Anesthesia Student Survival Guide: A Case-Based Approach

Foreword to the Third Edition
Preface
Prior Edition Contributors
Contents
Contributors
Part I: Introduction to Anesthesiology
1: How to Be a “Star” Student, Career Options, and the Match
Introduction
How to Be a “Star” Student
Career Options
The Future of the Medical Specialty of Anesthesiology
The Match
A Typical General Anesthesia Case
Preoperative Evaluation
Preoperative Medication
Monitoring
Induction and Intubation
Maintenance
Emergence
Post Anesthesia Care Unit (PACU) Management
Chapter Summary
Suggested Educational Resources
2: History of Anesthesia and Introduction to the Specialty
Introduction
The First Anesthetic Agents
What Is Anesthesia?
Who Administers Anesthesia?
Modern Anesthesia Machinery
Conclusion
Suggested Further Reading
Part II: Pharmacology
3: Pharmacology Principles
Basic Pharmacologic Principles
Pharmacokinetics
Absorption
Distribution
Metabolism and Excretion
Pharmacodynamics
Suggested Further Reading
4: Pharmacology of Intravenous Anesthetic Agents
Benzodiazepines
Opioids
Induction Agents
Neuromuscular Blocking Agents
Depolarizing NMBs
Nondepolarizing NMBs
Acetylcholinesterase Inhibitors
Anticholinergics
Suggested Further Reading
5: Pharmacology of Inhalational Anesthetics
Pharmacokinetics of Uptake, Distribution and Elimination
Induction
Emergence
Theories of Inhalational Anesthetic Action
Depth of Anesthesia and MAC
Nitrous Oxide
Concentration Effect
Second Gas Effect
Volatile Anesthetics (Isoflurane, Sevoflurane, and Desflurane)
Isoflurane
Sevoflurane
Desflurane
Suggested Further Reading
6: Pharmacology of Local Anesthetics
History of Local Anesthetics
Local Anesthetic Mechanism of Action
Factors Affecting Local Anesthetic Action
Local Anesthetic Metabolism
Uses of Local Anesthetics in Anesthesia Practice
Local Anesthetic Side Effects and Toxicity
Treatment of Local Anesthetic Toxicity
Suggested Further Reading
7: Pharmacology of Adjunct Agents
Sympathomimetics
Antiemetics
Antihypertensives
Dexmedetomidine
NSAIDs (Nonsteroidal Anti-inflammatory Drugs)
Suggested Further Reading
Part III: Preoperative Considerations
8: The Preoperative Patient Evaluation
Introduction
The Interview
History and Physical
Cardiovascular
Pulmonary
Hepatic and Gastrointestinal Disease
Hematologic Disorders
Endocrine
Renal
Neurologic Disease
Nutritional Status
The Aging Patient
Physical Exam
Medications/Allergies
Medical Records/Family History
Laboratory Data
Perioperative Risk Evaluation
Anesthesia Consent Form
Postoperative Opioid Prescribing
References
9: Airway Evaluation and Management
Introduction
Airway Anatomy
Airway Evaluation
Mask Ventilation
Supraglottic Airway
Direct Laryngoscopy and Tracheal Intubation
Rapid Sequence Induction
Fiber-Optic Intubation
Video Assisted Endotracheal Intubation (Glidescope, C-Trach, C-MAC, etc.)
