Fundamentals of Anesthesiology for Spaceflight

SPACE EXPLORATION BEYOND low Earth orbit has been termed as “exploration class space missions.”1Institute of Medicine (U.S.)Committee on Creating a Vision for Space Medicine during Travel Beyond Earth Orbit, National Academy of Science, Board on Health Sciences Policy. Executive Summary.in: Ball J.R. Evans Jr. C.H. Safe passage: Astronaut care for exploration missions. National Academies Press, Washington, DC2001: 1-22Google Scholar, 2Satava R.M. Lest we forget the future.J Am Coll Surg. 1997; 184: 519-520PubMed Google Scholar Such future missions may involve extended flights to the Moon, asteroids, or Mars and will most likely engage not only governmental space agencies but also the private sector, in what some have termed “the new space race.” During those missions, the risk for a crew member to require advanced medical care, including anesthesia and surgery, is significant.3Campbell M. Billica R. Surgical capabilities.in: Barratt M. Pool S.L. Principles of clinical medicine for space flight. Springer, New York2008: 123-137Crossref Scopus (13) Google Scholar, 4Comet B. Berry I. Berthier A. et al.MARSTECHCARE, necessary biomedical technologies for crew health control during long-duration interplanetary manned missions. ESTEC.Report No: 16423/02/NL/LvH. 2002 Dec; : 151Google Scholar, 5Kirkpatrick A.W. Ball C.G. Campbell M. et al.Severe traumatic injury during long duration spaceflight: Light years beyond ATLS.J Trauma Manag Outcomes. 2009; 3: 4Crossref PubMed Google Scholar In the first section of this review, human adaptation to the space environment is detailed, with a focus on the cardiovascular system, along with a discussion regarding which medical conditions may arise. The second part of the review focuses on discussing the extensive list of challenges associated with delivering an anesthetic procedure in space or on a foreign planetary surface. The challenge of providing advanced critical care in these settings encompasses many other issues that are beyond the scope of this review, which primarily focuses on anesthetic techniques. The boundary of space, according to the official definition of the International Aeronautics Federation, sits at an altitude of 100 km above sea level,6Sanz Fernández de Córdoba S: 100km altitude boundary for astronautics. Available at: http://www.fai.org/icare-records/100km-altitude-boundary-for-astronautics. Accessed February 15, 2016Google Scholar although the transition to space actually involves a series of boundaries progressively more hostile to human existence.7Locke J. Space environments.in: Davis J.R. Johnson R. Stepanek J. Fundamentals of Aerospace Medicine. 4th ed. Lippicott Williams & Wilkins, Philadelphia2008: 251-278Google Scholar The space stations in low Earth orbit travel at an altitude of 220 to 280 miles (350 to 450 km) and a speed of 17,500 mph (28,000 km/h). This velocity generates a centrifugal force capable of compensating Earth’s gravity, which at this altitude is still 88% of sea level’s gravity. Both forces counterbalance each other, leading to the state of weightlessness, or microgravity. In addition to the “conventional” medical conditions that threaten every human being, the unique environment of spaceflight, and in particular the loss of gravity, may predispose a person to the onset of a number of specific illnesses unique to space travel and especially prolonged weightlessness. Both types of conditions are summarized in Table 1.8Komorowski M. Neuhaus C. Hinkelbein P.D.J. Emergency medicine in space.Notfall Rettungsmed. 2015; 18: 268-273Crossref Scopus (8) Google Scholar The majority of this list overlaps with the risks identified by the National Aeronautics and Space Administration (NASA) Human Research Roadmap.9Watkins S: Space medicine exploration: Full medical condition list. Available at: https://humanresearchwiki.jsc.nasa.gov/images/c/cc/Space_Medicine_Exploration_Condition_List_Rev_B_2012.pdf. Accessed February 15, 2016Google ScholarTable 1Earth-like and Space-specific Medical Conditions in SpaceEarth-Like ConditionsSpace-Specific ConditionsTraumaCardiovascular deconditioningInfectionsRadiation exposureCardiovascular diseases: arrhythmias, myocardial ischemic events, strokeVision impairment and intracranial pressure syndromeRenal stoneHypobaric decompression sicknessPsychiatric disordersExposure to a toxic atmosphereCataractHypothermia/heat strokeCancerExposure to planetary dust(Adapted from Komorowski M, Neuhaus C, Hinkelbein PDJ: Emergency medicine in space. Notfall Rettungsmed 18:268-273, 2015.8Komorowski M. Neuhaus C. Hinkelbein P.D.J. Emergency medicine in space.Notfall Rettungsmed. 