Miller's Anesthesia, 2-Volume Set: Volume I + II [9 ed.] 0323596045, 9780323596046

Table of contents :
Front Cover
Front Matter
Copyright
Dedication
Associate Editors
Contributors
Preface
Contents
Video Contents
SECTION I • Introduction
1 - The Scope of Modern Anesthetic Practice
Introduction
Forces That Will Change Practice (Fig. 1.1)
Changing Patient Populations
Changing Locations of Care
Changes in the Anesthesia Workforce
Increasing Costs of Care
Increasing Focus on Safety and Quality
New Opportunities and Challenges in Research
Increasing Availability of Data
Conclusions
Acknowledgment
References
2 - Anesthesia and Analgesia in the Global Context
Introduction
Section 1: Anesthesia and “Global Health”
Scope and Scale of the Global Anesthesia, Surgery, and Pain Crises
Global Burden of Surgical Disease
Global Burden of Pain
Disparities in Access, Affordability, and Safety
Global Anesthesia, Surgery, and Pain Crises: Origins and Areas for Intervention
Misperceptions and Limited Data
Advocacy and Policy
Workforce Shortages and Strategies for Expansion
Infrastructure Challenges
Inequities in Analgesia
Section 2: Evolution of Anesthesia Care Models and Challenges Around the World
Africa
Uganda (Mary T. Nabukenya and Sarah Hodges)
South Africa (Hyla Kluyts)
North America
Canada (Tyler Law)
Mexico (Gerardo Prieto)
United States (Ronald D. Miller and Adrian W. Gelb)
Europe
Norway (Jannicke Mellin-Olsen)
Romania (Daniela Filipescu)
Asia and The Middle East
India (Bala Krishnan Kanni)
Lebanon and The Middle East (Patricia Yazbeck)
Pakistan (Fauzia Khan)
China (Yugaung Huang)
Vietnam (Thi Thanh Nguyen and Thang Cong Quyet)
South America
Paraguay (Rodrigo Sosa Argana)
Colombia (Pedro Ibarra)
Oceania
Australia and New Zealand (Rob McDougall)
Fiji and Pacific Island Nations (Sereima Bale)
Section 3: Essentials for Practice in Resource-Constrained Settings
Clinical and Technical Skills
Global Health Competencies
Conclusions
Acknowledgments
References
Appendix 1 Links and Useful Resources
References
3 - Perioperative Medicine
Introduction
The Anesthesiologist and Perioperative Medicine
Perioperative Management
Preoperative Assessment and Management
Intraoperative (Intraprocedural) Management
Postoperative Management
Coordinated Perioperative Management Strategies
Models of Perioperative Care
Patient-Centered Medical Home
Surgical Hospitalist
Enhanced Recovery After Surgery
Perioperative Surgical Home
Conclusion
References
4 - Informatics in Perioperative Medicine
Introduction
Computer Systems
Computer Networks
The Internet
Information Security
Standards for Healthcare Data Exchange
Regulation of Electronic Data Exchange
The Nature of Healthcare Information in the Anesthesia Encounter
Development and Deployment of Anesthesia Information Management Systems
Anatomy of an Anesthesia Information Management System
Advantages of Implementation of an Anesthesia Information Management System
Integration of Anesthesia Care Information with Operating Room Information Systems
Development of Decision Support Tools
Passive Decision Support Systems
Active Decision Support Systems
Impact of Decision Support in Anesthesia Care
Integration with the Enterprise Electronic Health Record
Billing System Interactions
Challenges in Anesthesia Information Management System Implementation
Additional Uses for Collected Data
Use for Medical Research
Measurement of Quality of Care
Interactions of Electronic Devices with the Delivery of Anesthesia Care
Conclusion
Acknowledgment
References
5 - Quality Improvement in Anesthesia Practice and Patient Safety
Definition of Quality
Aims of Quality in Health Care
Deming’s System of Profound Knowledge
Approaches to Quality Assessment
Quality Assurance Versus Continuous Quality Improvement
Frameworks for Improvement
Model for Improvement
Lean Methodology and Six Sigma
The Value Framework in Health Care
Quality Improvement Measures and Tools
Process and Outcome Measures
Analysis and Display of Quality Improvement Data
Run Charts and Control Charts
Failure Modes and Effects Analysis
Putting It All Together: An Example Quality Improvement Project
Dashboards and Scorecards
Additional Quality Improvement Evaluation and Communication Tools
Improvement Intervention Tools
Daily Goals Sheet
Checklists
Briefings and Debriefings
Sources of Quality Improvement Information
Incident Reporting
Published Literature
National Initiatives and Quality Metrics
Outcomes Research
Internal or External Institutional Reviews
Examples of Quality Improvement Programs
Collaborative Programs
Institute for Healthcare Improvement Breakthrough Series Collaboratives
Comprehensive Unit-Based Program
Challenges and Barriers to Quality Improvement Projects
Related concepts: improvement science and implementation science
The Future: Research, Education, and Ethics
Summary
Acknowledgments
References
6 - Avoiding Patient Harm in Anesthesia: Human Performance and Patient Safety
What this Chapter is About:An Overview
Readers Will Learn
WHAT THIS CHAPTER IS NOT ABOUT
Human Performance and Patient Safety in Anesthesia: Why is this Important
Nature of the Anesthesia Professional’s Operational Domain: A Dynamic and Complex Environment
Anesthesiology by its Nature Involves Crises
Criteria defining a complex and dynamic world
Production Pressure Resulting in Asymmetry Between Safety and Production
Nature of the Anesthesia Professional’s Work: Task Variation and Workload Management
Procedural Tasks of Anesthesia Professionals and Related Vulnerabilities
Preoperative Planning
Induction
Maintenance Phase of Anesthesia
Emergence
Pre-Use Checkout of Equipment/Anesthesia Machine Checkout
Cognitive Tasks of Administering Anesthesia AND RELATED VULNERABILITIES
Introduction of the Anesthesia Professional’s Core Cognitive Process Model
Management and Coordination of the Core Cognitive Process: Supervisory Control and Resource Management
Anesthesia Professional’s Workload and Methodologies to Measure It
Assessing the Performance of Anesthesia Professionals
Performance as a function of task density
Performance as a Function of Teaching, Delegation, and Supervision
Performance as a Function of Experience
What are the practical implications of performance assessment in Anesthesia
Benefits and Challenges of Assessing Performance
Benefits of the Scientific Study of Tasks and Performance in Anesthesia
Challenges of the Scientific Study of Tasks and Performance in Anesthesia
Patient Safety on the Individual and Team Level
Human Performance, Human Factors, and NonTechnical Skills
Human Performance and Human Factors
Human Factors and Nontechnical Skills
Human Factors on the Individual Level
Task Management
Situation Awareness
Decision Making
Performance-Shaping Factors on the Individual Level
Distractions and Interruptions in the Operating Room
Sleep Deprivation and Fatigue
Rest Breaks, Strategic Napping at Work, and Use of Caffeine
Aging Anesthesiologists
Illness and Drug Use
Professionals’ Attitudes as a Crucial Part of Human Performance and Patient Safety
Human Factors AT the Team Level
Effective Communication and Delegation of Tasks
Status and Hierarchy: Speaking Up
Teamwork
Leadership
Patient Safety Strategies AT the Individual and Team Level: Crisis Resource Management and Other Training Curricula
Crisis/Crew Resource Management
Other Curricula for Team Training: TeamSTEPPS and Clinical Team Training
Patient Safety on the Organizational Level
Systems Thinking
Human Failure: Human Error and Violations
Active Errors
Evolution and Investigation of Accidents: One Error is not the Cause of an Accident
Evaluation of Errors and Accidents: Hindsight Bias—“I knew it all Along” and Outcome Bias—“No Harm no Foul”
System Error Models: Normal Accident Theory and High Reliability Organization Theory
Safety I and Safety II: Ensuring that as Few Things as Possible go Wrong or that as Many Things as Possible go Right…
Resilience and Uncertainty Management: Safety is a Dynamic State, not all Risks can be Eliminated
Normalization of Deviance and Flirting with the Margin
Achieving High Reliabilty and System Thinking: Fundamental Elements for a Systematic Safety Approach
Culture of Safety
Organizational Learning
Characteristics of Successful Incident Reporting Systems
Continuous Training including simulation
. A pocket card of the 15 CRM key points is shown in Fig. 6.17
Continuous Optimization of Safety-Relevant Structures and Processes
The Bigger Picture: Patient Safety Efforts on the U.S. National and International Level
Patient Safety Milestones and Movements
Institutions Engaging in Patient Safety
Raising the Awareness for Patient Safety
Certified Education in Patient Safety for Health Care Professionals
National and International Evaluation of the Benefits of Patient Safety Programs
Patients for Patient Safety
Conclusion and Outlook
Acknowledgment
References
References
7 - Patient Simulation
What This Chapter Is About: An Overview
Readers will Learn
What this Chapter is not About
Simulation in Anesthesia: Why Is It Important
Application of Simulation in Anesthesia and Health Care
Use of Patient Simulation for Training and Education
Use of Patient Simulation for System Probing and Protocol Testing
Use of Patient Simulation for Testing Equipment and Supplies
Use of Patient Simulation for Performance Assessment
Use of Patient Simulation for Research
Other Uses of Patient Simulation
History, Development, and Types of Simulators and Simulation
Simulation Fidelity and Classification of Simulators
Sites of Simulation
Dedicated Simulation Center
Training and Probing Where Clinicians Work
In Situ Simulation
Peri-situ or Off-site Simulation
Sequential Location Simulation
Mobile Simulation: “Have Simulator, Will Travel”
Simulation Team Training Participants: Who Should Be Trained and in What Composition
Training Individuals
Training Crews: Interprofessional Single-Discipline Team Training
Training Teams: Interprofessional Multidiscipline Team Training
Cross Training: Changing Roles
EN-BLOC Training: Avoiding Sub-Threshold Training Effects
Patient Simulation Timing: Announced in Advance Versus Unannounced in Advance
Scopes of Simulation in Health Care: The 12 Dimensions of Simulation
Crisis Resource Management (ACRM; CRM): Part of Modern Patient Simulation Team Training
The Roots of Anesthesia Crisis Resource Management Training
Anesthesia Crisis Resource Management Curricula
Benefits of Crisis Resource Management-Based Simulation Training
Anatomy of a Patient Simulation Team Training Exercise
Scenario Design and Execution: Knowing the Learning Objectives and Making It Real
Goal Oriented: Establishing Learning Objectives
Cognitive Load Theory: Not too much, not too Little
Constraints and Limitations of Scenario Design Ideas
Scenario Design Templates AND Scenario Templates
Reality Versus Realism
Simulation Realism and Simulation Relevance
in-Scenario Information and Guiding
Debriefing: Heart and Soul of Patient Simulation
Simulators (Devices) Don’t Teach
Instruction Versus Facilitation—A New Way of Teaching
Debriefing Techniques
Use of Recorded Audio-Video Sequences in Debriefings
Excursion: Debriefing Techniques For Discussion of Real Clinical Cases
Excursion: Debriefing Techniques for Morbidity and Mortality Conferences
Debriefing in Different Cultures
Qualification and Certification of Simulation Instructors
Tasks of Simulation Instructors—Learning Objectives for Simulation Instructor Courses
Education, Training, AND Continuous Development of Simulation Instructors
Instructor Education and Training
Continuous Faculty Development
Certification of Simulation Instructors
Accreditation of Simulation Programs, Sites, and Centers
Benefits, Effectiveness, and Ecological Validity of Simulation Training
Benefits
Effectiveness
Ecological Validity of Patient Simulation: Is there Transferability to the Real World
Cost of Patient Simulation and Simulation Centers
Cost of Patient Simulation
Cost of Simulation Centers
Using Simulation for Assessment of Clinical Performance
Benefits Of Simulation-Based Performance Assessment
Pitfalls of Simulation-Based Performance Assessment
Using Simulation for the Evaluation and Testing of Anesthesia Professionals
Simulation Societies and Simulation Journals
The Future of Patient Simulation in Anesthesia
Appendix 7.1 Online Links and Useful Resources
Acknowledgment
References
8 - Ethical Aspects of Anesthesia Care
Clinical Ethics
Informed Consent and Informed Refusal
Competence and Capacity
Disclosure
Legal Implications of Informed Consent
Informed Refusal
Special Issues in Informed Consent and Informed Refusal
The Jehovah’s Witness Patient
The Pediatric Patient and Other Patients With Impaired Competence
Ethical Challenges of Preoperative Testing
Routine Preoperative Testing Protocols
Routine Preoperative Pregnancy and Human Immunodeficiency Virus Testing
Ethics of Anesthesia Involving Pregnant Women
Maternal-Fetal Conflicts
Informed Consent in Laboring Women
The Uncooperative Patient—Coercion and Restraint
Truth Telling—Disclosure of Errors and Apology
Advance Directives and Surrogate Decision Makers
Medical Decisions That May Require a Court Order
Do-Not-Attempt-Resuscitation Orders in the Operating Room
End-of-Life Decision Making
Withdrawal or Withholding of Medical Therapies
Terminal Sedation
Neuromuscular Blocking Drugs
Implantable Cardiac Devices
Physician-Assisted Suicide and Euthanasia
Ethical Issues in Organ Transplantation
Brain Death
Donation after Cardiac Death
Research Ethics
Human Subject Research
Children as Research Subjects
Ethics of Animal Research
Physician Participation in Executions
Moral Integrity—can the Physician be a Conscientious Objector in Medicine
References
SECTION II • Anesthetic Physiology
9 - Consciousness, Memory, and Anesthesia
Introduction
Scientific and Clinical Importance
Consciousness
Definitions
Subcortical Nuclei Regulating Arousal
Brainstem
Hypothalamus
Role of the Thalamus
Cortical-Subcortical Connectivity
Cortical Connectivity and Dynamics
Memory
History and Terminology
Organization and Function of Normal Memory
Multiple Memory Systems
Long-Term Potentiation, Synaptic Tagging, and the Consolidation Model of Memory
Reconsolidation
Phase Synchronization and Coupling
Effects of Anesthetic Drugs on Declarative Memory Function in Humans
Behavioral Studies of Retrograde Memory Effects
Mathematical Modeling of Anesthetic Amnesia
Anesthetic Effects on Attention and Arousal as Modulators of Encoding
Neuroimaging Studies of Cortical Encoding Processes
Neuroimaging Studies of Medial Temporal Lobe Function
Studies of Cortical Event-Related Potentials
Anesthetic Effects on Medial Temporal Lobe Plasticity
Human and Nonhuman Studies of Anesthetic Effects on Fear Memory Systems
The Amygdala-Dependent Fear System
Studies of Anesthetic Effects on Fear Systems in Nonhumans
Studies of Anesthetic Effects on Fear Systems in Humans
Clinical Relevance
Anesthetic Effects on Implicit Memory Function
References
10 -
Sleep Medicine
Physiology
Evolution
Circadian Rhythms
Sleep Stages and Sleep Cycles
Neuroanatomy of Sleep
Sleep-Promoting and Arousal Pathways
How to Assess Sleep
Questionnaires
Actigraphy
Respiratory Polygraphy
Polysomnography
Sleep Laboratory Testing
Out-of-Center Testing
Scoring of Sleep and Sleep Disordered Breathing
Sleep and Breathing
Respiratory Regulation During Sleep
Sleep-Disordered Breathing
Obstructive Sleep Apnea
Central Sleep Apnea
Obesity Hypoventilation Syndrome
Sleep and Anesthesia: Two Unequal Twins Influencing Perioperative Medicine
Clinical Picture of Sleep and Anesthesia
Activation of Sleep-Promoting Pathways During Anesthesia
Perioperative Interactions Between Anesthesia and Sleep
Sleep-Disordered Breathing and Airway Patency During Anesthesia
Perioperative Management in Patients with Sleep-Disordered Breathing
Preoperative Screening
Perioperative Management of Patients with Possible Sleep-Disordered Breathing
Knowledge Gaps and Future Research
Sleep and Sedation in the Intensive Care Unit
Noise and Light Exposure
Medication and Medical Procedures
Sleep and Sedation in the Intensive Care Unit
Pharmacological Treatment of Sleep Disturbances in Intensive Care Unit Patients
Consequences of Sleep Disturbance in ICU Patients
Perioperative Management of Other Sleep Disorders
Narcolepsy
Restless Legs Syndrome and Periodic Limb Movement Disorder
Acknowledgment
References
11 - Cerebral Physiology and the Effects of Anesthetic Drugs
The Anatomy of the Cerebral Circulation
Cerebrospinal Fluid Formation and Circulation
Regulation of Cerebral Blood Flow
Myogenic Regulation (Autoregulation) of Cerebral Blood Flow
Chemical Regulation of Cerebral Blood Flow
Cerebral Metabolic Rate
Neurogenic Regulation of Cerebral Blood Flow
Effects of Blood Viscosity on Cerebral Blood Flow
Cardiac Output
An Integrated Contemporary View of Cerebral Autoregulation
Vasoactive Drugs
Systemic Vasodilators
Catecholamine Agonists and Antagonists
Age
Effects of Anesthetics on Cerebral Blood Flow and Cerebral Metabolic Rate
Intravenous Anesthetic Drugs
Barbiturates
Propofol
Etomidate
Narcotics
Benzodiazepines
Droperidol
Ketamine
Lidocaine
Inhaled Anesthetics
Volatile Anesthetics
Nitrous Oxide
Muscle Relaxants
Nondepolarizing Relaxants
Succinylcholine
Other Effects of Anesthetics on Cerebral Physiology
Cerebrospinal Fluid Dynamics
Blood-Brain Barrier
Epileptogenesis
Volatile Anesthetics
Methohexital
Ketamine
Etomidate
Propofol
Narcotics
Neonatal Anesthetic Neurotoxicity
Cerebral Physiology in Pathologic States
Cerebral Ischemia—Pathophysiologic Considerations
Critical Cerebral Blood Flow Thresholds
Models of Cerebral Ischemia
Energy Failure and Excitotoxicity
The Nature of Neuronal Death
Timing of Neuronal Death
Brain Protection
Considerations Relevant to Complete Global Ischemia (Cardiac Arrest)
Considerations Relevant to Focal (Incomplete) Ischemia
Cerebral Ischemia: Influence of Physiologic Variables
Anchor 1081
Summary of Anesthetics and Neuroprotection
Deferring Elective Procedures After Stroke
Chronic Arterial Hypertension
Intracranial Hypertension
Brain Tumors
Coma and Epilepsy
References
12 - Neuromuscular Physiology and Pharmacology
Neuromuscular Transmission
Morphology
Quantal Theory
Neuromuscular Junction
Formation of Neurotransmitter at Motor Nerve Endings
Nerve Action Potential
Synaptic Vesicles and Recycling
Process of Exocytosis
Acetylcholinesterase
Postjunctional Acetylcholine Receptors
Synthesis and Stabilization of Postjunctional Receptors
Basic Electrophysiology of Neurotransmission
Drug Effects on Postjunctional Receptors
Classic Actions of Nondepolarizing Muscle Relaxants
Classic Actions of Depolarizing Muscle Relaxants
Nonclassic and Noncompetitive Actions of Neuromuscular Drugs
Desensitization Block
Channel Block
Phase II Block
Biology of Prejunctional and Postjunctional Nicotinic Acetylcholine Receptors
Postjunctional Conventional Acetylcholine Receptors in Muscle Versus Neuronal Acetylcholine Receptors in Muscle
Maintenance of Mature Neuromuscular Junctions
Re-Expression of Immature (Fetal) γ-Subunit and α7-Subunit Acetylcholine Receptors in Adult Life
Prejunctional Acetylcholine Receptors
Neuromuscular Junction at Extremes of Age
Newborn
Old Age
References
13 - Respiratory Physiology and Pathophysiology
Respiratory Physiology Is Central to the Practice of Anesthesia
Pulmonary Physiology in Health
Respiration in the Cell
Transport of O2 in the Blood
Transport of Co2 in the Blood
Oxygenation in the Pulmonary Artery
Ventilation
Alveolar Ventilation
Dead Space Ventilation
Static Lung Volumes—Functional Residual Capacity
Respiratory Mechanics
Compliance of the Respiratory System
Resistance of the Respiratory System
Airways
Tissue
Inertia or Acceleration of Gas and Tissue
Distribution of Inspired Gas
Airway Closure
Diffusion of Gas
Perfusion
Distribution of Lung Blood Flow
Distribution of Blood Flow in the Lung: the Effect of Gravity
Distribution of Blood Flow in the Lung: Influence of Factors Not Related to Gravity
Hypoxic Pulmonary Vasoconstriction
Clinical Assessment of Lung Function
Spirometry—Total Lung Capacity and Subdivisions
Diffusing Capacity (DLCO)—Diffusion Across Alveolar-Capillary Membranes
Surface Area
Membrane Thickness
Pressure Gradient
Molecular Weight and Solubility
Intraoperative Respiratory Events
Respiratory Function During Anesthesia
Lung Volume and Respiratory Mechanics During Anesthesia
Lung Volume
Compliance and Resistance of the Respiratory System
Atelectasis and Airway Closure During Anesthesia
Prevention of Atelectasis During Anesthesia
Positive End-Expiratory Pressure
Recruitment Maneuvers
Minimizing Gas Resorption
Maintenance of Muscle Tone
Atelectasis Following Surgery
Airway Closure
Distribution of Ventilation and Blood Flow During Anesthesia
Distribution of Ventilation
Distribution of Lung Blood Flow
Hypoxic Pulmonary Vasoconstriction
Ventilation-Perfusion Matching During Anesthesia
Dead Space, Shunt, and Ventilation-Perfusion Relationships
CO2 Elimination
Oxygenation
Factors that Influence Respiratory Function During Anesthesia
Spontaneous Breathing
Increased Oxygen Fraction
Body Position
Age
Obesity
Preexisting Lung Disease
Regional Anesthesia
Causes of Hypoxemia and Hypercapnia
Hypoventilation
Ventilation-Perfusion Mismatch
Effect of on CO2 Elimination
Impaired Diffusion
Right-to-Left Shunt
Respiratory Function During One-Lung Ventilation
Pneumoperitoneum
Lung Function After Cardiac Surgery
Protective Ventilation
Postoperative Physiotherapy
Intraoperative Hyperoxia
Effect of Sleep on Respiration
References
14 -
Cardiac Physiology
Physiology of the Intact Heart
CARDIAC CYCLE
Electrical Events and the Electrocardiogram
Mechanical Events
Ventricular Structure and Function
Ventricular Structure
Ventricular Function
Cardiac Output
Cellular Cardiac Physiology
Cellular Anatomy
Cardiomyocyte Structure and Function
Excitation System
Excitation-Contraction Coupling
Contractile System
Control of Cardiac Function
Neural Regulation of Cardiac Function
Hormones Affecting Cardiac Function
Sex Steroid Hormones and the Heart
Cardiac Reflexes
Baroreceptor Reflex (Carotid Sinus Reflex)
Chemoreceptor Reflex
Bainbridge Reflex
Bezold-Jarisch Reflex
Valsalva Maneuver
Cushing Reflex
Oculocardiac Reflex
Acknowledgment
References
15 - Gastrointestinal Physiology and Pathophysiology
Introduction
Gastrointestinal Anatomy and Function
Transit Time in Health and Disease
Methods of Evaluating Colonic Motility
The Effects of General Anesthesia on Bowel Function
Effect of Opioids on Bowel Function
Effect of Open Abdominal Surgery, Ischemia, Stomas, and Bowel Anastomosis on Gastrointestinal Physiology and Function
Gastrointestinal System Nociception
Abdominal Viscera Innervation
Celiac Plexus Anatomy
Abdominal Visceral Pain
Visceral Pain Treatment
Visceral Pain Block Techniques
Visceral/Celiac PLEXUS Block
Intraperitoneal Regional Anesthesia or Peritoneal Lavage
Celiac Plexus Block—Posterior and Trans-Crural Approach
Celiac Plexus Block—Anterior Approach
Endoscopic Ultrasound-Guided Celiac Plexus Block
