of these settings also heavily rely on techno- 5. Bishop, S. L. From earth analogues to space: learning how to boldly go. in logical substitutes for life support (e.g., polar or underwater stations). On Orbit and Beyond (ed. Vakoch, D. A.). 25–50 (Springer, Berlin Heidelberg, 2. Inadequate resources: limited equipment and consumables. 2013). 3. Inadequate medical skills: care provided by non-medical specialists 6. Institute of Medicine (U.S.), Committee on Creating a Vision for Space Medicine or non-physicians. during Travel Beyond Earth Orbit, National Academy of Science & Board on 4. Difﬁculties in evacuation, because of distance, logistics, or hazards. Health Sciences Policy. Safe Passage Astronaut Care for Exploration Missions. (John R. Ball, Charles H. Evans Jr., 2001). The four categories of environments that we selected are: 7. Descartin, K., Menger, R. & Watkins, S. D. Application of Advances in Telemedicine spaceﬂight in LEO, LMICs, the combat environment and ﬁnally for Long-Duration Space Flight. (NASA JSC, 2015). ICEs, such as polar bases in Antarctica, submarines, or remote 8. Campbell, M. & Billica, R. Surgical capabilities. in Principles of Clinical Medicine for expeditions. Space Flight, 123–137 (Springer, 2008). Then, on 1 March 2017, we conducted a literature search on 9. Comet, B. et al. MARSTECHCARE, Necessary Biomedical Technologies for Crew anaesthesia in the selected environments for the period 2000 to Health Control During Long-duration Interplanetary Manned Missions, Vol. 151 (ESTEC, 2002). 2016, in the PubMed, Scopus, Google Scholar and Cochrane 10. Drudi, L., Ball, C. G., Kirkpatrick, A. W., Saary, J. & Grenon, S. M. Surgery in space: databases. Research articles, reviews, case reports, guidelines and where are we at now? Acta Astronaut. 79,61–66 (2012). consensus statements, books and book chapters in the English 11. Kirkpatrick, A. W. et al Severe traumatic injury during long duration spaceﬂight: language were evaluated. The full search queries are provided in light years beyond ATLS. J. Trauma. Manag. Outcomes 3, 4 (2009). supplementary information. We have also examined publications 12. Komorowski, M., Fleming, S. & Kirkpatrick, A. W. Fundamentals of Anesthesiol- from space agencies (the NASA Technical Report Server), military ogy for Spaceﬂight. J. Cardiothorac. Vasc. Anesth. (2016). https://doi.org/10.1053/ (the US Defense Health Board, the Committee on Tactical Combat j.jvca.2016.01.007. Casualty Care, the UK Royal Army Medical Corps association) and 13. Kuypers, M. I. Emergency and wilderness medicine training for physician astronauts on exploration class missions. Wild Env. Med 24, 445–449 (2013). humanitarian, non-governmental organisations and professional 14. Agnew, J., Fibuch, E. & Hubbard, J. Anesthesia during and after exposure to bodies: the International Committee of the Red Cross, the WHO, microgravity. Aviat. Space Environ. Med. 75, 571–580 (2004). the World Federation of Societies of Anaesthesiologists, the DCP3, 15. Silverman, G. L. & McCartney, C. J. Regional Anesthesia for the management of the 2011 American Society of Anesthesiology Guidelines, the 2014 limb injuries in space. Aviat. Space Environ. Med. 79, 620–625 (2008). Lancet Commission on Global Surgery. Duplicate ﬁndings were 16. Robertson, D. et al. Clinical models of cardiovascular regulation after weight- removed. lessness. Med. Sci. Sports Exerc. 28, S80–S84 (1996). We screened 2448 search results by title and abstract for 17. Johnston, S. L., Arenare, B. A. & Smart, K. T. Medical evacuation and vehicles for possible inclusion. The full texts of 241 publications were assessed transport. in Principles of Clinical Medicine for Space Flight (eds Barratt, M. R. & Pool, S. L.) 139–161 (Springer, New York, 2008). for eligibility. 18. Taddeo, T. A. & Armstrong, C. W. Spaceﬂight Medical Systems. in Principles of Finally, all authors screened the search results by title and Clinical Medicine for Space Flight (eds Barratt, M. R. & Pool, S. L.) 69–100 (Springer, abstract and compiled an inclusive list of potential articles of New York, 2008). interest. All articles that were deemed suitable by at least one 19. Campbell, M. R. et al. Endoscopic surgery in weightlessness: the investigation of author were included for full review. All authors independently basic principles for surgery in space. Surg. Endosc. 15, 1413–1418 (2001). read all ﬁnal selected articles and extracted any information 20. Otto, C. et al. Into thin air: extreme ultrasound on Mt Everest. Wilderness Environ. relevant to the pre-deﬁned questions. Med. 20, 283–289 (2009). 21. Otto, C. et al. The Martian chronicles: remotely guided diagnosis and treatment in the Arctic Circle. Surg. Endosc. 24, 2170–2177 (2010). ACKNOWLEDGEMENTS 22. Sipes, W. E, Polk, J. D, Beven, G. & Shepanek, M. Behavioral Health and Perfor- mance. Space Physiology and Medicine (eds Nicogossian, A. E. et al.) 367–389 M.K. is funded by the UK Engineering and Physical Sciences Research Council through (Springer, New York, 2016). an Imperial College London President’s PhD scholarship. Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA npj Microgravity (2018) 5 Anaesthesia in austere environments... M Komorowski et al. 23. Nicogossian, A. E., Williams, D. R., Williams, R. S. & Schneider, V. S. Simulations 55. Mermel, L. A. Infection prevention and control during prolonged human space and Analogs (Test-Beds). In: A. E. Nicogossian et al. (eds.). Space Physiology and travel. Clin. Infect. Dis. 56, 123–130 (2013). Medicine, pp. 441–461 (Springer, New York, 2016).. 56. Smith, S. M. et al. Bone metabolism and renal stone risk during international 24. Simmons, S. C., Hamilton, D. R. & McDonald, P. V. Telemedicine. In: Principles of space station missions. Bone (2015). https://doi.org/10.1016/j.bone.2015.10.002 Clinical Medicine for Space Flight (eds Barratt, M. R. & Pool, S. L.) 163–179 57. Komorowski, M., Fleming, S. & Hinkelbein, J. Anaesthesia in outer space: the (Springer, New York, 2008). ultimate ambulatory setting? Curr. Opin. Anaesthesiol. 29, 649–654 (2016). 25. World Bank. World Bank Country and Lending Groups. (2017). https:// 58. Merry, A. F., Cooper, J. B., Soyannwo, O., Wilson, I. H. & Eichhorn, J. H. Interna- datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank- tional standards for a safe practice of anesthesia 2010. Can. J. Anaesth. 57, country-and-lending-groups and http://www.webcitation.org/6vvcpSNBw. 1027–1034 (2010). Accessed 27 Nov. 2017. 59. Pignaton, W. et al. Perioperative and anesthesia-related mortality. Medicine 95, 26. Bösenberg, A. T. Pediatric anesthesia in developing countries. Curr. Opin. 1–6 (2016). Anaesthesiol. 20, 204–210 (2007). 60. Dobson, M. B. Anaesthesia at the District Hospital. (World Health Organization, 27. Dubowitz, G., Detlefs, S. & McQueen, K. A. K. Global anesthesia workforce crisis: a 2001). preliminary survey revealing shortages contributing to undesirable outcomes 61. Neuen, B. L. Access to safe anesthesia: a global perspective. J. Glob. Health 1–7 and unsafe practices. World J. Surg. 34, 438–444 (2010). (2014). 28. Martin, J. et al. Survey of the capacity for essential surgery and anaesthesia 62. Schnittger, T. Regional anaesthesia in developing countries. Anaesthesia 62, services in Papua New Guinea. BMJ Open 5, e009841 (2015). 44–47 (2007). 29. McQueen, K. et al. The bare minimum: the reality of global anaesthesia and 63. Wilhelm, T. J. et al. Anaesthesia for elective inguinal hernia repair in rural Ghana patient safety. World J. Surg. 39, 2153–2160 (2015). —appeal for local anaesthesia in resource-poor countries. Trop. Doct. 36, 30. Merchant, A. et al. Evaluating progress in the global surgical crisis: contrasting 147–149 (2006). access to emergency and essential surgery and safe anesthesia around the 64. Ouro-Bang’na Maman, A. F., Agbétra, N., Egbohou, P., Sama, H. & Chobli, M. world. World J. Surg. 39, 2630–2635 (2015). Morbidité–mortalité périopératoire dans un pays en développement: expéri- 31. WHO. WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. (World ence du CHU de Lomé (Togo). Ann. Fr. Anesth. Réanimation 27, 1030–1033 Health Organization, 2009). (2008). 32. Essential surgery: disease control priorities, 3rd edn, Vol. 1 (The International 65. Eliassen, H. S. et al. Making whole blood available in austere medical environ- Bank for Reconstruction and Development/The World Bank, 2015). ments: donor performance and safety. Transfus. (Paris). 56, S166–S172 (2016). 33. Spiegel, D. A., Abdullah, F., Price, R. R., Gosselin, R. A. & Bickler, S. W. World Health 66. Ray, J. M. The treatment of maxillofacial trauma in austere conditions. Atlas Oral. Organization global initiative for emergency and essential surgical care: 2011 Maxillofac. Surg. Clin. North. Am. 21,9–14 (2013). and beyond. World J. Surg. 37, 1462–1469 (2013). 67. Convertino, V. A. & Cooke, W. H. Evaluation of cardiovascular risks of spaceﬂight 34. Buckenmaier, C. C., Lee, E. H., Shields, C. H., Sampson, J. B. & Chiles, J. H. Regional does not support the NASA bioastronautics critical path roadmap. Aviat. Space anesthesia in austere environments. Reg. Anesth. Pain. Med. 28, 321–327 (2003). Environ. Med. 76, 869–876 (2005). 35. Keene, D. D. et al. Died of wounds: a mortality review. J. R. Army. Med. Corps. 68. Epelman, S. & Hamilton, D. R. Medical mitigation strategies for acute radiation 162, 355–360 (2016). exposure during spaceﬂight. Aviat. Space Environ. Med. 77, 130–139 (2006). 36. Mahoney, P. F. Combat Anesthesia: The First 24 h. (Department of the Army, 69. Gillis, D. B. & Hamilton, D. R. Estimating outcomes of astronauts with myocardial 2016). infarction in exploration class space missions. Aviat. Space Environ. Med. 83, 37. Mahoney, P. F. & McFarland, C. C. Field anesthesia and military injury. in Trauma 79–91 (2012). Anesthesia (Cambridge University Press, 2008). 70. Hamilton, D. R. Cardiovascular disorders. in Principles of Clinical Medicine for 38. Mellor, A. J. Anaesthesia in austere environments. J. R. Army. Med. Corps. 151, Space Flight (eds Barratt, M. R. & Pool, S. L.). 317–359 (Springer, New York, 2008). 272–276 (2005). 71. Gunga, H.-C., Ahlefeld, V. W. von, Coriolano, H.-J. A., Werner, A. & Hoffmann, U. 39. National Association of Emergency Medical Technicians. Tactical combat The cardiovascular system in space. in Cardiovascular System, Red Blood Cells, casualty Care Guidelines for Medical Personnel. https://www.naemt.org/ and Oxygen Transport in Microgravity,11–34 (Springer International Publishing, education/naemt-tccc/tccc-mp-guidelinesand-curriculum (2016). 2016). 40. Imray, C. H. E., Grocott, M. P. W., Wilson, M. H., Hughes, A. & Auerbach, P. S. 72. Berwick, D. et al. Creating and Sustaining an Expert Trauma Care Workforce Extreme, expedition, and wilderness medicine. Lancet 386, 2520–2525 (2015). (National Academies Press, 2016). 41. Aaen-Larsen, B. Health care in the circumpolar world: Greenland. Int. J. Cir- 73. Morey, T. E. & Rice, M. J. Anesthesia in an austere setting: lessons learned from cumpolar Health 63,49–53 (2004). the haiti relief operation. Anesthesiol. Clin. 31, 107–115 (2013). 42. Grant, I. C. Telemedicine in the British Antarctic survey. Int. J. Circumpolar Health 74. Trelles, M., Dominguez, L. & Stewart, B. T. Surgery in low-income countries 63, 356–364 (2004). during crisis: experience at Médecins Sans Frontières facilities in 20 countries 43. Otto, C. et al. Evaluation of tele-ultrasound as a tool in remote diagnosis and between 2008 and 2014. Trop. Med. Int. Health 20, 968–971 (2015). clinical management at the Amundsen-Scott South Pole Station and the 75. Dobson, M. B. Draw-over anaesthesia Part 2—Practical application. in Update in McMurdo Research Station. Telemed. J. E-Health 19, 186–191 (2013). Anaesthesia (World Federation of Societies of Anaesthesiologists Publications, 44. Minard, C. G., de Carvalho, M. F. & Iyengar, M. S. Optimizing medical resources 1993). for spaceﬂight using the integrated medical model. Aviat. Space Environ. Med. 76. Skelton, T. et al. Low-cost simulation to teach anesthetists’ non-technical skills in 82, 890–894 (2011). Rwanda. Anesth. Analg. 123, 474–480 (2016). 45. Fisher, A. D., Miles, E. A., Cap, A. P., Strandenes, G. & Kane, S. F. Tactical damage 77. McQueen, K. et al. Anesthesia and perioperative care. in Essential Surgery: Dis- control resuscitation. Mil. Med. 180, 869–875 (2015). ease Control Priorities (eds H. T. et al.) 3rd edn, Vol. 1. Debas (The International 46. Grocott, M. & Johannson, L. Ketamine for emergency anaesthesia at very high Bank for Reconstruction and Development/The World Bank, 2015). altitude (4243 m above sea-level). Anaesthesia 62, 959–962 (2007). 