2015; 18: 268-273Crossref Scopus (8) Google Scholar) Open table in a new tab (Adapted from Komorowski M, Neuhaus C, Hinkelbein PDJ: Emergency medicine in space. Notfall Rettungsmed 18:268-273, 2015.8Komorowski M. Neuhaus C. Hinkelbein P.D.J. Emergency medicine in space.Notfall Rettungsmed. 2015; 18: 268-273Crossref Scopus (8) Google Scholar) The phases of launch and landing are extremely critical due to the stress put on the vehicles (and, subsequently, the crew within) by tremendous changes in velocity (accelerations and decelerations), and indeed, all human losses during spaceflight have occurred during those transition phases (Challenger, Columbia, Soyuz 1, and T11).10Baker E.S. Barratt M.R. Wear M.L. : Human response to spaceflight.in: Barratt M.R. Pool S.L. Principles of clinical medicine for space flight. Springer, New York2008: 27-58Crossref Scopus (35) Google Scholar The latest NASA Mars mission design concept corresponds to a 6-person crew conducting a 900-day mission.11Mars Architecture Steering Group: Mars design reference architecture 5.0. Available at: http://www.nasa.gov/pdf/373665main_NASA-SP-2009-566.pdf. Accessed February 15, 2016Google Scholar Recently, a NASA report outlined “deep space” cislunar missions for the 2020s followed by a Mars mission in the 2030s for “at least 4 crew” for “up to 1,100 days.”12NASA: NASA’s journey to Mars: Pioneering next steps in space exploration. Available at: https://www.nasa.gov/sites/default/files/atoms/files/journey-to-mars-next-steps-20151008_508.pdf. Accessed February 15, 2016Google Scholar In deep space, the vast distances involved imply that real-time communications will not remain possible, with delays between Earth and Mars, for example, reaching 4 to 20 minutes in each direction. An unprecedented level of crew autonomy will be necessary, including for medical care. With electronic transmissions limited by the speed of light, telemedicine, telementoring, and all The crew has not been but be limited to a crew medical is not a Williams et of on medical for a mission to Scopus Google Scholar An this and a medical with medical on Williams et of on medical for a mission to Scopus Google Scholar on the and to an that human that is and with the the is on on the An extremely hostile environment the by a of and and of human space flight. Barratt Pool Principles of clinical medicine for space flight. Available at: Accessed February 15, 2016Google Scholar in a environment involves an risk in the loss of pressure a or to the of toxic or of the A.W. Ball C.G. Campbell M. et al.Severe traumatic injury during long duration spaceflight: Light years beyond ATLS.J Trauma Manag Outcomes. 2009; 3: 4Crossref PubMed Google Scholar, A.W. Campbell M.R. et in and with to traumatic control in long-duration Am Coll Surg. Full Full PubMed Scopus Google Scholar transition a to environment an decompression between and a Space Google Scholar a decompression in a in a to of or decompression decompression between and a Space Google Scholar in space have been and the but also likely the to decompression of for and interplanetary Scopus Google Scholar, in M, and the from microgravity. Available at: Accessed February 15, 2016Google Scholar also is a risk of and with A.W. et of in the of PubMed Scopus Google Scholar at of and are by NASA for Mars exploration and the for and the risk of NASA’s journey to Mars: Pioneering next steps in space exploration. Available at: https://www.nasa.gov/sites/default/files/atoms/files/journey-to-mars-next-steps-20151008_508.pdf. Accessed February 15, 2016Google Scholar, to decompression of for and interplanetary Scopus Google Scholar in an and environment has and as and and in B. J. and during Mars PubMed Scopus Google Scholar The in low Earth orbit are from by the Health of on a mission to E.S. The the Scopus Google Scholar Beyond and the to have as Medical for during Space Google Scholar in space also to the risk of and Health of on a mission to E.S. The the Scopus Google Scholar The NASA of Astronaut Health identified an in from which has been the Billica Johnson et of the of Astronaut Health Space Google Scholar to the health of of planetary have been of the and by C. Johnson R. of NASA and : Scholar The conditions of and M. Billica R. Surgical capabilities.in: Barratt M. Pool S.L. Principles of clinical medicine for space flight. Springer, New York2008: 123-137Crossref Scopus (13) Google Scholar, 5Kirkpatrick A.W. Ball C.G. Campbell M. et al.Severe traumatic injury during long duration spaceflight: Light years beyond ATLS.J Trauma Manag Outcomes. 