Technical Aspects of Visceral Plexus Blocks
Complications of Visceral Pain Blocks
Indications for a Visceral Pain Block
Post-Laparatomy Pain Relief
Cancer Pain
Effects of Regional Anesthesia on Gastrointestinal Physiology
Effect on Gastrointestinal Motility and Postoperative Ileus
Effect on Enteric Anastomosis Dehiscence
Effect on Nutrition
Effect on Postoperative Nausea and Vomiting
Effect on Gastrointestinal Blood Flow and Volume
Enhanced Recovery After Surgery for Gastrointestinal Procedures— Physiologic Basis
Physiologic Basis of Eras
Perioperative Pain Control
Preoperative Carbohydrate Loading and Early Postoperative Feeding
Temperature Control
Nasogastric Tubes
Bowel Preparation
Drains
Fluid Management
Mobilization and Early Ambulation
Acknowledgment
References
16 - Hepatic Physiology, Pathophysiology, and Anesthetic Considerations
Surgical Anatomy, Hepatic Blood Flow, and the Biliary Tree
Cellular Anatomy
Liver Lobule and Acinus
Hepatocytes
Hepatic Stellate Cells
Myeloid Cells
Lymphocytes
Hepatic Physiology
Drug Metabolism
Protein Metabolism
Carbohydrate Metabolism
Lipid Metabolism
Bile and Enterohepatic Circulation
Role of the Liver in Coagulation
Heme Metabolism, Bilirubin, and Porphyrias
Hepatic Regulation of Hormones
Evaluation of the Liver
Clinical Assessment
Standard Laboratory Tests
Detection of Hepatocellular Injury
Aminotransferases
Lactate Dehydrogenase
Glutathione-S-Transferase
Detection of Cholestatic Disorders
Alkaline Phosphatase
Serum Bilirubin
Assessment of Hepatic Protein Synthesis
Serum Albumin
Prothrombin Time
Testing for Diagnosis of Specific Diseases
Testing in Management and Prognosis of Liver Disease
Noninvasive Serum Testing for Fibrosis
Quantitative Liver Tests
Measurement of Hepatic Blood Flow
Clearance Techniques
Indicator Dilution Techniques
Direct Measurements
Radiologic Methods
Hepatic Pathophysiology
Cholestatic Disease
Primary Biliary Cholangitis
Primary Sclerosing Cholangitis
Cirrhosis
Ascites
Renal Failure and Hepatorenal Syndrome
Hepatic Encephalopathy
Pulmonary Complications
Hepatocellular Carcinoma
Hepatic Effects of Anesthetic Agents
Inhalational Anesthetics
Nonhepatic Surgery in Patients With Liver Disease
Anesthetic Considerations for Procedures Involving the Liver
Strategies for Minimizing Blood Loss
Low Central Venous Pressure
Other Approaches to Reduce Blood Loss
Anesthetic Management
Enhanced Recovery After Surgery and Liver Resection
Acknowledgment
References
17 - Renal Anatomy, Physiology, Pharmacology, and Evaluation of Function
Introduction
Organization of the Kidney
The Nephron
The Renal Tubules
Formation of Urine
Glomerular Filtration
Mediator Control of the Glomerular Filtration Rate
The Dopaminergic System
Adenosine
Nitric Oxide
Renal Tubular System Physiology
The Loop of Henle
Distal Tubules and Macula Densa
Collecting Tubules
Collecting Ducts
Renal Autoregulation
Autoregulation of Renal Blood Flow
The Myogenic Mechanism of the Renal Blood Flow Autoregulation
Tubuloglomerular Feedback
Maintenance of Plasma Osmolality
Definition
Regulation of Osmolality
Role of Proximal Tubules and Loop of Henle
Medullary Interstitium
Vasa Recta
The Role of Urea
Renal Control of Intravascular Volume
Hypovolemia
Hypervolemia
Clinical Tests for Renal Function46,47
Urine Output
Creatinine
Blood Urea Nitrogen
Renal Clearance Techniques
Measurement of Tubular Function
Effect of Anesthetics on Renal Function
Effects of Mechanical Ventilation on Renal Function
Induced Hypotension
Acknowledgment
References
18 - Basic Principles of Pharmacology
Introduction
Fundamental Pharmacokinetic Concepts
Volume of Distribution
Clearance
Physiologic Model for Clearance
Hepatic Biotransformation
Pharmacokinetic Models
Physiologic Models
Compartmental Models
Zero Versus First-Order Kinetics
One-Compartment Model
Multicompartment Models
Special Interests in Anesthetic Pharmacokinetics
Front-End Kinetics
Back-End Kinetics
Hysteresis
Pharmacodynamic Principles
Potency and Efficacy
Effective Versus Lethal Doses
Anesthetic Drug Interactions
Drug Displays
Special Populations
Influence of Obesity on Anesthetic Drugs
Propofol
Opioids
Remifentanil
Dosing Scalars
Remifentanil Kinetic Models for Target-Controlled Infusions
Fentanyl
Other Opioids
Inhaled Anesthetics
Influence of Age on Anesthetic Drug Pharmacology
Summary
References
19 - Inhaled Anesthetics: Mechanisms of Action
History
The Unified Paradigm of Anesthetic Theories
Minimum Alveolar Concentration―A Bridge Between Past and Present
Shift From Lipid- to Protein-Centered Mechanisms
Diversity of Potential Anesthetic Targets
Anesthesia: A Composite Neuropharmacologic State
Integrated Effects on Central Nervous System Function
Immobility
Unconsciousness
Learning and Memory
Sedation
Identification of Molecular Sites of Anesthetic Action
Criteria for Identifying Sites Relevant to Anesthesia
Physicochemical Properties of Anesthetic Binding Sites
From Model Proteins to Receptors
Molecular Targets of Inhaled Anesthetics
Ligand-Gated ION Channels
Potentiation of Inhibitory GABAA and Glycine Receptors
Inhibition of Excitatory Acetylcholine and Glutamate Receptors
Voltage-Gated and other ION Channels
Na+ Channels
Ca2+ Channels
K+, HCN, and TRP Channels
Intracellular Signaling Mechanisms
G-Protein–Coupled Receptors
Protein Phosphorylation
Gene Expression
Cellular Mechanisms
Neuronal Excitability
Presynaptic Versus Postsynaptic Effects on Synaptic Transmission
Simple Circuits and Complex Networks
Simple Circuit Phenomena
Synaptic Plasticity
Spontaneously Active Circuits
Rhythms and Simulations
δ-Rhythms and Other Slow Rhythms
θ-Rhythms
γ-Rhythms
Models and Simulations
Research Strategies for the Future
Pharmacologic Approaches
Agonists, Antagonists, and Experimental Anesthetics
Nonimmobilizers
Photoreactive Anesthetics
Genetic Approaches
Whole-Organism Genetics
Molecular Genetics
Knockout and Knockin Animals
Forward and Population Genetics
Functional Imaging and High-Density Electroencephalography
Summary
References
20 - Inhaled Anesthetic Uptake, Distribution, Metabolism, and Toxicity
Introduction
Uptake and Distribution of Inhaled Anesthetics
Biophysical Properties of Inhaled Anesthetics: Partial Pressure, Hydrophobicity, and Partition Coefficients
Anesthetic Delivery, Uptake, and Distribution: a Multicompartmental Model
Upstream and Downstream Compartments and Anesthetic Transfer: Bulk Flow and Pressure Gradients
Rate of Wash-In of the Circuit: Equilibration Between Vaporizer and Circuit
Equilibration Between Circuit and Pulmonary Airspace
The Alveolar Anesthetic Concentration
Alveolar Uptake of Anesthetic into Pulmonary Blood
Other Factors That Affect the Rate of Rise of Palv
Distribution of Anesthetic into Tissues
The Mixed Venous Anesthetic Partial Pressure
Synthesis of the Model and Inhaled Anesthetic Induction: PK/PD
Pharmacodynamic Effects of Anesthetics on Uptake and Distribution
The Effect of Nitrous Oxide on Gas-Filled Spaces
Recovery from Anesthesia
Similarities and Differences to Induction
Context Sensitive Recovery from Anesthesia
Percutaneous and Visceral Anesthetic Loss
Effect of the Anesthetic Circuit
Clearance via Metabolism of Anesthetics
Additional Considerations and Possibilities
Diffusion Hypoxia
Metabolism and Toxicity of Inhaled Anesthetics
Biotransformation of Inhaled Anesthetics
Biotransformation in the Liver
Halothane Hepatotoxicity
Biotransformation in Kidneys
Fluoride-Associated Nephrotoxicity
Anesthetic Degradation in Carbon Dioxide Absorbents
Sevoflurane, Compound A, and Renal Toxicity
Carbon Monoxide and Heat
Nitrous Oxide, Vitamin B12, and Homocysteine
Anchor 818
Inhaled Anesthetics and Neurotoxicity
Inhaled Anesthetics and Environmental Effects
Global Warming Effects
Ozone Depletion
Exposure to Waste Anesthetic Gases
Xenon and Other Noble Gases
References
21 - Pulmonary Pharmacology and Inhaled Anesthetics
Introduction
Inhaled Anesthetics
Asthma and Bronchospasm Overview
Physiology of Bronchial Smooth Muscle
Role of Calcium
Histamine
Adrenergic Receptors
Effects of Inhaled Anesthetics
Effects of Inhaled Anesthetics on Bronchomotor Tone in Humans and the Work of Breathing
Mechanisms of Action of Volatile Anesthetics
Mucociliary Function and Surfactant
Normal Mucociliary Function
Effects of Inhaled Anesthetics on Mucociliary Function
Effects of Inhaled Anesthetics on Surfactant
Pulmonary Vascular Resistance
Regulation of Pulmonary Vascular Tone
Mechanisms of Hypoxic Pulmonary Vasoconstriction
Inhaled Anesthetics and Hypoxic Pulmonary Vasoconstriction
Effects of Volatile Anesthetics on Pulmonary Vasculature in Humans
Control of Respiration
Components of the Respiratory Regulatory System
Central Chemoreception
Central Pattern Generator
Integration of Peripheral Inputs
Respiratory Motor Output and Upper Airway Patency
Effects of Inhaled Anesthetics on Resting Ventilation
Effects of Inhaled Anesthetics on Chemoreflexes
Effects of Inhaled Anesthetics on the Hypercapnic Ventilatory Response
Effects of Volatile Anesthetic on the Hypoxic Ventilatory Response In Humans
Effects of Inhaled Anesthetics on Respiratory Muscle Activity
Effects of Inhaled Anesthetics on the Upper Airway
Effects of Inhaled Anesthetics on Defensive Airway Reflexes
Inhaled Anesthetics and Acute Lung Injury
Pathophysiology of Sepsis-Induced Acute Lung Injury
Effects of Inhaled Anesthetics on Experimental Sepsis-Induced Acute Lung Injury
Inhaled Anesthetics and Ventilator-Induced Lung Injury
Inhaled Anesthetics and Lung Ischemia-Reperfusion
Clinical Evidence
Nonvolatile Inhaled Agents
Nitrous Oxide
Sedative and Analgesic Effects
Gas Volume Expansion
Nausea And Vomiting
Pulmonary Hypertension
Potential Neurotoxicity of Nitrous Oxide
Xenon
Speed of Emergence and Postoperative Cognitive Dysfunction with Xenon
Intraoperative Hemodynamics and Postoperative Outcome
Use of Xenon in Critical Care
Postoperative Nausea and Vomiting
Airway Resistance
Apnea
Comparison of Nitrous Oxide and Xenon
Summary
Acknowledgment
References
22 - Inhaled Anesthetics: Delivery Systems
Functional Anatomy of the Anesthesia Workstation
Gas Supply System
High-Pressure Section
Intermediate-Pressure Section
Low-Pressure Section
Vaporizer Mount and Interlock System
Anesthetic Vaporizers
Physics
Modern Vaporizer Types
Anesthetic Breathing Circuits
Circle Breathing Systems
Mechanical Components of the Circle Breathing System
Sensors
Potential Circle System Problems
Carbon Dioxide Absorbers
Interactions of Inhaled Anesthetics With Absorbents
Mapleson Breathing Systems
Bain Circuit
Self-Inflating Manual Resuscitators
Anesthesia Ventilators
Classification
Pneumatically Driven Bellows Ventilator
Mechanically Driven Piston Ventilator
Maquet FLOW-i Anesthesia System With Volume Reflector
Dräger Anesthesia Systems With Turbine Ventilators
Target-Controlled Inhalational Anesthesia
Fresh Gas Flow Compensation and Fresh Gas Decoupling
Scavenging Systems
Classifications and Components
Hazards
Checking Your Anesthesia Workstation
2008 Recommendations for Pre-Anesthesia Checkout Procedures
Item 1: Verify Auxiliary Oxygen Cylinder and Self-Inflating Manual Ventilation Device Are Available and Functioning
Item 2: Verify Patient Suction Is Adequate to Clear the Airway
Item 3: Turn on Anesthesia Delivery System and Confirm That AC Power Is Available
Item 4: Verify Availability of Required Monitors and Check Alarms
Item 5: Verify That Pressure Is Adequate on the Spare Oxygen Cylinder Mounted on the Anesthesia Machine
Item 6: Verify That Piped Gas Pressures Are 50 psig or Higher
Item 7: Verify That Vaporizers Are Adequately Filled and, If Applicable, That the Filler Ports Are Tightly Closed
Item 8: Verify That No Leaks Are Present in the Gas Supply Lines Between the Flowmeters and the Common Gas Outlet
Item 9: Test Scavenging System Function
Item 10: Calibrate, or Verify Calibration of, the Oxygen Monitor and Check the Low Oxygen Alarm
Item 11: Verify Carbon Dioxide Absorbent Is Not Exhausted
Item 12: Breathing System Pressure and Leak Testing
Item 13: Verify That Gas Flows Properly Through the Breathing Circuit During Both Inspiration and Exhalation
Item 14: Document Completion of Checkout Procedures
Item 15: Confirm Ventilator Settings and Evaluate Readiness to Deliver Anesthesia Care (Anesthesia Time Out)
Additional Comments Pertaining to the ASA’s Pre-Anesthesia Checkout Procedure Recommendations (2008)
Automated Anesthesia Machine Checkout Procedures
Machine-Embedded Preanesthesia Machine Checkout Checklists
Developing a Local Preanesthesia Machine Checkout Checklist
Acknowledgment
References
References
23 - Intravenous Anesthetics
Propofol
History
Physicochemical Characteristics
Pharmacokinetics
Pharmacodynamics
Effects on the Central Nervous System
Effects on the Respiratory System
Effects on the Cardiovascular System
Other Effects
Uses
Induction and Maintenance of Anesthesia
Sedation
Side Effects and Contraindications
Barbiturates
History
Physicochemical Characteristics
Chemistry and Formulation
Structure-Activity Relationships
Pharmacokinetics
Metabolism
Pharmacology
Mechanism of Action
Effects on Cerebral Metabolism (Also see Chapter 57)
Pharmacodynamics
Effects on the Central Nervous System
Effects on the Respiratory System
Effects on the Cardiovascular System
Other Effects
Uses
Induction and Maintanance of Anesthesia
Dosing
Contraindications
Benzodiazepines
Introduction
Physicochemical Characteristics
Pharmacokinetics
Remimazolam (CNS 7056)
Pharmacodynamics
Effects on the Central Nervous System
Effects on the Respiratory System
Effects on the Cardiovascular System
Drug Interactions
Pharmacokinetic Drug Interactions
Pharmacodynamic Drug Interaction
Uses
Premedication
Sedation
Induction and Maintenance of Anesthesia
Nausea and Vomiting Prophylaxis
Side Effects and Contraindications
Flumazenil
Physicochemical Characteristics
Pharmacokinetics
Pharmacodynamics
Uses and Doses
Side Effects and Contraindications
Phencyclidines (Ketamine)
History
Physicochemical Characteristics
Pharmacokinetics
Pharmacodynamics
Effects on the Central Nervous System
Effects on the Respiratory System
Effects on the Cardiovascular System
Uses
Induction and Maintenance of Anesthesia
Pain Management
Sedation
Doses and Routes of Administration
Side Effects and Contraindications
Etomidate
History
Physicochemical Characteristics
Pharmacokinetics
Pharmacodynamics
Effects on the Central Nervous System
Effects on the Respiratory System
Effects on the Cardiovascular System
Endocrine Effects
Uses
Induction of Anesthesia
Treatment in Hypercortisolemia
Side Effects
Novel Etomidate Derivatives
Dexmedetomidine
History
Physicochemical Characteristics
Metabolism and Pharmacokinetics
Pharmacology
Effects on the Central Nervous System
Sedation
Analgesia
Central Nervous System Protection and Other Central Nervous System Effects
Effects on the Respiratory System
Effects on the Cardiovascular System
USES
Intensive Care Unit
Droperidol
History
Pharmacokinetics
Pharmacodynamics
Effects on the Central Nervous System
Effects on the Respiratory System
Effects on the Cardiovascular System
Uses
Summary
Acknowledgment
References
References
24 -
Opioids
Introduction
Pharmacology of Opioids
CLASSIFICATION OF OPIOID COMPOUNDS
BASIC STUDIES ON OPIOID RECEPTORS
Genetic Variations Which Influence Opioid Effects
Endogenous Opioid Peptides
Intracellular Signal Transduction Mechanism of Opioid Receptors
Biased Agonism
Mechanism of Opioid Analgesia
Brain
Spinal Cord
Peripheral Mechanism
Acupuncture
Mechanism of Mood Alterations and Rewarding Properties
Analysis of Knockout Mice
Actions of Opioids on Targets Other than Opioid Receptors
Physiologic Role of Nociceptin/Orphanin FQ
Neurophysiologic Effects of Opioids
Characteristics of The Analgesic Action of Opioids
Effects of Opioids on Consciousness
Hallucination
Electroencephalography
Evoked Responses
Cerebral Blood Flow and Cerebral Metabolic Rate
Intracranial Pressure
Neuroprotection
Muscle Rigidity
Neuroexcitatory Phenomena
Pupil Size
Thermoregulation and Shivering
Pruritus
Opioid-Induced Hyperalgesia
Respiratory Effects of Opioids
Effects on Airways
Respiratory Depression
Factors Affecting Opioid-Induced Respiratory Depression
Cardiovascular Effects of Opioids
Neurologic Mechanisms
Cardiac Mechanisms
Contractility
Cardiac Rhythm Conduction
Myocardial Ischemia
Coronary Circulation
Circulatory Reflexes
Histamine Release
Vascular Mechanisms
Opioids in Shock
Endocrinologic Effects of Opioids
Stress Reduction and Outcome
Opioid Tolerance
Management of Opioid-Dependent Patients
Renal and Urodynamic Effects of Opioids
Effects of Opioids on Digestive Organs
Effects on Gastrointestinal Tract
Biliary and Hepatic Effects
Nausea and Vomiting
Other Opioid Effects
Obstetrics
Anaphylactoid Reactions
Ocular Effects
Immune Effects
Cancer Progression
Wound Healing
Pharmacokinetics and Pharmacodynamics of Opioids
Physicochemical Properties
Pharmacokinetic Features of Individual Drugs
Morphine
Fentanyl
Alfentanil
Sufentanil
Remifentanil
Surrogate Measures of Opioid Potency
Factors Affecting Pharmacokinetics and Pharmacodynamics of Opioids
Age
Body Weight
Renal Failure
Hepatic Failure
Cardiopulmonary Bypass
Acid-Base Changes
Hemorrhagic Shock
Genetic Variations in Opioid Metabolism
Anesthetic Techniques Using Opioids
Analgesia
Sedation
Balanced Anesthesia
Fentanyl
Alfentanil
Sufentanil
Remifentanil
Total Intravenous Anesthesia
Opioid-Based (High-Dose Opioid) Anesthesia for Cardiac Surgery
Fentanyl
Sufentanil
Remifentanil
Other Applications of Opioids
Transdermal Therapeutic System
Iontophoresis
Transmucosal Drug Delivery
Oral Controlled-Release Medications
Extended-Release Epidural Morphine (DepoDur)
Other Opioid Agonists
Codeine
Oxycodone
Meperidine (Pethidine)
Hydromorphone
Levorphanol
Methadone
Oxymorphone
Piritramide
Tramadol
Morphine-6-Glucuronide
Agonist-Antagonist Opioid Compounds
Pentazocine
Butorphanol
Buprenorphine
Nalbuphine
Dezocine
Meptazinol
Opioid Antagonists
Naloxone
Reversal of Respiratory Depression by Naloxone
Other Applications of Naloxone
Naltrexone
Nalmefene
Methylnaltrexone
Naloxegol
Drug Interactions With Opioids
General Principles
Sedative-Hypnotics
Benzodiazepines
Barbiturates
Propofol
Etomidate
Ketamine
Inhaled Anesthetics
Muscle Relaxants
Monoamine Oxidase Inhibitors
Calcium Channel Blockers
Magnesium
Nonsteroidal Antiinflammatory Drugs
Acetaminophen
Gabapentinoids
Antidepressants
Diphenhydramine
Local Anesthetics
References
25 -
Nonopioid Pain Medications
Introduction
Calcium Channel Blockers
Gabapentin
Pregabalin
Zonisamide
Ziconotide
Levetiracetam
Sodium Channel Blockers
Lidocaine
Mexiletine
Carbamazepine
Oxcarbazepine
Lamotrigine
Topiramate
References
26 - Intravenous Drug Delivery Systems
Introduction
Pharmacodynamic Considerations
The Biophase
Direct-Effect Models
Indirect-Effect Models
Dose Implications of the Biophase
Drug Potency
Single Drugs
Pharmacodynamic Drug Interactions
Designing Dosing Regimens
Bolus Dose Calculations
Maintenance Infusion Rates
Recovery From Anesthesia
Displaying Pharmacologic Information
Intravenous Infusion Devices and Technologies
Manual Intravenous Infusion
Computer-Controlled Drug Delivery
Target-Controlled Infusion
Devices
Evaluation of Target-Controlled Infusion Delivery
Model Selection for Target-Controlled Infusion: Adult Propofol Models
Model Selection for Target-Controlled Infusion: Pediatric Propofol Models
Model Selection for Target-Controlled Infusion: Opioids
Rational Target Concentration Selection
Benefits of Target-Controlled Infusion
Plasma Versus Effect-Site Targeting
Safety of Target-Controlled Infusion
Patient-Controlled Analgesia and Sedation
Closed-Loop Controlled Intravenous Drug Delivery
Future Perspectives
References
27 - Pharmacology of Neuromuscular Blocking Drugs
History and Clinical Use
Principles of Action of Neuromuscular Blocking Drugs at the Neuromuscular Junction
Postjunctional Effects
Prejunctional Effects
Pharmacology of Succinylcholine
Structure-Activity Relationships
Pharmacokinetics and Pharmacodynamics
Butyrylcholinesterase Activity
Dibucaine Number and Atypical Butyrylcholinesterase Activity
Side Effects
Cardiovascular Effects
Hyperkalemia
Increased Intraocular Pressure
Increased Intragastric Pressure
Increased Intracranial Pressure
Myalgia
Masseter Muscle Rigidity
Anaphylaxis
Clinical Uses
Interactions With Anticholinesterases
Nondepolarizing Neuromuscular Blocking Drugs
Structure-Activity Relationships
Benzylisoquinolinium Compounds
Steroidal Neuromuscular Blockers
Asymmetric Mixed-Onium Fumarates and Analogues
Potency of Nondepolarizing Neuromuscular Blocking Drugs
Onset
Duration of Action
Clinical Management
Varying Sensitivities of Different Muscle Groups
Dosage
General Dosage Guidelines
Initial and Maintenance Dosage
Neuromuscular Blocking Drugs and Tracheal Intubation
Rapid Tracheal Intubation
Metabolism and Elimination
Steroidal Compounds
Benzylisoquinolinium Compounds
Asymmetric Mixed-Onium Fumarates
Adverse Effects of Neuromuscular Blocking Drugs
Autonomic Effects
Drug Interactions and Other Factors Affecting Response to Neuromuscular Blockers
Interactions Among Nondepolarizing Neuromuscular Blocking Drugs
Interactions Between Succinylcholine and Nondepolarizing Neuromuscular Blocking Drugs
Interactions With Inhaled Anesthetics
Interactions With Antibiotics
Temperature
Interactions With Magnesium and Calcium
Interactions With Lithium
Interactions With Local Anesthetic and Antidysrhythmic Drugs
Interactions With Antiepileptic Drugs
Interactions With Diuretics
Interactions With Other Drugs
Special Populations
Pediatric Patients
Older Patients
Obese Patients
Severe Renal Disease
Hepatobiliary Disease
Burns
Use of Neuromuscular Blocking Drugs and Weakness Syndromes in Critically Ill Patients
Critical Illness Myopathy
Critical Illness Polyneuropathy
Clinical Implications
Should Succinylcholine Be Used in Patients in the Intensive Care Unit
Should Nondepolarizing Neuromuscular Blocking Drugs Be Used in Patients in the Intensive Care Unit
Acknowledgment
References
References
28 - Reversal (Antagonism) of Neuromuscular Blockade
History
Antagonism of Neuromuscular Blockade: Current Management Practices
Residual Neuromuscular Blockade
Assessment of Residual Neuromuscular Blockade
Definitions of Residual Neuromuscular Blockade
Incidence of Residual Neuromuscular Blockade
Adverse Effects of Residual Blockade
Drugs Used to Antagonize (Reverse) Neuromuscular Blockade
Anticholinesterase Reversal of Neuromuscular Blockade
Mechanism of Action of Anticholinesterases
Pharmacokinetic and Pharmacodynamic Properties of Anticholinesterases
Factors Determining the Adequacy of Recovery Following Administration of Anticholinesterases
Complications Associated With Inhibitors of Acetylcholinesterase
Sugammadex Reversal of Neuromuscular Blockade
Structure-Activity Relationships and Mechanism of Action
Pharmacokinetics
Pharmacodynamics
Clinical Use of Sugammadex in Healthy Patients
Clinical Use of Sugammadex in Pediatric and Older Adult Patients
Clinical Use of Sugammadex in Special Patient Populations