78. Galvez, J. A. & Rehman, M. A. Telemedicine in anesthesia: an update. Curr. Opin. 47. Jochberger, S. et al Anesthesia and its allied disciplines in the developing world: a Anaesthesiol. 24, 459–462 (2011). nationwide survey of the Republic of Zambia. Anesth. Analg. 106,942–948 (2008). 79. Murray, A. W., Beaman, S. T., Kampik, C. W. & Quinlan, J. J. Simulation in the 48. Wong, E. G. et al. Operative trauma in low-resource settings: the experience of operating room. Best. Pract. Res. Clin. Anaesthesiol. 29,41–50 (2015). Médecins Sans Frontières in environments of conﬂict, postconﬂict, and disaster. 80. Ikeyama, T., Shimizu, N. & Ohta, K. Low-cost and ready-to-go remote-facilitated Surgery 157, 850–856 (2015). simulation-based learning. Simul. Healthc. 7, 35 (2012). 49. Strube, P. D. & Perkins, A. D. Combat anesthesia: a case report of a gunshot 81. Livingston, P. et al. Development of a simulation and skills centre in East Africa: a wound and new trauma protocols. Aana. J. 83, 247–253 (2015). Rwandan-Canadian partnership. Pan Afr. Med. J. 17, 315 (2014). 50. Department of Essential Health Technologies, World Health Organization. 82. Weaver, S. J. & Salas, E. Training and measurement at the extremes: developing Essential surgical care aide-memoire: surgical and emergency obstetrical care at and sustaining expert team performance in isolated, conﬁned, extreme envir- ﬁrst referral level. http://www.who.int/surgery/publications/en/Aide-Memoire_ onments. Proc. Hum. Factors Ergon. Soc. Annu. Meet. 54,90–93 (2010). surgery.pdf (2003). 83. West, P., Gustin, N. & Raimer, B. G. Telemedicine link with South Pole allows 51. WHO. Surgical Care at the District Hospital. (World Health Organization, 2003). remote knee surgery, National Science Foundation Ofﬁce of Legislative and 52. Clément, G. Psychological issues of spaceﬂight. in Fundamentals of Space Public Affairs, NS PR 02-61 (2002). Medicine. 217–255 (Springer, 2011). 84. Department of Defense. Tactical Combat Casualty Care and Wound Treatment. 53. Shayler, D. Disasters and Accidents in Manned Spaceﬂight. (Springer, 2000). (Skyhorse Publishing, 2016). 54. Crucian, B. et al. Immune system dysregulation occurs during short duration 85. Komorowski, M., Neuhaus, C. & Hinkelbein, P. D. J. Emergency medicine in space. spaceﬂight on board the space shuttle. J. Clin. Immunol. 33, 456–465 (2013). Notf. Rett. 18, 268–273 (2015). npj Microgravity (2018) 5 Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA Anaesthesia in austere environments... M Komorowski et al. 86. Saluja, I. S. et al. Survey of astronaut opinions on medical crewmembers for a 114. Nouruzi-Sedeh, P., Schumann, M. & Groeben, H. Laryngoscopy via Macintosh mission to Mars. Acta Astronaut. 63, 586–593 (2008). blade versus GlideScope: success rate and time for endotracheal intubation in 87. Komorowski, M. & Fleming, S. Intubation after rapid sequence induction per- untrained medical personnel. Anesthesiology 110,32–37 (2009). formed by non-medical personnel during space exploration missions: a simu- 115. Rudraraju, P. & Eisen, L. A. Conﬁrmation of endotracheal tube position: a nar- lation pilot study in a Mars analogue environment. Extrem. Physiol. Med. 4,19 rative review. J. Intensive Care. Med. 24, 283–292 (2009). (2015). 116. Komatsu, R. et al. Learning curves for bag-and-mask ventilation and orotracheal 88. Beam, A. L. & Kohane, I. S. Translating artiﬁcial intelligence into clinical care. intubation: an application of the cumulative sum method. Anesthesiology 112, JAMA 316, 2368–2369 (2016). 1525–1531 (2010). 89. Doarn, C. R., Williams, R. S., Nicogossian, A. E. & Polk, J. D. Training in space 117. Chesters, A. & Webb, T. Ketamine for procedural sedation by a doctor-paramedic medicine. in Space Physiology and Medicine (eds Nicogossian, A. E. et al.). prehospital care team: a 4-year description of practice. Eur. J. Emerg. Med. 22, 463–477 (Springer, New York, 2016). 401–406 (2015). 90. Jha, S. & Topol, E. J. Adapting to artiﬁcial intelligence: radiologists and pathol- 118. Bishop, R. A., Litch, J. A. & Stanton, J. M. Ketamine anesthesia at high altitude. ogists as information specialists. JAMA 316, 2353–2354 (2016). High. Alt. Med. Biol. 1, 111–114 (2000). 91. Jones, P. M. Human performance in space. Rev. Hum. Factors Ergon. 6, 172–197 119. Mulvey, J. M., Qadri, A. A. & Maqsood, M. A. Earthquake injuries and the use of (2010). ketamine for surgical procedures: the Kashmir experience. Anaesth. Intensive 92. Strangman, G. E., Sipes, W. & Beven, G. Human cognitive performance in Care. 34, 489–494 (2006). spaceﬂight and analogue environments. Aviat. Space Environ. Med. 85, 120. Russell, K. W. et al. Wilderness Medical Society Practice Guidelines for the 1033–1048 (2014). treatment of acute pain in remote environments. Wilderness Environ. Med. 25, 93. Walker, I. A. & Wilson, I. H. Anaesthesia in developing countries—a risk for 41–49 (2014). patients. Lancet Lond. Engl. 371, 968–969 (2008). 121. Burgess, C. & Dubbs, C. Cosmos/Bion: the age of the biosatellites. in Animals in 94. Jawa, R. S., Zakrison, T. L., Richards, A. T., Young, D. H. & Heir, J. S. Facilitating Space 277–305 (Springer, New York, 2007). safer surgery and anesthesia in a disaster zone. Am. J. Surg. 204, 406–409 (2012). 122. Groemer, G. E. et al. The feasibility of laryngoscope-guided tracheal intubation 95. Vincent, J.-L. The future of critical care medicine: integration and personaliza- in microgravity during parabolic ﬂight: a comparison of two techniques. Anesth. tion. Crit. Care. Med. 44, 386–389 (2016). Analg. 101, 1533–1535 (2005). 96. Ventola, C. L. Medical applications for 3D Printing: current and projected uses. 123. Keller, C. et al. Airway management during spaceﬂight: A comparison of four Pharm. Ther. 39, 704–711 (2014). airway devices in simulated microgravity. Anesthesiology 92, 1237–1241 (2000). 97. Mehta, P. & Bhayani, D. Impact of space environment on stability of medicines: 124. Rabitsch, W. et al. Airway management with endotracheal tube versus Combi- challenges and prospects. J. Pharm. Biomed. Anal. 136, 111–119 (2017). tube during parabolic ﬂights. Anesthesiology 105, 696–702 (2006). 98. Spinella, P. C. Warm fresh whole blood transfusion for severe hemorrhage: U.S. 125. Adesunkanmi, A. R. Where there is no anaesthetist: a study of 282 consecutive military and potential civilian applications. Crit. Care. Med. 36, S340–345 (2008). patients using intravenous, spinal and local inﬁltration anaesthetic techniques. 99. Mahmood, F. et al. Perioperative ultrasound training in anesthesiology: a call to Trop. Doct. 27,79–82 (1997). action. Anesth. Analg. 122, 1794–1804 (2016). 126. Aluisio, A. R., Teicher, C., Wiskel, T., Guy, A. & Levine, A. Focused training for 100. Talbot, M., Harvey, E. J., Reindl, R., Martineau, P. & Schneider, P. Ultrasound- humanitarian responders in regional anesthesia techniques for a planned ran- assisted external ﬁxation: a technique for austere environments. J. R. Army. Med. domized controlled trial in a disaster setting. PLOS Curr. Disasters (2016). Corps. 162, 456–459 (2016). doi:10.1371/currents.dis.e75f9f9d977ac8adededb381e3948a04 101. Nguyen, B.-V. et al. Determination of the learning curve for ultrasound-guided 127. Newton, M. & Bird, P. Impact of parallel anesthesia and surgical provider training jugular central venous catheter placement. Intensive Care. Med. 40,66–73 in Sub-Saharan Africa: a model for a resource-poor setting. World J. Surg. 34, (2014). 445–452 (2010). 102. Bye, S. M. & Manankov, A. Telemedicine in practice in Arkhangelsk region, 128. Kessler, J., Wegener, J. T., Hollmann, M. W. & Stevens, M. F. Teaching concepts in Russia: from a blank page to routine operation. Int. J. Circumpolar Health 66, ultrasound-guided regional anesthesia. Curr. Opin. Anaesthesiol. 29, 608–613 335–350 (2007). (2016). 103. Hemmerling, T. M. et al. Evaluation of a novel closed-loop total intravenous 129. Luyet, C. et al. Different learning curves for axillary brachial plexus block: anaesthesia drug delivery system: a randomized controlled trial. Br. J. Anaesth. ultrasound guidance versus nerve stimulation. Anesthesiol. Res. Pract. 2010,1–7 110, 1031–1039 (2013). (2010). 104. Baker, E. S., Barratt, M. R. & Wear, M. L. Human response to spaceﬂight. in 130. Hunter, J. G. Managing pain on the battleﬁeld: an introduction to continuous Principles of Clinical Medicine for Space Flight (eds Barratt, M. R. & Pool, S. L.). peripheral nerve blocks. J. R. Army. Med. Corps. 156, 230–232 (2010). 27–58 (Springer, 2008). 131. Chou, R. et al. Management of postoperative pain: a Clinical Practice Guideline 105. Lee, S. M. C., Feiveson, A. H., Stein, S., Stenger, M. B. & Platts, S. H. Orthostatic From the American Pain Society, the American Society of Regional Anesthesia intolerance after ISS and space shuttle missions. Aerosp. Med. Hum. Perform. 86, and Pain Medicine, and the American Society of Anesthesiologists’ Committee A54–A67 (2015). on Regional Anesthesia, Executive Committee, and Administrative Council. J. 106. Hargens, A. R. & Richardson, S. Cardiovascular adaptations, ﬂuid shifts, and Pain. 17, 131–157 (2016). countermeasures related to space ﬂight. Respir. Physiol. Neurobiol. 169 Suppl 1, 132. Clément and Buckley (eds) Artiﬁcial Gravity. (Springer, 2007). S30–S33 (2009). 133. Barash, P. G. et al. Clinical Anesthesia, 8e: Print + Ebook with Multimedia. (LWW, 107. Norﬂeet, W. Anesthetic concerns of spaceﬂight. Anesthesiology 98, 1219 (2000). 2017). 108. Modi, P. et al. Accuracy of inferior vena cava ultrasound for predicting dehy- 134. Miller, R. D. et al. Miller’s Anesthesia, 2-Volume Set, 8e. (Saunders, 2014). dration in children with acute diarrhea in resource-limited settings. PLoS. ONE. 11, e0146859 (2016). 109. Chisholm, C. B. et al. Focused Cardiac UltrasoundTraining: How Much Is Enough? Open Access This article is licensed under a Creative Commons J. Emerg. Med. 44, 818–822 (2013). Attribution 4.0 International License, which permits use, sharing, 110. Buis, M. L., Maissan, I. M., Hoeks, S. E., Klimek, M. & Stolker, R. J. Deﬁning the adaptation, distribution and reproduction in any medium or format, as long as you give learning curve for endotracheal intubation using direct laryngoscopy: a sys- appropriate credit to the original author(s) and the source, provide a link to the Creative tematic review. Resuscitation 99,63–71 (2016). Commons license, and indicate if changes were made. The images or other third party 111. Lascarrou, J. B. et al. Video laryngoscopy vs direct laryngoscopy on successful material in this article are included in the article’s Creative Commons license, unless ﬁrst-pass orotracheal intubation among ICU patients: a randomized clinical trial. indicated otherwise in a credit line to the material. If material is not included in the JAMA 317, 483–493 (2017). article’s Creative Commons license and your intended use is not permitted by statutory 112. Lewis, S. R., Butler, A. R., Parker, J., Cook, T. M. & Smith, A. F. Videolaryngoscopy regulation or exceeds the permitted use, you will need to obtain permission directly versus direct laryngoscopy for adult patients requiring tracheal intubation. from the copyright holder. To view a copy of this license, visit http://creativecommons. Cochrane Database Syst. Rev. 11, CD011136 (2016). org/licenses/by/4.0/. 113. Aguirre Ospina, O. D., Ríos Medina, Á. M., Calderón Marulanda, M. & Gómez Buitrago, L. M. Cumulative sum learning curves (CUSUM) in basic anaesthesia © The Author(s) 2018 procedures. Colomb. J. Anesthesiol. 42, 142–153 (2014). Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA npj Microgravity (2018) 5 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png npj Microgravity Springer Journals http://www.deepdyve.com/lp/springer-journals/anaesthesia-in-austere-environments-literature-review-and-WBLLWgdydq

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References (93)

F Mahmood (2016)
Perioperative ultrasound training in anesthesiology: a call to action
Anesth. Analg., 122
M Talbot, EJ Harvey, R Reindl, P Martineau, P Schneider (2016)
Ultrasound-assisted external fixation: a technique for austere environments
J. R. Army. Med. Corps., 162
S Jha, EJ Topol (2016)
Adapting to artificial intelligence: radiologists and pathologists as information specialists
JAMA, 316
TM Hemmerling (2013)
Evaluation of a novel closed-loop total intravenous anaesthesia drug delivery system: a randomized controlled trial
Br. J. Anaesth., 110
JB Lascarrou (2017)
Video laryngoscopy vs direct laryngoscopy on successful first-pass orotracheal intubation among ICU patients: a randomized clinical trial
JAMA, 317
M Komorowski, S Fleming, J Hinkelbein (2016)
Anaesthesia in outer space: the ultimate ambulatory setting?
