1. Context
As cutting-edge drugs and anesthesia techniques emerge, anesthesiologists must understand their mechanisms, optimal application, potential side effects, and mitigation strategies. This knowledge in academic settings can spur future research and groundbreaking solutions. Moreover, advancements in monitoring technologies and drug administration demand that anesthesiologists become well-versed in these concepts (1). Anesthesiologists play a crucial role as the primary physicians responsible for administering drugs that can reversibly alter consciousness and brain function. This places them squarely in the realm of clinical neuroscience, and the field of anesthesiology itself is rightly regarded as applied neuroscience (2, 3).
In light of these concepts, the Department of Anesthesiology, Critical Care, and Pain Medicine (DACCPM), SBMU, Tehran, Iran, aims to elevate the knowledge and appreciation of neuroscience among our anesthesiologists and residents, particularly concerning our field. This initiative will entail close collaboration with other departments and faculties within our university and nearby institutions. It is crucial to recognize that despite significant progress in anesthesiology, pharmacology, and neuroscience, there are still gaps in our understanding of how hypnotic drugs function, the mechanisms of losing and regaining consciousness, and the very nature of consciousness itself (4).
1.1. Historical Perspective and Evolution
1.1.1. Traditional Role of Anesthesiologists
The anesthesiologist plays a crucial role in ensuring patient safety and comfort before, during, and after surgery. Their expanding role includes providing intraoperative support, monitoring the patients, and reducing complications. With a strong record of quality and safety performance, anesthesiologists advocate for postoperative care and effectively manage the interplay between anesthesia, pain control, and patient well-being, contributing to a seamless surgical experience.
1.1.2. Emergence of Neuroscience in Anesthesiology
Research on general anesthesia, encompassing amnesia, hypnosis, analgesia, and areflexia, has intrigued scientists for decades. Understanding how anesthetic drugs suppress human consciousness, particularly through hypnosis, has posed challenges for anesthesiologists and neuroscientists (5, 6). Anesthetics reduce cerebral metabolism and blood flow, affecting the brain's thalamus. Even under anesthesia, the brain responds to stimuli in sensory areas to varying degrees. The impact of anesthetics on brain connectivity varies based on the drug type, dosage, and specific brain network (6, 7). Typically, patients under anesthesia experience partial suppression of brain connections rather than complete loss (8).
1.2. Anesthesiologist as an Applied/Clinical Neuroscientist
Anesthesiologists possess a unique ability to intentionally manipulate consciousness levels during medical or surgical procedures, whether in the operating room, outside of it, or in the ICU (9, 10). No other clinicians administer pharmaceutical agents in the cerebrospinal fluid to the extent that anesthesiologists do routinely during spinal anesthesia (5). Anesthetic drugs significantly impact neural pathways, underscoring the importance for every anesthesiologist to possess a thorough understanding of neural pathways, neurotransmitters, and brain function to elevate their practice (11, 12). Keeping abreast of the latest scientific advancements is imperative in this swiftly evolving field (5, 13). Key areas, such as the effects of anesthetics on the developing brain and the role of neuroscience in enhancing the management of acute or chronic pain, whether through pharmacological or non-pharmacological means, stand as pivotal focal points in the discipline (14, 15).
The ambitious mission set for anesthesiologists represents a formidable challenge. We are actively addressing these challenges through a range of innovative approaches, including computational neuroscience, neural circuit mapping, EEG brain activity measurements, advanced neuroimaging techniques, and in-depth studies of cellular pathways and neurotransmitters (16-18). This approach underscores the necessity for anesthesiologists to possess expertise in applied or clinical neuroscience. This includes proficiency in neurophysiological monitoring, implementation of brain protection strategies, and adept management of neurological disorders (19). Anesthesiologists are required to possess specialized knowledge and skills in neuroanatomy, neurophysiology, and neuromonitoring tools in order to effectively fulfill their role (20, 21).
1.3. Collaboration in Multidisciplinary Teams
Recognizing the importance of interdisciplinary collaboration and medicine among healthcare professionals is crucial for enhancing patient outcomes. Transitioning from an interdisciplinary to a multidisciplinary approach, and ultimately to a comprehensive transdisciplinary approach, is essential. This necessitates close collaboration with neurologists, neurosurgeons, basic scientists, and related specialists; collaborating with other clinical specialists, such as neurologists and neurosurgeons, is essential for enhancing patient outcomes (22). We have successfully established three academic memoranda of understanding and formal agreements, forging valuable partnerships with the School of Advanced Technologies in Medicine and the Neuroscience Research Center, both of which are affiliated with SBMU, Tehran, Iran.