Side Effects and Drug Interactions
Special Considerations
Cysteine Reversal of Fumarate Neuromuscular Blocking Drugs
References
29 - Local Anesthetics
Basic Pharmacology
Chemistry
The Local Anesthetic Molecule
Structure-Activity Relationships and Physicochemical Properties
Lipophilic-Hydrophilic Balance
Hydrogen Ion Concentration
Anatomy of the Peripheral Nerve
Structure of the Axonal Membrane
Physiology of Nerve Conduction
Mechanism of Action of Local Anesthetics (Pharmacodynamics)
Active Form
Electrophysiologic Effect of Local Anesthetics
The Nature of the Local Anesthetic
Binding Site
Neurophysiologic Aspects of Phasic Inhibition
Selective Block of Na+ Channel Isoforms
Sodium Channel Isoforms and Their Contribution to Human Diseases Characterized by Pain or Pain Insensitivity
Summary of Local Anesthetic Mechanisms
Clinical Pharmacology
General Considerations
Anesthetic Potency
Onset of Action
Duration of Action
Differential Sensory and Motor Blockade
Factors Influencing Anesthetic Activity in Humans
Dosage of Local Anesthetic
Addition of Additives
Site of Injection
Carbonation and pH Adjustment of Local Anesthetics
Mixtures of Local Anesthetics
Pregnancy
Choice of Local Anesthetic for Various Regional Anesthetic Procedures
Infiltration Anesthesia
Intravenous Regional Anesthesia
Peripheral and Truncal Nerve Blockade
Perineural and Plexus Infusions
Central Neural Blockade
Topical Anesthesia
Tumescent Anesthesia
Systemic Local Anesthetics for Postoperative Pain and Neuropathic Pain
Pharmacokinetics
Absorption
Distribution
Biotransformation and Excretion
Pharmacokinetic Alterations by Patient Status
Toxicity
Systemic Toxicity
Central Nervous System Toxicity
Cardiovascular System Toxicity
Comparative Cardiovascular Toxicity
Chiral Local Anesthetics: Ropivacaine and Levobupivacaine
Acidosis and Hypoxia
Indirect Cardiovascular Effects
Methemoglobinemia
Allergies
Local Tissue Toxicity
Development of Prolonged-Duration and Sensory- or Nociceptive-Selective Local Anesthetics
Slow-Release Formulations
Site 1 Blockers
Targeting of Specific Sodium Channel Isoforms
Targeting of Nociceptive Fibers
Biologic Mechanisms of Local Anesthetic Failure: Inflammation, Hyperalgesia, Tachyphylaxis, and Genetic Variants
Conclusions
Acknowledgment
References
SECTION III • Anesthesia Management
30 -
Risk of Anesthesia
Introduction
Framework of Perioperative Risk
Issues Related to Study Design
Types of Studies
Problems Inherent in Studying Anesthesia-Related Risk
Studies of Anesthesia-Related Mortality
Analysis of Intraoperative Cardiac Arrest
Perioperative Mortality and Morbidity in Outpatient Surgery
Use of Anesthesia Information Management Systems
Other Approaches to Discern the Root Cause of Morbidity and Mortality
Issues Associated with Anesthesia-Related Mortality
Risks Related to Patient Characteristics
Special Patient Groups
Obstetrics
Pediatrics
Older Adults
Risks Directly Related to the Anesthetic Drug
Risks Related to Surgery
Risks Related to the Location of Surgery and Postoperative Monitoring
Risks Related to the Anesthesia Provider
Improving Anesthesia Safety
Summary
References
31 - Preoperative Evaluation
Evolution of Preanesthesia Evaluation
Preoperative Evaluation
Goals and Benefits of Preanesthesia Evaluation
Clinical Examination During Preoperative Evaluation
Components of The Medical History
Assessment of Functional Capacity
Physical Examination
Frailty, Geriatric Conditions, and the Older Surgical Patient
Geriatric-Focused Assessment in the Older Surgical Patient
Function and Mobility
Cognition
Nutrition
Frailty
Additional Considerations
Preoperative Optimization for Frail Geriatric Patients (Table 31.4)
Decision Making for Surgery in Older Adults
Preoperative Evaluation of Patients With Coexisting Disease
Cardiovascular Disease
Hypertension
Ischemic Heart Disease
Coronary Stents
Heart Failure
Murmurs and Valvular Abnormalities
Infective Endocarditis Prophylaxis
Rhythm Disturbances on the Preoperative Electrocardiogram
Cardiovascular Implantable Electronic Devices
Peripheral Artery Disease
Pulmonary Disorders
Asthma
Chronic Obstructive Pulmonary Disease
Restrictive Pulmonary Disorders
Patients Scheduled for Lung Resection
Obstructive Sleep Apnea
Pulmonary Hypertension
Smokers and Second-Hand Smoke Exposure
Upper Respiratory Tract Infections
Cystic Fibrosis
Postoperative Pulmonary Complications
Endocrine Disorders
Diabetes Mellitus
Thyroid Disease
Parathyroid Disease
Hypothalamic-Pituitary-Adrenal Disorders
Multiple Endocrine Neoplasia Syndromes
Pheochromocytoma
Kidney Disease
Contrast-Induced Nephropathy
Hepatic Disorders
Hepatitis
Obstructive Jaundice
Miscellaneous Liver Diseases
Unexpected Elevated Liver Function Tests
Cirrhosis
Hematologic Disorders
Anemia
Sickle Cell Disease
Glucose-6-Phosphate Dehydrogenase Deficiency
Coagulopathies
Neurologic Disease
Cerebrovascular Disease
Asymptomatic Carotid Bruit
Seizure Disorder
Multiple Sclerosis
Aneurysms and Arteriovenous Malformations
Parkinson Disease
Neuromuscular Junction Disorders
Muscular Dystrophies and Myopathies
Central Nervous System Tumors
Musculoskeletal and Connective Tissue Diseases
Rheumatoid Arthritis
Ankylosing Spondylitis
Systemic Lupus Erythematosus
Systemic Sclerosis
Raynaud Phenomenon
Inherited Connective Tissue Disorders
Kyphoscoliosis
Cancers and Tumors in Preoperative Patients
Patients With Cancer
Mediastinal Masses
Von Hippel–Lindau disease
Carcinoid Tumors
Special Issues in Preoperative Evaluation
Pseudocholinesterase Deficiency
Malignant Hyperthermia
Morbidly Obese Patients
Patients with Transplanted Organs
Patients with Allergies
Human Immunodeficiency Virus Infection
Patients With A History of Substance Abuse
Breastfeeding Patients
Patients With do Not Resuscitate Orders
Preoperative Laboratory and Diagnostic Studies
Complete Blood Count, Hemoglobin, and Hematocrit
Renal Function Testing
Liver Function Testing
Coagulation Testing
Urinalysis
Pregnancy Test
Sickle Cell Test
Electrocardiogram
Chest Radiograph
Preoperative Risk Assessment
Role of Specialized Testing in Preoperative Risk Assessment
Preoperative Medication Management
Planning for Anesthesia
Preoperative Fasting Status
Planning for Postoperative Pain Management
Regulatory Issues
Preoperative Evaluation Clinic
Collaboration, Commitment, and Teamwork
Role of the Medical Consultant in Preoperative Evaluation
Structures and Activities of the Preoperative Evaluation Clinic
Impact on Operating Room Efficiency and Outcomes
Patient Satisfaction with Preoperative Evaluation Clinics
Conclusion
Acknowledgment
References
32 - Anesthetic Implications of Concurrent Diseases
Role of the Primary Care Physician or Consultant
Diseases Involving the Endocrine System and Disorders of Nutrition
Pancreatic Disorders
Preoperative and Preprocedure Diabetes Mellitus
Glucotoxicity
Diabetes and Accelerated Physiologic Aging
Other Conditions Associated With Diabetes
Emergency Surgery
Anticipated Newer Treatments of Diabetes
Insulinoma and Other Causes of Hypoglycemia
Disorders of Nutrition, Including Obesity
Hyperlipoproteinemia, Hyperlipidemia, and Hypolipidemia
Obesity
Other Eating Disorders: Anorexia Nervosa, Bulimia, and Starvation
Hyperalimentation (Total Parenteral or Enteral Nutrition)
Adrenocortical Malfunction
Physiologic Properties of Adrenocortical Hormones
Adrenocortical Hormone Excess
Adrenocortical Hormone Deficiency
Patients Taking Steroids for Other Reasons
Adrenal Cortex Function in Older Adults
Adrenal Medullary Sympathetic Hormone Excess: Pheochromocytoma
Hypofunction or Aberration in Function of the Sympathetic Nervous System (Dysautonomia)
Thyroid Dysfunction
Hyperthyroidism
Thyroid Storm
Hypothyroidism
Thyroid Nodules and Carcinoma
Disorders of Calcium Metabolism
Hyperparathyroidism and Hypercalcemia
Hypocalcemia
Osteoporosis
Pituitary Abnormalities
Anterior Pituitary Hypersecretion
Anterior Pituitary Hypofunction
Posterior Pituitary Hormone Excess and Deficiency
Diseases Involving the Cardiovascular System
Hypertension
Preoperative Administration of All Antihypertensive Drugs
Ischemic Heart Disease
Role of Coronary Artery Bypass Graft or Percutaneous Coronary Interventions Before Noncardiac Surgical Procedures
Perioperative Risk Factors for Cardiac Morbidity and Mortality
Preoperative and Preprocedure Therapy
Valvular Heart Disease
Preoperative Antibiotic Prophylaxis for Endocarditis
Cardiac Valve Prostheses and Anticoagulant Therapy and Prophylaxis for Deep Vein Thrombosis
Cardiac Conduction Disturbances: Cardiac Arrhythmias
Disorders of the Respiratory and Immune Systems
General Preoperative and Preprocedure Considerations
Specific Diseases
Pulmonary Vascular Diseases
Infectious Diseases of the Lung
Chronic Diseases of the Lung
Anaphylaxis, Anaphylactoid Responses, and Allergic Disorders Other than Those Related to Lung Diseases and Asthma
Primary Immunodeficiency Diseases
Diseases of the Central Nervous System, Neuromuscular Diseases, and Psychiatric Disorders
COMA
Epileptic Seizures
Back Pain, Neck Pain, and Spinal Canal Syndromes
Demyelinating Diseases
Metabolic Diseases
Neuromuscular Disorders
Down Syndrome
Preoperative Prediction of Increased Intracranial Pressure During Neurosurgery
Mental Disorders
Renal Disease and Electrolyte Disorders
Renal Disease
Causes and Systemic Effects of Renal Disorders
Patients With Insufficient but Functioning Kidneys
Patients Undergoing Dialysis
Drugs in Patients With Renal Failure
Infectious Disease
Electrolyte Disorders
Hyponatremia and Hypernatremia
Hypokalemia and Hyperkalemia
Gastrointestinal and Liver Diseases
Gastrointestinal Disease
Preoperative Search for Diverse Associated Disorders in Gastrointestinal Disease
Ulcerative Colitis and Carcinoid Tumors as Examples of Gastrointestinal Disease Affecting Other Systems
Liver Disease
Hematologic Disorders and Oncologic Disease
Hematologic Disorders
Sickle Cell Anemia and Related Hemoglobinopathies
Cytoskeletal Anemias (Hereditary Spherocytosis and Elliptocytosis), Enzyme-Deficient Anemias, and Autoimmune Hemolytic Anemias
Granulocytopenia
Platelet Disorders
Hemophilia and Related Clotting Disorders
Oncologic Disease
Patients Given Drug Therapy for Chronic and Acute Medical Conditions
Antihypertensive Drugs
Mood-Altering Drugs
Antiarrhythmic Drugs
Antibiotics
Medications for Glaucoma
References
33 - Anesthetic Implications of Complementary and Alternative Therapies
Herbal Medicines
Preoperative Assessment and Management
Echinacea
Ephedra
Garlic
Ginger
Ginkgo
Ginseng
Green Tea
Kava
Saw Palmetto
St. John’s wort
Valerian
Other Herbal Medicines
Common Dietary Supplements
Coenzyme Q10
Glucosamine and Chondroitin Sulfate
Fish Oil
Prebiotics and Probiotics
Other Dietary Supplements
Summary
Acupuncture
Mechanism and General Practice
Acupuncture for Postoperative Nausea and Vomiting
Deep Breathing
Music Therapy
Conclusion
Acknowledgment
References
34 - Patient Positioning and Associated Risks
Physiologic Considerations of Positioning
General Positioning Considerations
Specific Positions
Supine
Variations of the Supine Position
Complications of the Supine Position
Lithotomy
Lateral Decubitus
Prone
Sitting
Robotic Surgery
Peripheral Nerve Injury
Ulnar Nerve Injury
Brachial Plexus Injury
Other Upper Extremity Nerve Injury
Lower Extremity Nerve Injury
Evaluation and Treatment of Perioperative Neuropathies
Pressure Injuries
Bite Injuries
Anesthesia Outside the Operating Room
Perioperative Visual Loss
Retinal Ischemia: Branch and Central Retinal Artery Occlusion
Clinical Findings
Mechanisms of Retinal Ischemia
Central Retinal Artery Occlusion
Cardiac Surgery and Retinal Arterial Occlusion
Branch Retinal Artery Occlusion
Considerations in Head and Neck Surgery
Prognosis, Treatment, and Prevention
Ischemic Optic Neuropathy
Mechanisms
Blood Supply to the Optic Nerve
Control of Blood Flow
Histopathologic Findings
Patient Characteristics in Perioperative Ischemic Optic Neuropathy
Retrospective Case Series
Spine Surgery
Cardiac Surgery
Controversies and Anesthesia Management Recommendations
Prognosis, Treatment, and Prevention
American Society of Anesthesiologists Advisories (Updated With 2019 Advisory)
Visual Loss After Vitrectomy and Vitreal Gas Bubble Tamponade
Conclusion
Disclosure
Acknowledgment
References
References
35 - Neuromuscular Disorders Including Malignant Hyperthermia and Other Genetic Disorders
History
Physiology and Pathophysiology of Excitation-Contraction Coupling and Malignant Hyperthermia
Malignant Hyperthermia Is the Result of Abnormal Function of Muscle Calcium Release Units
Ryanodine Receptors
Voltage-Gated Calcium Channels: role of Cav1.1
Factors Other than Ryanodine Receptor Abnormalities
Dantrolene
Genetics
Distribution of RyR1 Mutations
Inheritance and Penetrance of Malignant Hyperthermia
In Vitro Contracture Test and Caffeine Halothane Contracture Test
Discordance Between Genetic and in Vitro Contracture Test/Caffeine/Halothane Contracture Tests Malignant Hyperthermia Testing
Guidelines for Genetic Screening
Fulminant Malignant Hyperthermia
Anesthetic Triggering
Nonanesthetic Malignant Hyperthermia
Malignant Hyperthermia–Associated Syndromes
Masseter Spasm (“Thiopental-Succinylcholine or Halothane-Succinylcholine Rigidity”)
Core Myopathies
King-Denborough Syndrome
Diagnosis in the Operating Room and Postanesthesia Care Unit
Treatment
Anesthesia for Susceptible Patients
Evaluation of Susceptibility
Multiple Sclerosis
Anesthetic Considerations
Motor Neuron Disorders
Anesthetic Considerations
Guillain-Barré Syndrome
Anesthetic Considerations
Critical Illness Polyneuropathy and Critical Illness Myopathy
Anesthetic Considerations
Hereditary Motor-Sensory Neuropathies, including Charcot-Marie-Tooth Disease
Anesthetic Considerations
Duchenne Muscular Dystrophy and Becker Muscular Dystrophy
Diagnosis and Differential Diagnosis
Anesthetic Considerations
Limb-Girdle Muscular Dystrophy
Myotonic Dystrophy
Anesthetic Considerations
Myotonia Congenita
Anesthetic Considerations
Myotubular Myopathy
Anesthetic Considerations
Metabolic Myopathies
Glycogen Storage Disease Type I
Anesthesia Considerations
Glycogen Storage Disease Type II (Acid Maltase Deficiency)
Anesthetic Considerations
Mitochondrial Myopathies
Mitochondrial Myopathy, Encephalopathy, Lactic Acidosis, and Stroke-Like Episodes
Myoclonic Epilepsy with Ragged Red Fibers
Anesthetic Considerations
Preoperative Evaluation
Induction and Maintenance of Anesthesia
Myasthenia Gravis
Anesthetic Considerations
Eaton-Lambert Myasthenic Syndrome
Anesthetic Considerations
Periodic Paralysis (Hyperkalemic, Hypokalemic, and Normokalemic)
Anesthetic Considerations
Summary
Acknowledgment
References
References
36 - Cardiovascular Monitoring
Introduction to Cardiovascular Monitoring: Focused Physical Examination
Heart Rate and Pulse Rate Monitoring
Electrocardiography Monitoring
Electrocardiogram Lead Placement and Selection
Standard Lead Systems
Alternative Lead Systems
Electrocardiogram Filter Selection
Electrocardiogram Gain Selection
Electrocardiogram Pacing Mode
Electrocardiogram Displays and Recordings
Electrocardiogram Artifacts
Electrocardiogram Monitoring for Myocardial Ischemia
Automated Real-Time ST-Segment Monitoring
Electrocardiogram Criteria for Acute Myocardial Ischemia
Blood Pressure Monitoring
Indirect Measurement of Arterial Blood Pressure
Manual Intermittent Techniques
Automated Intermittent Techniques
Complications of Noninvasive Blood Pressure Measurement
Automated Continuous Techniques
Direct Measurement of Arterial Blood Pressure
Percutaneous Radial Artery Cannulation
Alternative Arterial Pressure Monitoring Sites
Complications of Direct Arterial Pressure Monitoring
Technical Aspects of Direct Blood Pressure Measurement
Natural Frequency, Damping Coefficient, and Dynamic Response of Pressure Monitoring Systems
Pressure Monitoring System Components
Transducer Setup: Zeroing and Leveling
Normal Arterial Pressure Waveforms
Arterial Blood Pressure Gradients
Abnormal Arterial Pressure Waveforms
Arterial Pressure Monitoring and Waveform Analysis for Prediction of Volume Responsiveness
Central Venous Pressure Monitoring
Central Venous Cannulation
Choosing the Catheter, Site, and Method for Central Venous Cannulation
Complications of Central Venous Pressure Monitoring
Mechanical Complications of Central Venous Catheterization
Thromboembolic Complications of Central Venous Catheterization
Infectious Complications of Central Venous Catheterization
Other Complications of Central Venous Catheterization
Physiologic Considerations for Central Venous Pressure Monitoring
Central Venous Pressure and Venous Return
Central Venous Pressure and Cardiac Function
Normal Central Venous Pressure Waveforms
Abnormal Central Venous Pressure Waveforms
Pulmonary Artery Catheter Monitoring
Pulmonary Artery Catheter Insertion
Complications of Pulmonary Artery Catheter Monitoring
Normal Pulmonary Artery Pressures and Waveforms
Abnormal Pulmonary Artery and Wedge Pressure Waveforms
Physiologic Considerations for Pulmonary Artery Catheter Monitoring: Prediction of Left Ventricular Preload
Pulmonary Artery Catheter-Derived Hemodynamic Variables
Pulmonary Artery Catheterization: Indications and Outcome Controversy
Special Types of Pulmonary Artery Catheters
Mixed Venous Oximetry Pulmonary Artery Catheter
Right Ventricular Ejection Fraction Pulmonary Artery Catheter
Cardiac Output Monitoring
Thermodilution Cardiac Output Monitoring
Sources of Error in Thermodilution Cardiac Output Monitoring
Continuous Thermodilution Cardiac Output Monitoring
Transpulmonary Thermodilution Cardiac Output
Lithium Dilution Cardiac Output Monitoring
Other Methods For Monitoring Cardiac Output and Perfusion
Esophageal Doppler Cardiac Output Monitoring
Bioimpedance and Bioreactance Cardiac Output Monitoring
Partial CO2 Rebreathing Cardiac Output Monitoring
Pulse Contour Cardiac Output Monitoring
Acknowledgment
References
37 - Perioperative Echocardiography
Introduction
History of Perioperative Echocardiography
Intraoperative Transesophageal Echocardiography
Critical Care Echocardiography
Principles of Ultrasound
Ultrasound Modalities
Strain and Strain-Rate Imaging
Harmonic Imaging
Contrast Echocardiography
Three-Dimensional Image Acquisition
Imaging Modes
Two-Dimensional Multiplane Acquisition
Real-Time Three-Dimensional Imaging
Gated Acquisition
Color Flow Doppler
Quantitative Analysis
Multiplanar Reformatting
Advanced Applications
Indications and Practice Guidelines
Perioperative Transesophageal Echocardiography
Critical Care
Transesophageal Echocardiography Examination
CONTRAINDICATIONS AND COMPLICATIONS
Transesophageal Echocardiography Image Acquisition
Probe Manipulation and Imaging Planes
Basic Examination
Comprehensive Examination
Epicardial and Epiaortic Imaging
Transthoracic Echocardiography Examination
Transthoracic Echocardiography Image Acquisition
Focused Cardiac Ultrasound Versus Limited Examination
Comprehensive Examination
Qualitative Assessment
Ventricular Size and Function
Left Ventricle
Right Ventricle
Valvular Function
Quantitative Assessment
Ventricular Size and Function
Left Ventricle
Right Ventricle
Diastolic Function
Valvular Function
Stenosis
Regurgitation
Hemodynamic Measurements
Cardiac Output
Continuity Principle
Bernoulli Equation
Intracardiac Pressure Estimates
Hemodynamic Failure and Shock
Ventricular Dysfunction
Severe Hypovolemia
Left Ventricular Outflow Tract Obstruction
Cardiac Tamponade
Pulmonary Embolism
Intraoperative Transesophageal Echocardiography - Noncardiac Surgery
Monitoring Role
Myocardial Ischemia
Liver Transplantation
Lung Transplantation
Vascular Surgery/Endovascular Procedures
Rescue Role
Intraoperative Transesophageal Echocardiography - Cardiac Surgery
Mitral Valve Repair
Tricuspid Valve Repair
Aortic Dissection
Mechanical Circulatory Support (MCS)
Durable Mechanical Circulatory Support
Temporary Mechanical Circulatory Support
Congenital Heart Surgery
Other Surgical Procedures
Intraprocedural Transesophageal Echocardiography- Structural Heart Interventions
Transcatheter Aortic Valve Replacement
Valve Sizing
Intraprocedural Examination
Transesophageal Echocardiography Versus Transthoracic Echocardiography
Transcatheter Mitral Valve Repair
Other Percutaneous Structural Heart Procedures
Emerging Technologies
Fusion Imaging
Three-Dimensional Printing
Artificial Intelligence/Machine Learning
Perioperative Transthoracic Echocardiography and Focused Cardiac Ultrasound
Critical Care
Fluid Responsiveness
Post-Cardiac Surgery
Trauma and Resuscitation
Other Clinical Applications
Handheld Cardiac Ultrasound
Miniature Tee Probes
Training and Certification
Knowledge Expectations and Training
Certification
Future Directions
Acknowledgment
References
38 - Implantable Cardiac Pulse Generators: Pacemakers and Cardioverter-Defibrillators
Basic Cardiac Implantable Electronic Device Function
Pacemakers
Implantable Cardioverter-Defibrillators
Cardiac Resynchronization Therapy Devices
Perioperative Considerations
Preoperative Assessment
Preoperative Information Transfer
Electromagnetic Interference
Magnets
Electromagnetic Interference Damage to the Cardiac Implantable Electronic Device
Intraoperative Management
Postoperative Management
Emergency Protocol
Specific Surgical Procedures
Cardioversion
Radiofrequency Ablation
Lithotripsy
Radiation
Electroconvulsive Therapy
Endoscopy
Emerging Technologies
Conclusions
Acknowledgment
References
39 - Neurologic Monitoring
Monitoring Modalities
Monitors of Adequacy of Nervous System Blood Flow
Global Blood Flow Monitoring Techniques (Noninvasive)
Tissue-Level Blood Flow Monitoring Techniques (Invasive)
Tissue Partial Pressure of Oxygen Monitoring
Monitors of Nervous System Function
Electroencephalogram
Evoked Potentials
Reactions to Intraoperative Changes in Monitored Responses
Clinical Applications of Neurologic Monitoring
Neurovascular Surgery (Also See Chapters 56 And 57)
Extracranial Neurovascular Surgery: Carotid Vascular Surgery (Monitors: Electroencephalogram, Somatosensory-Evoked Potentials, T...
Intracranial Neurovascular Surgery (Monitors: Somatosensory-Evoked Potentials, Motor-Evoked Potentials)
Supratentorial Intracranial Nonvascular Surgery (Monitors: Awake Patient, Electroencephalogram, Somatosensory-Evoked Potentials)...
Seizure Focus Localization Surgery
Motor Strip Localization
Posterior Fossa Surgery (Monitors: Brainstem Auditory-Evoked Potentials, Cranial Nerve Monitoring, Somatosenory-Evoked Potential...
Microvascular Decompression of Cranial Nerves V, VII, and IX
Vestibular Nerve Schwannoma
Other Posterior Fossa Neoplasms
Spinal Column and Spinal Cord Surgery (Monitors: Somatosensory-Evoked Potentials, Motor-Evoked Potentials, Electromyogram, And B...
Peripheral Nerve Surgery (Monitors: Electromyogram, Nerve Action Potential)
Applications of Intraoperative Monitoring to Pediatric Patients
Cardiopulmonary Bypass
Intensive Care Applications of Neurologic Monitoring (Monitors: Electroencephalogram, Evoked Potentials, Transcranial Doppler, J...