Curr. Opin. Anaesthesiol., 29
DB Gillis, DR Hamilton (2012)
Estimating outcomes of astronauts with myocardial infarction in exploration class space missions
Aviat. Space Environ. Med., 83
J Agnew, E Fibuch, J Hubbard (2004)
Anesthesia during and after exposure to microgravity
Aviat. Space Environ. Med., 75
C Otto (2009)
Into thin air: extreme ultrasound on Mt Everest
Wilderness Environ. Med., 20
K McQueen (2015)
The bare minimum: the reality of global anaesthesia and patient safety
World J. Surg., 39
W Rabitsch (2006)
Airway management with endotracheal tube versus Combitube during parabolic flights
Anesthesiology, 105
C Otto (2013)
Evaluation of tele-ultrasound as a tool in remote diagnosis and clinical management at the Amundsen-Scott South Pole Station and the McMurdo Research Station
Telemed. J. E-Health, 19
AD Fisher, EA Miles, AP Cap, G Strandenes, SF Kane (2015)
Tactical damage control resuscitation
Mil. Med., 180
AF Ouro-Bang’na Maman, N Agbétra, P Egbohou, H Sama, M Chobli (2008)
Morbidité–mortalité périopératoire dans un pays en développement: expérience du CHU de Lomé (Togo)
Ann. Fr. Anesth. Réanimation, 27
CHE Imray, MPW Grocott, MH Wilson, A Hughes, PS Auerbach (2015)
Extreme, expedition, and wilderness medicine
Lancet, 386
A Chesters, T Webb (2015)
Ketamine for procedural sedation by a doctor-paramedic prehospital care team: a 4-year description of practice
Eur. J. Emerg. Med., 22
M Grocott, L Johannson (2007)
Ketamine for emergency anaesthesia at very high altitude (4243 m above sea-level)
Anaesthesia, 62
C Keller (2000)
Airway management during spaceflight: A comparison of four airway devices in simulated microgravity
Anesthesiology, 92
P Livingston (2014)
Development of a simulation and skills centre in East Africa: a Rwandan-Canadian partnership
Pan Afr. Med. J., 17
CG Minard, MF Carvalho, MS Iyengar (2011)
Optimizing medical resources for spaceflight using the integrated medical model
Aviat. Space Environ. Med., 82
JL Vincent (2016)
The future of critical care medicine: integration and personalization
Crit. Care. Med., 44
P Nouruzi-Sedeh, M Schumann, H Groeben (2009)
Laryngoscopy via Macintosh blade versus GlideScope: success rate and time for endotracheal intubation in untrained medical personnel
Anesthesiology, 110
S Jochberger (2008)
Anesthesia and its allied disciplines in the developing world: a nationwide survey of the Republic of Zambia
Anesth. Analg., 106
B Crucian (2013)
Immune system dysregulation occurs during short duration spaceflight on board the space shuttle
J. Clin. Immunol., 33
M Trelles, L Dominguez, BT Stewart (2015)
Surgery in low-income countries during crisis: experience at Médecins Sans Frontières facilities in 20 countries between 2008 and 2014
Trop. Med. Int. Health, 20
P Mehta, D Bhayani (2017)
Impact of space environment on stability of medicines: challenges and prospects
J. Pharm. Biomed. Anal., 136
P Modi (2016)
Accuracy of inferior vena cava ultrasound for predicting dehydration in children with acute diarrhea in resource-limited settings
PLoS. ONE., 11
KW Russell (2014)
Wilderness Medical Society Practice Guidelines for the treatment of acute pain in remote environments
Wilderness Environ. Med., 25
AT Bösenberg (2007)
Pediatric anesthesia in developing countries
Curr. Opin. Anaesthesiol., 20
CB Chisholm (2013)
Focused Cardiac UltrasoundTraining: How Much Is Enough?
J. Emerg. Med., 44
TJ Wilhelm (2006)
Anaesthesia for elective inguinal hernia repair in rural Ghana—appeal for local anaesthesia in resource-poor countries
Trop. Doct., 36
W Norfleet (2000)
Anesthetic concerns of spaceflight
Anesthesiology, 98
OD Aguirre Ospina, AacuteM Ríos Medina, M Calderón Marulanda, LM Gómez Buitrago (2014)
Cumulative sum learning curves (CUSUM) in basic anaesthesia procedures
Colomb. J. Anesthesiol., 42
AW Kirkpatrick (2009)
Severe traumatic injury during long duration spaceflight: light years beyond ATLS
J. Trauma. Manag. Outcomes, 3
JM Mulvey, AA Qadri, MA Maqsood (2006)
Earthquake injuries and the use of ketamine for surgical procedures: the Kashmir experience
Anaesth. Intensive Care., 34
A Merchant (2015)
Evaluating progress in the global surgical crisis: contrasting access to emergency and essential surgery and safe anesthesia around the world
World J. Surg., 39
AJ Mellor (2005)
Anaesthesia in austere environments
J. R. Army. Med. Corps., 151
SMC Lee, AH Feiveson, S Stein, MB Stenger, SH Platts (2015)
Orthostatic intolerance after ISS and space shuttle missions
Aerosp. Med. Hum. Perform., 86
JA Galvez, MA Rehman (2011)
Telemedicine in anesthesia: an update
Curr. Opin. Anaesthesiol., 24
R Chou (2016)
Management of postoperative pain: a Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council
J. Pain., 17
HS Eliassen (2016)
Making whole blood available in austere medical environments: donor performance and safety
Transfus. (Paris)., 56
PD Strube, AD Perkins (2015)
Combat anesthesia: a case report of a gunshot wound and new trauma protocols
Aana. J., 83
PC Spinella (2008)
Warm fresh whole blood transfusion for severe hemorrhage: U.S. military and potential civilian applications
Crit. Care. Med., 36
CL Ventola (2014)
Medical applications for 3D Printing: current and projected uses
Pharm. Ther., 39
GE Strangman, W Sipes, G Beven (2014)
Human cognitive performance in spaceflight and analogue environments
Aviat. Space Environ. Med., 85
SM Bye, A Manankov (2007)
Int. J. Circumpolar Health
MR Campbell (2001)
Endoscopic surgery in weightlessness: the investigation of basic principles for surgery in space
Surg. Endosc., 15
VA Convertino, WH Cooke (2005)
Evaluation of cardiovascular risks of spaceflight does not support the NASA bioastronautics critical path roadmap
Aviat. Space Environ. Med., 76
IC Grant (2004)
Telemedicine in the British Antarctic survey
Int. J. Circumpolar Health, 63
T Ikeyama, N Shimizu, K Ohta (2012)
Low-cost and ready-to-go remote-facilitated simulation-based learning
Simul. Healthc., 7
M Komorowski, S Fleming (2015)
Intubation after rapid sequence induction performed by non-medical personnel during space exploration missions: a simulation pilot study in a Mars analogue environment
Extrem. Physiol. Med., 4
C Luyet (2010)
Different learning curves for axillary brachial plexus block: ultrasound guidance versus nerve stimulation
Anesthesiol. Res. Pract., 2010
PM Jones (2010)
Human performance in space
Rev. Hum. Factors Ergon., 6
RA Bishop, JA Litch, JM Stanton (2000)
Ketamine anesthesia at high altitude
High. Alt. Med. Biol., 1
DA Spiegel, F Abdullah, RR Price, RA Gosselin, SW Bickler (2013)
World Health Organization global initiative for emergency and essential surgical care: 2011 and beyond
World J. Surg., 37
DD Keene (2016)
Died of wounds: a mortality review
J. R. Army. Med. Corps., 162
SJ Weaver, E Salas (2010)
Training and measurement at the extremes: developing and sustaining expert team performance in isolated, confined, extreme environments
Proc. Hum. Factors Ergon. Soc. Annu. Meet., 54
IS Saluja (2008)
Survey of astronaut opinions on medical crewmembers for a mission to Mars
Acta Astronaut., 63
M Newton, P Bird (2010)
Impact of parallel anesthesia and surgical provider training in Sub-Saharan Africa: a model for a resource-poor setting
World J. Surg., 34
B Aaen-Larsen (2004)
Health care in the circumpolar world: Greenland
Int. J. Circumpolar Health, 63
JG Hunter (2010)
Managing pain on the battlefield: an introduction to continuous peripheral nerve blocks
J. R. Army. Med. Corps., 156
EG Wong (2015)
Operative trauma in low-resource settings: the experience of Médecins Sans Frontières in environments of conflict, postconflict, and disaster
Surgery, 157
AW Murray, ST Beaman, CW Kampik, JJ Quinlan (2015)
Simulation in the operating room
Best. Pract. Res. Clin. Anaesthesiol., 29
AF Merry, JB Cooper, O Soyannwo, IH Wilson, JH Eichhorn (2010)
International standards for a safe practice of anesthesia 2010
Can. J. Anaesth., 57
S Epelman, DR Hamilton (2006)
Medical mitigation strategies for acute radiation exposure during spaceflight
Aviat. Space Environ. Med., 77
T Skelton (2016)
Low-cost simulation to teach anesthetists’ non-technical skills in Rwanda
Anesth. Analg., 123
AL Beam, IS Kohane (2016)
Translating artificial intelligence into clinical care
JAMA, 316
ML Buis, IM Maissan, SE Hoeks, M Klimek, RJ Stolker (2016)
Defining the learning curve for endotracheal intubation using direct laryngoscopy: a systematic review
Resuscitation, 99
AR Adesunkanmi (1997)
Where there is no anaesthetist: a study of 282 consecutive patients using intravenous, spinal and local infiltration anaesthetic techniques
Trop. Doct., 27
D Robertson (1996)
Clinical models of cardiovascular regulation after weightlessness
Med. Sci. Sports Exerc., 28
C Otto (2010)
The Martian chronicles: remotely guided diagnosis and treatment in the Arctic Circle
Surg. Endosc., 24
T Schnittger (2007)
Regional anaesthesia in developing countries
Anaesthesia, 62
LA Mermel (2013)
Infection prevention and control during prolonged human space travel
Clin. Infect. Dis., 56
SR Lewis, AR Butler, J Parker, TM Cook, AF Smith (2016)
Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation
Cochrane Database Syst. Rev., 11
J Martin (2015)
Survey of the capacity for essential surgery and anaesthesia services in Papua New Guinea
BMJ Open, 5
MI Kuypers (2013)
Emergency and wilderness medicine training for physician astronauts on exploration class missions
Wild Env. Med, 24
AR Hargens, S Richardson (2009)
Cardiovascular adaptations, fluid shifts, and countermeasures related to space flight
Respir. Physiol. Neurobiol., 169 Suppl 1
CG Ball (2012)
Prophylactic surgery prior to extended-duration space flight: Is the benefit worth the risk?
Can. J. Surg., 55
TE Morey, MJ Rice (2013)
Anesthesia in an austere setting: lessons learned from the haiti relief operation
Anesthesiol. Clin., 31
P Rudraraju, LA Eisen (2009)
Confirmation of endotracheal tube position: a narrative review
J. Intensive Care. Med., 24
R Komatsu (2010)
Learning curves for bag-and-mask ventilation and orotracheal intubation: an application of the cumulative sum method
Anesthesiology, 112
J Kessler, JT Wegener, MW Hollmann, MF Stevens (2016)
Teaching concepts in ultrasound-guided regional anesthesia
Curr. Opin. Anaesthesiol., 29
G Dubowitz, S Detlefs, KAK McQueen (2010)
Global anesthesia workforce crisis: a preliminary survey revealing shortages contributing to undesirable outcomes and unsafe practices
World J. Surg., 34
RS Jawa, TL Zakrison, AT Richards, DH Young, JS Heir (2012)
Facilitating safer surgery and anesthesia in a disaster zone
Am. J. Surg., 204
GL Silverman, CJ McCartney (2008)
Regional Anesthesia for the management of limb injuries in space
Aviat. Space Environ. Med., 79
GE Groemer (2005)
The feasibility of laryngoscope-guided tracheal intubation in microgravity during parabolic flight: a comparison of two techniques
Anesth. Analg., 101
CC Buckenmaier, EH Lee, CH Shields, JB Sampson, JH Chiles (2003)
Regional anesthesia in austere environments
Reg. Anesth. Pain. Med., 28
M Komorowski, C Neuhaus, PDJ Hinkelbein (2015)
Emergency medicine in space
Notf. Rett., 18
L Drudi, CG Ball, AW Kirkpatrick, J Saary, SM Grenon (2012)
Surgery in space: where are we at now?