1.4. Innovative Approaches, Techniques, and Technologies
Equally important is working with basic science departments, as they often require access to patients and face challenges when conducting experiments outside clinical settings without the guidance of experienced physicians (23, 24). Integrating neuroscience into anesthesiology is vital for gaining new insights into pharmacology and drug effects. One such example is ketamine, which has traditionally been viewed as a pro-convulsive agent to be avoided in patients with seizure histories. However, recent studies have demonstrated its effectiveness as an anticonvulsant in patients with refractory seizures, likely due to its interaction with NMDA receptors (6, 25).
Furthermore, neuroscience can help address significant dilemmas in anesthesia, such as the true impact of anesthesia on the developing brain in children, strategies for treating patients with hypoxic brain injuries, and understanding the transition from acute to chronic pain (26). Neuroscience equips anesthesiologists with advanced tools to directly impact the brain, going beyond traditional medication. Techniques like transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and photobiomodulation (PBM therapy) offer additional avenues for closely monitoring patients during both neurosurgical and non-neurosurgical procedures (11, 12, 27, 28).
We have successfully established connections with basic science faculties specializing in cellular and molecular biology and neuroimaging. We have actively encouraged them to redirect their research focus towards clinical applications. Recognizing the limitations of available equipment in our developing country, we have prioritized techniques that require less advanced technology. For instance, we are utilizing 1.5 Tesla MRI machines rather than 3 or 7 Tesla machines. This strategic approach has led us to emphasize structural studies such as voxel-based morphometry (VBM) over functional studies (29, 30). Despite encountering challenges, we have embarked on groundbreaking research in neurocritical areas using accessible devices, such as olfactory stimulation in comatose patients (31). While we may lack advanced equipment, we leverage our proximity to a substantial patient population in educational hospitals in the capital to drive impactful advancements in neurology.
1.5. Patient Outcomes and Safety
Adopting an approach rooted in applied neuroscience by anesthesiologists is not only a scientifically sound method but also enhances the quality of anesthesia at the patient's bedside. This approach significantly improves the precision of evidence-based medicine for anesthesiologists, particularly in relation to one of the most crucial body systems: The nervous system (32, 33) This safety approach not only involves personalized anesthesia and tailored administration of anesthetic drugs but also enhances the delivery of anesthetics to the developing brain (34-37).
1.6. Educational Initiatives
In August 2023, we successfully hosted the inaugural one-day congress on “Anesthesiology and Neuroscience” in partnership with several prestigious institutes, establishing connections with additional departments such as neurology and neurosurgery, multiple hospitals (including private ones), and institutions outside the health system within the Iranian Ministry of Science.
We have launched a series of engaging lectures and journal clubs focused on neuroscience to instill a neuroscientific mindset among our trainees. Additionally, we are thrilled to announce our new partnerships with the esteemed Neuroscience Research Center at SBMU in Tehran, Iran. Through these collaborations, we have introduced an innovative 15-day course as part of the Neuroanesthesia fellowships curriculum at the Neuroscience Research Center, offering our fellows valuable hands-on experience and expertise.
1.7. Research Opportunities and Research Flagship for Anesthesiology
To truly advance our understanding of neuroscience in anesthesia, it is essential to delve into both basic and clinical research, while also exploring the frontiers of scientific knowledge. With this goal in mind, we have redoubled our research endeavors and forged stronger collaborations in areas such as regenerative medicine, cellular and molecular medicine, and other cutting-edge fields.
2. Discussion
In spite of significant progress in neuroscience research over the last decade, a substantial disparity persists between laboratory findings and practical clinical applications. We have organized our research objectives into the following subcategories.
2.1. Artificial intelligence and neuroscience
Recognizing that artificial intelligence (AI) has advanced by imitating the brain's functions is critical. The AI holds the potential to greatly enhance anesthesia practice by swiftly predicting complications during the perioperative period. Moreover, the parallels between AI and the brain could unveil profound insights into the realm of neuroscience, as neuroscience has already laid the groundwork for AI (38, 39).