Continuous Electroencephalogram Monitoring
Cerebral Ischemia
Prognosis in Coma and Determination of Brain Death
Nonsurgical Factors Influencing Monitoring Results
Anesthesia and The Electroencephalogram
Intravenous Anesthetic Drugs
Inhaled Anesthetics
Anesthesia and Sensory-Evoked Responses
Volatile Anesthetics
Intravenous Anesthetics
Anesthesia and Motor-Evoked Potentials
Pathophysiologic Effects on the Electroencephalogram
Hypoxia
Hypotension
Hypothermia
Hypercarbia and Hypocarbia
Untoward Events
Physiologic Factors Influencing Sensory-Evoked Responses
Summary
References
References
40 - Monitoring the State of the Brain and Central Nervous System During General Anesthesia and Sedation
Induction of General Anesthesia
Physiologic Signs of Loss of Consciousness
Electroencephalogram-Markers of Loss of Consciousness
Maintenance of General Anesthesia: Physiologic Signs and the Nociceptive-Medullary-Autonomic Pathway
Maintenance of General Anesthesia: Electroencephalogram-Based Indices of Level of Consciousness
Bispectral Index
Patient Safety Index
Narcotrend
Entropy
End-Tidal Anesthetic CONCENTRATION
Other Strategies for Monitoring Level of Consciousness
Emergence From General Anesthesia
Electroencephalogram-Based Indices and Return of Consciousness
Physiologic Signs and Return of Consciousness
Emerging Strategies for Monitoring the Brain States of General Anesthesia and Sedation
Unprocessed Electroencephalogram and the Spectrogram
Changes in Electroencephalogram Signatures with Aging
Implications for Monitoring Anesthetic State
Normalized Symbolic Transfer Entropy
Closed-Loop Anesthetic Delivery Systems
Monitoring Antinociception
References
References
41 -
Respiratory Monitoring
Overview of Respiratory Monitoring
AMERICAN SOCIETY OF ANESTHESIOLOGISTS STANDARDS
The Physical Examination
Pulse Oximetry
PHYSIOLOGIC FUNDAMENTALS
MEASUREMENT PRINCIPLES
Oximetry
Pulse Oximetry
LIMITATIONS AND SOURCES OF ERROR
Pulse Oximeter Probes
Mixed Venous Oxygen Saturation
PHYSIOLOGIC FUNDAMENTALS
MEASUREMENT PRINCIPLES
APPLICATIONS AND INTERPRETATION
Tissue Oxygenation
CLINICAL APPLICATIONS
Capnometry and Capnography
GENERAL CONCEPTS
MEASUREMENT PRINCIPLES
TIME CAPNOGRAM
VOLUME CAPNOGRAM
Blood Gas Analysis
PHYSIOLOGIC FUNDAMENTALS
MEASUREMENT PRINCIPLES
Effect of Temperature
LIMITATIONS AND SOURCES OF ERRORS
Monitoring Lung Flows, Volumes, and Pressures
DYNAMIC RESPIRATORY MECHANICS
STATIC RESPIRATORY MECHANICS
WORK OF BREATHING AND MECHANICAL POWER
MONITORING OF RESPIRATORY PRESSURES
MONITORING OF RESPIRATORY FLOWS
MONITORING OF RESPIRATORY VOLUME
Plethysmographic Monitoring
Respiratory Rate Monitoring: Apnea Monitoring
Imaging for Respiratory Monitoring
CHEST RADIOGRAPHY
ULTRASONOGRAPHY
ELECTRICAL IMPEDANCE TOMOGRAPHY
Point of Care Tests
Respiratory Monitoring in Special Conditions
HIGH-FREQUENCY VENTILATION
JET VENTILATION
PATIENT TRANSPORT
Automated Data Systems
Additional Monitored Variables
NITROGEN WASHOUT AND END-EXPIRATORY LUNG VOLUME
TRANSCUTANEOUS MEASUREMENTS OF PARTIAL PRESSURES OF OXYGEN AND CARBON DIOXIDE
LUNG WATER
Imaging Techniques
Indicator Dilution Methods
References
References
42 - Renal Pathophysiology and Treatment for Perioperative Ischemia and Nephrotoxic Injury
Introduction and Acute Kidney Injury Definitions
Pathophysiologic Processes of Ischemic Acute Kidney Injury
RENAL RESPONSE TO HYPOPERFUSION: AUTOREGULATION AND DISTRIBUTION OF CARDIAC OUTPUT TO THE KIDNEYS
Detection of Acute Kidney Injury
LABORATORY TESTS OF SERUM AND URINE AS MARKERS OF RENAL FUNCTION
NOVEL (EARLY) BIOMARKERS OF ACUTE KIDNEY INJURY
New Filtration-Based Markers of Renal Dysfunction
Biomarkers Reflecting Renal Tubular Cell Damage (Tubular Enzymuria)
Biomarkers Reflecting Renal Tubular Cell Dysfunction (Tubular Proteinuria)
Biomarkers Reflecting Renal Tubular Cell Response to Stress
Preoperative Evaluation of Renal Function and Risk Stratification
Perioperative Acute Kidney Injury: Mechanisms and Treatment
REGIONAL ANESTHESIA
EFFECTS OF INHALED ANESTHETICS
EFFECTS OF INTRAVENOUS ANESTHETICS
SPECIFIC PERIOPERATIVE PERTURBATIONS AND RENAL FUNCTION
INTRAOPERATIVE MANAGEMENT FOR AKI PREVENTION: OXYGEN DELIVERY: BLOOD GAS, ACID-BASE BALANCE, AND HEMATOCRIT
Perioperative Blood Pressure and Fluid Management
EXCESSIVE INTRAVASCULAR VOLUME AND THE ABDOMINAL COMPARTMENT SYNDROME
Nephrotoxins and Acute Kidney Injury
Renal Replacement Therapy
Summary
Acknowledgment
References
References
43 - Neuromuscular Monitoring
Principles of Peripheral Nerve Stimulation
SUPRAMAXIMAL STIMULATION
CALIBRATION
IMPEDANCE
SAFETY MARGIN
Types of Peripheral Nerve Stimulation
Basic Considerations
STIMULATING ELECTRODES
Sites of Nerve Stimulation and Different Muscle Responses
NERVE-MUSCLE UNIT
Patterns of Nerve Stimulation
SINGLE-TWITCH STIMULATION
TRAIN-OF-FOUR STIMULATION
DOUBLE-BURST STIMULATION
TETANIC STIMULATION
POSTTETANIC COUNT STIMULATION
Equipment
Peripheral Nerve Stimulator
Objective Monitors
MECHANOMYOGRAPHY
ELECTROMYOGRAPHY
ACCELEROMYOGRAPHY
KINEMYOGRAPHY
CUFF PRESSURE MODALITY (CPM)
COMPRESSOMYOGRAPHY
PHONOMYOGRAPHY
Evaluation of Recorded Evoked Responses
NONDEPOLARIZING NEUROMUSCULAR BLOCK
Intense Neuromuscular Block
Deep Neuromuscular Block
Moderate Neuromuscular Block
Recovery from Neuromuscular Block
DEPOLARIZING NEUROMUSCULAR BLOCK (PHASE I AND II BLOCKS)
Use of Nerve Stimulators in Daily Clinical Practice
PREPARATIONS BEFORE INDUCTION OF ANESTHESIA AND ADMINISTRATION OF THE NEUROMUSCULAR BLOCKING AGENT
USE OF A NERVE STIMULATOR DURING INDUCTION OF ANESTHESIA
USE OF A NERVE STIMULATOR DURING SURGERY
USE OF A NERVE STIMULATOR DURING REVERSAL OF NEUROMUSCULAR BLOCK
When to Use a Peripheral Nerve Stimulator
Acknowledgment
References
References
44 - Airway Management in the Adult
Introduction
ALGORITHMS FOR MANAGEMENT OF THE DIFFICULT AIRWAY
The American Society of Anesthesiologists Algorithm
Other Difficult Airway Algorithms
Human Factors and Cognitive Aids
Functional Airway Anatomy
NASAL CAVITY
ORAL CAVITY
PHARYNX
LARYNX
TRACHEA AND BRONCHI
Airway Assessment
TRADITIONAL METRICS
NEW MODALITIES
Physiologic Concepts for Airway Management
PREOXYGENATION
APNEIC OXYGENATION
PULMONARY ASPIRATION OF GASTRIC CONTENTS
AIRWAY REFLEXES AND THE PHYSIOLOGIC RESPONSE TO INTUBATION OF THE TRACHEA
Anesthesia for Airway Management
AIRWAY MANAGEMENT AFTER THE INDUCTION OF GENERAL ANESTHESIA
Standard Intravenous Induction with Neuromuscular Blockade
Rapid-Sequence Induction and Intubation
Inhalational Induction of Anesthesia
Intravenous Induction Without Neuromuscular Blocking Drugs
AIRWAY MANAGEMENT IN AN AWAKE (NON-ANESTHETIZED) PATIENT
Mask Ventilation
Supraglottic Airways
LARYNGEAL MASK AIRWAY
LMA Classic
LMA ProSeal
LMA Supreme
NEWER LMA MODELS
OTHER PERILARYNGEAL SEALERS
CUFFLESS ANATOMICALLY PRESHAPED SEALERS
CUFFED PHARYNGEAL SEALERS
Tracheal Intubation
ENDOTRACHEAL TUBES
ENDOTRACHEAL TUBE INTRODUCERS
OROTRACHEAL VERSUS NASOTRACHEAL INTUBATION
DIRECT LARYNGOSCOPY
Preparation and Positioning
Technique
Nasotracheal Intubation Technique
Confirmation of Endotracheal Tube Placement
Securing the Endotracheal Tube
INDIRECT LARYNGOSCOPY
Flexible Intubation Scopes
Rigid Indirect Laryngoscopes
Lighted Optical Stylets
Video Laryngoscopes
Lighted Stylets
RETROGRADE INTUBATION
DOUBLE-LUMEN TUBES AND BRONCHIAL BLOCKERS
COMBINATION TECHNIQUES
Tracheal Intubation Through a Supraglottic Airway Device
Combined Direct Laryngoscopy Techniques
Combined Video-Assisted Laryngoscopy Techniques
Combined Retrograde Intubation Techniques
Emergency Front of Neck Access
TRANSTRACHEAL JET VENTILATION
CRICOTHYROTOMY
Extubation of the Trachea
GENERAL CONSIDERATIONS FOR EXTUBATION OF THE TRACHEA
EXTUBATION AND REINTUBATION OF THE DIFFICULT AIRWAY
Dissemination of Critical Airway Information
Summary
References
References
45 - Spinal, Epidural, and Caudal Anesthesia
Principles
Practice
Historical Perspectives
Anatomy
BLOOD SUPPLY
Anatomic Variations
NERVE ROOTS
CEREBROSPINAL FLUID
EPIDURAL SPACE
Mechanism of Action
DRUG UPTAKE
DRUG DISTRIBUTION
DRUG ELIMINATION
Physiologic Effects
CARDIOVASCULAR
Stroke Volume
Heart Rate
Coronary Blood Flow
Treatment
CENTRAL NERVOUS SYSTEM
RESPIRATORY
Pregnancy
Obesity (also see Chapter 58)
GASTROINTESTINAL
RENAL
Indications
NEURAXIAL ANESTHESIA
NEURAXIAL ANALGESIA
Contraindications
ABSOLUTE
RELATIVE
Neurologic
Cardiac (also see Chapter 54)
Hematologic
Infection
Spinal Anesthesia
FACTORS AFFECTING BLOCK HEIGHT
Drug Factors
Patient Factors
Procedure Factors
DURATION
PHARMACOLOGY
Short- and Intermediate-Acting Local Anesthetics
Long-Acting Local Anesthetics
Spinal Additives
Technique
SPECIAL SPINAL TECHNIQUES
Continuous Spinal Anesthesia
Unilateral Spinal Anesthesia and Selective Spinal Anesthesia
BLOCK MONITORING
Epidural Anesthesia
FACTORS AFFECTING EPIDURAL BLOCK HEIGHT
Drug Factors
Patient Factors
Procedure Factors
PHARMACOLOGY
Short-Acting and Intermediate-Acting Local Anesthetics
Long-Acting Local Anesthetics
Epidural Additives
EPIDURAL TECHNIQUE
Preparation
Position
Projection and Puncture
Paramedian Approach
Combined Spinal-Epidural
TECHNIQUE
Caudal Anesthesia
PHARMACOLOGY
TECHNIQUE
Complications
NEUROLOGIC
Paraplegia
Cauda Equina Syndrome
Epidural Hematoma
Nerve Injury
Arachnoiditis
Post–Dural Puncture Headache
Transient Neurologic Symptoms
CARDIOVASCULAR
Hypotension
Bradycardia
Cardiac Arrest (also see Chapter 87)
RESPIRATORY
INFECTION
BACKACHE
NAUSEA AND VOMITING
URINARY RETENTION
PRURITUS
SHIVERING
WRONG ROUTE ADMINISTRATION
COMPLICATIONS UNIQUE TO EPIDURAL ANESTHESIA
Intravascular Injection
Subdural Injection
COMPLICATIONS UNIQUE TO COMBINED SPINAL-EPIDURALS
Outcomes
Recent Advances
ULTRASOUND
Acknowledgment
References
References
46 - Peripheral Nerve Blocks and Ultrasound Guidance for Regional Anesthesia
Introduction
Techniques for Localizing Neural Structures
PARESTHESIA TECHNIQUES
PERIPHERAL NERVE STIMULATION
Ultrasound Guidance
FUNDAMENTAL ASSUMPTIONS AND ARTIFACTS
Transducer Selection, Manipulation, and Modes of Imaging
Needle Tip Visibility
Approaches to Regional Block With Ultrasound
REGIONAL BLOCK TECHNIQUES
Cervical Plexus Blocks
Clinical Applications
Superficial Cervical Plexus
Brachial Plexus Blocks
BRACHIAL PLEXUS ANATOMY
Interscalene Blocks
Ultrasound-Guided Technique
Side Effects and Complications
Ultrasound-Guided Technique
Side Effects and Complications
Indications
Ultrasound-Guided Technique
Shoulder Block (Suprascapular Nerve Plus Axillary [Circumflex] Nerve Block)42
Side Effects and Complications
INFRACLAVICULAR BLOCKS
AXILLARY BLOCKS
Trunk Blocks
INTERCOSTAL NERVE BLOCKS
Clinical Applications
Intercostal Block Technique
Alternative Techniques
Side Effects and Complications
TRANSVERSUS ABDOMINIS PLANE BLOCKS
ILIOINGUINAL AND ILIOHYPOGASTRIC NERVE BLOCKS
Indications
Side Effects and Complications
Lower Extremity Blocks
LOWER EXTREMITY ANATOMY
FEMORAL NERVE BLOCKS
Fascia Iliaca (Modified Femoral Nerve) Blocks
SAPHENOUS NERVE BLOCKS ABOVE THE KNEE (INCLUDING ADDUCTOR CANAL BLOCK)
Indications
Anatomy
Technique
Side Effects and Complications
SAPHENOUS NERVE BLOCKS BELOW THE KNEE
Indications
Anatomy
Technique
Side Effects and Complications
SCIATIC NERVE BLOCKS IN THE POPLITEAL FOSSA
ALTERNATIVE APPROACHES TO SCIATIC NERVE BLOCK
NERVE BLOCKS AT THE ANKLE
Tibial Nerve Technique
Side Effects and Complications
INTRAVENOUS REGIONAL ANESTHESIA (OR BIER BLOCK)
Introduction and Clinical Applications
Technique (Upper Extremity)
Prerequisites
Extremity Exsanguination and Tourniquet Inflation
Tourniquet Deflation
Comments
Complications
Continuous Catheter Techniques
TESTING THE CATHETER
SECURING THE CATHETER
Choice of Local Anesthetic
Complications and Safety
Training
Summary and Conclusions
Acknowledgments
References
References
47 - Perioperative Fluid and Electrolyte Therapy
Physiology
FLUID COMPARTMENTS
PHYSICOCHEMICAL LAWS GOVERNING FLUID AND ELECTROLYTE MOVEMENT
Diffusion
Osmosis
Osmolality
Tonicity
Oncotic Pressure
FLUID COMPARTMENT BARRIERS AND DISTRIBUTION
Cell Membrane
Carrier Proteins
Vascular Endothelium
PHYSIOLOGIC CONTROL OF OVERALL FLUID BALANCE
Acute Disturbances in Circulating Volume
Long-Term Control of Circulating Intravascular Volume
ELECTROLYTE PHYSIOLOGY
Sodium Physiology
Potassium Physiology
Calcium Physiology
Magnesium Physiology
Phosphate Physiology
Chloride Physiology
ACID-BASE DISTURBANCES AND FLUID THERAPY
Hyperchloremic Acidosis
Bicarbonate Administration
Fluid Pharmacology
CRYSTALLOIDS
Saline Solutions
Balanced Crystalloid Solutions
Dextrose Solutions
COLLOIDS
Semisynthetic Colloids
Human Plasma Derivatives
Clinical Fluid and Electrolyte Management
PATHOPHYSIOLOGIC FLUID ALTERATIONS IN THE PERIOPERATIVE PHASE
Preoperative
Intraoperative
Postoperative
ASSESSMENT AND TREATMENT OF PERIOPERATIVE FLUID AND ELECTROLYTE IMBALANCE
Intravascular Volume
Electrolyte Imbalance
Sodium Disorders
Calcium Disorders
Magnesium Disorders
Phosphate Disorders
PRACTICAL MANAGEMENT OF PERIOPERATIVE FLUID THERAPY
Quantity of Fluid
Appropriate Fluid Selection
Saline-Based or Balanced Solutions
Special Considerations
Patient Factors
Surgical Factors
References
References
48 - Perioperative Acid-Base Balance
Introduction—Why Is Acid-Base Balance Important?
What Are Acids and Bases?
What Determines the Acidity or Alkalinity of a Solution?
STRONG IONS
WEAK ACID “BUFFER” SOLUTIONS
CARBON DIOXIDE
FACTORS INDEPENDENTLY INFLUENCING WATER DISSOCIATION
Acid-Base Abnormalities
RESPIRATORY ACID-BASE ABNORMALITIES
Respiratory Alkalosis
Respiratory Acidosis
METABOLIC ACID-BASE DISTURBANCES
Regulation of Acid-Base Balance
Analytic Tools Used in Acid-Base Chemistry
THE DESCRIPTIVE (CO2-BICARBONATE [BOSTON]) APPROACH
ANION GAP APPROACH
THE SEMI-QUANTITATIVE (BASE DEFICIT/EXCESS [COPENHAGEN]) APPROACH
STEWART APPROACH
Acid-Base Problems in Perioperative and Critical Care Medicine
RESPIRATORY ACIDOSIS AND ALKALOSIS
Metabolic Acidosis and Alkalosis
METABOLIC ACIDOSIS
LACTIC ACIDOSIS
Ketoacidosis
Renal Acidosis
Hyperchloremic Acidosis
Perioperative Metabolic Alkalosis
ACID-BASE DISTURBANCES IN CRITICAL ILLNESS
TREATING ACID-BASE DISTURBANCES
Summary
Acknowledgment
References
References
49 - Patient Blood Management: Transfusion Therapy
Evolution and Recent History of Blood Transfusion Therapy
THE 1960S
THE 1970S THROUGH THE 1980S
1990S THROUGH THE 2000S
2010 TO THE PRESENT
Blood Procurement
SOURCE OF DONORS
TRANSFUSION-TRANSMISSIBLE INFECTIONS
Posttransfusion Hepatitis
Cytomegalovirus
Zika Virus
Other Transfusion-Associated Infectious Diseases
BIOCHEMICAL CHANGES IN STORED BLOOD
CHANGES IN OXYGEN TRANSPORT
CLINICAL IMPLICATIONS: DURATION OF BLOOD STORAGE
Blood Component Therapy: Indications for Transfusion
ALLOGENEIC (HOMOLOGOUS) BLOOD
ADDITIONAL BLOOD TRANSFUSIONS
Measurement of Blood Loss
Determination of Hemoglobin Concentration
Preoperative Anemia
Liberal Versus Restrictive Transfusion Strategy
General Conclusions
PLATELET CONCENTRATES
FRESH FROZEN PLASMA
CRYOPRECIPITATE
MASSIVE TRANSFUSION AND TRANSFUSION RATIOS
Synthetic Oxygen-Carrying Substances
HB-BASED OXYGEN CARRIERS
Autologous Blood
PREOPERATIVE AUTOLOGOUS DONATION
ACUTE NORMOVOLEMIC HEMODILUTION
INTRAOPERATIVE CELL SALVAGE
Clinical Studies
POSTOPERATIVE CELL SALVAGE
Compatibility Testing
GENERAL PRINCIPLES
ABO-RH TYPING
ANTIBODY SCREENING
CROSSMATCHING
ELECTRONIC CROSSMATCH
Maximal Surgical Blood Order Schedule
Emergency Transfusion
TYPE-SPECIFIC, PARTIALLY CROSSMATCHED BLOOD
TYPE-SPECIFIC, UNCROSSMATCHED BLOOD
TYPE O RH-NEGATIVE (UNIVERSAL DONOR), UNCROSSMATCHED BLOOD
Fresh Whole Blood
Complications
COAGULATION ABNORMALITIES
THROMBOCYTOPENIA
LOW LEVELS OF FIBRINOGEN AND FACTORS V AND VIII
DISSEMINATED INTRAVASCULAR COAGULATION–LIKE SYNDROME
DIAGNOSIS AND TREATMENT OF A HEMORRHAGIC DIATHESIS AFTER BLOOD TRANSFUSIONS
Citrate Intoxication and Hyperkalemia
Temperature
Acid-Base Abnormalities
Transfusion Reactions
HEMOLYTIC TRANSFUSION REACTION
Signs and Symptoms
Treatment
DELAYED HEMOLYTIC TRANSFUSION REACTION (IMMUNE EXTRAVASCULAR REACTION)
TRANSFUSION-RELATED ACUTE LUNG INJURY
TRANSFUSION ASSOCIATED CIRCULATORY OVERLOAD
NONHEMOLYTIC TRANSFUSION REACTIONS
OTHER ADVERSE EFFECTS OF BLOOD TRANSFUSION
Transfusion-Associated Graft-Versus-Host Disease
Transfusion-Related Immunomodulation
OTHER NONINFECTIOUS RISKS OF BLOOD TRANSFUSIONS
Leukoreduction and Irradiation of Blood Transfusions
GENERAL CONSIDERATIONS
IRRADIATED BLOOD PRODUCTS
Informed Consent
Acknowledgment
References
References
50 - Patient Blood Management: Coagulation
Introduction
Normal Hemostasis
VASCULAR ENDOTHELIAL ROLE IN HEMOSTASIS
PLATELETS AND HEMOSTASIS
PLASMA-MEDIATED HEMOSTASIS
Extrinsic Pathway of Coagulation
Intrinsic Pathway of Coagulation
Common Pathway of Coagulation
Intrinsic Anticoagulant Mechanisms
Disorders of Hemostasis
EVALUATION OF BLEEDING DISORDERS
INHERITED BLEEDING DISORDERS
Von Willebrand Disease
Hemophilias
ACQUIRED BLEEDING DISORDERS
Drug Induced
Liver Disease
Renal Disease
Disseminated Intravascular Coagulation
CARDIOPULMONARY BYPASS-ASSOCIATED COAGULOPATHY
TRAUMA-INDUCED COAGULOPATHY
PROTHROMBOTIC STATES
INHERITED THROMBOTIC DISORDERS
ACQUIRED THROMBOTIC DISORDERS
Antiphospholipid Syndrome
HEPARIN-INDUCED THROMBOCYTOPENIA
MONITORING COAGULATION
COMMON LABORATORY-BASED MEASURES OF COAGULATION
Prothrombin Time
Activated Partial Thromboplastin Time
Anti-Factor Xa Activity
Platelet Count and Bleeding Time
COMMON POINT-OF-CARE MEASURES OF COAGULATION
Activated Clotting Time
Heparin Concentration Measurement
Viscoelastic Measures of Coagulation
Platelet Function Monitors
Antithrombotics, Thrombolytics, and Procoagulant Drugs
ANTIPLATELET AGENTS
Cyclooxygenase Inhibitors
Aspirin
NONSTEROIDAL ANTIINFLAMMATORY DRUGS
P2Y12 RECEPTOR ANTAGONISTS
GLYCOPROTEIN IIB/IIIA INHIBITORS
ANTICOAGULANTS
Vitamin K Antagonists
Unfractionated Heparin
Low Molecular Weight Heparin and Fondaparinux
Direct Thrombin Inhibitors
Direct Oral Anticoagulants
THROMBOLYTICS
PROCOAGULANT DRUGS
Antifibrinolytics
Factor Replacements
Perioperative Management of Anticoagulation
VITAMIN K ANTAGONISTS
HEPARINS
ASPIRIN
NEURAXIAL ANESTHESIA AND ANTICOAGULATION
Emergent Reversal of Anticoagulants
VITAMIN K ANTAGONISTS
DIRECT THROMBIN INHIBITORS
EMERGING AGENTS
Conclusion
Acknowledgment
References
References
SECTION IV • Adult Subspecialty Management
51 - Management of the Patient with Chronic Pain
Introduction
PHYSIOLOGICAL CHANGES IN PERSISTENT PAIN
Excitatory Mechanisms
Inhibitory Mechanisms
Translation of Basic Research
CLINICAL DEFINITIONS, PREVALENCE, AND CLASSIFICATION OF CHRONIC PAIN
Definitions
Prevalence
Classification
Biopsychosocial Concept of Chronic Pain
INTERDISCIPLINARY MANAGEMENT OF CHRONIC PAIN
Psychology
Physical Therapy
Occupational Therapy
Anesthesiology
Drugs Used for Chronic Pain
OPIOIDS
NONSTEROIDAL ANTIINFLAMMATORY DRUGS AND ANTIPYRETIC ANALGESICS
SEROTONERGIC DRUGS
ANTIEPILEPTIC DRUGS
ANTIDEPRESSANTS
TOPICAL ANALGESICS
OTHER ANALGESICS AND ADJUVANTS
DEVELOPMENT OF NOVEL ANALGESICS
Interventional Methods used for Chronic Pain
DIAGNOSTIC NERVE BLOCKS
THERAPEUTIC NERVE BLOCKS
Cancer Pain
Non-Cancer-Associated Pain
CONTINUOUS CATHETER TECHNIQUES
Cancer Pain
Non-Cancer-Associated Pain
STIMULATION TECHNIQUES
Perioperative Management of Patients with Chronic Pain
CHARACTERISTICS OF CHRONIC PAIN PATIENTS IN THE PERIOPERATIVE PERIOD
CHRONIC USE OF ANALGESICS AND ADJUVANT DRUGS
DEPENDENCE, ADDICTION, AND PSEUDOADDICTION
MANAGEMENT AND PRACTICAL RECOMMENDATIONS
Preoperative Evaluation (also see Chapter 31)
Perioperative Management
Postoperative Regional Anesthesia
Postoperative Intravenous Opioids
Perioperative Transdermal Opioids
Acknowledgment
References
References
52 -
Palliative Medicine
What Is Palliative Medicine?
DEFINITION
PRIMARY VERSUS SPECIALIST PALLIATIVE MEDICINE
HISTORY OF PALLIATIVE MEDICINE
WHY IS PALLIATIVE MEDICINE NEEDED?
WHY IS PALLIATIVE MEDICINE IMPORTANT TO ANESTHESIOLOGISTS?
GLOBAL PALLIATIVE CARE
PALLIATIVE CARE TEAM
Where Is Palliative Care Delivered?