Evaluation and Management of the Difficult Airway
Suggested Further Reading
10: The Anesthesia Machine
The Anesthesia Machine Components
Pipeline Inlets
Cylinder Inlets
Cylinders
Pressure Regulation
Fail-Safe System
Flowmeters
Vaporizers
Gas Outlet
Alarms
Waste-Gas Scavengers
Oxygen Flush Valve
Anesthesia Machine Checkout
Anesthesia Breathing Systems
Humidifiers
The Mechanical Ventilator
Suggested Readings
11: Anesthesia Equipment and Monitors
Introduction
Blood Pressure Monitoring
Electrocardiographic Monitoring
Pulse Oximetry
Capnography and Ventilation Monitoring
Monitoring Muscle Relaxation
Monitoring the Depth of Anesthesia
Temperature Monitoring
Central Venous Pressure (CVP) and Pulse Pressure Variability (PPV) Monitoring
Pulmonary Artery Pressure Monitoring
Other Special Patient Monitors
Other Anesthesia Equipment
Standards for Basic Anesthetic Monitoring
Committee of Origin: Standards and Practice Parameters
Standard I
Objective
Standard II
Oxygenation
Objective
Methods
Ventilation
Objective
Methods
Circulation
Objective
Methods
Body Temperature
Objective
Methods
Suggested Further Reading
Part IV: Intraoperative Considerations
12: Anesthetic Techniques: General, Sedation, MAC
The Anesthesiologist and the Airline Pilot
Preflight Check
Takeoff
Cruising Altitude
Landing
Taxi to the Terminal
Anesthetic Techniques
Monitored Anesthesia Care (MAC)/Anesthesia Sedation
Choice of Anesthetic Technique
General Anesthesia
Physiology of General Anesthetics
Suggested Further Reading
13: Anesthetic Techniques: Regional
Introduction
Neuraxial Anesthesia
Neuraxial Anatomy
Indications and Contraindications
Mechanism of Action
Epidural Anesthesia
Technique
Pharmacology of Epidural Anesthesia
Spinal Anesthesia
Technique
Factors Effecting Level and Duration of Local Anesthesia
Caudal Anesthesia
Combined Spinal–Epidural
Complications and Side Effects: Spinal and Epidural Anesthesia
Cauda Equina Syndrome (CES)
Transient Neurologic Syndrome (TNS)
Cardiovascular Changes
Post-dural Puncture Headache (PDPH)
High/Total Spinal Anesthesia
Urinary Retention
Intravascular Injection/LAST (Local Anesthetic Systemic Toxicity)
Spinal/Epidural Hematoma
Epidural Abscess
Peripheral Nerve Blocks
Identification of the Target Nerve
Brachial Plexus and Upper Extremity Blocks
Interscalene Block
Supraclavicular Block
Infraclavicular Block
Axillary Block
Lower Extremity Peripheral Nerve Block
Femoral Nerve Block
Sciatic Nerve Block
Ankle Block
Peripheral Nerve Catheters
Intravenous Regional Anesthesia (Bier Block)
Suggested Further Reading
14: Electrolytes and Acid-Base Balance
Introduction to Serum Osmolality
Introduction to Serum Electrolyte Composition
Physiologic Regulation of Electrolytes
Sodium
Potassium
Chloride
Calcium
Magnesium
Phosphate
Introduction to Acid Base Physiology
Metabolic Abnormalities
Metabolic Acidosis
Metabolic Alkalosis
Respiratory Abnormalities
Respiratory Acidosis
Respiratory Alkalosis
Evaluating Multiple Disorders
Suggested Reading
15: Fluids and Transfusion Therapy
Fluid Therapy
Body Fluid Compartments
Perioperative Fluid Balance
Selection of Resuscitative Fluid
Crystalloids
Colloid Solutions
Crystalloid Versus Colloid
Transfusion Therapy and Blood Components
Blood Groups and Compatibility
Red Blood Cells
Plasma
Platelets
Cryoprecipitate
Complications of Product Transfusion
Conclusions
References
16: Peripheral, Arterial, and Central Lines and Gastric Tube Placement
Peripheral Intravenous Lines
Technique
Troubleshooting
Arterial Catheters
Site of Cannulation
Technique
Troubleshooting
Central Venous Catheter Insertion
Cannula Size and Length