Acta Astronaut., 79
JM Ray (2013)
The treatment of maxillofacial trauma in austere conditions
Atlas Oral. Maxillofac. Surg. Clin. North. Am., 21
W Pignaton (2016)
Perioperative and anesthesia-related mortality
Medicine, 95
IA Walker, IH Wilson (2008)
Anaesthesia in developing countries—a risk for patients
Lancet Lond. Engl., 371
BV Nguyen (2014)
Determination of the learning curve for ultrasound-guided jugular central venous catheter placement
Intensive Care. Med., 40

Publisher: Springer Journals
Copyright: Copyright © 2018 by The Author(s)
Subject: Life Sciences; Life Sciences, general; Classical and Continuum Physics; Biotechnology; Immunology; Space Sciences (including Extraterrestrial Physics, Space Exploration and Astronautics) ; Applied Microbiology
eISSN: 2373-8065
DOI: 10.1038/s41526-018-0039-y
Publisher site: See Article on Publisher Site

Abstract

www.nature.com/npjmgrav REVIEW ARTICLE OPEN Anaesthesia in austere environments: literature review and considerations for future space exploration missions 1,2,3 4 1 5 Matthieu Komorowski , Sarah Fleming , Mala Mawkin and Jochen Hinkelbein Future space exploration missions will take humans far beyond low Earth orbit and require complete crew autonomy. The ability to provide anaesthesia will be important given the expected risk of severe medical events requiring surgery. Knowledge and experience of such procedures during space missions is currently extremely limited. Austere and isolated environments (such as polar bases or submarines) have been used extensively as test beds for spaceﬂight to probe hazards, train crews, develop clinical protocols and countermeasures for prospective space missions. We have conducted a literature review on anaesthesia in austere environments relevant to distant space missions. In each setting, we assessed how the problems related to the provision of anaesthesia (e.g., medical kit and skills) are dealt with or prepared for. We analysed how these factors could be applied to the unique environment of a space exploration mission. The delivery of anaesthesia will be complicated by many factors including space-induced physiological changes and limitations in skills and equipment. The basic principles of a safe anaesthesia in an austere environment (appropriate training, presence of minimal safety and monitoring equipment, etc.) can be extended to the context of a space exploration mission. Skills redundancy is an important safety factor, and basic competency in anaesthesia should be part of the skillset of several crewmembers. The literature suggests that safe and effective anaesthesia could be achieved by a physician during future space exploration missions. In a life-or-limb situation, non-physicians may be able to conduct anaesthetic procedures, including simpliﬁed general anaesthesia. npj Microgravity (2018) 4:5 ; doi:10.1038/s41526-018-0039-y INTRODUCTION contingency plan for any severe illness occurring in LEO includes 2,17,18 rapid stabilisation in orbit and station evacuation. Therefore, Signiﬁcant plans have been drawn by government space agencies it is likely that the ﬁrst extra-terrestrial anaesthesia will be and private companies for manned spaceﬂights beyond low Earth conducted during a SEM. orbit (LEO) in the coming years, with a focus on missions to Mars. Researchers have extensively used space analogue environ- Such ﬂights have been termed space exploration missions (SEM). ments (such as polar bases or submarines) to probe hazards, The latest National Aeronautics and Space Administration (NASA) develop crew proﬁciency, validate medical technologies and mission design called for a 900-day mission for a crew of 6, with 2,3,5,19–21 countermeasures for prospective space missions. Study- around 6 months spent in transit, each way, and 500 days on the ing medical care in these space analogue environments can Mars surface. provide predictive insight into the many factors that will impact These interplanetary missions will present great challenges to 3,5,22 2,3 healthcare delivery during future SEM. the ﬁeld of space medicine. During the exploration of frontiers Our objective is therefore to conduct a literature review about on Earth, human physiologic maladaptation, illness, and injury anaesthesia in space analogue environments, to further our have accounted for more failures than technical or environmental 4–6 understanding of the challenges at stake and propose factors. Beyond the immediate vicinity of Earth, there will be no some possible solutions. We will present how various problems possibility for the crew to return swiftly to the ground or to be 3,7 have been addressed in relevant settings, and discuss how assisted in real-time from Earth. Such space exploration will 2,4 this information could be applied to the unique environment of a entail extreme isolation and therefore total crew autonomy. SEM. The question of surgical preparedness, and the extent of Among the expected severe medical conditions, surgical 4,8–13 problems are of central concern, and will require anaesthesia, the surgical procedures that the crew will be able to carry out which currently represents a gap in space medicine knowl- are outside the scope of this work. This literature review will 12,14,15 edge. No human has ever required an anaesthetic aim to provide important information for the design of the on- procedure in space or shortly after returning to Earth. It is not board healthcare system and protocols for future SEM, as well appropriate to test protocols on healthy astronauts in space, and as clues for future research pathways to help close remaining 12,14,16 efﬁcient ground models do not exist. The current gaps. 1 2 Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Exhibition road, London SW7 2AZ, UK; Space Medicine Team, ISS Operations and Astronauts Group, European Astronaut Centre, European Space Agency, Linder Hoehe, Köln 51147, Germany; Institute for Space Medicine and Physiology (MEDES), 1 Avenue du Professeur 4 5 Jean Poulhes, Toulouse 31400, France; Maidstone Hospital, Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Maidstone ME16 9QQ, UK and Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln, Kerpener Straße 62, Köln 50937, Germany Correspondence: Matthieu Komorowski (m.komorowski14@imperial.ac.uk) Received: 30 April 2017 Revised: 30 January 2018 Accepted: 31 January 2018 Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA Anaesthesia in austere environments... M Komorowski et al. Fig. 1 PRISMA ﬂow diagram of publications reporting on anaesthesia in austere environments relevant to a future space exploration mission, published from January 2000 to December 2016 RESULTS Combat anaesthesia refers to the provision of anaesthesia by trained professionals or non-medics to soldiers and civilians in Publications inclusion ﬂow diagram armed conﬂict environments. This setting is characterised by little The Fig. 1 shows the results of the review process. We screened to no infrastructure, limited logistical support, in remote or 2448 search results by title and abstract for possible inclusion. The 34–39 dangerous areas. full texts of 241 publications were assessed for eligibility. In total, Isolated and conﬁned environments (ICEs) include a broad 134 publications were included in the review, represented by 55 variety of places that present hostile and harsh physical conditions research articles, 31 reviews, 17 book chapters, 9 books, 9 reports, 5,23,40 posing threats to human health and life. ICEs encompass a 5 clinical guidelines, 5 editorials and 3 case reports. wide range of environments and medical specialties such as expedition, wilderness, mountain, diving, underwater, polar, 20,23,40–43 Characteristics of the selected austere environments sailing, aviation, jungle, desert, among others. In ICEs, A summary of the characteristics and limitations of the four micro-societies of scientists and explorers expose themselves selected environments is shown in Table 1. willingly to such environments. In general, the teams include LEO can be used as an 'in-space' analogue for interplanetary trained physicians or paramedics carrying a limited medical kit. travel research. Orbital ﬂights represent the closest analogue to Their ability to perform advanced medical care is sometimes so SEM in terms of environmental exposure, but lacks experience of limited that ICEs have been described as 'fourth world' medicine. invasive medical procedures and isolation. Indeed, crews can communicate in real-time with the ground, beneﬁt from Expected medical and surgical conditions telemedical support and can be readily evacuated in case of In austere environments, the precise anticipation of likely medical 2,7,23,24 serious illness. conditions is important because it inﬂuences the design of the Low and middle income countries (LMICs) are deﬁned as those 9,40,44 health system (equipment, personnel and skills). In these with a gross national income per capita, calculated using the environments, most surgical conditions are traumatic or infec- World Bank Atlas method, of $12,235 or less. These countries are 2,21,26,28,32,34,35,38–41,45–48 tious. Several sources have listed the invariably afﬂicted by severe limitations in healthcare resources surgical procedures which should be available anywhere at any 26–31 32,39,49–51 and skilled personnel. Several signiﬁcant international endea- time, as they are deemed essential. vours such as the WHO Emergency and Essential Surgical Care No human surgery has ever happened in space, and indeed programme, the Lancet Commission on Global surgery and the astronauts have experienced very few events that could have World Bank publication Essential Surgery in Disease Control required surgery. Station evacuations have occurred on three Priorities in Developing Countries—3rd Edition (DCP3) have instances in the 1970’s and 1980’s for suspected appendicitis and released guidelines and tools to improve safety and cost- dysrhythmias but were also hastened by psychological issues and 4,22,52,53 effectiveness of surgery and anaesthesia in resource-poor crew conﬂicts. 28,32,33 settings. They have been deﬁning 'the lowest common The likelihood of events requiring anaesthesia during SEM can anaesthesia denominator', which is an appealing concept for be estimated to some extent from large case series from ground- future SEM where facilities and skills may be reduced to the bare analogue populations, military and civilian populations, and data minimum. gathered throughout the 140 person-years of cumulated npj Microgravity (2018) 5 Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA 1234567890():,; Anaesthesia in austere environments... M Komorowski et al. 8–10,13 spaceﬂight experience. For example, the risk of acute appendicitis has been estimated as 1–2 per 100,000 person-days, which would be equivalent to 1–2 cases every 45 years for a 6- person space crew. The cumulated risk of severe event requiring surgery may add up to one or more during a 900-day Mars 4,8,9,19 mission. However, owing to the duration, remoteness, activities (more extra-vehicular activities—EVAs) of SEM, the exposure to the hazards of space will be different than in LEO and lead to various types of medical conditions. Overall, experts have estimated that the most signiﬁcant risks for SEM are trauma, 9,11 54,55 haemorrhagic shock and infections. Indeed, a loss of bone mineral density of 1–2% per month has been measured and increases the risk of renal stones and possibly of osteoporotic 2,3,56 fractures after a few months into the ﬂight. Although the risk of severe trauma is low in weightlessness, objects conserve their mass and therefore still carry kinetic energy when in move- 11,15 ment. The vast number of EVAs planned during surface exploration will expose the astronauts to a high cumulated risk of 9,13,57 traumatic accidents and hypobaric decompression sickness. The risk of infection is increased in space, due to space-induced immunosuppression and possible increase in bacterial viru- 54,55 lence. The full list of expected conditions is summarised in Table 2, along with non-surgical illnesses, provided for 9,13,57 reference. The provision of anaesthesia under these circumstances will be restricted to procedures which are absolutely essential for the 29,31,58 saving of life or limb. Non-operative treatment may also be 4,10 chosen, for example for uncomplicated appendicitis. Of note, prophylactic removal of the appendix and/or gall bladder is being considered. Causes of death The analysis of the root causes of death in austere environments provides some insight into the most critical aspects of healthcare safety, and helps identify potential strategies for improving 35,59 outcomes. Perioperative mortality is usually due to a combination of factors related to patients, surgery, anaesthesia and general 31,48,59 management. In LMICs, shortages and misdistribution in the anaesthetic workforce, as well as deﬁcits in health infrastructure 28,30,31,60–63 have been consistently correlated to mortality. Most often, perioperative deaths in LMICs are related to acute anaemia or septic shock, frequently hastened by pre-existing morbid 31,48,59,61,64 conditions. In the combat environment, haemorrhage 35,36,45 remains the most common cause of death. In these circumstances, the prevention and prompt correction of major blood loss is critical and requires the availability of blood 31,36,49,64,65 products. Postoperative infections are usually pre- vented with antibiotic prophylaxis and sterilization of instru- 31,66 ments, although the risk of post-operative infection persists in situations such as trauma with contamination, hollow viscus perforation or intra-abdominal abscess and will require full course of antibiotics. Less often, deaths occur as a direct consequence of anaesthesia. In LMICs and elsewhere, preventable anaesthesia mortality stems from two main factors: hypoxemia and hypotension, which are primarily related to failed intubation and induction of anaesthesia 29,31,60,64 in the presence of hypovolaemia. Anaphylaxis, aspiration, cardiac events and medication interactions are also potentially 31,60 life-threatening problems. The safety objective for a mission to Mars has been deﬁned by some experts at 3% of individual risk of death per year. A signiﬁcant portion of this risk is related to spacecraft failure, the rest being represented by death from trauma and medical illness, which amounts to approximately 0.24% per individual and per mission. Trauma, infections, haemorrhage, radiation sickness and cardiovascular events represent the most likely causes of Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA npj Microgravity (2018) 5 Table 1. Summary of the characteristics and limitations of the selected analogue environments LEO LMIC/humanitarian Combat ICE Description Use of LEO as analogue for interplanetary Resource-poor setting with lack of Out of hospital austere setting, high Expeditions in environments such travel research equipment and medical