INPATIENT PALLIATIVE CARE TEAMS
Outcomes With Palliative Care Teams
When to Consult Palliative Care Teams
Palliative Care in the Surgical Intensive Care Unit
Trigger Criteria in the Surgical Intensive Care Unit
OUTPATIENT PALLIATIVE CARE
Differences Between Hospice Care and Palliative Care
HOSPICE CARE IN THE UNITED STATES
Who Is Eligible for Hospice Care?
Recipients of Hospice Care
Outcomes of Hospice Care
PALLIATIVE CARE AND ANESTHESIOLOGISTS
Surgery in Seriously Ill Patients
Communicating Surgery Risk in Seriously Ill Patients
Anesthetic Concerns in the Patient Receiving Palliative Care
PREOPERATIVE CONSIDERATIONS
INTRAOPERATIVE CONCERNS
ANESTHETIC CHOICE AND CANCER
POSTOPERATIVE COURSE
Communication
ADVANCE CARE PLANNING
OUTCOMES OF ADVANCE CARE PLANNING
PHYSICIAN COMMUNICATION SKILLS TRAINING
PHYSICIAN COMMUNICATION SKILLS
The Surgical “Contract”
WHAT DO FAMILIES CONSIDER IMPORTANT IN END-OF-LIFE COMMUNICATION?
SPIRITUALITY AT THE END OF LIFE
COMMUNICATION FRAMEWORKS
Family Meetings
Breaking Bad News
Responding to Emotion
Requests for Nondisclosure
Time-Limited Trials
RESUSCITATION STATUS
Outcomes of Cardiopulmonary Resuscitation
Resuscitation Status Discussions
Perioperative Limitations on Treatment
Prognosis
DISEASE TRAJECTORIES
PROGNOSTIC TOOLS
Congestive Heart Failure
Dementia
Chronic Obstructive Pulmonary Disease
Liver Disease
Renal Disease
SYMPTOM MANAGEMENT
Alternative Routes of Drug Delivery
Pain
Bone Pain
Neuropathic Pain
Pain in the Intensive Care Unit
OPIOID USE
Interventional Pain Management at the End of Life
NAUSEA AND VOMITING
Nausea and Vomiting Related to Chemotherapy and Radiation Therapy
BOWEL OBSTRUCTION
ARTIFICIAL HYDRATION AND NUTRITION
DYSPNEA
DEPRESSION AND ANXIETY IN THE PATIENT RECEIVING PALLIATIVE CARE
DELIRIUM AT THE END OF LIFE
BLEEDING IN THE PATIENT RECEIVING PALLIATIVE CARE
The Dying Process
WITHDRAWAL OF LIFE SUPPORT
Outcomes of Withdrawal of Life Support
Paralytic Drugs in the Withdrawal of Life Support
PEDIATRIC HOSPICE CARE AND PALLIATIVE CARE
Characteristics of the Pediatric Palliative Care Population
Symptom Management in Pediatric Palliative Care
References
References
53 - Anesthesia for Thoracic Surgery
Introduction
PREOPERATIVE EVALUATION OF THE THORACIC SURGERY PATIENT (SEE CHAPTER 31)
PERIOPERATIVE COMPLICATIONS
ASSESSMENT OF RESPIRATORY FUNCTION
RESPIRATORY MECHANICS
Lung Parenchymal Function
Cardiopulmonary Interaction
Ventilation Perfusion Scintigraphy
Combination of Tests
Concomitant Medical Conditions
CARDIAC DISEASE
Ischemia
Arrhythmia
Congestive Heart Failure
Pulmonary Hypertension
AGE
RENAL DYSFUNCTION
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Respiratory Drive
Nocturnal Hypoxemia
Right Ventricular Dysfunction
Bullae
Flow limitation
Auto-Positive End-Expiratory Pressure
PREOPERATIVE THERAPY OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
PHYSIOTHERAPY
PRIMARY THORACIC TUMORS
Non–Small-Cell Lung Cancer
Squamous Cell Carcinoma
Adenocarcinoma
Large-Cell Undifferentiated Carcinoma
Small-Cell Lung Cancer
Carcinoid Tumors
Pleural Tumors
ASSESSMENT OF THE PATIENT WITH LUNG CANCER
POSTOPERATIVE ANALGESIA
PREMEDICATION
SUMMARY OF THE INITIAL PREOPERATIVE ASSESSMENT
FINAL PREOPERATIVE ASSESSMENT
Difficult Endobronchial Intubation
Prediction of Desaturation During One-Lung Ventilation
Assessment for Repeat Thoracic Surgery
Intraoperative Monitoring
OXYGENATION
CAPNOMETRY
Invasive Hemodynamic Monitoring
ARTERIAL LINE
CENTRAL VENOUS PRESSURES
PULMONARY ARTERY CATHETERS
FIBEROPTIC BRONCHOSCOPY
CONTINUOUS SPIROMETRY
TRANSESOPHAGEAL ECHOCARDIOGRAPHY
Other Monitoring Technology
Indirect Cardiac Output
Lung Isolation
DOUBLE-LUMEN ENDOTRACHEAL TUBES
Size Selection
Methods of Insertion
RIGHT-SIDED DOUBLE-LUMEN ENDOBRONCHIAL TUBES
Positioning of Double-Lumen Tubes
Problems Related to Double-Lumen Tubes
BRONCHIAL BLOCKERS
Wire-Guided Endobronchial Blocker (Arndt Blocker)
Cohen Endobronchial Blocker
Fuji Uniblocker
EZ-Blocker
Complications Related to the Bronchial Blockers
Difficult Airways and One-Lung Ventilation
Lung-Isolation Techniques in Patients With a Tracheostomy in Place
POSITIONING
Position Change
Neurovascular Complications
Physiologic Changes in the Lateral Position
. Significant changes in ventilation develop between the lungs when the patient is placed in the lateral position.130 The compli...
. Gravity has some effect on distribution of pulmonary blood flow. In the lateral position, the blood flow to the dependent lung...
Anesthetic Management
FLUID MANAGEMENT
TEMPERATURE
PREVENTION OF BRONCHOSPASM
CORONARY ARTERY DISEASE
Management of One-Lung Ventilation
HYPOXEMIA
INTRAOPERATIVE POSITION
Hypoxic Pulmonary Vasoconstriction
CHOICE OF ANESTHETIC
CARDIAC OUTPUT
Ventilation Strategies During One-Lung Ventilation
RESPIRATORY ACID-BASE STATUS
POSITIVE END-EXPIRATORY PRESSURE
TIDAL VOLUME
VOLUME-CONTROL VERSUS PRESSURE-CONTROL VENTILATION
Prediction of Hypoxemia During One-Lung Ventilation
PREOPERATIVE VENTILATION-PERFUSION SCAN
SIDE OF OPERATION
TWO-LUNG OXYGENATION
PREOPERATIVE SPIROMETRY
Treatment of Hypoxemia During One-Lung Ventilation
PHARMACOLOGIC MANIPULATIONS
INTERMITTENT REINFLATION OF THE NONVENTILATED LUNG
PARTIAL VENTILATION METHODS
MECHANICAL RESTRICTION OF PULMONARY BLOOD FLOW
HYPOXEMIA PROPHYLAXIS
BILATERAL PULMONARY SURGERY
Anesthetic Management for Common Surgical Procedures
FLEXIBLE FIBEROPTIC BRONCHOSCOPY
Anesthetic Management
RIGID BRONCHOSCOPY
Anesthetic Management
MEDIASTINOSCOPY
Anesthetic Management
ENDOBRONCHIAL ULTRASOUND-GUIDED BIOPSY
Pulmonary Surgery
MINIMALLY INVASIVE THORACOSCOPIC SURGERY
ANESTHETIC TECHNIQUE
Lobectomy
SLEEVE LOBECTOMY
Pneumonectomy
EXTRAPLEURAL PNEUMONECTOMY
SLEEVE PNEUMONECTOMY
Limited Pulmonary Resections: Segmentectomy and Wedge Resection
Anesthetic Management for Specific Surgical Procedures
ESOPHAGEAL SURGERY
Esophagectomy
. Transthoracic esophagectomy is commonly a two-phase procedure. The first phase involves a laparotomy performed with the patien...
. Airway management is done with an SLT. Apart from this, anesthetic management is essentially the same as for a transthoracic a...
. Minimally invasive esophagectomy involves the use of laparoscopic, thoracoscopic, and/or robotic surgical approaches. For a la...
Esophageal Surgery for Benign Disease
. Although most patients with gastroesophageal reflux have a hiatal hernia, most patients with a hiatal hernia do not have signi...
. Chronic reflux of acidic gastric contents can lead to ulceration, inflammation, and eventually stricture of the esophagus. The...
. There are multiple causes of esophageal perforation, including foreign bodies, endoscopy, bougienage, traumatic tracheal intub...
. Achalasia is a disorder in which there is a lack of peristalsis of the esophagus and a failure of the lower esophageal sphinct...
. Esophagorespiratory tract fistula in an adult is most often due to malignancy. Occasionally, the fistula is benign, and may be...
. Zenker diverticulum is actually a diverticulum of the lower pharynx. It arises from a weakness at the junction of the thyropha...
Anesthesia for Tracheal Resection
BRONCHIECTASIS/LUNG ABSCESS/EMPYEMA
Anesthetic Management
BRONCHOPLEURAL FISTULA
Anesthetic Management
Blebs, Bullae, Cysts, and Pneumatoceles
BLEBS
BULLAE
CYSTS
PNEUMATOCELE
Lung Transplantation
ANESTHESIA FOR THE PATIENT AFTER LUNG TRANSPLANTATION
LUNG VOLUME REDUCTION
Pulmonary Hemorrhage
PULMONARY ARTERY CATHETER-INDUCED HEMORRHAGE
During Weaning from Cardiopulmonary Bypass
Posttracheostomy Hemorrhage
Pulmonary Thromboendarterectomy
Bronchopulmonary Lavage
Mediastinal Masses
MANAGEMENT
Thymectomy for Myasthenia Gravis
NONINTUBATED THORACIC SURGERY
EXTRACORPOREAL MEMBRANE OXYGENATION
Postoperative Management
ENHANCED RECOVERY AFTER SURGERY
EARLY MAJOR COMPLICATIONS
Respiratory Failure
Cardiac Herniation
Postoperative Analgesia
SYSTEMIC ANALGESIA
Opioids
Nonsteroidal Antiinflammatory Drugs
Ketamine
Dexmedetomidine
Intravenous Lidocaine
Gabapentinoids
LOCAL ANESTHETICS/NERVE BLOCKS
Intercostal Nerve Blocks
Epidural Analgesia
Paravertebral Block
Ultrasound-Guided Blocks
POSTOPERATIVE PAIN MANAGEMENT PROBLEMS
Shoulder Pain
Postthoracotomy Neuralgia and Chronic Incisional Pain
MANAGEMENT OF OPIOID TOLERANT PATIENTS
References
References
54 - Anesthesia for Cardiac Surgical Procedures
Cardiovascular Disease in the 21st Century
AGE, GENDER, AND RACE
GENETIC INFLUENCES IN CARDIAC DISEASE
Approach to Anesthesia for the Adult Cardiac Patient
PREOPERATIVE EVALUATION, PREPARATION, AND MONITORING
Heart and Vascular System
Central Nervous System
Monitoring
Renal System
Endocrine System
Hematologic System
Unique Hematologic Considerations in Cardiac Surgery
INDUCTION OF ANESTHESIA AND THE PREBYPASS PERIOD
Premedication
Induction of Anesthesia
The Pre-Cardiopulmonary Bypass Period
Onset of Cardiopulmonary Bypass
WEANING FROM CARDIOPULMONARY BYPASS
The “CVP” Mnemonic
TERMINATION OF CARDIOPULMONARY BYPASS
CHEST CLOSURE
TRANSPORT TO THE INTENSIVE CARE UNIT
Phase 1: Equipment and Technology Handover
Phase 2: Information Handover
Phase 3: Questions and Discussion
THE POSTBYPASS PERIOD: COMMON PROBLEMS AFTER CARDIOPULMONARY BYPASS
Awareness
Cardiovascular Decompensation (Low Cardiac Output Syndrome)
Right Heart Failure
Right Ventricular Dysfunction or Failure
Vasoplegia
Dysrhythmias
Hypertension
Renal Insufficiency
Central Nervous System Dysfunction
Respiratory Insufficiency
Metabolic Disturbances
Pain
Bleeding and Coagulopathy
Cardiopulmonary Bypass
CIRCUITRY AND EQUIPMENT
Blood Tubing
Venous Reservoirs
Arterial Pumps
Heat Exchanger
Oxygenator
Arterial Line Filter
SEQUENCE OF EVENTS
Circuit Selection and Priming
Anticoagulation
Cannulation
Initiation and Maintenance of Cardiopulmonary Bypass
Myocardial Protection
Weaning and Termination of Cardiopulmonary Bypass
OTHER ISSUES
Temperature
Blood Gas Management
Inflammatory Response to Cardiopulmonary Bypass
Modification of Surgical Techniques or Perfusion Techniques
Perfusion Technology
Pharmacologic Strategies
DEEP HYPOTHERMIC CIRCULATORY ARREST
LEFT HEART BYPASS
CARDIOPULMONARY SUPPORT AND EXTRACORPOREAL MEMBRANE OXYGENATION CIRCUITS
Specific Cardiovascular Disease States
CORONARY ARTERY DISEASE
Pathophysiology of Coronary Disease
On-Pump Coronary Artery Bypass Grafting Surgery
Off-Pump Coronary Artery Bypass Surgery, Minimally Invasive Coronary Artery Bypass Surgery, and Hybrid Coronary Revascularizatio...
CARDIAC VALVE LESIONS
Mitral Valve Disease
Anatomy of the Mitral Valve
Mitral Stenosis
Aortic Valve Disease
Aortic Stenosis
Aortic Regurgitation
Other Valvular Disease
Structural Heart Procedures
HEART FAILURE
Medical Management of Heart Failure
Surgical Management of Heart Failure
CARDIOMYOPATHIES
Hypertrophic Cardiomyopathy
Cardiac Transplantation
CONGENITAL HEART DISEASE IN ADULTS
Background and Current Perspective
Preoperative Anesthetic Considerations
Intraoperative Anesthetic Considerations
OTHER CARDIAC PROCEDURES
Surgical Ablation of Atrial Fibrillation
Pericardial Tamponade and Constrictive Pericarditis
Constrictive Pericarditis
Cardiac and Aortic Trauma
Ischemic and Other Emergencies in the Cardiac Catheterization Laboratory
Procedures in the Hybrid Operating Room
GENERAL CONSIDERATIONS
HYBRID OPERATING ROOM
Acknowledgment
References
References
55 - Anesthesia for Correction of Cardiac Arrhythmias
Historical Perspectives
Scope of Cardiac Arrhythmias
Normal Cardiac Rhythm
Cardiac Arrhythmias
INDICATIONS FOR CORRECTION OF CARDIAC ARRHYTHMIAS
Permanent Pacing
Resynchronization Therapy
PREOPERATIVE EVALUATION
ANESTHETIC CONSIDERATIONS
Pacemakers
Monitored Anesthesia Care
General Anesthesia
Implantable Cardioverter-Defibrillator
PREOPERATIVE EVALUATION
ANESTHETIC CONSIDERATIONS
Monitored Anesthesia Care
General Anesthesia
EXTRACTION OF DEVICES
POSTOPERATIVE CARE
Correction of Cardiac Arrhythmias With Ablation Therapy
ANESTHETIC CONSIDERATIONS
Future Trends
References
References
56 - Anesthesia for Vascular Surgery
Preoperative Evaluation
COEXISTING DISEASE
PERIOPERATIVE AND LONG-TERM CARDIAC OUTCOMES
GUIDELINE‐BASED APPROACH
CARDIAC RISK ASSESSMENT
Clinical Risk Indices
Noninvasive Diagnostic Cardiac Testing
Cardiac Catheterization and Prophylactic Revascularization
ASSESSMENT OF PULMONARY FUNCTION
ASSESSMENT OF RENAL FUNCTION
PERIOPERATIVE Β-ADRENERGIC BLOCKER THERAPY
PERIOPERATIVE STATIN THERAPY
PERIOPERATIVE DUAL ANTIPLATELET THERAPY
Abdominal Aortic Reconstruction
NATURAL HISTORY AND SURGICAL MORTALITY
Abdominal Aortic Aneurysm
Aortoiliac Occlusive Disease
Renal and Visceral Arterial Insufficiency
AORTIC CROSS CLAMPING
Hemodynamic and Metabolic Changes
RENAL FUNCTION AND PROTECTION
THERAPEUTIC STRATEGIES
AORTIC UNCLAMPING
ANESTHETIC MANAGEMENT
Intraoperative Monitoring
Cell Salvage
Anesthetic Drugs and Techniques
Temperature Control
THORACOABDOMINAL AORTIC SURGERY
ETIOLOGY AND CLASSIFICATION
MORBIDITY AND MORTALITY
PREOPERATIVE PREPARATION AND MONITORING
ANESTHETIC MANAGEMENT
Simple Aortic Cross Clamping
Left Heart Bypass
Deep Hypothermic Circulatory Arrest
Anesthetic Technique
Spinal Cord Ischemia and Protection
Renal Ischemia and Protection
Coagulation and Metabolic Management
Endovascular Aortic Repair Surgery
HISTORY OF ENDOVASCULAR AORTIC REPAIR
ADVANCEMENTS IN STENT-GRAFT DEVICES
ANESTHETIC MANAGEMENT
Spinal Cord Blood Supply
Anesthesia Roadmap for EVARs
CHOICE OF ANESTHESIA
Radiation Safety
Renal Protection
Vascular Access and Blood Loss
Temperature Control
Spinal Cord Protection
POTENTIAL COMPLICATIONS
Early and Late Complications
Endoleaks
Postimplantation Syndrome
Hybrid Arch Repairs
ANESTHETIC MANAGEMENT OF HYBRID ARCH REPAIRS
Carotid Endarterectomy
INDICATIONS
PERIOPERATIVE MORBIDITY AND MORTALITY
PREOPERATIVE ASSESSMENT
ANESTHETIC MANAGEMENT
General Anesthesia
Regional and Local Anesthesia
Regional Versus General Anesthesia
Carbon Dioxide and Glucose Management
NEUROLOGIC MONITORING AND CEREBRAL PERFUSION
Carotid Artery Stump Pressure
Regional Cerebral Blood Flow
Electroencephalography
Somatosensory Evoked Potentials
Transcranial Doppler Ultrasonography
Cerebral Oxygenation
POSTOPERATIVE CONSIDERATIONS
Endovascular Treatment of Carotid Disease: Carotid Artery Stenting
Lower Extremity Revascularization
PERIPHERAL ARTERY DISEASE
PERIOPERATIVE MANAGEMENT OF ANTIPLATELETS AND ANTICOAGULANT IN PAD PATIENTS
Single Antiplatelet Therapy in Symptomatic Peripheral Artery Disease
Dual Antiplatelet Therapy in Symptomatic Peripheral Artery Disease
OPEN BYPASS SURGERIES AND ANESTHESIA MANAGEMENT
ENDOVASCULAR TREATMENT OF PERIPHERAL ARTERIAL DISEASE
Acknowledgment
References
References
57 - Anesthesia for Neurologic Surgery and Neurointerventions
Recurrent Issues in Neuroanesthesia
CONTROL OF INTRACRANIAL PRESSURE AND BRAIN RELAXATION
PNEUMOCEPHALUS
VENOUS AIR EMBOLISM
Detection of Venous Air Embolism
Which Patients Should Have a Right Heart Catheter?
Which Vein Should Be Used for Right Heart Access?
Positioning the Right Heart Catheter
Paradoxical Air Embolism
Transpulmonary Passage of Air
Nitrous Oxide
MONITORING
INTRAVENOUS FLUID MANAGEMENT
Which Colloid Solutions Should Be Used?
GLUCOSE MANAGEMENT
HYPOTHERMIA
EMERGENCE FROM ANESTHESIA
SELECTION OF ANESTHETICS
MANAGEMENT OF PACO2
Hypocapnia-Induced Cerebral Ischemia
Duration of Hypocapnia-Induced Reduction in Cerebral Blood Flow
MANAGEMENT OF ARTERIAL BLOOD PRESSURE
STEROIDS
OSMOTHERAPY AND DIURETICS
Mannitol
Hypertonic Saline
Diuretic Combinations
ANTICONVULSANTS
POSITIONING
General Considerations
Supine
Semilateral
Lateral
Prone
Sitting
. The properly positioned patient is more commonly in a modified recumbent position as shown in Fig. 57.8 rather than truly sitt...
. Hypotension should be avoided. Prepositioning hydration, compressive stockings, and slow, incremental adjustment of table posi...
. There have been sporadic reports of upper airway obstruction after posterior fossa procedures in which swelling of pharyngeal ...
. The sitting position has been implicated as a cause of rare instances of unexplained postoperative quadriplegia. It has been h...
Specific Procedures
SUPRATENTORIAL TUMORS
Preoperative Preparation
Monitoring
Management of Anesthesia
ANEURYSMS AND ARTERIOVENOUS MALFORMATIONS
Preoperative Evaluation
Anesthetic Technique
Monitoring
Special Considerations for Specific Aneurysms
Arteriovenous Malformations
HEAD INJURY
Intubating the Trachea of a Head-Injured Patient
The Cervical Spine
Anesthetic Technique
Monitoring
Hypothermia
POSTERIOR FOSSA PROCEDURES
Brainstem Stimulation
Balloon Compression of the Trigeminal Ganglion
TRANSSPHENOIDAL SURGERY
Preoperative Evaluation
Monitoring
Anesthetic Technique
Diabetes Insipidus
AWAKE CRANIOTOMY AND SEIZURE SURGERY
Presurgical Evaluation
Anesthesia for Electroencephalogram Electrode Placement
Preanesthetic Evaluation and Preparation
Anesthetic Technique
STEREOTACTIC PROCEDURES
NEUROENDOSCOPIC PROCEDURES
NEUROINTERVENTIONAL PROCEDURES
ANESTHETIC TECHNIQUE
ACUTE THROMBECTOMY
Tumors and Arteriovenous Malformations
Intracranial Aneurysms
Stent-Assisted Revascularization or Stent-Assisted Aneurysm Coil Embolization
CEREBROSPINAL FLUID SHUNTING PROCEDURES
Anesthetic Management
Pediatric Ventriculoperitoneal Shunts
PEDIATRIC NEUROSURGERY
SPINAL SURGERY
References
References
58 - Anesthesia for Bariatric Surgery
Obesity as a Disease
METABOLIC SYNDROME
OBSTRUCTIVE SLEEP APNEA—HYPOPNEA SYNDROME
Nonsurgical Management of Obesity
BEHAVIORAL INTERVENTIONS AND MODIFICATION
PHARMACOTHERAPY FOR WEIGHT LOSS
ALTERNATIVE PHARMACOLOGIC OPTIONS
IMPLANTED ELECTRICAL STIMULATORS
Surgical Management of Obesity
OPERATIVE PROCEDURES
RESTRICTIVE PROCEDURES
MALABSORPTIVE PROCEDURES
MINIMALLY INVASIVE PROCEDURES
HEALTH BENEFITS OF BARIATRIC SURGERY
Anesthetic Management of the Bariatric Surgical Patient
PREOPERATIVE EVALUATION
INTRAOPERATIVE CARE
Patient Positioning
Airway Management
Anesthetic Drugs and Dosing
Induction of Anesthesia
POSTOPERATIVE MANAGEMENT
MANAGEMENT OF COMPLICATIONS
Considerations for Management of the Obese Patient Presenting for Nonbariatric Surgery
References
References
59 - Anesthesia and the Renal and Genitourinary Systems
Innervation of the Genitourinary System
KIDNEY AND ABDOMINAL URETER
BLADDER AND URETHRA
PROSTATE AND PROSTATIC URETHRA
PENIS AND SCROTUM
TESTES
Renal Blood Flow
Anesthesia for Patients With Renal Disease
EVALUATION OF RENAL FUNCTION
GLOMERULAR FUNCTION
Glomerular Filtration Rate
Blood Urea Nitrogen
Creatinine and Creatinine Clearance
TUBULAR FUNCTION
Concentration
Protein
Glucose
ADDITIONAL DIAGNOSTIC TESTS
Urinalysis and Appearance
Urine and Serum Electrolytes With Blood Gases
Imaging Studies
IMPORTANT PATHOPHYSIOLOGIC MANIFESTATIONS OF CHRONIC RENAL FAILURE
Hypervolemia
Acidemia
Hyperkalemia
Cardiac and Pulmonary Manifestations
Hematologic Manifestations
EFFECTS OF DRUGS IN PATIENTS WITH REDUCED RENAL FUNCTION
Opioids
Inhaled Anesthetics
Intravenous Anesthetics
Muscle Relaxants and Their Antagonists
Vasopressors and Antihypertensive Drugs
ACUTE KIDNEY INJURY AND HEMODIALYSIS
PERIOPERATIVE MANAGEMENT OF PATIENTS WITH ACUTE KIDNEY INJURY
Dialysis
Nondialytic Management
Renal and Genitourinary Procedures
TRANSURETHRAL RESECTION OF THE PROSTATE
Pathophysiology of Prostate Hyperplasia
Surgical Procedures
Irrigation Solutions
Anesthetic Considerations for Transurethral Resection of the Prostate
Morbidity and Mortality After Transurethral Resection of the Prostate
COMPLICATIONS OF TRANSURETHRAL RESECTION OF THE PROSTATE
Absorption of Irrigating Solution
Excessive Circulatory Volume, Hyponatremia, and Hypoosmolarity
Glycine Toxicity
Ammonia Toxicity
Bladder Perforation
Transient Bacteremia and Septicemia
Hypothermia
Bleeding and Coagulopathy
Treatment of Transurethral Resection of Prostate Syndrome
Laser Resection, Plasma Vaporization, Microwave Ablation, and Aquablation of the Prostate
URETEROSCOPIC LITHOTRIPSY AND PERCUTANEOUS NEPHROLITHOTRIPSY
EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY
Biomechanical Effects of Shock Wave Therapy
Anesthetic Choices for Lithotripsy
Newer Generations of Lithotripters
Contraindications
Open Radical Surgery in Urology
Radical Nephrectomy
Radical Cystectomy
Radical Prostatectomy
Comparison of Anesthetic Techniques for Radical Prostatectomy
Robotic and Laparoscopic Surgery in Urology
Robotic-Assisted Radical Prostatectomy
Robotic-Assisted Radical Cystectomy With Diversion
LAPAROSCOPIC NEPHRECTOMY
Robotic-Assisted Partial Nephrectomy
Urogenital Pain Syndromes and Treatment
POSTOPERATIVE PAIN AND TREATMENT
Inflammatory Pain
Neuropathic Pain
Postoperative Urinary Retention
Enhanced Recovery After Surgery
CHRONIC POSTSURGICAL PAIN
Perioperative Management Considerations
ACUTE OR CHRONIC NONMALIGNANT PAIN
Benign Renal Masses
Polycystic Kidney Disease
NEPHROLITHIASIS
INFECTIOUS RENAL DISEASE
INTERSTITIAL CYSTITIS
NEURALGIAS
CHRONIC PROSTATITIS
PRIAPISM
CHRONIC PELVIC PAIN IN WOMEN
TESTICULAR PAIN
MEDICATIONS
NERVE BLOCKS AND NEUROMODULATION
CANCER-RELATED PAIN
Pediatric Tumors
Renal Cell Carcinoma
Bladder Cancer
Prostate Cancer
Uterine and Cervical Cancer
Neurolysis
Intrathecal Medications
Acknowledgment
References
References
60 - Anesthesia for Abdominal Organ Transplantation
Kidney Transplantation
INDICATIONS FOR KIDNEY TRANSPLANTATION
PATHOPHYSIOLOGY OF END-STAGE RENAL DISEASE
ANESTHESIA FOR KIDNEY TRANSPLANTATION: PREOPERATIVE EVALUATION
Day of Surgery
ANESTHESIA FOR KIDNEY TRANSPLANT: INTRAOPERATIVE MANAGEMENT
ANESTHESIA FOR KIDNEY TRANSPLANT: POSTOPERATIVE MANAGEMENT
ORGAN MATCHING AND ALLOCATION
ANESTHESIA FOR PATIENTS AFTER KIDNEY TRANSPLANTATION
Pancreas Transplantation
INDICATIONS FOR PANCREAS AND KIDNEY-PANCREAS TRANSPLANTATION
PATHOPHYSIOLOGY OF PANCREATIC INSUFFICIENCY
ANESTHESIA FOR PANCREAS TRANSPLANTATION: PREOPERATIVE EVALUATION
ANESTHESIA FOR PANCREAS TRANSPLANTATION: INTRAOPERATIVE MANAGEMENT
ANESTHETIC MANAGEMENT OF PANCREAS TRANSPLANTATION: POSTOPERATIVE MANAGEMENT
ORGAN MATCHING AND ALLOCATION
ANESTHESIA FOR PATIENTS AFTER PANCREAS TRANSPLANTATION
Liver Transplantation
INDICATIONS FOR LIVER TRANSPLANTATION
TRENDS IN LIVER TRANSPLANTATION
PATHOPHYSIOLOGY AND EVALUATION FOR LISTING
Cardiovascular Complications
Pulmonary Complications
Renal Dysfunction
Hepatic Encephalopathy
Ascites
Varices
Hemostasis
OBESITY AND SARCOPENIA
SURGICAL PROCEDURE
Preoperative Considerations
. The allocation policy in the United States, adopted by many programs worldwide, uses MELD scores to prioritize allocation of g...