Ultrasound Guidance
Internal Jugular Vein
Subclavian Vein
Femoral Vein
Complications
Orogastric and Nasogastric Tubes
Suggested Readings
17: Intraoperative Problems
General Concepts
Cardiovascular
Respiratory
Temperature Disturbances
Allergic Reactions
Post Operative Complications
References
Part V: Systems Physiology and Anesthetic Subspecialties
18: Cardiac and Thoracic Anesthesiology
Cardiac Anesthesia
Normal Cardiovascular Anatomy
Normal Cardiovascular Physiology
Cardiac Pathophysiology
Anesthetic Management for Cardiac Surgery
Minimally Invasive Cardiac Procedures
Thoracic Anesthesia
Anatomy
Common Presenting Thoracic Pathology
Lung Cancer
Mediastinal Mass
Preoperative Evaluation
Anesthetic Management
One-Lung Ventilation
References & Suggested Further Reading
19: Physiology & Anesthesia for Neurologic, ENT and Ophthalmologic Surgery
Neuroanesthesia - Physiology
Intracranial Pressure (ICP)
Cerebral Blood Flow
Blood Brain Barrier (BBB)
Neuromonitoring
Neurophysiology – Anesthetic Effects
Neurosurgical Procedures – Anesthetic Management
General Goals
Craniotomy
Preoperative Considerations
Intra-Operative Considerations
Neurovascular Surgery: Aneurysm Clipping/AVM Resection
Neurologic Disease and Anesthesia: Special Considerations [5]
Myasthenia Gravis (MG)
Eaton-Lambert Syndrome (Table 19.2)
Multiple Sclerosis
Guillain-Barre Syndrome
Neuroleptic Malignant Syndrome (NMS)
Parkinson’s Disease
Epilepsy
Otolaryngology (ENT) – Anesthetic Approach
Specialized Equipment
Preoperative Planning
Intra-Operative Issues
Neck Dissection
Endoscopic Sinus Surgery (FESS)
Inner Ear Surgery
Airway Surgery
Ophthalmology
References
20: Obstetric Anesthesia
Normal Physiologic Changes of Pregnancy
Cardiovascular
Respiratory
Central Nervous System
Hematologic
Gastrointestinal
Renal
Musculoskeletal
Uteroplacental Blood Flow
Maternal Fetal Exchange
Intrapartum Fetal Evaluation
Neonatal Evaluation
Anesthesia for Vaginal Delivery
Non-pharmacologic Options for Labor Pain
Systemic Medications for Labor Pain
Neuraxial Anesthesia
Epidural Analgesia
Combined Spinal-Epidural Analgesia
Dural Puncture Epidural
Continuous Spinal Analgesia
Neurologic Complications of the Neuraxial Techniques
Common Myths Regarding Neuraxial Analgesia
Anesthesia for Cesarean Section
Spinal Anesthesia
Epidural Anesthesia
General Anesthesia
Severe Maternal Morbidity
Antepartum/Postpartum Hemorrhage
Maternal Hypertensive Disorders
Suggested Further Reading
21: Physiology and Anesthesia for General and Bariatric Surgery
Obesity
Physiologic Changes Associated with Obesity
Cardiovascular System
Respiratory System
Gastrointestinal System
Endocrine and Metabolic System
Neurological and Psychological Problems
Airway Challenges in Obesity
Surgery for Obesity
Anesthetic Considerations
Preoperative Evaluation
Intraoperative Considerations
Postoperative Considerations
Anesthesia Considerations for General Abdominal Surgery
Preoperative Evaluation
Intraoperative Considerations
Laparoscopic Surgery
Laparotomy
Postoperative Considerations
Anesthetic Considerations for Common Abdominal Surgeries
Esophageal Surgery
Stomach Surgery
Small and Large Bowel Surgery
Hemorrhoid Surgery
Liver and Biliary Tract Surgery
Spleen Surgery
Pancreatic Surgery
Hernia Surgery
Suggested Further Reading
22: Anesthesia for Urological Surgery
Anatomy
Patient Positioning
Preoperative Assessment
Anesthetic Management
Cystoscopy/Ureteroscopy/TURBT
TURP
Laser Surgery in Urology
Radical Prostatectomy: Open, Laparoscopic, Robotic
Radical Cystectomy
Nephrectomy: Open or Laparoscopic
Renal Transplantation
Orchiectomy, Orchidopexy, Penile Surgery