expertise prevalence of severe trauma and blast as: mountain, high altitude, polar, injuries jungle, desert Volume of surgical Nil High High Low procedures Technological and ++ +++ ++ ++ equipment constraints Human constraints ++ +++ ++ ++ Patient physiological ++ secondary to exposure to ± Soldiers are healthy individuals before ± (possible hypoxia, hypo/ alterations microgravity injury hyperthermia) Limitations for No experience of surgery or anaesthesia. Does not provide microgravity and/or Does not provide microgravity and/or Does not provide microgravity applicability to SEM Lacks total isolation (option to evacuate, radiation exposures. Anaesthesia providers radiation exposures. Pathology nearly and/or radiation exposures real-time telemedicine) very different from astronaut population exclusively traumatic. Well trained providers LEO low earth orbit, LMIC low and middle income country, ICE isolated and conﬁned environment +: present; ++: important; +++: major skill erosion is not expected in environments with a high caseload Anaesthesia in austere environments... M Komorowski et al. Table 2. List of expected surgical conditions, recommended procedures and medical illnesses during SEM, not including pregnancy-related conditions 1- Surgical conditions and procedures 2-Non-surgical conditions 1.1- Trauma 2.1- General medical conditions Suturing laceration Minor trauma, sprains and strains Tube thoracostomy Infections: pneumonia, cellulitis, gastroenteritis, urinary tract infection, corneal infection, Fracture reduction latent viral reactivation Irrigation and debridement of open fractures Cardiovascular diseases: myocardial infarction, cardiac dysrhythmias Fractures: external and internal ﬁxation; use of traction Renal stones Trauma laparotomy Psychiatric: depression, anxiety, sleep disorders or Eescharotomy/fasciotomy Cancer Trauma-related amputations Skin grafting Burr hole Surgical airway 1.2- General surgical 2.2- Space-speciﬁc conditions Drainage of superﬁcial abscess Cardiovascular deconditioning, orthostatic intolerance Dental extraction, drainage of dental abscess Radiation exposure Repair of perforations: for example, perforated peptic Visual impairment and intracranial pressure syndrome ulcer Space motion sickness Appendectomy Environmental exposure including hypobaric decompression sickness, toxic atmosphere, Bowel obstruction, colostomy hypothermia/heat stroke, planetary dust Gall bladder disease, including emergency surgery Relief of urinary obstruction: catheterisation, suprapubic cystostomy Treatment of renal stone including nephrostomy Hernia, including incarceration Drainage of septic arthritis Biopsy 13,32,50,51,57 Adapted from. 9,11,55,67–70 death. The risk of infection appears increased in space, due difference with future SEMs is represented by the high number of 27,29,30,77 to several factors related to immunosuppression, possible increase in patients treated by anaesthetic providers in LMICs. bacterial virulence, and presence of particles in suspension. The Consequently, skill retention is less an issue in LMICs, while haemodynamic tolerance to blood loss or sepsis is expected to be representing a huge challenge in future long-term SEMs. poor due to changes in volaemia and cardiovascular performance Simulation plays an important role in the acquisition of 67,71 experienced after exposure to microgravity. anaesthetic and non-technical skills, both for doctors and non- In LMICs, surgeries with a low probability of success and a high doctors, as demonstrated in many studies looking at patient 31,32,48,60,72,73 78,79 probability of death are often not attempted. outcomes. Models for simulation in low-resources settings and 76,78–81 Similarly, during a SEM, the crew must prepare for non- distance learning of anaesthetic skills have been proposed. survivable illnesses or injuries that will exceed the local treatment 'Just-in-time' training allows practitioners to gain or refresh skills capability. on-the-spot, for example in case of unexpected scenarios. We retrieved the case of a spinal anaesthesia delivered in Antarctica by a non-anaesthetist with remote support. Medical skills of anaesthesia provider(s) In combat environments, personnel with various levels of To achieve the minimum standard in patient safety, models for medical skills deal with trauma casualties, often severe and in surgical and anaesthesia training have been devel- 38,39,45,49,72 29,31,32,39,48,49,60,74 large numbers. Nurse anaesthetists have been and oped. These models are organised in several remain the main providers of anaesthesia care to military layers of complexity, with successive strata allowing increasingly 36,49 personnel. The observation that over 90% of deaths happen complex procedures. In these models, the core components before the wounded reach a medical facility has led to efforts to provide basic resuscitative and primary trauma capacity that do 30,31,39,60,75 broaden medical training to non-medical personnel on the ﬁeld, not require extensive equipment or skills. The second including for advanced procedures such as thoracocentesis and level allows treatment of most life-threatening conditions and 39,45,84 surgical airway. includes spinal and ketamine-based anaesthesia, laparotomy, 31,49 The current International Space Station (ISS) programme amputation, closed and open orthopaedic surgery. This requires the presence on-board of a crew medical ofﬁcer, who is requires physician-level skills but not necessarily that of an 2,18,85 not necessarily a physician. The ideal proﬁle for the crew anaesthetist, to provide full resuscitation and general and spinal physician on future SEM is still debated, due to the uniqueness of anaesthesia. The third level requires specialist-level skills to 13,86 31,60 the operation. The best physician proﬁle for a SEM could be an deliver prolonged multi-organ support. In these models, emergency medicine doctor with additional training in surgery medical services in scarce environments focus on primary care 13,86 rather than on more advanced medical and surgical care, which and wilderness medicine. Importantly, the crew doctor will 28,31 likely saves more lives. spend most of his time on non-medical tasks, which increases In LMICs, the shortage of physicians is such that it is common further the complexity of his training during mission for non-doctors (nurses, anaesthetic ofﬁcers, clinical assistants…) preparation. to carry out anaesthesia and surgery, many of whom have little The crew physician will need to have a broad knowledge base, 26,28,29,47,76 medical background and are trained 'on the job'. Their to be competent in basic surgical skills and in the management of 27–29 13,85,86 ability to deal with complex cases remains limited. A key the critically ill and injured. One of the most important npj Microgravity (2018) 5 Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA Anaesthesia in austere environments... M Komorowski et al. qualities will be ﬂexibility and thus the ability to improvise in The care of a surgical patient requires a range of support 13,40 medical scenarios that may have been unseen before. services and equipment that extend well beyond anaesthesia, Most likely, a single physician will oversee both the surgery and such as running water, electricity, surgical equipment and the anaesthesia. Skills redundancy will be critical to enhance sterilization means, personal protective equipment, laboratory crew safety, especially if the physician himself becomes ill, injured, work, imaging equipment, ideally continuous oxygen and blood 18,85,87 26,28,30,31,45,49,51 incapacitated or dies. In this situation, it has been suggested products. Sterilization of surgical instruments in 12,87 that non-physicians could perform advanced medical care. It austere environments is challenging, but simple dry heat or 31,66 appears advisable to train several crewmembers to manage the antiseptic methods are acceptable. most common emergencies, for example matching the ﬁrst level Checklists are a simple and cost-effective way to improve 31,32,77 29,94,95 of competency of the WHO or DCP3 models. patient safety. They are particularly useful where expertise is Signiﬁcant advances have occurred in recent years in the ﬁeld limited, because they help with memory recall and clarify the of artiﬁcial intelligence in medicine, that offers the promises of minimum expected critical safety steps in a complex process. more effective monitoring, improved disease detection and The current ISS medical kit does not allow for general 2,88 development of efﬁcient decisions support systems. Autono- anaesthesia (GA) or prolonged organ support and will need to 8,18,87 mous diagnostic systems, closed-loop automated anaesthesia or be profoundly updated for a SEM. The design of the medical other decision support systems could simplify training require- kit must balance crew skills with constraints in volume, weight, 88–90 ments and improve patient safety. power requirements against the load of expected medical conditions, which partly depends on the mission proﬁle (e.g., 9,44,87 mission duration, number of EVAs…) and crew size. Non-clinical skills, behavioural health and performance During SEM, restrictions in storage and up-mass and the Prolonged exposure to factors such as stress, workload, fatigue, impossibility to re-supply may lead to shortages in tools and social isolation, altered lighting conditions and circadian cues all consumables. On-demand 3D printing of equipment is promis- contribute to degraded performance, both on ICEs and in ing. Methods to ensure drug stability during the mission must 82,91,92 space. The negative psychological response to living in ICEs be developed and validated. The expected lack of blood include mild cognitive impairment, time-sense disturbances, products could be mitigated using fresh whole blood transfusion, motivational decline, sleep disorders, psychosomatic symptoms, similar to the concept of 'walking blood bank' in combat 5,6,22,52,91,92 anxiety, depression and social conﬂicts. Maintaining medicine. This would imply that blood compatibility could crew behavioural health and performance has arose as one of the 45,49,65 become a selection criteria. Ultrasonography is likely to 5,6,22,82,91,92 most challenging aspects of prolonged stays in ICEs. remain the leading imaging modality in future SEM. It can be Practical concepts aimed at improving operational performance used for a variety of tasks related to anaesthesia and surgery, such both in austere environments and in space have been proposed. as nerve localisation, assessment of volaemia and cardiac function, Schematically, they revolve around three aspects of performance, 13,99,100 line placement, and assisting external ﬁxation of fractures. all non-speciﬁc but directly applicable to medical skills: correct Acquisition of several critical skills appears shorter with ultra- crew selection, training prior to the mission, and skills acquisition sound, even in novices. For example, with a standardised teaching 82,91 and maintenance during the mission. Identifying 'the right program, ultrasound-guided central venous catheter insertion can stuff' for an unprecedented challenge such as a SEM, both at the be learnt by non-experts after less than ten procedures individual and the team level, and then maintaining mental health and crew cohesion during the entire ﬂight will be a key 5,22,52,91 Telemedicine component of mission success. Medical and psychological standards for crewmember selection are likely to be extremely Telemedicine relies on remote communication technologies to 22,52,91 restrictive owing to limitations in medical care and support. allow experts to provide diagnosis and/or therapeutic advice for 2,20,21,24,41,43,78,102 In austere environments, many non-clinical skills of the physician patients situated in an isolated place. Real-time 31,36,49,73 contribute to healthcare safety. These can be divided into communication is not mandatory for telemedicine. For example, personnel skills (e.g., team coordination, communication, or augmenting remote consultation by transmitting X-rays, ultra- logistics) and technical skills (e.g., troubleshooting equipment, sound images and digital photographs by email has proven very 5,40,82,91 40,41 use of safety equipment, or orientation). valuable. The proof of concept of a remotely administered general and spinal anaesthesia in real-time have been demon- 83,103 strated. Telemedicine is already extensively used in space- Medical kits ﬂight for remote diagnosis and treatment, monitoring and training In austere environments, a desirable situation for medical support 7,18,23,24 of astronauts. Real time telecommunication will not be is to match the equipment and personnel competencies to deal available during a mission to Mars, with delays ranging from 5 to 40,44 with the most likely medical conditions. 20 min each way, depending on the relative position of the The basic equipment required for safe anaesthesia need not be 4,21 planets. Concepts of delayed asynchronous tele-guidance for elaborate: a basic mechanical ventilator, monitoring including a surgery on Mars have been proposed. pulse oximeter and capnography, airway equipment and a 30,31,51,58,60,93 restricted range of drugs. In the most deprived Preoperative assessment settings, limited kit, even though not ideal, can be adapted to maximise patient care. It has been suggested that the The preoperative assessment of a patient in difﬁcult environments monitoring setup could even be reduced further to continuous should insist on the assessment of the risk of aspiration and clinical monitoring and a pulse oximeter, for a solution that is truly difﬁcult airway, and estimation of the recent ﬂuid loss from 29 31,60 achievable in the poorest settings. This is less relevant to future bleeding, vomiting, diarrhoea, anorexia or other. Most patients SEM since acquisition cost may be less important than the mass of are hypovolaemic due the ongoing pathological process requiring 38,40 the equipment. Oxygen is desirable but unavailable in most surgery (trauma or infection) or secondary to dehydration. 