Basics of Anesthesia

Cover
Title Page
Copyright
Contributors
Foreword
Preface to Seventh Edition
Section I: Introduction
Chapter 1: Scope of Anesthesia Practice
Definition of Anesthesiology as a Specialty
Evolution of Anesthesia as a Multidisciplinary Medical Specialty
Pain Management
Critical Care Medicine
Pediatric Anesthesia
Cardiac Anesthesia
Obstetric Anesthesia
Other Surgical Areas of Anesthesia
Perioperative Patient Care
Preoperative Evaluation
Operating Room Theaters
Postanesthesia Care Unit
Training and Certification in Anesthesiology
Postgraduate (Residency) Training in Anesthesiology
American Board of Anesthesiology
Credentialing and Privileging
Other Anesthetic Providers
Certified Registered Nurse Anesthetists
Anesthesiologist Assistants
Quality of Care and Safety in Anesthesia
Continuous Quality Improvement
Organizations with Emphasis on Anesthesia Quality and Safety
Anesthesia Patient Safety Foundation
Anesthesia Quality Institute
American Society of Anesthesiologists Closed Claims Project and Its Registries
Foundation for Anesthesia Education and Research
Professional Liability
Adverse Events
Risks of Anesthesia
Hazards of Working in the Operating Room
Summary and Future Outlook
Questions of the Day
References
Chapter 2: Learning Anesthesia
Competencies and Milestones
Structured Approach to Anesthesia Care
Preoperative Evaluation
Creating the Anesthesia Plan
Preparing the Operating Room
Managing the Intraoperative Anesthetic
Patient Follow-up
Learning Strategies
Learning Orientation Versus Performance Orientation
Teaching Anesthesia
Questions of the Day
References
Chapter 3: Anesthesia and Health Information Technology
History of Anesthesia Documentation and Aims
The Demand for Data
Professional Performance Data Reporting with Health It
Features of the Electronic Health Record in Anesthesia and Perioperative Care
Health Care Information Privacy and Security
Selected Key Topics for Health IT
Interoperability
System Design, User Interface, and Usability
Clinical Decision Support
Transitioning to Health IT: From Paper Records to an AIMS, and Beyond
Legal Issues and Responsibilities of the AIMS User
Conclusion and the Future
Questions of the Day
References
Section II: Pharmacology and Physiology
Chapter 4: Basic Pharmacologic Principles
Pharmacokinetic Principles
Pharmacodynamic Principles
Potency and Efficacy
Anesthetic Drug Interactions
Special Populations
Influence of Obesity on Anesthetic Drugs
Influence of Increasing Age on Anesthetic Drug Pharmacology
Summary
Questions of the Day
References
Chapter 5: Clinical Cardiac and Pulmonary Physiology
Hemodynamics
Arterial Blood Pressure
Physiologic Approach to Hypotension
Cardiac Reflexes
Autonomic Nervous System
Baroreceptors
Coronary Blood Flow
Pulmonary Circulation
Pulmonary Artery Pressure
Pulmonary Vascular Resistance
Zones of the Lung
Pulmonary Edema
Pulmonary Gas Exchange
Oxygen
Carbon Dioxide
Pulmonary Mechanics
Static Properties
Dynamic Properties and Airway Resistance
Control of Breathing
Central Integration and Rhythm Generation
Central Chemoreceptors
Peripheral Chemoreceptors
Hypercapnic Ventilatory Response
Hypoxic Ventilatory Response
Effects of Anesthesia
Disorders of Ventilatory Control
Integration of the Heart and Lungs
Oxygen Delivery
Oxygen Extraction
Questions of the Day
References
Chapter 6: Autonomic Nervous System
Anatomy of the Autonomic Nervous System
The Sympathetic Nervous System
The Parasympathetic Nervous System
Adrenergic Pharmacology
Endogenous Catecholamines
Synthetic Catecholamines
Noncatecholamine Sympathomimetic Amines
Selective α-adrenergic Receptor Agonists
α1-Adrenergic Agonists
α2-Adrenergic Agonists
β2-adrenergic Receptor Agonists
ADRENERGIC RECEPTOR AGONISTS
ADRENERGIC RECEPTOR ANTAGONISTS
α-adrenergic Receptor Antagonists
Phenoxybenzamine
Prazosin
Yohimbine
β-adrenergic Antagonists
Adverse Effects of β-adrenergic blockade
Specific β-Adrenergic Blockers
Cholinergic Pharmacology
Muscarinic Antagonists
Cholinesterase Inhibitors
Questions of the Day
References
Chapter 7: Inhaled Anesthetics
History
The First Inhaled Anesthetics