Intraoperative Management
Preanhepatic Stage
Anhepatic Stage
Neohepatic Stage
Management of Transfusion, Hemostasis, and Coagulation
Postoperative Care
ACUTE LIVER FAILURE
LIVING DONOR LIVER TRANSPLANTATION
PEDIATRIC LIVER TRANSPLANTATION
ORGAN MATCHING AND ALLOCATION
ANESTHESIA FOR PATIENTS AFTER LIVER TRANSPLANTATION
INTESTINAL, LIVER-INTESTINAL, AND MULTIVISCERAL TRANSPLANT
Background
Surgical Procedures
Preoperative Assessment
Intraoperative Management
Postoperative Care
Conclusion
POSTABDOMINAL TRANSPLANTATION COMPLICATIONS
Surgical Complications
Infection
Immunosuppression
Malignancy
Long-Term Survival
Conclusions
References
References
61 - Anesthesia for Organ Procurement
Introduction
Management of Organ Donors After Declaration of Neurologic Death
PATHOPHYSIOLOGIC CHANGES WITH NEUROLOGIC DEATH
CARDIOVASCULAR RESPONSES TO NEUROLOGIC DEATH
RESPIRATORY RESPONSES TO NEUROLOGIC DEATH
ENDOCRINE, METABOLIC, AND STRESS RESPONSES TO NEUROLOGIC DEATH
Donation After Circulatory (Cardiac) Death
Extended Criteria Donor
Management of Organ Donors Before Procurement
CARDIOVASCULAR MANAGEMENT
PULMONARY MANAGEMENT
TEMPERATURE
HORMONES, STEROIDS, ELECTROLYTES, AND GLYCEMIC CONTROL
DONOR MANAGEMENT GOALS
Management of Donors After Circulatory Death
Management of Organ Donor During Procurement Surgery
Management of Living Organ Donors
LIVING KIDNEY DONOR
LIVING LIVER DONOR
LIVING LUNG DONOR
ISCHEMIA-REPERFUSION INJURY
Organ Preservation and Management After Procurement
References
References
62 - Anesthesia for Obstetrics
Physiologic Changes During Pregnancy and Delivery
CARDIOVASCULAR CHANGES
Physical Examination and Cardiac Studies
Intravascular Volume
Cardiac Output
Systemic Vascular Resistance
Aortocaval Compression
RESPIRATORY SYSTEM CHANGES
The Upper Airway
Ventilation and Oxygenation
Lung Volumes
GASTROINTESTINAL CHANGES
HEPATIC AND BILIARY CHANGES
RENAL CHANGES
HEMATOLOGIC CHANGES
Coagulation
NEUROLOGIC CHANGES
Uteroplacental Physiology
UTERINE BLOOD FLOW
PLACENTAL EXCHANGE
Oxygen Transfer
Drug Transfer
FETAL CIRCULATION AND PHYSIOLOGY
Labor Progress
LABOR AND FETAL MONITORING
CONTRACTION MONITORING
FETAL HEART RATE TRACING
FETAL HEART RATE CATEGORIES
Labor Analgesia
NONPHARMACOLOGIC LABOR PAIN MANAGEMENT
CONSIDERATIONS FOR PHARMACOLOGIC TREATMENT OF PAIN IN LABOR
SYSTEMIC MEDICATIONS
INHALED ANALGESIA
NEURAXIAL ANALGESIA
Neuraxial Analgesia and Progress of Labor
Timing of Placement
Epidural Analgesia
Spinal Analgesia
Combined Spinal-Epidural Analgesia
Dural Puncture Epidural
Neuraxial Analgesic Medications
Administration Techniques
Contraindications of Neuraxial Anesthesia
OTHER REGIONAL NERVE BLOCKS
Anesthesia Considerations for Operative Delivery
Anesthesia for Cesarean Delivery
MATERNAL RISKS AND CONSIDERATIONS
SPINAL ANESTHESIA
EPIDURAL ANESTHESIA
COMBINED SPINAL-EPIDURAL ANESTHESIA
GENERAL ANESTHESIA
Induction of Anesthesia: Intravenously Administered Drugs
Muscle Relaxants
Maintenance of General Anesthesia
Postcesarean Pain Control and Recovery
Complications of Regional Anesthesia
POSTDURAL PUNCTURE HEADACHE
EPIDURAL HEMATOMA
NEUROLOGIC INJURY
LOCAL ANESTHETIC SYSTEMIC TOXICITY
TOTAL SPINAL BLOCK
OTHER COMPLICATIONS
Maternal Comorbidities
HYPERTENSIVE DISORDERS
COAGULOPATHIES
OBESITY
CARDIAC DISEASE
ANTICOAGULATION
PULMONARY DISEASE
NEUROLOGIC DISORDERS
OPIOID DEPENDENCE
Anesthesia for Malpresentation and External Cephalic Version
Obstetric Emergencies
MATERNAL MORTALITY
OBSTETRIC HEMORRHAGE
Placenta Previa and Accreta
Vasa Previa
Placental Abruption
Uterine Rupture
Uterine Atony
Management of Massive Obstetric Hemorrhage
AMNIOTIC FLUID EMBOLISM
SHOULDER DYSTOCIA
OTHER OBSTETRIC EMERGENCIES
ADVANCED CARDIAC LIFE SUPPORT IN PREGNANCY
Nonobstetric Surgery During Pregnancy
PERIOPERATIVE CONSIDERATIONS
ANESTHETIC TOXICITY
PERIOPERATIVE FETAL HEART RATE MONITORING
ANESTHETIC MANAGEMENT
POSTOPERATIVE PAIN CONTROL
SPECIFIC SURGICAL TECHNIQUES
Laparoscopy
Trauma
Cardiac Surgery
Neurosurgery
Acknowledgment
References
References
63 - Anesthesia for Fetal Surgery and Other Fetal Therapies
Indications, Procedures,and Outcomes
ANEMIA AND INTRAUTERINE TRANSFUSION
CONGENITAL HEART DEFECTS
OBSTRUCTIVE UROPATHY
Twin Reversed Arterial Perfusion Sequence
TWIN-TO-TWIN TRANSFUSION SYNDROME
AMNIOTIC BAND SYNDROME
CONGENITAL DIAPHRAGMATIC HERNIA
MYELOMENINGOCELE
SACROCOCCYGEAL TERATOMA
CONGENITAL PULMONARY LESIONS
Preoperative Assessment and Counseling
Intraoperative Management and Considerations
FETAL PHYSIOLOGY AND MONITORING
FETAL ANESTHESIA, ANALGESIA, AND PAIN PERCEPTION
MANAGEMENT OF MINIMALLY INVASIVE PROCEDURES
MANAGEMENT OF OPEN PROCEDURES
Postoperative Management and Considerations
Management of Ex Utero Intrapartum Treatment Procedure
Conclusions and Future Considerations
References
References
64 - Anesthesia for Orthopedic Surgery
Preoperative Evaluation
EPIDEMIOLOGY AND DEMOGRAPHICS OF ORTHOPEDIC SURGERY
CARDIOVASCULAR COMORBIDITIES
Coronary Artery Disease
Other Cardiac Comorbidities
FRAILTY
NEUROLOGIC COMORBIDITIES
THROMBOEMBOLIC DISEASE
PULMONARY, RENAL, HEMATOLOGIC, ENDOCRINE DISEASES, AND NUTRITIONAL STATUS
COMPLICATIONS AND OUTCOME
Special Considerations for Conditions Leading to Orthopedic Surgery
OSTEOARTHRITIS
RHEUMATOID ARTHRITIS
ANKYLOSING SPONDYLITIS
ACHONDROPLASIA
Orthopedic Procedures in Children with Special Conditions
JUVENILE IDIOPATHIC ARTHRITIS
OSTEOGENESIS IMPERFECTA
CEREBRAL PALSY
SPINA BIFIDA
DUCHENNE MUSCULAR DYSTROPHY
ARTHROGRYPOSIS MULTIPLEX CONGENITA
Perioperative Management of the Orthopedic Patient
SPECIAL CONSIDERATIONS
Antifibrinolytic Drugs
Fat Embolism Syndrome
Bone-Cement Implantation Syndrome
ORTHOPEDIC TRAUMA
Pelvic Fractures
Femur Fractures
Tibia Fractures
Upper Extremity Fractures
Extremity Replantation
UPPER EXTREMITY SURGERIES
Hand Surgery
Shoulder and Elbow Surgery
LOWER EXTREMITY SURGERY
Knee and Hip Arthroscopy
Hip and Knee Arthroplasties
Foot and Ankle Surgery
Anesthesia for Spine Surgery
PREOPERATIVE ASSESSMENT
SPINAL TRAUMA
COMMON SPINAL PROCEDURES
INTRAOPERATIVE NEUROPHYSIOLOGIC MONITORING
PERIOPERATIVE VISUAL LOSS
POSTOPERATIVE PAIN AFTER SPINAL SURGERY
Acknowledgment
References
References
65 -
Geriatric Anesthesia
Organ-Specific Age-Related Physiologic and Pathologic Changes
CARDIOVASCULAR SYSTEM
Vascular Changes With Age
Myocardium
Cardiac Valves
Sympathetic and Autonomic System
RESPIRATORY SYSTEM
RENAL SYSTEM
GASTROINTESTINAL AND HEPATIC SYSTEMS
MUSCULOSKELETAL SYSTEM
CENTRAL NERVOUS SYSTEM
Preoperative Assessment
COGNITIVE ASSESSMENT AND DELIRIUM RISK
FUNCTIONAL/FRAILTY SCREENING
PALLIATIVE CARE
POLYPHARMACY
DEPRESSION AND ALCOHOL SCREENING
CAPACITY/ADVANCED DIRECTIVES/EXPECTATIONS/SUPPORT
Capacity
Shared Decision Making/Expectations
Intraoperative Management Considerations for Older Adults
Postoperative Concerns
Outcomes
Acknowledgment
References
References
66 -
Anesthesia for Trauma
Introduction
EPIDEMIOLOGY
MODERN TRAUMA SYSTEMS AND REGIONALIZATION
Prioritizing Trauma Care
PREHOSPITAL TRIAGE
BLUNT VERSUS PENETRATING TRAUMA
ADVANCED TRAUMA LIFE SUPPORT
INJURY PATTERNS PROMPTING URGENT OPERATIVE INTERVENTION
Anesthesia in War and Austere Conditions
Emergency Airway Management
INDICATIONS
APPROACH TO ENDOTRACHEAL INTUBATION
PROPHYLAXIS AGAINST PULMONARY ASPIRATION OF GASTRIC CONTENTS
PROTECTION OF THE CERVICAL SPINE
PERSONNEL
ANESTHETICS AND INDUCTION OF ANESTHESIA
NEUROMUSCULAR BLOCKING DRUGS
ADJUNCTS TO ENDOTRACHEAL INTUBATION
FACIAL AND PHARYNGEAL TRAUMA
THE FIELD PLACED AIRWAY
Resuscitation from Hemorrhagic Shock
PATHOPHYSIOLOGY OF HEMORRHAGIC SHOCK
ACUTE TRAUMATIC COAGULOPATHY
ASSESSMENT OF THE HEMOSTATIC SYSTEM
GENERAL APPROACH TO RESUSCITATION
Phase 1: Uncontrolled Hemorrhage
. In the setting of trauma, “permissive” rather than “deliberate” hypotension is controversial and has been the focus of numerou...
. As discussed earlier, management of the early coagulopathy associated with trauma must be incorporated into the overall phase ...
Phase 2, Controlled Hemorrhage
Phase 3, Restoration of Physiology
RESUSCITATION FLUIDS
RESUSCITATION EQUIPMENT
Trauma to the Central Nervous System
TRAUMATIC BRAIN INJURY AND CONCOMITANT TRAUMA
MANAGEMENT OF INTRACRANIAL PRESSURE IN THE OPERATING ROOM
SPINAL CORD INJURY
INTRAOPERATIVE MANAGEMENT OF SPINAL CORD INJURY
Orthopedic and Soft Tissue Trauma
SPECIFIC ORTHOPEDIC CONDITIONS
SOFT TISSUE TRAUMA
Other Traumatic Injuries
HEAD AND NECK SURGERY
CHEST INJURIES: PULMONARY
CHEST INJURIES: TRAUMATIC AORTIC INJURY
CHEST INJURIES: RIB FRACTURES
CHEST INJURIES: CARDIAC INJURY
ABDOMINAL INJURY
Selected Patient Populations
TRAUMA AND PREGNANCY
PEDIATRIC TRAUMA PATIENTS
OLDER TRAUMA PATIENTS
JEHOVAH’S WITNESS PATIENTS
Postoperative Care
EMERGENCE AND TRACHEAL EXTUBATION
ACUTE PAIN MANAGEMENT
Summary
Acknowledgment
References
References
67 - Prehospital Care for Medical Emergencies and Trauma
Background
BASIC VERSUS ADVANCED LIFE SUPPORT AND BEYOND
BASIC LIFE SUPPORT
ADVANCED LIFE SUPPORT, INTENSIVE CARE–LEVEL PREHOSPITAL CARE
Emergency Medical Technician and Paramedic-Based Emergency Medical Service Systems
Primary Survey and Initial Assessment at the Scene
MONITORS
POINT OF CARE ULTRASOUND
Out-of-Hospital Cardiac Arrest
ACUTE CORONARY SYNDROME
PREHOSPITAL DIAGNOSIS AND ELECTROCARDIOGRAPHY
PREHOSPITAL TREATMENT AND FIBRINOLYSIS
MECHANICAL CIRCULATORY SUPPORT
Prehospital Extracorporeal Cardiac Life Support
Respiratory Distress
EVALUATION
MANAGEMENT
Neurologic Injury and Head Injury
TRAUMATIC BRAIN INJURY
SPINAL CORD INJURY
ACUTE STROKE MANAGEMENT
SEIZURE
ALTERED MENTAL STATUS
Prehospital Trauma
TRIAGE
SCENE SECURITY
PRIMARY AND SECONDARY SURVEYS
STAY AND PLAY
SCOOP AND RUN
FURTHER CONSIDERATIONS
BALANCED RESUSCITATION
HEMORRHAGE CONTROL
ANTIFIBRINOLYTICS
TOURNIQUETS
RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA
FUTURE DIRECTIONS AND CHALLENGES
TRAUMA TRIAGE
Point-of-Care Diagnostics
Overdose/Toxicology/Environmental Exposure
EVALUATION
MANAGEMENT
ENVIRONMENTAL EXPOSURES
Horizons in Prehospital Care
Acknowledgment
References
References
68 - Biological, Natural, and Human-Induced Disasters: The Role of the Anesthesiologist
Introduction
Section 1: Natural Disasters
EARTHQUAKES
TORNADOES
TSUNAMI
HURRICANES
Section 2: Acts of Terrorism
SEPTEMBER 11, 2001 ATTACKS
MASS SHOOTINGS
BOSTON MARATHON BOMBING
Section 3: Chemical, Biological, Radiological, and Nuclear Warfare
HISTORICAL ASPECT OF CHEMICAL, BIOLOGICAL, RADIOLOGICAL, AND NUCLEAR WARFARE
CHEMICAL, BIOLOGICAL, RADIOLOGICAL, OR NUCLEAR HAZARDS DEFINED
Chemical
Biological
Radiological and Nuclear Weapons and Effects
Mass Casualty Situations and Chemical, Biological, Radiological, or Nuclear Attacks
Incident Management During a Chemical, Biological, Radiological, or Nuclear Attack and Personal Protective Equipment
Decontamination
Summary of Chemical, Biological, Radiological, or Nuclear Section
Section 4: Epidemic and Pandemic Infectious Outbreaks
PANDEMIC INFLUENZA A
SEVERE ACUTE RESPIRATORY SYNDROME
MIDDLE EAST RESPIRATORY SYNDROME
EBOLA VIRUS DISEASE
PERSONAL PROTECTION
Acknowledgment
References
References
69 - Anesthesia for Ophthalmic Surgery
Overview of Ophthalmic Anesthesia
OCULAR ANATOMY
OCULOCARDIAC REFLEX
INTRAOCULAR PRESSURE
OPHTHALMIC DRUGS
OPHTHALMIC PROCEDURES
Preoperative Evaluation
LABORATORY STUDIES
CARDIOVASCULAR EVALUATION
ANTICOAGULATION
Orbital Blocks
RETROBULBAR BLOCK
PERIBULBAR BLOCK
SUB-TENON BLOCK
FACIAL NERVE BLOCK
LOCAL ANESTHETIC SOLUTIONS FOR REGIONAL TECHNIQUES
Monitored Anesthesia Care
MONITORED ANESTHESIA CARE FOR CATARACT SURGERY UNDER TOPICAL ANESTHESIA
MONITORED ANESTHESIA CARE FOR OPHTHALMIC SURGERY WITH AN ORBITAL BLOCK
SPECIAL CONSIDERATIONS IN MONITORED ANESTHESIA CARE
General Anesthesia
Anesthesia for Pediatric Ophthalmology
GLAUCOMA
STRABISMUS
RETINOPATHY OF PREMATURITY
Postoperative Considerations in Ophthalmic Surgery
Ophthalmic Emergencies
OPEN GLOBE AND FULL STOMACH
Anesthesia-Related Eye Injuries
Acknowledgment
?Complete references available online at expertconsult.com
References
References
70 - Anesthesia for Otolaryngologic and Head-Neck Surgery
Synopsis of Ear, Nose, and Throat Anatomy
Preoperative Evaluation for Ear, Nose, and Throat Surgery
Airway Management in Otolaryngology
Airway Disorders in Otolaryngology
ANGIOEDEMA
ACUTE EPIGLOTTITIS
RETROPHARYNGEAL ABSCESS
LUDWIG ANGINA
AIRWAY TUMORS, POLYPS, AND GRANULOMAS
LARYNGEAL PAPILLOMATOSIS
Anesthesia for Panendoscopy
Otolaryngologic Trauma
Nasal Surgery
Tonsillectomy and Adenoidectomy
Endoscopic Sinus Surgery
Thyroid and Parathyroid Surgery
Airway Fires
Ear Surgery
Parotid and Other Salivary Gland Surgery
Sleep Apnea Surgery
Zenker Diverticulum
Anesthesia for Surgical Airways: Cricothyrotomy and Tracheostomy
Neck Dissection and Laryngectomy
Maxillary, Mandibular, and Temporomandibular Joint Surgery
Ear, Nose, and Throat Laser Surgery
Phonosurgery
Head and Neck Flap Reconstructive Surgery
Stridor and Heliox
Anesthesia for Face Transplantation
Acknowledgment
References
References
71 - Anesthesia for Robotic Surgery
What Is a Robot?
Why Is the Robot Preferred?
When Is the Robot Used?
Future Applications of Robotic Surgery
ROBOTICALLY ASSISTED INTUBATION
ROBOTIC SURGERY PHYSIOLOGY
Insufflation With CO2
Pulmonary Vasoconstriction
Cerebral Vascular Effects
Systemic Effects of Hypercapnia
Physiologic Changes Associated With Patient Positioning
CARDIOVASCULAR EFFECTS
INTRAOCULAR EFFECTS
URINARY OUTPUT
Types of Robotic Surgery
UROLOGIC PROCEDURES
Robotic-Assisted Retropubic Prostatectomies
Robotic-Assisted Radical Cystectomy
Robotic-Assisted Nephrectomy
GYNECOLOGIC SURGERY
Robotic-Assisted Hysterectomy
Other Gynecological Surgeries
General Surgery
Otolaryngology
TONSILLECTOMY
HEAD AND NECK DISSECTION
CARDIAC (SEE ALSO CHAPTER 54 ANESTHESIA FOR CARDIAC SURGICAL PROCEDURES)
Mitral Valve Replacement
Coronary Artery Bypass Grafting
ROBOTIC-ASSISTED THORACOSCOPIC SURGERY (SEE ALSO CHAPTER 53 ANESTHESIA FOR THORACIC SURGERY)
Summary
Acknowledgment
References
References
72 - Ambulatory (Outpatient) Anesthesia
Introduction
Benefits of Ambulatory Surgery
Facilities for Ambulatory Surgery
HOSPITAL INTEGRATED
HOSPITAL SELF-CONTAINED
FREESTANDING
OFFICE-BASED
Patient Selection Criteria
SURGICAL FACTORS
MEDICAL FACTORS
Obstructive Sleep Apnea
Age
Cardiovascular Disease
SOCIAL FACTORS
Preoperative Assessment
THE ROLE OF PREOPERATIVE ASSESSMENT
MECHANISMS AND TIMING OF PREOPERATIVE ASSESSMENT
PREOPERATIVE INVESTIGATION
Patient Preparation
PROVISION OF INFORMATION
PREOPERATIVE FASTING
PREMEDICATION
Management of Anxiety
Anxiolytic Premedication
Analgesic Premedication
Prophylactic Antiemetics
Antacid and Gastrokinetic Premedication
Anesthetic Techniques
CHOICE OF TECHNIQUE
GENERAL ANESTHESIA
INTRAVENOUS ANESTHESIA
Propofol
INHALED ANESTHETICS
Sevoflurane
Desflurane
ANESTHETIC ADJUVANTS
Nitrous Oxide
Opioid Analgesics
Nonopioid Analgesia
Cardiovascular Drugs
Neuromuscular Blocking Drugs
AIRWAY MANAGEMENT
REGIONAL ANESTHESIA
Spinal Anesthesia
New Drugs for Ambulatory Spinal Anesthesia
Epidural Anesthesia
Intravenous Regional Anesthesia
Other Local and Regional Anesthetic Techniques
SEDATION
Choice of Sedatives
Midazolam
Propofol
Potential New Sedatives
Analgesic Adjuvants
Delivery of Sedation
Monitoring Depth of Anesthesia
Recovery from Ambulatory Anesthesia
EARLY RECOVERY
SECOND-STAGE RECOVERY
FAST-TRACK RECOVERY
Postoperative Pain
MULTIMODAL ANALGESIA
RESCUE ANALGESIA
PAIN MANAGEMENT AT HOME
Managing Opioid Complications
Local Anesthetic Administration at Home
Postoperative Nausea and Vomiting
RISK ASSESSMENT AND STRATEGIES
ANTIEMETIC AGENTS
First-Generation Drugs
Serotonin 5-HT3 Receptor Antagonists
Steroids
Neurokinin-1 Antagonists
MANAGING PERSISTENT NAUSEA AND VOMITING
Special Areas
OFFICE-BASED PRACTICE
ANESTHESIA IN REMOTE LOCATIONS
Home Readiness and Beyond
PATIENT INFORMATION
CRITERIA FOR DISCHARGE
AFTERCARE AND FOLLOW-UP
Follow-Up and Outcome Measures
Adverse Effects After Ambulatory Surgery
Patient Satisfaction With Ambulatory Surgery
?Complete references available online at expertconsult.com
References
References
73 - Non-Operating Room Anesthesia
Overview: Defining Non-Operating Room Anesthesia—What It Is and How We Got Here
NOVEL CHARACTERISTICS OF NORA CASES
UNIQUE OBSTACLES: FROM PHYSICAL ENVIRONMENT TO THE MEDICINE–ANESTHESIOLOGY CULTURE GAP
FINANCIAL AND OPERATIONAL CONSTRAINTS
EFFECTS OF PAYMENT SYSTEMS
OPERATIONAL CONSTRAINTS
Transitional Priorities for Anesthesiologists Outside of the Operating Room
DEFINING INTERDISCIPLINARY SAFETY IN NON-OPERATING ROOM LOCATIONS: STANDARDIZATION, RELIABILITY, AND COMMUNICATION
OTHER GENERAL CONSIDERATIONS FOR NORA CARE
Continuous Learning
Culture of Accountability and Responsibility
Support for Teamwork Structure
Effective Communication and Flow of Information
NON-OPERATING ROOM ANESTHESIA LOCATIONS: SOME LOGISTICAL ISSUES
Sites of Care
Supplies and Equipment
MONITORING IN NON-OPERATING ROOM ANESTHESIA LOCATIONS
PREPROCEDURAL EVALUATION FOR NON-OPERATING ROOM ANESTHESIA CASES
OTHER CONSIDERATIONS
Specific Procedure-Related Issues
GASTROINTESTINAL PROCEDURES IN THE ENDOSCOPY SUITE
Reimbursement Constraints
Esophagogastroduodenoscopy
Sigmoidoscopy and Colonoscopy
Endoscopic Retrograde Cholangiopancreatography
NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY: THE NEXT FRONTIER?