29,30,58 71,104 LMICs. In the absence of a mechanical ventilator, manual In space, microgravity affects most physiological systems. ventilation can be handled by a non-physician, who has usually The loss of the gravitational stimuli profoundly alters the 60,75 been trained on-the-job. The equipment for local and regional cardiovascular system, which rapidly becomes unable to respond 67,71,105 anaesthesia (RA) is much more limited, which makes it very efﬁciently to challenges such as orthostatism or blood loss. desirable in resource-poor environments, but only when anaes- The cardiovascular proﬁle of a microgravity-exposed individual 15,34,61–63 thesia providers are competent. is marked by a 15–20% hypovolemia, altered baroreﬂex and Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA npj Microgravity (2018) 5 Anaesthesia in austere environments... M Komorowski et al. Fig. 2 Fluid shift in space, and its involvement in post-ﬂight orthostatic intolerance. Immediately after entering weightlessness, a portion of the blood volume shifts towards the upper body, leading to the 'puffy face' and 'chicken legs' syndrome. Post-ﬂight, the combination of hypovolaemia and hypo-reactivity of the cardiovascular system commonly leads to orthostatic hypotension. Reproduced with permission from Gunga 26,47 systemic vascular resistances, changes in adrenergic receptors, to 90%) are carried out under GA without intubation. Oro- 110–112 mixed systolic-diastolic cardiac dysfunction, all leading to up to tracheal intubation requires extensive training. It has been 12,67,71,104,106 20% decrease in exercise tolerance. These factors estimated that over 50–60 conventional oro-tracheal procedures 110,113 expose the astronaut to a signiﬁcant risk of cardiovascular collapse were necessary for a novice to reach a 90% success rate. 12,14,107 during induction of GA and mechanical ventilation. The With videolaryngoscopy, this number may drop to less than ten 112,114 cardiovascular system faces its biggest challenges of spaceﬂight procedures. Even if the majority of the literature identiﬁed upon return (Fig. 2). Orthostatic intolerance affects over 80% of ISS steeper learning curves and shorter intubation time with crewmembers and is regarded as one of the most serious videolaryngoscopy, negative studies exist and this technique still 2,67,71,104 111,112 cardiovascular problems upon return to Earth. The extent requires appropriate training. Capnography should be used of the cardiovascular alterations in partial gravity (such as on Mars) to conﬁrm successful airway insertion. In one study, novices and the level of gravity required to prevent these effects are could achieve a 80% success rate in bag-and-mask ventilation 71 116 currently unknown. after a median of 25 procedures. The patient’s volaemic status and cardiac function should be Ketamine is the drug of choice for non-anaesthetic trained 31,38,60,77,117 assessed with physical examination and ultrasound, and if doctors, because it is cost-effective and relatively safe. possible optimised before induction. The expected volume of It is used extensively in adult and paediatric populations in military 26,38,46,47,77,117–120 ultrasound procedures required to train a non-expert at these anaesthesia, LMICs and during disaster relief. techniques can be estimated from the literature. Several days of Properly trained individuals can use propofol, although it is a poor training and 25 supervised procedures were necessary to train choice for induction in patients with shock, even after ﬂuid nurses to perform ultrasound measurement of the aorta and resuscitation. inferior vena cava diameters in a resource-limited setting. At In 2002, a NASA working group stated that the safe delivery of least 10 h of mixed didactic and scanning training and 45 anaesthesia in space could be achievable. Inhaled anaesthesia is procedures may be required for emergency physicians to become not an option in the closed environment of a spacecraft, because proﬁcient in focused cardiac ultrasound. In the microgravity- of issues of cabin pollution and because vaporisers would be 12,15,107 exposed patient, it may be advisable to administer a low dose of unreliable in reduced gravity. Among intravenous agents, 12,14,57 vasopressors (alpha-agonists) preventively before induction, ketamine appears to be the safest choice. Of note, 12,14,87 especially if GA or mechanical ventilation are anticipated. ketamine-based anaesthesia has been performed on 22 monkeys shortly after spaceﬂight. Hallucinations and emergence phe- nomena can be mitigated with premedication and overall are a General and regional anaesthesia lesser concern in a life-or-death situation. Gastric motility is slower General anaesthesia. In LMICs, where medical expertise and in space, at least during the ﬁrst days, possibly for longer, so airway equipment is lacking, a vast proportion of procedures (up npj Microgravity (2018) 5 Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA Anaesthesia in austere environments... M Komorowski et al. Table 3. Summary of ﬁndings and recommendations 1. The equipment, protocols and training programme for anaesthesia need to be developed and designed alongside all related medical sub- specialties, in particular surgery. 2. The basic principles of safe surgery (safety checklist, prevention of surgical site infection, conﬁrmation of site and procedure, etc.) must be guaranteed. Checklists should be provided for all the essential steps, including general surgical safety (following the WHO model), preoperative assessment and anaesthetic procedures. 3. The personnel in charge of delivering anaesthesia require speciﬁc training. 4. Skills redundancy will be an important safety parameter. Several crewmembers must be trained to achieve at least a basic level of competency (similar to WHO level 1). 5. Most expected conditions requiring anaesthesia are traumatic and infectious. The availability of blood products or substitutes is expected to improve the survivability of severe bleeding. 6. Non-anaesthetists can perform anaesthesia. Physicians are preferred, but as a last resort (life-or-limb situation), non-physicians could attempt to perform advanced medical care including surgery and anaesthesia. 7. A restricted set of equipment can be sufﬁcient. The strict minimum set of required equipment for anaesthesia is small, but caring for a surgical patient requires extensive equipment and consumables that spans well beyond. 8. The number of available anaesthesia protocols should be minimised, and efforts should be made to simplify them. 9. Ketamine appears to be the most suitable intravenous anaesthetic agent for general anaesthesia and procedural sedation. Videolaryngoscopes could be the preferred equipment for endotracheal intubation. 10. Regional anaesthesia is an appealing option for limb surgery. A limited number of blocks are sufﬁcient. Ultrasound guidance accelerates training and improves success rate. systematic rapid sequence induction is advisable. Succinylcholine condition, training and experience of the anaesthetist and is contraindicated after exposure to microgravity because of surgeon, availability of drugs and equipment, degree of urgency, 12,14,107 60 changes in the neuromuscular junction. Both operator and presence of a full stomach, and ﬁnally patient’s preference. patient must be restrained if conventional laryngoscopy is to be Anaesthesia providers with limited experience should limit attempted in weightlessness, otherwise supraglottic devices are themselves to a small number of safe, widely applicable 122–124 an option. Videolaryngoscopes have been tested in a Mars techniques, to improve familiarity and conﬁdence through regular analogue simulation. practice. Dobson suggested that because of limited skills and 75,94 supplies, GA use should be minimised whenever possible. Regional and perimedullar anaesthesia. The use of RA in difﬁcult During SEMs, in the absence of strong evidence, it appears environments is appealing, because it requires fewer preoperative, sensible to formulate choices based on a worst-case scenario 15,34,38,62,94 intraoperative and postoperative resources. Indeed, approach and consider that astronauts requiring surgery will be regional and perimedullar anaesthesia (spinal anaesthesia in severely deconditioned, hypovolemic, at risk for arrhythmias, particular) are often the preferred choice where expertise is difﬁcult to intubate, intolerant to succinylcholine, have a full available, but are otherwise virtually non- stomach, and be managed by non-medical personnel with limited 26,28,34,38,47,48,62,64 12,57 existent. They are regularly delivered by non- training, if the crew medical doctor is incapacitated or dead. anaesthetists, demonstrating that they can successfully be trained Overall, we argue that RA should be attempted whenever 38,62,83,125–127 12,15 to RA techniques in austere environments. Most limb possible. When not suitable or in case of failure, GA will be surgery is feasible with only 3 blocks (axillary brachial plexus, necessary. We recommend to implement a limited number of 12,15,57,128 femoral and sciatic blocks). The use of ultrasound for RA simpliﬁed intravenous anaesthesia protocols that could be has accelerated the training of anaesthesia residents and narrowed down to two options only: conscious sedation (for 12,57,128 improved success rates. In ultrasound-guided nerve blocks, procedural anaesthesia, peripheral surgery and superﬁcial trunk anaesthesia residents commonly require a minimum of 10–15 surgery) and GA with endotracheal intubation (for head, face and 12,57,87 procedures per block to achieve a 90% success rate. Many deep trunk surgery). additional techniques such as intravenous RA or haematoma 12,38,120 blocks can be of value in difﬁcult environments. In LMICs, Postoperative care intra-abdominal surgery such as caesarean section are commonly The most important aspects of postoperative monitoring do not performed under RA alone, after inﬁltration of the abdominal wall rely on complex equipment: airway patency, haemodynamic and by large volumes of lidocaine. respiratory stability, urine output, warmth of peripheries and pain For future SEM, RA is an extremely interesting and safe option 31,60 control. Following surgery, the most severe patients will despite its limitations, and efforts should be made to integrate RA 12,15,57 require sustained invasive support, which occurs typically in an into the crew physician’s skillset. The absence of sedation intensive care unit. In LMICs, such facilities are excessively and shorter recovery times will enable a faster return to full limited. operations and minimise the impact on the mission, in an A key focus of the postoperative period involves pain control, environment where everyone will have a unique and valuable which is more difﬁcult and inconsistent in austere environ- skillset. The safety and efﬁcacy of perimedullar anaesthesia in ments. The Wilderness Medical Society guidelines propose a weightlessness or in partial gravity is unknown but concerns have pyramidal approach to pain management in austere environ- been expressed about the effect of the sympathetic block on a ments, with simple physical and comfort measures representing microgravity-exposed patient. the basis of the management, before any escalation of care. The ideal medication for austere environments (compact, non-sedat- Choice of anaesthetic technique ing, long shelf-life, with multiple routes of administration, minimal 36,120 The general approach for choosing an anaesthetic technique in a side effects and a wide spectrum of use) does not exist. difﬁcult environment depends on several factors: patient’s Potent drugs with harmful side effects (narcotics, ketamine) are Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA npj Microgravity (2018) 5 Anaesthesia in austere environments... M Komorowski et al. Table 4. List of questions used in the literature review Category Questions Usefulness of analogues 1. What characteristics of each selected austere environment are relevant to a SEM? Expected conditions 2. What medical and surgical conditions are encountered in austere environments and expected during a SEM? 3. What factors contribute to patient death in austere environments and a SEM? Medical skills 4. What is the proﬁle and medical skills of anaesthesia providers in austere environments? What medical skills are recommended for a SEM? 5. What non-clinical skills are important for healthcare delivery in austere environments? How can human behaviour and performance be optimised? Medical kits 6. What equipment is necessary or optional for anaesthesia in austere environments and during a SEM? 7. How is telemedicine used for healthcare in remote environments? How could it be used during future SEM? Pre, per and postoperative 8. How is the patient assessed and resuscitated before receiving an anaesthetic procedure? What are the management speciﬁcities of the physiology of the microgravity-exposed patient? 9. How is general anaesthesia administered in austere environments? How is the airway managed? 10. What is the role of regional and perimedullar anaesthesia in austere environments? What blocks are recommended? 11. What considerations are important for choosing the most appropriate anaesthetic technique in austere environments? 12. How is the patient managed in the post-operative period in austere environments? What are the guidelines for pain control? They explore various aspects of anaesthesia in austere environments and during a future SEM, and correspond to potential current gaps in space medicine knowledge and/or technology. Refer to text for explanations on how the list was established. reserved for the most severe pain, only after safer and less- cognitive aptitudes and ability to deal with extreme stress, are invasive therapies have been considered. Local and regional among the best candidates to overcome such a challenge. Besides anaesthesia are valid choices for pain relief, provided the caregiver the very unique context of a spaceﬂight, the ﬁndings of this 34,120,130 is accustomed to these techniques. research could also beneﬁt Earth-based initiatives and the general Postoperative care and pain control during SEM should follow public, by improving anaesthesia delivery and safety in remote general Earth-based guidance, with the necessary adjustments and resource-poor settings. aiming at improving crew recovery and limiting resource While the analysis of space analogue environments is important 57,120,131 utilisation. The provision of critical care during SEM is given the restricted access to space, no substitute can fully beyond the strict scope of this review, but if we extrapolate from replicate the uniqueness of a future SEM, where a self-reliant the current ISS capabilities, it is unlikely that the crew will have the restricted crew will be exposed to exceptional challenges and capacity to provide prolonged organ support of one or several risks, some of which are impossible to foresee. Space analogues 12,18,87 critically ill patients following surgery or resuscitation. are only simulations of greater or lesser ﬁdelity along varying 5,23 dimensions of interest. We have not included research carried out in highly controlled simulation centres, because very few DISCUSSION studies have explored the question of anaesthetic care provided Imray (2015) anticipated that future developments in healthcare in by non-medical personnel, but also because the very attributes of difﬁcult environments will be determined by the needs of modern the environment that have the greatest impact on performance day explorers. He argues that travellers will encounter 'environ- are removed in simulation studies (e.g., real danger, uncontrolled ments where physiological and geographical extremes