2.2. Translational Neuroanesthesia
The field of neuroscience and anesthesia research has encountered significant challenges due to disparities between human and animal models. However, by embracing translational science, we can effectively address these issues (40). Despite considerable progress, the intricate mechanisms of consciousness and anesthesia still harbor numerous enigmas that demand exploration (6). Furthermore, several severe perioperative neurocognitive complications, including delirium, stroke, and postoperative cognitive disorder, remain inadequately diagnosed and treated due to the absence of specific monitors and biomarkers for early detection (8). Even in cases of diagnosis, there is a dearth of evidence to support intervention.
2.3. Monitoring
By incorporating pulse oximetry and capnography, we have already made significant strides in improving patient safety. However, it is crucial to note that current brain state monitoring lacks the ability to provide real-time and precise information about brain function. Furthermore, the absence of direct and reliable nociception monitoring in the operating room is a significant gap. We strongly believe that integrating EEG and other hemodynamic monitors with AI holds great promise for addressing these critical needs (41, 42).
2.4. Guidelines
While there are numerous guidelines available for perioperative management of cardiovascular and respiratory complications, it is important to note the absence of a specific guideline for neurologic complications, with the exception of delirium (43).
The application of neuroscience in anesthesia not only enhances the scientific aspects and research strategies but also significantly expands the field's influence and creates new opportunities (44). This contributes to professional development, strengthening the prestige of the work and having a practical impact on solving patients' problems, leading to specialized clinical roles or academic positions (45, 46). In other words, when new solutions in unique scientific fields translate into clinical approaches, it increases the professional impact of the field. This path serves as an objective example of how anesthesia strengthens the effectiveness of science, advances research goals, and expands helpful science.
Extensive research has delved into various theories and interventions in pain management, but there is still a need for further clarification on their effectiveness. Understanding and managing pain is a critical focus of neuroscience research. The importance of early diagnosis cannot be overstated, as it is the key to managing and preventing chronic pain. Investigating the exact mechanisms is the crucial first step in achieving these goals (47). Furthermore, the introduction of vaccines for substance use disorders underscores the potential for innovative solutions (48). Protecting the brain, particularly in cases of ischemic brain damage, is a paramount focus for anesthesiologists, irrespective of its origin (49). Despite several interventions showing promise in animal studies, none have proven effective in clinical settings, prompting the need for continued exploration and innovation (50).
The key challenge in applied neuroscience is the financial constraints, especially in developing countries like Iran. The successful integration of neuroscience into clinics relies on the close collaboration between basic scientists and clinicians. Translational scientists are adept at overcoming the unique challenges of translating research into practical applications (51). However, the achievement of goals in applied neuroscience hinges not only on overcoming obstacles but also on meticulous planning (52). In the DACCPM, the neuroscience committee meticulously investigated the neuroscience gap, assessed existing laboratory and clinical facilities, and developed a comprehensive roadmap, instilling confidence in the process.
3. Conclusions
Anesthesia is a vital discipline with deep connections to diverse surgical fields and physiological systems, making it an essential component of every hospital. Our collaborative efforts in anesthesia and neuroscience have notably enriched the training curriculum for our residents and fellows. Through a successful partnership with the Neuroscience Research Center, we have seamlessly integrated a two-week rotation for our Neuroanesthesia fellows, providing them with invaluable training opportunities.
The focus on translation in medical research has become imperative in recent decades. Concurrently, there have been significant advancements in neuroscience and Neuroanesthesia. However, effective communication is crucial for enhancing the population's overall health. Only a few organizations are dedicated to this cause, and none are in developing countries. These countries' significant limitations are the need for more financial support and educated translational scientists. Anesthesiologists are well-equipped to address this challenge due to their professional characteristics, making them influential translational scientists at a lower cost. Instead of establishing new organizations, expanding connections with existing research institutes and obtaining research grants would be more practical by submitting well-designed multidisciplinary proposals.
Additionally, there is a need for more biobanks and extensive datasets, and anesthesiologists can contribute samples due to their consistent exposure to neuroscience. Our research focuses on three key areas: Fundamental neuroscience emphasizing regenerative medicine, technological advancements in AI, and the convergence of these fields. The rapid advancement of medical technology, including AI, robotics, and brain-computer interfaces (BCIs), combined with a deeper understanding of cellular mechanisms, will bring about a revolutionary change in anesthesia practice. Innovations such as personalized anesthesia using BCIs, advanced drug delivery systems, and reliable robotic assistants are poised to bring the most significant transformations.