Interventional Pulmonary Procedures
COMMON BRONCHOSCOPIC PROCEDURES
Novel Anesthetic Concerns
Anesthesiology for Image-Guided Interventions: Evolution of a New Interface
Diagnostic and Therapeutic Interventions: New Challenges
EQUIPMENT LAYOUT
Radiation Exposure
Contrast Material
Bleeding
VASCULAR INTERVENTIONAL PROCEDURES
BILIARY AND HEPATIC INTERVENTIONS
GASTROINTESTINAL AND GENITOURINARY INTERVENTIONS
PERCUTANEOUS INTERVENTIONS FOR ONCOLOGY
Procedures Guided by Computed Tomography, Positron Emission Tomography, and Magnetic Resonance Imaging
COMPUTED TOMOGRAPHY
Computed Tomography–Guided Biopsies
Computed Tomography–Guided Therapeutic Interventions
Catheter Drainage
Computed Tomography–Guided Ablation
Computed Tomography–Guided Injections for Pain Management
POSITRON EMISSION TOMOGRAPHY AND POSITRON EMISSION TOMOGRAPHY COMPUTED TOMOGRAPHY
MAGNETIC RESONANCE–GUIDED INTERVENTIONS
Physical Constraints of Magnetic Resonance Imaging Suites
Magnetic Resonance Imaging–Guided Interventions
Image-Guided Procedures for Specialty Areas: Neuroradiology and Interventional Cardiology
Procedures in the Neuroradiology Suite
GENERAL CONSIDERATIONS FOR ANESTHESIOLOGISTS IN THE INTERVENTIONAL SUITE
ENDOVASCULAR TREATMENT OF CEREBRAL ANEURYSMS
ENDOVASCULAR TREATMENT OF ARTERIOVENOUS MALFORMATIONS
Interventional Neuroradiology: Acute Stroke Treatments
Interventional Cardiology Procedures: General Considerations for the Electrophysiology and Catheterization Laboratories
THE ELECTROPHYSIOLOGY LABORATORY ENVIRONMENT: UNIQUE CHALLENGES FOR ANESTHESIOLOGISTS
Room Configuration and Equipment Layout
Anesthesiologists in the Electrophysiology Laboratory
DIAGNOSTIC ELECTROPHYSIOLOGY STUDIES
CATHETER ABLATION
ELECTROPHYSIOLOGIC DEVICES
Implantable Cardioverter-Defibrillators
Pacemakers
Anesthesiologists in the Catheterization Laboratory
PERCUTANEOUS CORONARY INTERVENTIONS
INTRAAORTIC BALLOON PUMPS AND PERCUTANEOUS VENTRICULAR ASSIST DEVICES
PERCUTANEOUS CLOSURE OF SEPTAL DEFECTS
PERIPHERAL ARTERIAL DISEASE
PERCUTANEOUS VALVE REPAIR AND REPLACEMENT
PERCUTANEOUS MITRAL VALVE REPAIR
Percutaneous Aortic Valve Replacement (Transcatheter Aortic Valve Replacement)
Common Complications and Remedies
. A number of vascular problems can occur during insertion and removal of the introducer sheath. Vascular dissection or perforat...
. Transvenous pacing is used to establish rapid ventricular pacing and a near-zero cardiac output state during ballooning of the...
. Patients respond idiosyncratically to balloon valvuloplasty; new-onset aortic insufficiency may require significant support an...
. Embolization into the aorta can occur as a result of ejection because of inadequate pacer capture or inappropriately high depl...
. Coronary occlusion is a potential problem if calcium or native aortic valve tissue occludes a coronary ostium. Prior coronary ...
. Cardiovascular collapse during transfemoral procedures may require cardiopulmonary support. Institutional variability exists r...
. Acute stroke is potentially detectable with unilateral changes in cerebral oximetry readings. The higher stroke rate of cohort...
Interventional Echocardiography Anesthesiologists as Co-Proceduralists—The Road Ahead
The Road Ahead: Toward a Comprehensive Strategy
SOME ADDITIONAL CONSIDERATIONS
Operational Effectiveness
Costs, Uniqueness, and Value-Added
Strategic Positioning
Financial Silos and Teamwork
Sustainable Strategy: Key Points
Acknowledgment
References
References
74 - Clinical Care in Extreme Environments: Physiology at High Altitude and in Space
Introduction to Altitude and Explanation of Hypobaric Hypoxia and Its Effect on Physiologic Performance
Physiologic Responses to Hypoxia/Acclimatization
CARDIOVASCULAR RESPONSES
RESPIRATORY RESPONSES
RENAL AND ENDOCRINE CHANGES
CENTRAL NERVOUS SYSTEM
GASTROINTESTINAL
Altitude Illness
ACUTE MOUNTAIN SICKNESS
HIGH-ALTITUDE CEREBRAL EDEMA
High-Altitude Pulmonary Edema
CHRONIC MOUNTAIN SICKNESS
COMORBIDITY AT ALTITUDE
CHILDREN
PREGNANCY
GENERAL PRINCIPLES
ANESTHETIC EQUIPMENT
GENERAL ANESTHESIA
REGIONAL ANESTHESIA
APPLICATION TO FLIGHT, INCLUDING AIR TRANSPORT OF CRITICALLY UNWELL PATIENTS
Space Medicine
INTRODUCTION TO SPACE EXPLORATION AND MEDICINE
RISK OF DISEASE AMONG ASTRONAUTS DURING SPACE TRAVEL
The Environmental Challenges Posed by Spaceflight
EXTREME ACCELERATIONS/DECELERATIONS
RADIATION
ISOLATION, CONFINEMENT, SLEEP DISTURBANCE, AND OTHER PSYCHOLOGICAL CHALLENGES
DECOMPRESSION AND CHANGING OXYGEN CONCENTRATIONS
MICROGRAVITY
Cardiovascular Physiology During Space Flight
Pulmonary Physiology During Space Flight
Musculoskeletal Physiology During Space Flight
Central Nervous System and Psychological Challenges During Space Flight
The Effect of Spaceflight on Other Physiologic Systems (Including the Immune and Gastric Systems)
Potential Medical Scenarios During Manned Space Missions
Thoughts and Considerations for Anesthetic Provision in Space
GENERAL PRINCIPLES
PREOPERATIVE PERIOD
General Anesthesia in Space
Regional Anesthesia in Space
References
References
75 - Clinical Care in Extreme Environments: High Pressure, Immersion, Drowning, Hypo- and Hyperthermia
Introduction
Physiology of Immersion
ACUTE EFFECTS OF IMMERSION
PROLONGED IMMERSION AND RESCUE
IMMERSION PULMONARY EDEMA
Drowning
DEFINITION
PREVALENCE
PATHOPHYSIOLOGY
RESCUE AND RESUSCITATION
HOSPITAL CARE
Circulation and Renal support
Neuroresuscitation
OUTCOME OF DROWNING
PREVENTION
Hypothermia
PHYSIOLOGY OF HYPOTHERMIA
CLINICAL CONSIDERATIONS
TREATMENT OF HYPOTHERMIA
HYPOTHERMIA OUTCOME
Hyperthermia
PHYSIOLOGY OF HYPERTHERMIA
CLINICAL SCENARIOS
TREATMENT OF HYPERTHERMIA
HYPERTHERMIA OUTCOME
Effects of Increased Gas Pressure
HISTORY
INCREASED BAROMETRIC PRESSURE EFFECTS
INCREASED PARTIAL PRESSURE OF OXYGEN
ELEVATION OF INERT GAS PARTIAL PRESSURE
ELEVATION OF ABSOLUTE PRESSURE
High-Pressure Nervous Syndrome
Pressure Reversal of Anesthesia
EFFECTS OF HYPERBARIC EXPOSURE ON DRUG DISPOSITION
Hyperbaric Oxygen Therapy
RATIONALE FOR HYPERBARIC TREATMENT OF SELECTED ACUTE CLINICAL ENTITIES
Carbon Monoxide Poisoning
Gas Embolism and Decompression Sickness
Acute Infections
Support of Arterial Oxygenation in Therapeutic Lung Lavage
Maintenance of Oxygen Transport in Severe Anemia
Crush Injury
Central Retinal Artery Occlusion and Central Retinal Vein Occlusion
Idiopathic Sudden Sensorineural Hearing Loss
THERAPEUTIC SYSTEMS
HYPERBARIC TREATMENT SCHEDULES
SIDE EFFECTS OF HYPERBARIC OXYGEN THERAPY
Oxygen Toxicity
Inert Gas Uptake
Barotrauma
PRACTICAL ASPECTS OF HYPERBARIC THERAPY
Middle Ear Pressure Equilibration
Pulmonary Pressure Equilibration
Patient Monitoring
Intravenous Fluid Administration
Blood Gas Assessment and Ventilator Management
Other Medical Devices
Atmosphere Control
Fire Hazards
Evaluation of a Patient for Safety of Hyperbaric Oxygen Treatment
Delivery of Anesthesia at Increased Ambient Pressure
. Inhaled anesthesia of any type can pollute the enclosed chamber atmosphere with anesthetic gases, which may exert pharmacologi...
. The increased ambient pressure in a hyperbaric chamber allows nitrous oxide to be used at partial pressures exceeding its MAC....
. The effect of a volatile anesthetic on a patient is proportional not to the alveolar concentration but to the partial pressure...
. Intravenous anesthetics behave similarly and are unlikely to be affected within the usual clinical range of ambient pressure (...
. Regional anesthesia is likely to be both safe and effective in a hyperbaric environment by avoiding the requirement for mechan...
FUTURE DIRECTIONS IN HYPERBARIC OXYGEN THERAPY
Preoperative Hyperbaric Oxygenation
Stroke
Acute Traumatic Brain Injury
Summary
References
References
SECTION V • Pediatric Anesthesia
76 - Regional Anesthesia in Children
Introduction
Relevant Differences Between Children and Adults
ANATOMIC DIFFERENCES
Change in Body Size Resulting From the Growth Process
Delayed Ossification of Bones and Fusion of Sacral Vertebrae
Development of Curvature of the Spine
Loose Attachment of Fasciae and Fluidity of Epidural Fat
Delayed Myelinization of Nerve Fibers
PAIN PERCEPTION
PHARMACOLOGY OF LOCAL ANESTHETICS AND ADDITIVES
Local Anesthetics
Local Fixation
Systemic Absorption and Distribution
Opioids
Other Additives
PHYSIOLOGIC FACTORS
PSYCHOLOGICAL FACTORS
Indications, Contraindications, and Complications
INDICATIONS
Anesthetic Indications
Intraoperative and Postoperative Analgesia and Procedural Pain
Management of Nonsurgical Pain
Chronic Pain Relief and Palliative Care
Nonanalgesic Indications
CONTRAINDICATIONS AND LIMITATIONS
Absolute Contraindications to Neuraxial Blocks
Absolute Contraindications to Peripheral Nerve Block Procedure
Patients at Risk for Compartment Syndrome
Hemoglobinopathies
Bone and Joint Deformities
Preexisting Neurologic Disorders or Diseases
COMPLICATIONS
Local Complications
Systemic Complications
Epidemiology
Selection of Materials and Anesthetic Solution
SELECTION OF BLOCK PROCEDURE
SELECTION OF EQUIPMENT
SELECTION OF DRUG
Anatomic Identification in Regional Anesthesia
MANUAL APPROACHES
Electrical Stimulation
Ultrasound Techniques
Safety, Precautions and Discharge Criteria
ACCEPTABLE ENVIRONMENTS FOR PERFORMING A REGIONAL BLOCK
SEDATION AND GENERAL ANESTHESIA
PATIENT MONITORING AND SAFETY PRECAUTIONS DURING THE BLOCK PROCEDURE
Monitoring and Anesthesia Chart
Technique of Injection
Assessment of the Block
POSTOPERATIVE MONITORING IN THE RECOVERY ROOM
DISCHARGE CRITERIA AFTER SINGLE-SHOT PROCEDURES
MANAGEMENT OF CONTINUOUS REGIONAL TECHNIQUES
Neuraxial Blocks
CAUDAL ANESTHESIA
Ultrasound Guidance for Caudal Block Placement
Anatomy of the Sacral Hiatus
Technique
EPIDURAL ANESTHESIA
Anatomy and Physiology
Indications and Contraindications
Techniques
SPINAL ANESTHESIA
Anatomy and Physiology
Indications and Contraindications
Technique
Drugs and Doses
Adverse Effects and Complications
Upper Extremity Conduction Blocks
ANATOMIC CONSIDERATIONS
CERVICAL BRACHIAL PLEXUS BLOCKS
Interscalene Approach
Parascalene Approach
SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK
INFRACLAVICULAR BRACHIAL PLEXUS BLOCKS
Infraclavicular Approaches
Midclavicular Approaches
Paracoracoid Approaches
Ultrasound-Guided Infraclavicular Block
Axillary Approach
DISTAL CONDUCTION BLOCKS
Elbow and Forearm Approaches
DIGITAL BLOCKS
Lower Extremity Conduction Blocks
LUMBAR PLEXUS NERVE BLOCKS
Anatomic Considerations
Psoas Compartment Block (Direct Lumbar Plexus Block)
Femoral Nerve Block
Fascia Iliaca Compartment Blocks
Other Lumbar Plexus Nerve Blocks
SCIATIC NERVE BLOCKS
Anatomic Considerations
Indications and Contraindications
Proximal Sciatic Nerve Blocks
Popliteal Sciatic Approach
Metatarsal Blocks
Truncal Blocks
PERIPHERAL BLOCKS FOR ABDOMINAL WALL SURGERY
Rectus Sheath and Paraumbilical Block
Rectus Sheath Block
Ilioinguinal and Iliohypogastric Nerve Blocks
Transversus Abdominis Plane Block
Ilioinguinal Nerve Block
Transversus Abdominis Plane Block
PERIPHERAL BLOCKS FOR PENILE SURGERY
Penile Block
Pudendal Nerve Block
INTERCOSTAL NERVE BLOCK
THORACIC PARAVERTEBRAL SPACE BLOCK
OTHER NERVE BLOCKS OF THE TRUNK
ERECTOR SPINAE PLANE BLOCKS
Face, Head, and Neck Nerve Blocks
NERVE BLOCK OF THE FACE
Anatomic Considerations
Superficial Trigeminal Nerve Blocks
Suprazygomatic Approach to Maxillary Nerve
Mandibular Nerve Block
Block of the Nose: Nasociliary Nerve Block and External Nasal Nerve Block
Nerve Blocks of the External Ear
Nerve Block of the Head
Nerve Block of the Neck
Other Procedures
INTRAVENOUS REGIONAL ANESTHESIA
Intradermal Wheals
Wound Infiltration
Acknowledgment
References
References
77 - Pediatric Anesthesia
Physiologic Considerations
INTRAUTERINE DEVELOPMENT
NEONATAL AND INFANT PHYSIOLOGY
Cardiovascular System
Respiratory System
The Kidneys
The Liver
Gastrointestinal System
Hematology and Coagulation System
Central Nervous System
Thermoregulation
Pharmacology
DEVELOPMENTAL PHARMACOLOGY
Body Composition
Protein Binding
Clearance
Pharmacodynamic Differences
INHALED ANESTHETICS
Potency of Inhaled Anesthetics in Children
Pharmacokinetics of Inhaled Anesthetics in Children
Halothane
Sevoflurane
Isoflurane
Desflurane
Nitrous Oxide
Xenon
Emergence Agitation and Delirium
INTRAVENOUS GENERAL ANESTHETICS
Propofol
Total Intravenous Anesthesia in Children
Thiopental
Ketamine
Etomidate
Α2 AGONISTS
Clonidine
Dexmedetomidine
OPIOIDS
Morphine
Codeine
Meperidine
Fentanyl
Alfentanil
Sufentanil
Remifentanil
Tramadol
MUSCLE RELAXANTS AND REVERSAL AGENTS
Succinylcholine
Nondepolarizing Muscle Relaxants
Sugammadex
THE IMPACT OF ANESTHESIA ON THE DEVELOPING BRAIN
Animal data
Translating the Animal Data to Humans
Human Study Outcomes
Results From Studies That Look at Specific Developmental Disorders
Perioperative Management
PREOPERATIVE EVALUATION
The Child With an Upper Respiratory Tract Infection
PERIOPERATIVE ANXIETY IN CHILDREN
PREOPERATIVE FASTING
ANESTHESIA INDUCTION
AIRWAY MANAGEMENT AND VENTILATION
Airway Management
The Child With Stridor
Ventilation Strategies
EQUIPMENT AND MONITORING
SAFETY ISSUES
FLUID MANAGEMENT
Regional Anesthesia and Analgesia
Important Pediatric Anesthesia Scenarios
NEONATAL ANESTHESIA
ANESTHESIA FOR SPECIFIC NEONATAL SURGICAL PROCEDURES
Meningomyelocele
Omphalocele and Gastroschisis
Tracheoesophageal Fistula
Congenital Diaphragmatic Hernia
ANESTHESIA FOR SPECIFIC SURGICAL PROCEDURES IN INFANTS
Pyloric Stenosis
Infant Inguinal Hernia Repair
Cleft Lip and Palate
ANESTHESIA FOR SPECIFIC PROCEDURES AND CONDITIONS IN OLDER CHILDREN
Anterior Mediastinal Mass
Inhaled Foreign Body
Tonsillectomy and Obstructive Sleep Apnea
Muscle Biopsy
Child With Developmental Disability
Acknowledgment
References
References
78 - Anesthesia for Pediatric Cardiac Surgery
Unique Features of Pediatric Cardiac Anesthesia
PHYSIOLOGIC CONSIDERATIONS AND MATURATIONAL FEATURES OF THE PEDIATRIC PATIENT
CONGENITAL HEART DISEASE
Physiologic Approach to Congenital Heart Disease
Anesthetic Management
PREOPERATIVE MANAGEMENT
Anesthetic Evaluation
Concurrent Medications and Drug Interactions
INTRAOPERATIVE MANAGEMENT
Operating Room Preparation
Physiologic Monitoring
Special Monitoring
Induction and Maintenance of Anesthesia
Cardiopulmonary Bypass
DIFFERENCES BETWEEN ADULT AND PEDIATRIC CARDIOPULMONARY BYPASS
Volume of Priming Solutions
Temperature
Hemodilution
BLOOD GAS MANAGEMENT
INITIATION OF CARDIOPULMONARY BYPASS
PUMP FLOW RATES
SPECIAL TECHNIQUES
Deep Hypothermic Circulatory Arrest
Regional Cerebral Perfusion
Glucose Regulation
Renal Effects
Pulmonary Effects
STRESS RESPONSE AND CARDIOPULMONARY BYPASS
DISCONTINUATION OF CARDIOPULMONARY BYPASS
ULTRAFILTRATION
SPECIFIC PROBLEMS ENCOUNTERED IN DISCONTINUING CARDIOPULMONARY BYPASS
Left Ventricular Dysfunction
Right Ventricular Dysfunction
Pulmonary Artery Hypertension
Anticoagulation, Hemostasis, and Blood Conservation
Postoperative Management
POSTOPERATIVE NEUROPSYCHOLOGIC MORBIDITY
MECHANICAL ASSIST DEVICES
Anesthesia for Heart and Lung Transplantation
Anesthesia for Closed-Heart Operations
Anesthesia for Interventional or Diagnostic Cardiac Procedures
TRANSCATHETER TECHNIQUE FOR ATRIAL SEPTAL DEFECT CLOSURES
TRANSCATHETER VENTRICULAR SEPTAL DEFECT CLOSURES
ANGIOPLASTY OF BRANCH PULMONARY ARTERY STENOSIS
BALLOON VALVULOTOMIES
COIL EMBOLIZATION
VALVE PROSTHESES
EMERGENT PROCEDURES
ENDOMYOCARDIAL BIOPSY
CARDIAC CATHETERIZATION OF PATIENTS SUPPORTED BY EXTRACORPOREAL MEMBRANE OXYGENATION
Adult Congenital Heart Disease
EPIDEMIOLOGY AND CLASSIFICATION
CONSIDERATIONS IN THE CARE OF PATIENTS WITH ADULT CONGENITAL HEART DISEASE
SPECIFIC LESIONS WITH UNIQUE CONSIDERATIONS FOR ADULT CONGENITAL HEART DISEASE
Tetralogy of Fallot
Fontan Circulations
Transposition of the Great Arteries
Pediatric Cardiac Electrophysiology
DIAGNOSTIC EVALUATION
Cardiac Event Monitoring
Insertable Cardiac Recorders
RADIOFREQUENCY ABLATION OF ACCESSORY PATHWAYS
Intraatrial Reentrant Tachycardia
Arrhythmias and Sudden Cardiac Death
IMPLANTATION OF PACEMAKERS AND DEFIBRILLATORS
Advances in Resynchronization Therapy
Anesthesia for Noncardiac Surgery
INFECTIVE ENDOCARDITIS PROPHYLAXIS: AMERICAN HEART ASSOCIATION GUIDELINES
MAGNETIC RESONANCE IMAGING OF THE HEART
Offsite Anesthesia in Cardiac Surgery Patients
Acknowledgment
References
References
79 - Pediatric and Neonatal Critical Care
Relationship Between the Intensive Care Unit and the Operating Room
Family Partnered Care in the Pediatric Intensive Care Unit
Disclosure of Medical Errors
Organization of the Pediatric Intensive Care Unit
Cardiovascular System
STRUCTURAL AND FUNCTIONAL DEVELOPMENT
DEVELOPMENT OF THE CIRCULATION
DEVELOPMENT OF AUTONOMIC CONTROL OF THE CIRCULATION
MYOCARDIAL METABOLISM
Common Cardiovascular Disease States
CONGENITAL HEART DISEASE
ACUTE CIRCULATORY FAILURE IN CHILDREN (SHOCK AND SEPSIS)
Shock
Classification of Shock
Diagnosis of Shock
Compensatory Mechanisms
Therapy and Outcomes
Cardiovascular Pharmacology
EPINEPHRINE
Dopamine
Vasopressin
Isoproterenol
Dobutamine
Norepinephrine
Milrinone
Levosimendan
Nesiritide
Digitalis
Calcium
Bicarbonate Therapy
Vasodilators
Nicardipine
Sodium Nitroprusside
Hydralazine
Tolazoline and Phentolamine
Prostaglandin E1
Nitric Oxide
Disorders of Cardiac Rhythm
HYPERTENSION
Neonatal Resuscitation
INITIAL ASSESSMENT OF THE FETUS AT BIRTH
ONGOING ASSESSMENT
CLEARING THE AIRWAY
TEMPERATURE CONTROL
OXYGEN
VENTILATION
PNEUMOTHORAX
ENDOTRACHEAL INTUBATION
CARDIAC COMPRESSIONS
MEDICATIONS
Epinephrine
Naloxone
DETECTION OF HYPOVOLEMIA
TREATMENT OF HYPOVOLEMIA
OTHER CAUSES OF HYPOTENSION
MECONIUM
COLOR
RESUSCITATION EQUIPMENT
PEDIATRIC CARDIAC ARREST AND RESUSCITATION
Phases of Resuscitation
PREARREST
NO FLOW/LOW FLOW
Airway-Breathing-Circulation or Circulation-Airway-Breathing
POSTARREST/RESUSCITATION
Interventions During the Cardiac Arrest (No Flow) and Cardiopulmonary Resuscitation (Low Flow)
AIRWAY AND BREATHING
CIRCULATION: OPTIMIZING BLOOD FLOW DURING LOW FLOW CARDIOPULMONARY RESUSCITATION: PUSH HARD, PUSH FAST
CHEST COMPRESSION DEPTH
COMPRESSION/VENTILATION RATIOS
DUTY CYCLE
CIRCUMFERENTIAL VERSUS FOCAL STERNAL COMPRESSIONS
OPEN-CHEST CARDIOPULMONARY RESUSCITATION
MEDICATIONS USED TO TREAT CARDIAC ARREST
Vasopressors
Antiarrhythmic Medications
POST-RESUSCITATION INTERVENTIONS
Temperature Management
Glucose Control
Blood Pressure Management
Post-resuscitation Myocardial Dysfunction
NEUROMONITORING
QUALITY OF CARDIOPULMONARY RESUSCITATION
EXTRACORPOREAL MEMBRANE OXYGENATION-CARDIOPULMONARY RESUSCITATION
Ventricular Fibrillation and Ventricular Tachycardia in Children
ANTIARRHYTHMIC MEDICATIONS: LIDOCAINE AND AMIODARONE
PEDIATRIC AUTOMATED EXTERNAL DEFIBRILLATORS
WHEN SHOULD CARDIOPULMONARY RESUSCITATION BE DISCONTINUED?