necessitate events, situational ambiguity, or the interaction with the extreme prompt and innovative approaches to rescue, medical care, and transportation'. Future SEMs perfectly illustrate this statement. environment itself). Bishop has argued that the value of this However, medical preparedness for SEM is difﬁcult to achieve as research was very limited once these features were experimentation in space is constrained by access and operational compromised. resources, and because of the small sample size and low incidence While this review provides useful clues regarding some critical of medical conditions. The need to ﬁnd relevant terrestrial aspects of anaesthesia in space, several factors remained substitutes is driven by extraordinary demands for mission unexplored and warrant further research. More research needs success. Among medical procedures, the delivery of anaesthesia to be done to deﬁne the ultimate skillset of the astronaut currently represents a gap in knowledge. Therefore, we have physician, design tools to prevent skills erosion during the ﬂight analysed an extensive set of topics surrounding the practice of 5,13,22 and address the question of skills redundancy. Designing the anaesthesia in environments relevant to SEM, with the objective of on-board medical kit will take place in parallel, and will partly be closing this gap. driven by anaesthetic and surgical capability and engineering The summary of our results is shown in Table 3. The literature 8,18,44 requirements. A return to gravity is increasingly difﬁcult with seems to indicate that non-anaesthetists, and, as a last resort, non- increasing ﬂight duration. More research is needed to investi- physicians, could potentially provide effective and relatively safe gate the synergistic effects of prolonged exposure to space- anaesthetic procedures during future SEM, provided that they derived stressors and partial gravity on human systems, and to receive the appropriate training during the preparatory phase. It 2,71,132 resolve some contradictory ﬁndings. makes little doubt that astronauts, with their extensive skill-set, npj Microgravity (2018) 5 Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA Anaesthesia in austere environments... M Komorowski et al. CONCLUSION AUTHOR CONTRIBUTIONS M.K. and J.H. made substantial contributions to the conception and design of the Future spaceﬂight medical systems must permit a well-trained article. All authors reviewed independently all the selected articles. M.K. was medical ofﬁcer to autonomously provide care for the crew during responsible for drafting the manuscript. S.F. and M.M. were responsible for revising the mission. Many considerations beyond the speciﬁc illness or the draft for wording and important intellectual content. J.H. made substantial injury will inﬂuence the outcome, including environmental factors, contributions to drafting the article and to the tables. All authors revised and communications, supplies, crew preparation, skills redundancy approved the ﬁnal version. and teamwork. Preparation for the management of surgical conditions is only in its infancy, but safe and efﬁcient anaesthesia could theoretically be achievable. ADDITIONAL INFORMATION Supplementary information accompanies the paper on the npj Microgravity website (https://doi.org/10.1038/s41526-018-0039-y). METHODS Competing interests: The authors declare no competing interests. First, we established the list of the relevant questions that the literature review had to address. These questions explore various Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims aspects of anaesthesia in austere environments and represent in published maps and institutional afﬁliations. potential gaps in knowledge and/or technology for delivering anaesthesia during a prospective SEM. The list covers aspects such as medical training, the content of the medical kit, expected REFERENCES scenarios, physiological changes relevant to anaesthesia, etc. It 1. Mars Architecture Steering Group (Mars Design Reference Architecture 5.0, was established from exploring reference anaesthesia text- 2009). 133,134 books, as well as from the authors’ expertise. The Table 4 2. Doarn, C. R, Williams, R. S, Schneider, V. S. & Polk, J. D. Principles of crew health summarizes the ﬁnal list of 12 questions. monitoring and care. in Space Physiology and Medicine (ed. Nicogossian, A. E.). Secondly, we selected space analogue environments, charac- 393–421 (Springer, New York, 2016). terised by the presence of up to four types of constraints that 3. Nicogossian, A. E. The environment of space exploration. in Space 5,12,23,30,40 match those of a SEM: Physiology and Medicine (eds Nicogossian, A. E. et al.) 59–94 (Springer, New York, 2016). 1. Environmental challenges, represented by extreme, hostile or 4. Ball, C. G. et al. Prophylactic surgery prior to extended-duration space ﬂight: Is uncontrolled conditions and physical and social isolation and the beneﬁt worth the risk? Can. J. Surg. 55, 125–131 (2012). conﬁnement. Some of these settings also heavily rely on techno- 5. Bishop, S. L. From earth analogues to space: learning how to boldly go. in logical substitutes for life support (e.g., polar or underwater stations). On Orbit and Beyond (ed. Vakoch, D. A.). 25–50 (Springer, Berlin Heidelberg, 2. Inadequate resources: limited equipment and consumables. 2013). 3. Inadequate medical skills: care provided by non-medical specialists 6. Institute of Medicine (U.S.), Committee on Creating a Vision for Space Medicine or non-physicians. during Travel Beyond Earth Orbit, National Academy of Science & Board on 4. Difﬁculties in evacuation, because of distance, logistics, or hazards. Health Sciences Policy. Safe Passage Astronaut Care for Exploration Missions. (John R. Ball, Charles H. Evans Jr., 2001). The four categories of environments that we selected are: 7. Descartin, K., Menger, R. & Watkins, S. D. Application of Advances in Telemedicine spaceﬂight in LEO, LMICs, the combat environment and ﬁnally for Long-Duration Space Flight. (NASA JSC, 2015). ICEs, such as polar bases in Antarctica, submarines, or remote 8. Campbell, M. & Billica, R. Surgical capabilities. in Principles of Clinical Medicine for expeditions. Space Flight, 123–137 (Springer, 2008). Then, on 1 March 2017, we conducted a literature search on 9. Comet, B. et al. MARSTECHCARE, Necessary Biomedical Technologies for Crew anaesthesia in the selected environments for the period 2000 to Health Control During Long-duration Interplanetary Manned Missions, Vol. 151 (ESTEC, 2002). 2016, in the PubMed, Scopus, Google Scholar and Cochrane 10. Drudi, L., Ball, C. G., Kirkpatrick, A. W., Saary, J. & Grenon, S. M. Surgery in space: databases. Research articles, reviews, case reports, guidelines and where are we at now? Acta Astronaut. 79,61–66 (2012). consensus statements, books and book chapters in the English 11. Kirkpatrick, A. W. et al Severe traumatic injury during long duration spaceﬂight: language were evaluated. The full search queries are provided in light years beyond ATLS. J. Trauma. Manag. Outcomes 3, 4 (2009). supplementary information. We have also examined publications 12. Komorowski, M., Fleming, S. & Kirkpatrick, A. W. Fundamentals of Anesthesiol- from space agencies (the NASA Technical Report Server), military ogy for Spaceﬂight. J. Cardiothorac. Vasc. Anesth. (2016). https://doi.org/10.1053/ (the US Defense Health Board, the Committee on Tactical Combat j.jvca.2016.01.007. Casualty Care, the UK Royal Army Medical Corps association) and 13. Kuypers, M. I. Emergency and wilderness medicine training for physician astronauts on exploration class missions. Wild Env. Med 24, 445–449 (2013). humanitarian, non-governmental organisations and professional 14. Agnew, J., Fibuch, E. & Hubbard, J. Anesthesia during and after exposure to bodies: the International Committee of the Red Cross, the WHO, microgravity. Aviat. Space Environ. Med. 75, 571–580 (2004). the World Federation of Societies of Anaesthesiologists, the DCP3, 15. Silverman, G. L. & McCartney, C. J. Regional Anesthesia for the management of the 2011 American Society of Anesthesiology Guidelines, the 2014 limb injuries in space. Aviat. Space Environ. Med. 79, 620–625 (2008). Lancet Commission on Global Surgery. Duplicate ﬁndings were 16. Robertson, D. et al. Clinical models of cardiovascular regulation after weight- removed. lessness. Med. Sci. Sports Exerc. 28, S80–S84 (1996). We screened 2448 search results by title and abstract for 17. Johnston, S. L., Arenare, B. A. & Smart, K. T. Medical evacuation and vehicles for possible inclusion. The full texts of 241 publications were assessed transport. in Principles of Clinical Medicine for Space Flight (eds Barratt, M. R. & Pool, S. L.) 139–161 (Springer, New York, 2008). for eligibility. 18. Taddeo, T. A. & Armstrong, C. W. Spaceﬂight Medical Systems. in Principles of Finally, all authors screened the search results by title and Clinical Medicine for Space Flight (eds Barratt, M. R. & Pool, S. L.) 69–100 (Springer, abstract and compiled an inclusive list of potential articles of New York, 2008). interest. All articles that were deemed suitable by at least one 19. Campbell, M. R. et al. Endoscopic surgery in weightlessness: the investigation of author were included for full review. All authors independently basic principles for surgery in space. Surg. Endosc. 15, 1413–1418 (2001). read all ﬁnal selected articles and extracted any information 20. Otto, C. et al. Into thin air: extreme ultrasound on Mt Everest. Wilderness Environ. relevant to the pre-deﬁned questions. Med. 20, 283–289 (2009). 21. Otto, C. et al. The Martian chronicles: remotely guided diagnosis and treatment in the Arctic Circle. Surg. Endosc. 24, 2170–2177 (2010). ACKNOWLEDGEMENTS 22. Sipes, W. E, Polk, J. D, Beven, G. & Shepanek, M. Behavioral Health and Perfor- mance. Space Physiology and Medicine (eds Nicogossian, A. E. et al.) 367–389 M.K. is funded by the UK Engineering and Physical Sciences Research Council through (Springer, New York, 2016). an Imperial College London President’s PhD scholarship. Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA npj Microgravity (2018) 5 Anaesthesia in austere environments... M Komorowski et al. 23. Nicogossian, A. E., Williams, D. R., Williams, R. S. & Schneider, V. S. Simulations 55. Mermel, L. A. Infection prevention and control during prolonged human space and Analogs (Test-Beds). In: A. E. Nicogossian et al. (eds.). Space Physiology and travel. Clin. Infect. Dis. 56, 123–130 (2013). Medicine, pp. 441–461 (Springer, New York, 2016).. 56. Smith, S. M. et al. Bone metabolism and renal stone risk during international 24. Simmons, S. C., Hamilton, D. R. & McDonald, P. V. Telemedicine. In: Principles of space station missions. Bone (2015). https://doi.org/10.1016/j.bone.2015.10.002 Clinical Medicine for Space Flight (eds Barratt, M. R. & Pool, S. L.) 163–179 57. Komorowski, M., Fleming, S. & Hinkelbein, J. Anaesthesia in outer space: the (Springer, New York, 2008). ultimate ambulatory setting? Curr. Opin. Anaesthesiol. 29, 649–654 (2016). 25. World Bank. World Bank Country and Lending Groups. (2017). https:// 58. Merry, A. F., Cooper, J. B., Soyannwo, O., Wilson, I. H. & Eichhorn, J. H. Interna- datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank- tional standards for a safe practice of anesthesia 2010. Can. J. Anaesth. 57, country-and-lending-groups and http://www.webcitation.org/6vvcpSNBw. 1027–1034 (2010). Accessed 27 Nov. 2017. 59. Pignaton, W. et al. Perioperative and anesthesia-related mortality. Medicine 95, 26. Bösenberg, A. T. Pediatric anesthesia in developing countries. Curr. Opin. 1–6 (2016). Anaesthesiol. 20, 204–210 (2007). 60. Dobson, M. B. Anaesthesia at the District Hospital. (World Health Organization, 27. Dubowitz, G., Detlefs, S. & McQueen, K. A. K. Global anesthesia workforce crisis: a 2001). preliminary survey revealing shortages contributing to undesirable outcomes 61. Neuen, B. L. Access to safe anesthesia: a global perspective. J. Glob. Health 1–7 and unsafe practices. World J. Surg. 34, 438–444 (2010). (2014). 28. Martin, J. et al. Survey of the capacity for essential surgery and anaesthesia 62. Schnittger, T. Regional anaesthesia in developing countries. Anaesthesia 62, services in Papua New Guinea. BMJ Open 5, e009841 (2015). 44–47 (2007). 29. McQueen, K. et al. The bare minimum: the reality of global anaesthesia and 63. Wilhelm, T. J. et al. Anaesthesia for elective inguinal hernia repair in rural Ghana patient safety. World J. Surg. 39, 2153–2160 (2015). —appeal for local anaesthesia in resource-poor countries. Trop. Doct. 36, 30. Merchant, A. et al. Evaluating progress in the global surgical crisis: contrasting 147–149 (2006). access to emergency and essential surgery and safe anesthesia around the 64. Ouro-Bang’na Maman, A. F., Agbétra, N., Egbohou, P., Sama, H. & Chobli, M. world. World J. Surg. 39, 2630–2635 (2015). Morbidité–mortalité périopératoire dans un pays en développement: expéri- 31. WHO. WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. (World ence du CHU de Lomé (Togo). Ann. Fr. Anesth. Réanimation 27, 1030–1033 Health Organization, 2009). (2008). 32. Essential surgery: disease control priorities, 3rd edn, Vol. 1 (The International 65. Eliassen, H. S. et al. Making whole blood available in austere medical environ- Bank for Reconstruction and Development/The World Bank, 2015). ments: donor performance and safety. Transfus. (Paris). 56, S166–S172 (2016). 33. Spiegel, D. A., Abdullah, F., Price, R. R., Gosselin, R. A. & Bickler, S. W. World Health 66. Ray, J. M. The treatment of maxillofacial trauma in austere conditions. Atlas Oral. Organization global initiative for emergency and essential surgical care: 2011 Maxillofac. Surg. Clin. North. Am. 21,9–14 (2013). and beyond. World J. Surg. 37, 1462–1469 (2013). 67. Convertino, V. A. & Cooke, W. H. Evaluation of cardiovascular risks of spaceﬂight 34. Buckenmaier, C. C., Lee, E. H., Shields, C. H., Sampson, J. B. & Chiles, J. H. Regional does not support the NASA bioastronautics critical path roadmap. Aviat. Space anesthesia in austere environments. Reg. Anesth. Pain. Med. 28, 321–327 (2003). Environ. Med. 76, 869–876 (2005). 35. Keene, D. D. et al. Died of wounds: a mortality review. J. R. Army. Med. Corps. 68. Epelman, S. & Hamilton, D. R. Medical mitigation strategies for acute radiation 162, 355–360 (2016). exposure during spaceﬂight. Aviat. Space Environ. Med. 77, 130–139 (2006). 36. Mahoney, P. F. Combat Anesthesia: The First 24 h. (Department of the Army, 69. Gillis, D. B. & Hamilton, D. R. Estimating outcomes of astronauts with myocardial 2016). infarction in exploration class space missions. Aviat. Space Environ. Med. 83, 37. Mahoney, P. F. & McFarland, C. C. Field anesthesia and military injury. in Trauma 79–91 (2012). Anesthesia (Cambridge University Press, 2008). 70. Hamilton, D. R. Cardiovascular disorders. in Principles of Clinical Medicine for 38. Mellor, A. J. Anaesthesia in austere environments. J. R. Army. Med. Corps. 