Extracorporeal Shock Wave Lithotripsy
Complications of Urologic Surgery
Suggested Further Reading
23: Anesthesia for Pediatric Surgical Procedures
Preoperative Evaluation
Psychological Assessment
Physiological Assessment
Anatomy and Physiology
Airway
Transition from Fetal to Neonatal Circulation
Respiratory
Cardiac
Neurologic
Hematologic
Hepatic
Renal
Gastrointestinal
Skin
Intraoperative Care
Pharmacology
OR Equipment and Setup
Venous Access
Arterial Access
Intravenous Fluids
Pediatric Drug Preparation
Techniques
Induction
Maintenance
Emergence
Pain Management
Pediatric Surgical Conditions
References
24: Physiology and Anesthesia for Older Adults
Physiological Changes with Aging
Cardiovascular System Changes
Pulmonary System Changes
Renal System Changes
Nervous System Changes
Postoperative Cognitive Dysfunction and Delirium
Pharmacokinetic and Pharmacodynamic Changes
Anesthetic Management
Preoperative Examination
Premedication
Monitoring
Intraoperative Management
General Anesthesia Versus Regional Anesthesia
The Postoperative Period
Suggested Further Reading
25: Ambulatory Anesthesia
Introduction
Ambulatory Surgery
Preoperative Considerations
Intraoperative Management
Postoperative Management
Suggested Further Reading
26: Non-operating Room Anesthesia
Introduction
General Considerations of NORA
Gastroenterology (GI) Endoscopy
Electrophysiology Lab (EP)
Diagnostic Radiology
Neuro-interventional (NIR) and Interventional Radiology (IR)
Interventional Pulmonology
Electroconvulsive Therapy (ECT)
References
27: Orthopedic Surgery
Introduction
Choice of Anesthetic
Upper Extremity
Hip Surgery
Knee Surgery
Ankle and Foot Surgery
Postoperative Analgesia
Orthopedic Trauma
Special Considerations
Blood Loss
Positioning Injuries
Tourniquet Issues
Methyl Methacrylate Cement
Fat Embolism
Antithrombotic Prophylaxis
References
28: Trauma Surgery
Introduction
Mechanism of Injury
Initial Patient Evaluation and Management
Hemorrhaging Shock
Pathophysiology of Hemorrhaging Shock
Airway Management in Trauma Patient
Resuscitation Strategies of Hemorrhagic Shock
Damage Control Resuscitation
Support for Coagulation
References
Part VI: Postoperative Considerations
29: Acute Pain Management
Introduction
Basic Pain Sensation in the Normal Individual
General Pain Definitions
Treatment of Acute Pain
Multimodal Analgesia
Opioids
Regional Analgesic Techniques
Resources and Suggested Further Reading
30: Perioperative Acute and Chronic Pain Management
Introduction
Basic Pain Sensation in the Normal Individual
General Pain Definitions
Acute Versus Chronic Pain
Treatment of Pain
Acute Pain
Chronic Pain
Common Chronic Pain Medications Classifications
Opioids
Alpha-2-Agonist: (Tizanidine)
Anticonvulsants: (Gabapentin, Carbamazepine, and Oxcarbamazepine, Pregabalin)
Tricyclic Antidepressants: (Nortiptyline, Amitriptyline)
Serotonin-Norepinephrine Reuptake Inhibitors: (Venlafaxine, Duloxetine)
Cancer Pain
Common Pain Syndromes
Spinal Stenosis
Radicular Pain
Facet Arthropathy
Discogenic Pain
Complex Regional Pain Syndrome
Myofascial Pain
Sacroiliac Joint Dysfunction
Postherpetic Neuralgia
Physical Therapy
Psychological Therapy
Palliative Care
Suggested Further Reading
31: Postoperative Anesthesia Care Unit and Common Postoperative Problems
Admission
Postoperative Respiratory Complications
Postoperative Hemodynamic Complications
Postoperative Neurologic and Other Complications
Postoperative Nausea and Vomiting (PONV)
Pain Control
Hypothermia and Shivering
Discharge Criteria
General Condition
Hemodynamics
Respiratory Status
Airway
Pain Control
Renal Function