Respiratory System
STRUCTURAL AND FUNCTIONAL DEVELOPMENT: AGE-DEPENDENT VARIABLES
Airways and Alveoli
Pulmonary Circulation
Biochemical Development
Respiratory Transition: Placenta to Lung
Mechanics of Breathing
Lung Compliance Versus Age
Chest Wall
Upper Airway
Closing Capacity
Resistive Forces
Control of Breathing
Oxygen Transport: Oxygen Loading and Unloading
RESPIRATORY FAILURE
MONITORING OF RESPIRATORY FUNCTION
RESPIRATORY FAILURE
HYPOVENTILATION SYNDROMES IN CHILDREN WITH NORMAL LUNGS
Primary Pulmonary Alveolar or Interstitial Disorders
Obstructive Airway Disease
RESPIRATORY CARE
PEDIATRIC ACUTE RESPIRATORY DISTRESS SYNDROME
PRINCIPLES OF LUNG PROTECTIVE STRATEGIES: LIMITING VENTILATOR ASSOCIATED LUNG INJURY
ADJUVANT THERAPIES FOR ACUTE RESPIRATORY DISTRESS SYNDROME
Prone Positioning
Surfactant Therapy
Corticosteroids
Nitric Oxide
Extracorporeal Membrane Oxygenation
ADJUNCTIVE PHARMACOLOGIC THERAPY: SEDATIVES AND ANALGESICS
WEANING FROM MECHANICAL VENTILATION
RESPIRATORY DISORDERS
Laryngotracheobronchitis (Croup)
Epiglottitis
Bronchiolitis
Cystic Fibrosis
Bronchopulmonary Dysplasia
Sleep Apnea
Foreign Body Aspiration
Upper Airway Obstruction and Meningomyelocele
ASTHMA
Asthma Therapy
Pulmonary Hypertension
CENTRAL NERVOUS SYSTEM
Functional Postnatal Neurologic Development
Assessment of Neurologic Function
Laboratory Assessment of Neurologic Function
Traumatic Brain Injury
Cerebral Perfusion Pressure and Cerebral Blood Flow
Respiratory Management in the Brain Injured Child
Hypoxic-Ischemic Encephalopathy
Hydrocephalus
Tumors
Status Epilepticus in Children
Renal System
ENDOCRINE SYSTEM
Adrenal Axis
Congenital Adrenal Hyperplasia
Pheochromocytoma
Iatrogenic Chronic Adrenal Insufficiency
Anterior Pituitary
Diabetes Insipidus
Syndrome of Inappropriate Secretion of Antidiuretic Hormone
Pancreas/Insulin
GASTROINTESTINAL SYSTEM
Structural and Functional Development of the Intestine
Development of the Liver
Congenital Malformations
Enteral and Parenteral Nutrition for the Critically Ill Child
Hematology
Oncology
Leukostasis
Tumor Lysis Syndrome
Mediastinal Mass
IMMUNITY AND INFECTION
Empiric Antibiotic Coverage
Prevention of Health Care–Associated Infections
Ventilator-Associated Pneumonia
Catheter-Associated Blood Stream Infections
Urinary Tract Infection
Infections in the Newborn
PEDIATRIC TRAUMA
Prenatal and Perinatal Injuries
Trauma in Children
Child Abuse
Ingestion Injury
Transport of the Critically Ill Child
Acknowledgment
References
References
SECTION VI • Postoperative Care
80 -The Postanesthesia Care Unit
Admission to the Postanesthesia Care Unit
The Standards for Postanesthesia Care
Early Postoperative Physiologic Changes
Transport to the Postanesthesia Care Unit
Upper Airway Obstruction
LOSS OF PHARYNGEAL MUSCLE TONE
RESIDUAL NEUROMUSCULAR BLOCKADE
LARYNGOSPASM
EDEMA OR HEMATOMA
OBSTRUCTIVE SLEEP APNEA
Management of Upper Airway Obstruction
Differential Diagnosis of Arterial Hypoxemia in the Postanesthesia Care Unit
ALVEOLAR HYPOVENTILATION
DECREASED ALVEOLAR OXYGEN PRESSURE
VENTILATION-PERFUSION MISMATCH AND SHUNT
INCREASED VENOUS ADMIXTURE
DECREASED DIFFUSION CAPACITY
Pulmonary Edema
POSTOBSTRUCTIVE PULMONARY EDEMA
TRANSFUSION-RELATED ACUTE LUNG INJURY
TRANSFUSION-ASSOCIATED CIRCULATORY OVERLOAD (TACO)
Monitoring and Treatment of Hypoxemia
OXYGEN SUPPLEMENTATION
LIMITATIONS OF PULSE OXIMETRY
Oxygen Delivery Systems
SUPPLEMENTAL OXYGEN
CONTINUOUS POSITIVE AIRWAY PRESSURE
NONINVASIVE POSITIVE-PRESSURE VENTILATION
Hemodynamic Instability
SYSTEMIC HYPERTENSION
SYSTEMIC HYPOTENSION
Hypovolemic (Decreased Preload)
Distributive (Decreased Afterload)
Cardiogenic (Intrinsic Pump Failure)
Extracardiac/Obstructive Shock
Myocardial Ischemia: Evaluation and Treatment
EVALUATION
TREATMENT
Cardiac Arrhythmias
TACHYCARDIA
BRADYCARDIA
ATRIAL ARRHYTHMIAS
VENTRICULAR ARRHYTHMIAS
TREATMENT
Renal Dysfunction
OLIGURIA
Intravascular Volume Depletion
Postoperative Urinary Retention
CONTRAST NEPHROPATHY
INTRAABDOMINAL HYPERTENSION
RHABDOMYOLYSIS
Postoperative Hypothermia and Shivering
MECHANISM
TREATMENT
CLINICAL EFFECTS
Postoperative Nausea and Vomiting
PREVENTION AND TREATMENT
Delirium
RISK FACTORS
PROPHYLAXIS AND MANAGEMENT
Emergence Excitement
Delayed Awakening
Discharge Criteria
POSTANESTHESIA SCORING SYSTEMS
Infection Control
Postoperative Management of Patients Undergoing Transcatheter Aortic Valve Replacement and Transcatheter Mitral Valve Repair
Immediate Postoperative Care of Craniotomies
Potentially Devastating Visual Complications
CORNEAL ABRASIONS
POSTOPERATIVE VISION LOSS
Future Considerations
INTENSIVE CARE
OUTPATIENT PROCEDURES
Summary
Acknowledgment
References
References
81 -
Acute Postoperative Pain
Fundamental Considerations
PAIN PATHWAYS AND THE NEUROBIOLOGY OF NOCICEPTION
ACUTE AND CHRONIC EFFECTS OF POSTOPERATIVE PAIN
Acute Effects
Chronic Effects
Preventive Analgesia
Multimodal Approach to Perioperative Recovery/Enhanced Recovery after Surgery
Treatment Methods
Systemic Analgesic Techniques
OPIOIDS
Advantages and Characteristics
Intravenous Patient-Controlled Analgesia
NON-OPIOIDS
Nonsteroidal Antiinflammatory Agents
Acetaminophen
Gabapentinoids
KETAMINE
Tramadol
Regional Analgesic Techniques
Single-Dose Neuraxial Opioids
Continuous Epidural Analgesia
Analgesic Drugs
Location of Catheter Insertion
Side Effects of Neuraxial Analgesic Drugs
Patient-Controlled Epidural Analgesia
Benefits of Epidural Analgesia
Risks With Epidural Analgesia
Peripheral Regional Analgesia
Truncal Blocks
Intraarticular and Local Infiltration Analgesia
OTHER TECHNIQUES
POSTOPERATIVE ANALGESIA IN SPECIAL POPULATIONS
OPIOID-TOLERANT PATIENTS: PATIENTS WITH PREEXISTING PAIN
PEDIATRIC PATIENTS
OBESITY, OBSTRUCTIVE SLEEP APNEA, AND SLEEP
INPATIENT PAIN SERVICES
Acknowledgment
References
References
82 - Cognitive Dysfunction and Other Long-Term Complications of Surgery and Anesthesia
Introduction
Nomenclature, Diagnosis, and Measurement
NOMENCLATURE
Preexisting Cognitive Impairment
Delirium
Postoperative Cognitive Dysfunction
Cognitive Concern
Activities of Daily Living Assessment
Objective Testing
MEASUREMENT AND DIAGNOSIS OF PERIOPERATIVE NEUROCOGNITIVE DISORDERS
Assumptions Underlying Assessment of Postoperative Cognitive Dysfunction/Perioperative Neurocognitive Disorder
Cognitive Decline Outcome Criteria
Issues Associated With Repeated Testing
Summary
Risk Factors, Informed Consent, and Perioperative Management
RISK FACTORS
INFORMED CONSENT
PREOPERATIVE MANAGEMENT
Intraoperative Management
TYPE OF ANESTHESIA
DEXMEDETOMIDINE
KETAMINE
INTRAOPERATIVE BRAIN MONITORING
BLOOD PRESSURE CONTROL
Postoperative Management
PAIN MANAGEMENT
Mechanisms and Biomarkers
AMYLOIDOPATHY
CELL AND MOLECULAR STUDIES
ANIMAL STUDIES
HUMAN STUDIES
AMYLOIDOPATHY SUMMARY
TAUOPATHY
CELL AND MOLECULAR STUDIES
ANIMAL STUDIES
HUMAN STUDIES
TAUOPATHY SUMMARY
CALCIUM DYSREGULATION
CELL AND MOLECULAR STUDIES
ANIMAL AND HUMAN STUDIES
CALCIUM SUMMARY
NEUROINFLAMMATION
CELL AND MOLECULAR STUDIES
ANIMAL STUDIES
HUMAN STUDIES
NEUROINFLAMMATION SUMMARY
Summary
CLOSING COMMENTS
Acknowledgment
References
References
SECTION VII • Critical Care Medicine
83 - Critical Care Anesthesiology
Introduction
HISTORY OF CRITICAL CARE MEDICINE AND THE ROLE OF ANESTHESIA INTENSIVISTS
Intensive Care Unit Structure and Management
CAPACITY, UTILIZATION, AND COST
STRUCTURE AND STAFFING PATTERNS IN THE INTENSIVE CARE UNIT
MANAGEMENT AND QUALITY IMPROVEMENT
Acute Respiratory Distress Syndrome and Lung Protective Ventilation
ACUTE RESPIRATORY DISTRESS SYNDROME
“BABY LUNG”
LUNG PROTECTIVE VENTILATION
PERMISSIVE HYPERCAPNIA
VENTILATION MODES IN ACUTE RESPIRATORY DISTRESS SYNDROME
POSITIVE END-EXPIRATORY PRESSURE AND OPEN LUNG STRATEGIES
POSITIVE END-EXPIRATORY PRESSURE
OPEN LUNG STRATEGIES
Esophageal Manometry, Transpulmonary Pressures, and Positive End-Expiratory Pressure
Decremental Positive End-Expiratory Pressure Trials
Recruitment Maneuvers
PRONE POSITIONING
SELF-INDUCED LUNG INJURY
NEUROMUSCULAR BLOCKADE
NONINVASIVE POSITIVE-PRESSURE VENTILATION AND HIGH-FLOW NASAL CANNULA
SUMMARY OF EVIDENCE-BASED VENTILATION IN ARDS AND FUTURE RESEARCH
MANAGEMENT OF PAIN AND AGITATION
Sepsis and Shock
INFECTION, SYSTEMIC INFLAMMATORY RESPONSE SYNDROME, AND SEPSIS
SEPTIC SHOCK
SURVIVING SEPSIS CAMPAIGN
HEMODYNAMIC SUPPORT IN SEPTIC SHOCK
Hemodynamic Resuscitation in Shock
END-ORGAN PERFUSION
Urine Output
Lactate
Standard Base Deficit
Other Tissue-Specific Perfusion Markers
CARDIAC OUTPUT
Pulmonary Artery Catheter, Thermal Dilution
Transpulmonary Thermal Dilution or Lithium Dye Dilution
Pulse Contour Analysis
ELECTRICAL BIOREACTANCE AND IMPEDANCE
TRANSTHORACIC AND TRANSESOPHAGEAL ECHOCARDIOGRAPHY
Mixed Venous and Central Venous Saturation
FLUID RESPONSIVENESS
SUMMARY OF FLUID RESUSCITATION IN SHOCK
Care for Patients Receiving Cancer Immunotherapy in the Intensive Care Unit
IMMUNE CHECKPOINT INHIBITORS
CHIMERIC ANTIGEN RECEPTOR T CELLS
Point-of-Care Ultrasound in Critical Care
VASCULAR ULTRASOUND
PULMONARY ULTRASOUND
CARDIAC ULTRASOUND
OTHER APPLICATIONS AND THE FUTURE
Conclusion
Acknowledgment
References
References
84 -
Neurocritical Care
Intracranial Physiology and Cerebrovascular Autoregulation
General Cardiopulmonary Considerations
Fluids, Electrolytes, and Nutrition
Temperature Control
Monitoring
CLINICAL EXAMINATION
INTRACRANIAL PRESSURE AND CEREBRAL PERFUSION PRESSURE
Intracranial Pressure
Cerebral Perfusion Pressure
CEREBRAL BLOOD FLOW
Thermal Diffusion Flowmetry
Transcranial Doppler Monitoring
CEREBROVASCULAR AUTOREGULATION AND VASOMOTOR REACTIVITY
CEREBRAL OXYGENATION
Jugular Venous Oxygen Saturation
Brain Tissue Oxygen Tension
Near-Infrared Spectroscopy
BRAIN METABOLISM AND BIOCHEMISTRY—CEREBRAL MICRODIALYSIS
NEUROPHYSIOLOGIC MONITORING
Electroencephalography
Evoked Potentials
MULTIMODALITY NEUROMONITORING
RADIOGRAPHIC IMAGING
Common Diseases in the Neurocritical Care Unit
TRAUMATIC BRAIN INJURY
Pathophysiology
Treatment
SPINAL CORD INJURY
Cerebrovascular Disease
SUBARACHNOID HEMORRHAGE
Early Brain Injury
Secondary Brain Injury
ISCHEMIC STROKE
INTRACEREBRAL HEMORRHAGE
STATUS EPILEPTICUS
Neuromuscular Disease
GUILLAIN-BARRÉ SYNDROME
MYASTHENIA GRAVIS
Central Nervous System Infection
MENINGITIS
ENCEPHALITIS
Postoperative Neurosurgical Care
BRAIN DEATH
Ethical Considerations
Conclusion
Acknowledgment
References
References
85 - Extracorporeal Membrane Oxygenation and Cardiac Devices
Introduction
History of Extracorporeal Cardiorespiratory Support
ECMO for Respiratory Failure (VV ECMO)
INDICATIONS FOR VV ECMO IN RESPIRATORY FAILURE
CONTRAINDICATIONS TO VV ECMO
Extracorporeal Membrane Oxygenation for Patients Awaiting and Undergoing Lung Transplantation
ECMO for Circulatory Failure (VA ECMO)
INDICATIONS FOR VA ECMO
CONTRAINDICATIONS TO VA ECMO
The Ethics of Extracorporeal Membrane Oxygenation
The Mechanics of Extracorporeal Membrane Oxygenation
THE PUMP
THE OXYGENATOR
PULSATILITY WITH VA ECMO
FLOW AND GAS EXCHANGE PHYSIOLOGY WITH VV ECMO
FLOW AND GAS EXCHANGE PHYSIOLOGY WITH VA ECMO
EXTRACORPOREAL MEMBRANE OXYGENATION FOR THE FAILING RIGHT HEART
Vascular Access for Extracorporeal Membrane Oxygenation
CANNULATION FOR VV ECMO
CANNULATION FOR VA ECMO
CANNULATION FOR VPA ECMO
ALTERNATIVE CANNULATION STRATEGIES
Monitoring on Extracorporeal Membrane Oxygenation
PUMP PRESSURES AND FLOWS
INTRAVASCULAR PRESSURES
TISSUE OXIMETRY
Anticoagulation
Therapeutic Monitoring of Unfractionated Heparin (Table 85.4)
ACTIVATED CLOTTING TIME
ACTIVATED PARTIAL THROMBOPLASTIN TIME
ANTI-FACTOR XA (“HEPARIN LEVEL”)
HEPARIN-INDUCED THROMBOCYTOPENIA
Weaning from Extracorporeal Membrane Oxygenation
WEANING FROM VA ECMO
WEANING FROM VV ECMO
WEANING THE PATIENT WITH SEPARATE RVAD, LVAD, AND ECMO
Complications of Extracorporeal Membrane Oxygenation
PERIPHERAL EXTREMITY ISCHEMIA
The Anesthesiologist’s Role in Extracorporeal Membrane Oxygenation
Acknowledgment
References
References
86 - Cardiopulmonary Resuscitation and Advanced Cardiac Life Support
Sudden Cardiac Arrest and Cardiopulmonary Resuscitation
BRIEF HISTORY AND PHYSIOLOGIC CONSIDERATIONS
BASIC LIFE SUPPORT
Recognition of Sudden Cardiac Arrest
Bystander Cardiopulmonary Resuscitation
Shock First or Chest Compressions?
Automated External Defibrillators and Manual Defibrillation
Single versus Stacked Defibrillation
Determination of Efficiency of Cardiopulmonary Resuscitation
Update to Airway Management and Ventilation in Cardiac Arrest
ADVANCED CARDIAC LIFE SUPPORT: MANAGEMENT OF CARDIAC ARREST
Asystole
Pulseless Electrical Activity
Pulseless Ventricular Tachycardia or Ventricular Fibrillation
Resuscitation Medications During Cardiac Arrest
. Epinephrine produces beneficial effects in patients during cardiac arrest, primarily due to its α-adrenergic effects increasin...
. Vasopressin is a nonadrenergic peripheral vasoconstrictor that also causes coronary and renal vasoconstriction. Studies compar...
. The role of antiarrhythmic medications during shock-refractory VF/pulseless VT is to facilitate the restoration and maintenanc...
. The use of steroids in cardiac arrest has been assessed in both IHCA and OHCA settings. In IHCA, patients administered steroid...
Cardiopulmonary Resuscitation in Patients With Mechanical Circulatory Support
Cardiopulmonary Resuscitation Using a Mechanical Cardiopulmonary Resuscitation Device
Echocardiography in Cardiac Arrest
Cardiac or Respiratory Arrest Associated With Opioid Overdose
Recognition and Emergency Response for Suspected Stroke
Recognition and Management of Specific Arrythmias
BRADYARRHYTHMIAS
TACHYARRHYTHMIA
Postresuscitation Interventions
EMERGENCY PERCUTANEOUS CORONARY INTERVENTION
TARGETED TEMPERATURE MANAGEMENT
POSTRESUSCITATION OXYGEN AND VENTILATION THERAPY
GLYCEMIC CONTROL IN THE POST–CARDIAC ARREST PATIENT
DETERMINE THE CAUSE AND EXTENT OF INJURY AFTER CARDIAC ARREST
Laboratory Testing
Chest Radiographs
Computed Tomography Imaging
Magnetic Resonance Imaging of the Brain
Echocardiography and Critical Care Ultrasonography
TERMINATION OF RESUSCITATION EFFORTS—INDICATORS OF POOR OUTCOME POST-RETURN OF SPONTANEOUS CIRCULATION
Pediatric Resuscitation
PEDIATRIC BASIC LIFE SUPPORT
PEDIATRIC ADVANCED LIFE SUPPORT
HIGHLIGHTING THE SIMILARITIES OR DIFFERENCES VERSUS ADULT RESUSCITATION
FOREIGN BODY AIRWAY OBSTRUCTION
DROWNING
SUDDEN UNEXPLAINED DEATHS
TERMINATION OF PEDIATRIC RESUSCITATION ATTEMPTS
Future of Resuscitation Science and Care
INDIVIDUALIZED CARDIOPULMONARY RESUSCITATION
Extracorporeal Membrane Oxygenation
COORDINATED POSTRESUSCITATION CARE
Acknowledgment
References
References
SECTION VIII • Ancillary Responsibilities and Problems
87 - Acute and Anesthetic Care of the Burn-Injured Patient
Introduction
Pathophysiology
Burn Shock
Negative Imbibition Pressure
Permeability Effects Of The Burn
Fluid Loss in Burns: The Temporal Aspect
Mediators Important in Fluid Loss
Hemodynamic Alterations
Inhalation Injury
Pathophysiology
Diagnosis of Inhalation Injury
Treatment
Acute Management
Patient Evaluation
Estimation of Size and Depth of Burn Injury
Fluid Resuscitation
Endpoints for the Fluid Treatment
Fluid Creep/Resuscitation Failure
Electrical Injury
Chemical Burns
Cold Injury
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis
Special Considerations
Pediatrics
Elderly
Obese Patients
Infection Control
Metabolic Considerations
Nutrition
Anesthetic Management
Preoperative Evaluation
Intraoperative Management
Airway Management
Vascular Access
Ventilator Management
Monitoring
Pharmacologic Considerations
Anesthetic Drugs
Opioids
NSAIDS
α2 Agonists
Anxiolytics
Gabapentin
Ketamine
Regional Anesthesia
Muscle Relaxants
Fluid Management and Blood Loss During Excision
Temperature Management
Surgical Considerations
Postoperative Care
Pain Management
Conclusion
References
References
88 - Occupational Safety, Infection Control, and Substance Abuse
Physical Exposures
INHALATIONAL ANESTHETICS
Provider Health Effects
Fetal Health Effects
Mitigating Health effects
RADIATION
Ionizing Radiation: X-rays
Mitigating Health Effects
Nonionizing Radiation: Lasers
SURGICAL SMOKE
Infectious Exposures
INFECTION PRECAUTIONS
Standard Precautions
Environmental Controls
Needlestick and Sharps Safety
Vaccine Preventable Illness
TRANSMISSION OF INFECTIOUS AGENTS
Contact Transmission
Droplet Transmission
Airborne Transmission
Complex Transmission
Bloodborne Organisms
Emerging Diseases
Substance Use Disorders
EPIDEMIOLOGY
ETIOLOGY
IMPACT
PREVENTION AND DETECTION
INTERVENTION, TREATMENT, PROGNOSIS, AND REENTRY
Fatigue
INCIDENCE AND IMPACT
GUIDELINES
REQUIREMENTS AND RECOMMENDATIONS
Acknowledgment
References
References
89 - Clinical Research
Introduction
Key Principles
RANDOM ERROR
SYSTEMATIC ERROR
Confounding
Selection Bias
Information Bias
DESIGN ERROR
STATISTICAL INFERENCE
Study Design
OBSERVATIONAL STUDIES
Descriptive Studies
Analytic Studies
Surveys
Health Services Research
EXPERIMENTAL STUDIES
Unrandomized Studies
Randomized Studies
ANALYSES OF PUBLISHED RESEARCH
Systematic Reviews
Metaanalyses
Individual Patient Metaanalysis
Study Protocol
HYPOTHESES
POPULATION
INTERVENTIONS AND COMPARATORS
OUTCOMES
SAMPLE SIZE
DATA ANALYSIS PLAN
SUPPORTING STUDIES
Feasibility and Pilot Studies
Sub-Studies
Sub-Analyses
Ethical and Regulatory Considerations
ETHICS APPROVAL
REGISTRATION
REGULATORY APPROVAL
DATA SHARING
Study Management
FINANCIAL MANAGEMENT
DATA MANAGEMENT
HUMAN RESOURCE MANAGEMENT
ADVERSE EVENT REPORTING
MONITORING AND AUDIT
Study Reporting
MANUSCRIPT
AUTHORSHIP
PUBLISHING
RESEARCH INTEGRITY
Reflection, Feedback, and Forward Planning
References
References
90 - Interpreting the Medical Literature
Introduction
INTENT OF THE CHAPTER
The Publication Process
TYPES OF JOURNALS
TYPES OF JOURNAL ARTICLES
THE PEER REVIEW PROCESS
Accessing the Medical Literature
PRIMARY LITERATURE
SECONDARY LITERATURE
TRADITIONAL AND SOCIAL MEDIA
Assessing the Methodology of a Study
THE “EVIDENCE PYRAMID” AND ITS EVOLUTION
BASIC RESEARCH DESIGNS
BIG DATA AND PRAGMATIC CLINICAL TRIALS
Tools to Ensure Study Quality
RECOGNITION OF THE NEED FOR STANDARDS IN STUDY REPORTING
SUMMARY OF REPORTING GUIDELINES
REGISTRATION OF CLINICAL TRIALS AND STUDY PROTOCOLS
Interpreting the Analysis of a Study
THE CONCERN OVER P < .05
REDUCING BIAS IN STUDY DESIGN
CORRELATION VERSUS CAUSATION
DATA-DRIVEN ANALYTIC METHODS
The Dark Side of the Medical Literature
INCENTIVES TO PUBLISH POOR-QUALITY RESEARCH
For Researchers
For Medical Journals
MISCONDUCT IN THE PUBLICATION PROCESS
EVOLVING MECHANISMS TO DETECT RESEARCH MISCONDUCT
Conclusions
References
References