151, Space Flight (eds Barratt, M. R. & Pool, S. L.). 317–359 (Springer, New York, 2008). 272–276 (2005). 71. Gunga, H.-C., Ahlefeld, V. W. von, Coriolano, H.-J. A., Werner, A. & Hoffmann, U. 39. National Association of Emergency Medical Technicians. Tactical combat The cardiovascular system in space. in Cardiovascular System, Red Blood Cells, casualty Care Guidelines for Medical Personnel. https://www.naemt.org/ and Oxygen Transport in Microgravity,11–34 (Springer International Publishing, education/naemt-tccc/tccc-mp-guidelinesand-curriculum (2016). 2016). 40. Imray, C. H. E., Grocott, M. P. W., Wilson, M. H., Hughes, A. & Auerbach, P. S. 72. Berwick, D. et al. Creating and Sustaining an Expert Trauma Care Workforce Extreme, expedition, and wilderness medicine. Lancet 386, 2520–2525 (2015). (National Academies Press, 2016). 41. Aaen-Larsen, B. Health care in the circumpolar world: Greenland. Int. J. Cir- 73. Morey, T. E. & Rice, M. J. Anesthesia in an austere setting: lessons learned from cumpolar Health 63,49–53 (2004). the haiti relief operation. Anesthesiol. Clin. 31, 107–115 (2013). 42. Grant, I. C. Telemedicine in the British Antarctic survey. Int. J. Circumpolar Health 74. Trelles, M., Dominguez, L. & Stewart, B. T. Surgery in low-income countries 63, 356–364 (2004). during crisis: experience at Médecins Sans Frontières facilities in 20 countries 43. Otto, C. et al. Evaluation of tele-ultrasound as a tool in remote diagnosis and between 2008 and 2014. Trop. Med. Int. Health 20, 968–971 (2015). clinical management at the Amundsen-Scott South Pole Station and the 75. Dobson, M. B. Draw-over anaesthesia Part 2—Practical application. in Update in McMurdo Research Station. Telemed. J. E-Health 19, 186–191 (2013). Anaesthesia (World Federation of Societies of Anaesthesiologists Publications, 44. Minard, C. G., de Carvalho, M. F. & Iyengar, M. S. Optimizing medical resources 1993). for spaceﬂight using the integrated medical model. Aviat. Space Environ. Med. 76. Skelton, T. et al. Low-cost simulation to teach anesthetists’ non-technical skills in 82, 890–894 (2011). Rwanda. Anesth. Analg. 123, 474–480 (2016). 45. Fisher, A. D., Miles, E. A., Cap, A. P., Strandenes, G. & Kane, S. F. Tactical damage 77. McQueen, K. et al. Anesthesia and perioperative care. in Essential Surgery: Dis- control resuscitation. Mil. Med. 180, 869–875 (2015). ease Control Priorities (eds H. T. et al.) 3rd edn, Vol. 1. Debas (The International 46. Grocott, M. & Johannson, L. Ketamine for emergency anaesthesia at very high Bank for Reconstruction and Development/The World Bank, 2015). altitude (4243 m above sea-level). Anaesthesia 62, 959–962 (2007). 78. Galvez, J. A. & Rehman, M. A. Telemedicine in anesthesia: an update. Curr. Opin. 47. Jochberger, S. et al Anesthesia and its allied disciplines in the developing world: a Anaesthesiol. 24, 459–462 (2011). nationwide survey of the Republic of Zambia. Anesth. Analg. 106,942–948 (2008). 79. Murray, A. W., Beaman, S. T., Kampik, C. W. & Quinlan, J. J. Simulation in the 48. Wong, E. G. et al. Operative trauma in low-resource settings: the experience of operating room. Best. Pract. Res. Clin. Anaesthesiol. 29,41–50 (2015). Médecins Sans Frontières in environments of conﬂict, postconﬂict, and disaster. 80. Ikeyama, T., Shimizu, N. & Ohta, K. Low-cost and ready-to-go remote-facilitated Surgery 157, 850–856 (2015). simulation-based learning. Simul. Healthc. 7, 35 (2012). 49. Strube, P. D. & Perkins, A. D. Combat anesthesia: a case report of a gunshot 81. Livingston, P. et al. Development of a simulation and skills centre in East Africa: a wound and new trauma protocols. Aana. J. 83, 247–253 (2015). Rwandan-Canadian partnership. Pan Afr. Med. J. 17, 315 (2014). 50. Department of Essential Health Technologies, World Health Organization. 82. Weaver, S. J. & Salas, E. Training and measurement at the extremes: developing Essential surgical care aide-memoire: surgical and emergency obstetrical care at and sustaining expert team performance in isolated, conﬁned, extreme envir- ﬁrst referral level. http://www.who.int/surgery/publications/en/Aide-Memoire_ onments. Proc. Hum. Factors Ergon. Soc. Annu. Meet. 54,90–93 (2010). surgery.pdf (2003). 83. West, P., Gustin, N. & Raimer, B. G. Telemedicine link with South Pole allows 51. WHO. Surgical Care at the District Hospital. (World Health Organization, 2003). remote knee surgery, National Science Foundation Ofﬁce of Legislative and 52. Clément, G. Psychological issues of spaceﬂight. in Fundamentals of Space Public Affairs, NS PR 02-61 (2002). Medicine. 217–255 (Springer, 2011). 84. Department of Defense. Tactical Combat Casualty Care and Wound Treatment. 53. Shayler, D. Disasters and Accidents in Manned Spaceﬂight. (Springer, 2000). (Skyhorse Publishing, 2016). 54. Crucian, B. et al. Immune system dysregulation occurs during short duration 85. Komorowski, M., Neuhaus, C. & Hinkelbein, P. D. J. Emergency medicine in space. spaceﬂight on board the space shuttle. J. Clin. Immunol. 33, 456–465 (2013). Notf. Rett. 18, 268–273 (2015). npj Microgravity (2018) 5 Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA Anaesthesia in austere environments... M Komorowski et al. 86. Saluja, I. S. et al. Survey of astronaut opinions on medical crewmembers for a 114. Nouruzi-Sedeh, P., Schumann, M. & Groeben, H. Laryngoscopy via Macintosh mission to Mars. Acta Astronaut. 63, 586–593 (2008). blade versus GlideScope: success rate and time for endotracheal intubation in 87. Komorowski, M. & Fleming, S. Intubation after rapid sequence induction per- untrained medical personnel. Anesthesiology 110,32–37 (2009). formed by non-medical personnel during space exploration missions: a simu- 115. Rudraraju, P. & Eisen, L. A. Conﬁrmation of endotracheal tube position: a nar- lation pilot study in a Mars analogue environment. Extrem. Physiol. Med. 4,19 rative review. J. Intensive Care. Med. 24, 283–292 (2009). (2015). 116. Komatsu, R. et al. Learning curves for bag-and-mask ventilation and orotracheal 88. Beam, A. L. & Kohane, I. S. Translating artiﬁcial intelligence into clinical care. intubation: an application of the cumulative sum method. Anesthesiology 112, JAMA 316, 2368–2369 (2016). 1525–1531 (2010). 89. Doarn, C. R., Williams, R. S., Nicogossian, A. E. & Polk, J. D. Training in space 117. Chesters, A. & Webb, T. Ketamine for procedural sedation by a doctor-paramedic medicine. in Space Physiology and Medicine (eds Nicogossian, A. E. et al.). prehospital care team: a 4-year description of practice. Eur. J. Emerg. Med. 22, 463–477 (Springer, New York, 2016). 401–406 (2015). 90. Jha, S. & Topol, E. J. Adapting to artiﬁcial intelligence: radiologists and pathol- 118. Bishop, R. A., Litch, J. A. & Stanton, J. M. Ketamine anesthesia at high altitude. ogists as information specialists. JAMA 316, 2353–2354 (2016). High. Alt. Med. Biol. 1, 111–114 (2000). 91. Jones, P. M. Human performance in space. Rev. Hum. Factors Ergon. 6, 172–197 119. Mulvey, J. M., Qadri, A. A. & Maqsood, M. A. Earthquake injuries and the use of (2010). ketamine for surgical procedures: the Kashmir experience. Anaesth. Intensive 92. Strangman, G. E., Sipes, W. & Beven, G. Human cognitive performance in Care. 34, 489–494 (2006). spaceﬂight and analogue environments. Aviat. Space Environ. Med. 85, 120. Russell, K. W. et al. Wilderness Medical Society Practice Guidelines for the 1033–1048 (2014). treatment of acute pain in remote environments. Wilderness Environ. Med. 25, 93. Walker, I. A. & Wilson, I. H. Anaesthesia in developing countries—a risk for 41–49 (2014). patients. Lancet Lond. Engl. 371, 968–969 (2008). 121. Burgess, C. & Dubbs, C. Cosmos/Bion: the age of the biosatellites. in Animals in 94. Jawa, R. S., Zakrison, T. L., Richards, A. T., Young, D. H. & Heir, J. S. Facilitating Space 277–305 (Springer, New York, 2007). safer surgery and anesthesia in a disaster zone. Am. J. Surg. 204, 406–409 (2012). 122. Groemer, G. E. et al. The feasibility of laryngoscope-guided tracheal intubation 95. Vincent, J.-L. The future of critical care medicine: integration and personaliza- in microgravity during parabolic ﬂight: a comparison of two techniques. Anesth. tion. Crit. Care. Med. 44, 386–389 (2016). Analg. 101, 1533–1535 (2005). 96. Ventola, C. L. Medical applications for 3D Printing: current and projected uses. 123. Keller, C. et al. Airway management during spaceﬂight: A comparison of four Pharm. Ther. 39, 704–711 (2014). airway devices in simulated microgravity. Anesthesiology 92, 1237–1241 (2000). 97. Mehta, P. & Bhayani, D. Impact of space environment on stability of medicines: 124. Rabitsch, W. et al. Airway management with endotracheal tube versus Combi- challenges and prospects. J. Pharm. Biomed. Anal. 136, 111–119 (2017). tube during parabolic ﬂights. Anesthesiology 105, 696–702 (2006). 98. Spinella, P. C. Warm fresh whole blood transfusion for severe hemorrhage: U.S. 125. Adesunkanmi, A. R. Where there is no anaesthetist: a study of 282 consecutive military and potential civilian applications. Crit. Care. Med. 36, S340–345 (2008). patients using intravenous, spinal and local inﬁltration anaesthetic techniques. 99. Mahmood, F. et al. Perioperative ultrasound training in anesthesiology: a call to Trop. Doct. 27,79–82 (1997). action. Anesth. Analg. 122, 1794–1804 (2016). 126. Aluisio, A. R., Teicher, C., Wiskel, T., Guy, A. & Levine, A. Focused training for 100. Talbot, M., Harvey, E. J., Reindl, R., Martineau, P. & Schneider, P. Ultrasound- humanitarian responders in regional anesthesia techniques for a planned ran- assisted external ﬁxation: a technique for austere environments. J. R. Army. Med. domized controlled trial in a disaster setting. PLOS Curr. Disasters (2016). Corps. 162, 456–459 (2016). doi:10.1371/currents.dis.e75f9f9d977ac8adededb381e3948a04 101. Nguyen, B.-V. et al. Determination of the learning curve for ultrasound-guided 127. Newton, M. & Bird, P. Impact of parallel anesthesia and surgical provider training jugular central venous catheter placement. Intensive Care. Med. 40,66–73 in Sub-Saharan Africa: a model for a resource-poor setting. World J. Surg. 34, (2014). 445–452 (2010). 102. Bye, S. M. & Manankov, A. Telemedicine in practice in Arkhangelsk region, 128. Kessler, J., Wegener, J. T., Hollmann, M. W. & Stevens, M. F. Teaching concepts in Russia: from a blank page to routine operation. Int. J. Circumpolar Health 66, ultrasound-guided regional anesthesia. Curr. Opin. Anaesthesiol. 29, 608–613 335–350 (2007). (2016). 103. Hemmerling, T. M. et al. Evaluation of a novel closed-loop total intravenous 129. Luyet, C. et al. Different learning curves for axillary brachial plexus block: anaesthesia drug delivery system: a randomized controlled trial. Br. J. Anaesth. ultrasound guidance versus nerve stimulation. Anesthesiol. Res. Pract. 2010,1–7 110, 1031–1039 (2013). (2010). 104. Baker, E. S., Barratt, M. R. & Wear, M. L. Human response to spaceﬂight. in 130. Hunter, J. G. Managing pain on the battleﬁeld: an introduction to continuous Principles of Clinical Medicine for Space Flight (eds Barratt, M. R. & Pool, S. L.). peripheral nerve blocks. J. R. Army. Med. Corps. 156, 230–232 (2010). 27–58 (Springer, 2008). 131. Chou, R. et al. Management of postoperative pain: a Clinical Practice Guideline 105. Lee, S. M. C., Feiveson, A. H., Stein, S., Stenger, M. B. & Platts, S. H. Orthostatic From the American Pain Society, the American Society of Regional Anesthesia intolerance after ISS and space shuttle missions. Aerosp. Med. Hum. Perform. 86, and Pain Medicine, and the American Society of Anesthesiologists’ Committee A54–A67 (2015). on Regional Anesthesia, Executive Committee, and Administrative Council. J. 106. Hargens, A. R. & Richardson, S. Cardiovascular adaptations, ﬂuid shifts, and Pain. 17, 131–157 (2016). countermeasures related to space ﬂight. Respir. Physiol. Neurobiol. 169 Suppl 1, 132. Clément and Buckley (eds) Artiﬁcial Gravity. (Springer, 2007). S30–S33 (2009). 133. Barash, P. G. et al. Clinical Anesthesia, 8e: Print + Ebook with Multimedia. (LWW, 107. Norﬂeet, W. Anesthetic concerns of spaceﬂight. Anesthesiology 98, 1219 (2000). 2017). 108. Modi, P. et al. Accuracy of inferior vena cava ultrasound for predicting dehy- 134. Miller, R. D. et al. Miller’s Anesthesia, 2-Volume Set, 8e. (Saunders, 2014). dration in children with acute diarrhea in resource-limited settings. PLoS. ONE. 11, e0146859 (2016). 109. Chisholm, C. B. et al. Focused Cardiac UltrasoundTraining: How Much Is Enough? Open Access This article is licensed under a Creative Commons J. Emerg. Med. 44, 818–822 (2013). Attribution 4.0 International License, which permits use, sharing, 110. Buis, M. L., Maissan, I. M., Hoeks, S. E., Klimek, M. & Stolker, R. J. Deﬁning the adaptation, distribution and reproduction in any medium or format, as long as you give learning curve for endotracheal intubation using direct laryngoscopy: a sys- appropriate credit to the original author(s) and the source, provide a link to the Creative tematic review. Resuscitation 99,63–71 (2016). Commons license, and indicate if changes were made. The images or other third party 111. Lascarrou, J. B. et al. Video laryngoscopy vs direct laryngoscopy on successful material in this article are included in the article’s Creative Commons license, unless ﬁrst-pass orotracheal intubation among ICU patients: a randomized clinical trial. indicated otherwise in a credit line to the material. If material is not included in the JAMA 317, 483–493 (2017). article’s Creative Commons license and your intended use is not permitted by statutory 112. Lewis, S. R., Butler, A. R., Parker, J., Cook, T. M. & Smith, A. F. Videolaryngoscopy regulation or exceeds the permitted use, you will need to obtain permission directly versus direct laryngoscopy for adult patients requiring tracheal intubation. from the copyright holder. To view a copy of this license, visit http://creativecommons. Cochrane Database Syst. Rev. 11, CD011136 (2016). org/licenses/by/4.0/. 113. Aguirre Ospina, O. D., Ríos Medina, Á. M., Calderón Marulanda, M. & Gómez Buitrago, L. M. Cumulative sum learning curves (CUSUM) in basic anaesthesia © The Author(s) 2018 procedures. Colomb. J. Anesthesiol. 42, 142–153 (2014). Published in cooperation with the Biodesign Institute at Arizona State University, with the support of NASA npj Microgravity (2018) 5

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Anaesthesia in austere environments: literature review and considerations for future space exploration missions

Anaesthesia in austere environments: literature review and considerations for future space exploration missions

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Anaesthesia in austere environments: literature review and considerations for future space exploration missions

Anaesthesia in austere environments: literature review and considerations for future space exploration missions

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