Labs and Diagnostic Tests
Suggested Further Reading
32: Introduction to Critical Care
Initial Assessment of the Critically Ill Patient
Oxygen Balance
Oxygen Transport
Markers of Oxygen Balance and Tissue Perfusion
Lactate
Central Venous and Mixed Venous Blood Oxygen Saturation
Hemodynamic Monitoring (Also See Chap. 11)
Goals
Invasive Arterial Blood Pressure Monitoring
Cardiac Output
Central Venous Pressure Monitoring
Pulmonary Artery Catheter
Shock
Classification of Shock
Management of Shock
Vasoactive Agents Commonly Used in Shock
Septic Shock
Acute Respiratory Failure
Hypoxemic Respiratory Failure
Hypercapnic Respiratory Failure
Management of Acute Respiratory Failure
Acute Respiratory Distress Syndrome (ARDS)
Mechanical Ventilation
Commonly Used Modes of Ventilation
Assist-Control Ventilation (Also Known as CMV, Continuous Mandatory Ventilation)
Intermittent Mandatory Ventilation (IMV)
Pressure Support Ventilation
Positive End-Expiratory Pressure
Inspiratory Pressures
Initiating Mechanical Ventilation
AutoPEEP
Noninvasive Positive-Pressure Ventilation (NIPPV)
Ventilator-Associated Pneumonia
Supportive Care in the ICU
Measures to Prevent Nosocomial Infections Include
Sedation Management
Glucose Management
Thromboprophylaxis
Malignancy
Stress Ulcer Prophylaxis
Nutrition
Ethical Decisions and End-of-Life Care (Also See Chap. 31, Ethical Issues in Anesthesia)
Suggested Further Reading
33: Enhanced Recovery After Surgery and the Perioperative Surgical Home
Enhanced Recovery After Surgery
The Perioperative Surgical Home
Preoperative Assessment
Intraoperative Goals
Postoperative Management
Addressing the Opioid Epidemic
Summary
References
Part VII: Special Topics
34: Professionalism, Teamwork, and Interaction with Other Specialties
Defining Professionalism
Individual Professionalism
Maintaining and Demonstrating Empathy
Cultivating One’s Professional Identity as a Physician: Social Media Pitfalls and Substance Use Disorders
Team Professionalism
Best Communication Practices: Closed-Loop Communication and Speaking-Up
Teamwork
Putting It All Together
References
35: Quality Assurance, Patient and Provider Safety
The History of Patient Safety
Quality Assurance
The ASA Closed Claims Study
Challenges Facing the Anesthesia Provider
Steps to Ensure High Quality Anesthesia Care and Patient Safety
Common Perioperative Complications
Difficult Airway
Dental Trauma
Eye Injury
Peripheral Nerve Injuries
Intraoperative Recall
The Future
References
36: Ethical and Legal Issues in Anesthesia
Informed Consent
Guide to Obtaining Informed Consent
Malpractice
Advanced Directives
Do Not Resuscitate (DNR)/Do Not Intubate (DNI)
Suggested Further Reading
37: Clinical Simulation in Anesthesia Education
Introduction
What Is Simulation?
What Is the History Behind Medical Simulation?
What Are the Benefits of Participating in Medical Simulation?
What Is the Evidence Behind Medical Simulation?
How Is High-Fidelity Simulation Used in Medical Training?
What Is Crisis Resource Management?
What Is in a Simulation Laboratory?
What Can a Mannequin Do?
What Should You Expect in the Simulation Laboratory?
What Are the Expectations of You, the Learner, in Simulation Scenarios?
How Do You Make the Best of the Simulation Experience?
References
38: Infection Control and COVID-19
Antibiotic Prophylaxis
Other General Prevention Measures
Interventions Specific to Anesthesiology Practice
COVID-19
References
Appendix A. ASA Difficult Airway Algorithm
Appendix B. Malignant Hyperthermia
Definition
Mechanism
Presenting Signs and Diagnosis
Treatment
Suggested Further Reading
Index