2009; 3: 4Crossref PubMed Google to and of of cardiovascular risks of spaceflight not the NASA Space Google Health of on a mission to E.S. The the Scopus Google Scholar, Medical for during Space Google the of and B. J. and during Mars PubMed Scopus Google and challenges regarding the of surgery, and critical M. et anesthesia for space exploration Space PubMed Scopus Google Scholar, et and in manned space PubMed Scopus Google Scholar, A.W. Campbell M.R. et and care in review of and with for critical care and in Am Coll Surg. 1997; 184: Google Scholar the human of and conditions the to M. Billica R. Surgical capabilities.in: Barratt M. Pool S.L. Principles of clinical medicine for space flight. Springer, New York2008: 123-137Crossref Scopus (13) Google Scholar, 5Kirkpatrick A.W. Ball C.G. Campbell M. et al.Severe traumatic injury during long duration spaceflight: Light years beyond ATLS.J Trauma Manag Outcomes. 2009; 3: 4Crossref PubMed Google Scholar, of Scopus (35) Google Scholar have the risk of a medical during a mission to be of which corresponds to years for a crew of during a 900-day mission to B. Berry I. Berthier A. et al.MARSTECHCARE, necessary biomedical technologies for crew health control during long-duration interplanetary manned missions. ESTEC.Report No: 16423/02/NL/LvH. 2002 Dec; : 151Google Scholar, M. B. et missions Scopus Google Scholar, Barratt M.R. Pool S.L. Principles of clinical medicine for space flight. Springer, New York2008: Scopus Google Scholar, S.L. et in Full Full PubMed Scopus Google Scholar The risk of from or during an exploration mission to Mars has been to be B. Berry I. Berthier A. et al.MARSTECHCARE, necessary biomedical technologies for crew health control during long-duration interplanetary manned missions. ESTEC.Report No: 16423/02/NL/LvH. 2002 Dec; : 151Google Scholar In the risk on Earth in and in the of to is Health Health Available at: Accessed February 15, 2016Google Scholar put these in the for the risk of from is or of medical B. Berry I. Berthier A. et al.MARSTECHCARE, necessary biomedical technologies for crew health control during long-duration interplanetary manned missions. ESTEC.Report No: 16423/02/NL/LvH. 2002 Dec; : 151Google Scholar of for medical care in spaceflight involves regarding to of will be or of the mission will that are and the will be or in A.W. Campbell M.R. et and care in review of and with for critical care and in Am Coll Surg. 1997; 184: Google Scholar years of space medicine has a of human is by E.S. Barratt M.R. Wear M.L. : Human response to spaceflight.in: Barratt M.R. Pool S.L. Principles of clinical medicine for space flight. Springer, New York2008: 27-58Crossref Scopus (35) Google Scholar The human has of years and is for this not J. Space and Google Scholar these of on not a with as long as the of of the and medical care during or spaceflight, the cardiovascular is of the most critical to cardiovascular which are summarized in Table A. M. et and pressure during long duration 2015; PubMed Scopus Google Scholar, J. J. during and to Space Google Scholar, et pressure in PubMed Scopus Google Scholar, et pressure in Google Scholar, and to space 2009; PubMed Scopus Google Scholar, et of during Google Scholar, of the Space Google Scholar, of and in Space 1997; PubMed Scopus Google Scholar, control during space and for human Google Scholar, M. et in PubMed Scopus Google Scholar, B. J. control 2009; Scopus Google Scholar, et in on human cardiovascular Google Scholar, C. et of in Google Scholar, A. et of in during space PubMed Scopus Google Scholar, et during in and is associated with PubMed Scopus Google Scholar, C. et in PubMed Scopus Google ScholarTable in in E.S. Barratt M.R. 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