Nitrous Oxide
Diethyl Ether
Chloroform
Inhaled Anesthetics Between 1920 and 1940
Fluorine Chemistry and Modern Inhaled Anesthetics
Halothane
Methoxyflurane
Enflurane
Isoflurane
Sevoflurane and Desflurane
Mechanism of Action
Measurable Characteristics
Physical Properties
Molecular Structure
Vapor Pressure and Delivery
Economic and Environmental Considerations
Stability
Relative Potency of Inhaled Anesthetics
Pharmacokinetics of Inhaled Anesthetics
Factors That Determine the Alveolar Partial Pressure
Recovery From Anesthesia
Feasibility of Inhaled Anesthetic Use for Sedation in ICU
Effects on Organ Systems
Circulatory Effects
Ventilation Effects
Central Nervous System Effects
Neuromuscular Effects
Malignant Hyperthermia
Hepatic Effects
Renal Effects
Questions of the Day
References
Chapter 8: Intravenous Anesthetics
Propofol
Physicochemical Characteristics
Pharmacokinetics
Pharmacodynamics
Clinical Uses
Fospropofol
Physicochemical Characteristics
Pharmacokinetics
Pharmacodynamics
Clinical Uses
Barbiturates
Physicochemical Characteristics
Pharmacokinetics
Pharmacodynamics
Side Effects
Clinical Uses
Benzodiazepines
Physicochemical Characteristics
Pharmacokinetics
Pharmacodynamics
Side Effects
Clinical Uses
Ketamine
Physicochemical Characteristics
Pharmacokinetics
Pharmacodynamics
Clinical Uses
Etomidate
Physicochemical Characteristics
Pharmacokinetics
Pharmacodynamics
Clinical Uses
Dexmedetomidine
Physicochemical Characteristics
Pharmacokinetics
Pharmacodynamics
Clinical Uses
Questions of the Day
References
Chapter 9: Opioids
Basic Pharmacology
Structure-Activity
Mechanism
Metabolism
Clinical Pharmacology
Pharmacokinetics
Pharmacodynamics
Drug Interactions
Special Populations
Unique Features of Individual Opioids
Opioid Agonist-Antagonists and Pure Antagonists
Clinical Application
Common Clinical Indications
Rational Drug Selection and Administration
Emerging Developments
Opioids and Cancer Recurrence
Opioid Abuse Epidemic
Questions of the Day
References
Chapter 10: Local Anesthetics
History
Nerve Conduction
Local Anesthetic Actions on Sodium Channels
pH, Net Charge, and Lipid Solubility
Differential Local Anesthetic Blockade
Spread of Local Anesthesia After Injection
Pharmacokinetics
Local Anesthetic Vasoactivity
Metabolism
Additives
Adverse Effects
Systemic Toxicity
Lipid Resuscitation
Local Tissue Toxicity
Allergic Reactions
Specific Local Anesthetics
Amino Esters
Amino Amides
Single Enantiomers
Topical Local Anesthetics
Tumescent Local Anesthesia
Systemic Local Anesthetics for Acute and Chronic Pain
When Local Anesthesia Fails
Future Local Anesthetics
Conclusions
Questions of the Day
References
Chapter 11: Neuromuscular Blocking Drugs
Clinical Uses
Choice of Neuromuscular Blocking Drug
Hypersensitivity Reactions
Neuromuscular Junction
Prejunctional Receptors and Release of Acetylcholine
Postjunctional Receptors
Extrajunctional Receptors
Structure-Activity Relationships
Depolarizing Neuromuscular Blocking Drugs
Characteristics of Blockade
Metabolism
Adverse Side Effects
Nondepolarizing Neuromuscular Blocking Drugs
Pharmacokinetics
Pharmacodynamic Responses
Cardiovascular Effects
Critical Care Medicine and Critical Illness Myopathy and Polyneuropathy
Long-Acting Nondepolarizing Neuromuscular Blocking Drug
Pancuronium
Intermediate-Acting Nondepolarizing Neuromuscular Blocking Drugs
Vecuronium
Rocuronium
Atracurium
Cisatracurium
Short-Acting Nondepolarizing Neuromuscular Blocking Drug
Mivacurium
Monitoring the Effects of Nondepolarizing Neuromuscular Blocking Drugs
Patterns of Stimulation
Antagonism of Nondepolarizing Neuromuscular Blocking Drugs
Adverse Outcomes From Inadequate Antagonism of Neuromuscular Blockade
Anticholinesterase Drugs (Neostigmine)
Factors Influencing the Success of Antagonism of Neuromuscular Blocking Drugs
Evaluation of the Adequacy of Antagonism
A New Antagonist of Neuromuscular Blocking Drugs
Summary
Questions of the Day
References
Chapter 12: Anesthetic Neurotoxicity
Anesthetic Drugs as a Cause for Neurodegeneration and Long-Term Neurocognitive Deficits
Basic Science of Anesthetic-Induced Developmental Neurotoxicity
Age-Dependent Vulnerability of Anesthetic
Characterization of AIDN
Relevant Anesthetic Durations and Concentrations
Anesthetic and Sedative Drugs
Alleviation of AIDN
Clinical Evidence for Neurotoxicity
Intraoperative Course and Neurocognitive Outcomes
Arterial Blood Pressure
Hypocapnia and the Brain
Oxygen Management
Temperature
Conclusion
Questions of the Day
References
Section III: Preoperative Preparation and Intraoperative Management
Chapter 13: Preoperative Evaluation and Medication
Preoperative Assessment: Overview
History and Physical Examination
Investigations and Testing
Consultations
Anesthetic Implications of Common Comorbid Conditions
Hypertension
Coronary Artery Disease
Heart Failure
Valvular Disease
Cardiac Implantable Electronic Devices
Pulmonary Disease
Obstructive Sleep Apnea
Obesity
Diabetes Mellitus
Renal Disease
Anemia
Elderly Patients
Formulation of an Anesthetic Plan
Risk Assessment and Informed Consent
Medications
Fasting Guidelines
Conclusion
Questions of the Day
References
Chapter 14: Choice of Anesthetic Technique
Types of Anesthesia
Choosing an Appropriate Anesthetic Technique
Practical Aspects of Anesthesia Choice
General Anesthesia
Regional Anesthesia
Monitored Anesthesia Care
Environmental Impact
Questions of the Day
References
Chapter 15: Anesthesia Delivery Systems
Anesthesia Workstation
Fail-Safe Valve
Compressed Gases
Flowmeters
Vaporizers
Physics of Vaporization
Vaporizer Classification and Design
Anesthetic Breathing Systems
Mapleson Breathing Systems
Mapleson F (Jackson-Rees) System
Bain System
Circle System
Closed Anesthetic Breathing System
Anesthesia Machine Ventilators
Bellows
Humidity and Heat Exchange in the Breathing Circuit
Humidification
Pollution of the Atmosphere with Anesthetic Gases
Scavenging Systems
Periodic Preventive Maintenance of Anesthesia Equipment
Anesthetic Technique
Adequate Room Ventilation
Elimination of Carbon Dioxide
Carbon Dioxide Absorbents
Efficiency of Carbon Dioxide Neutralization
Degradation of Inhaled Anesthetics
Checking Anesthesia Machine and Circle System Function
ASA 2008 Recommendations for Preanesthesia Checkout Procedures
Questions of the Day
References
Chapter 16: Airway Management
Anatomy and Physiology of the Upper Airway
Nose
Mouth and Pharynx
Larynx
Trachea
Airway Assessment
History and Anatomic Examination
Airway Management Techniques
Ventilation Via a Face Mask
Supraglottic Airway Devices
Laryngeal Mask Airway
Air-Q Masked Laryngeal Airways
I-Gel
Esophageal Tracheal Combitube and King Laryngeal Tube
Endotracheal Intubation
Difficult Airway Management
Direct Laryngoscopy
Choice of Direct Laryngoscope Blade
Video Laryngoscopes
Endotracheal Tube Stylets, Introducers, and Airway Exchange Catheters
Flexible Fiberoptic Endotracheal Intubation
Awake Fiberoptic Endotracheal Intubation
Blind Nasotracheal Intubation
Endotracheal Tube Sizes
Confirmation of Endotracheal Intubation
Rapid Sequence Induction of Anesthesia With Cricoid Pressure
Transtracheal Techniques
Cricothyrotomy
Transtracheal Jet Ventilation
Retrograde Endotracheal Intubation
Endotracheal Extubation
Complications
Complications During Laryngoscopy and Endotracheal Intubation
Complications While the Endotracheal Tube Is in Place
Complications After Endotracheal Extubation
Airway Management in Infants and Children
Airway Management Differences Between Infants and Adults
Managing the Normal Airway in Infants and Children
Preanesthetic Medication and Parental Presence During Induction of Anesthesia
Induction of Anesthesia
Direct Laryngoscopy and Endotracheal Intubation
Managing the Difficult Airway in Infants and Children
Tracheal Extubation in Infants and Children
Questions of the Day
References
Chapter 17: Spinal, Epidural, and Caudal Anesthesia
Principles
Practice
Anatomy
Spinal Nerves
Blood Supply
Anatomic Variations
Mechanism of Action
Drug Uptake and Distribution
Drug Elimination
Physiologic Effects
Cardiovascular
Central Nervous System
Respiratory
Gastrointestinal
Renal
Indications
Neuraxial Anesthesia
Neuraxial Analgesia
Contraindications
Absolute
Relative
Spinal Anesthesia
Factors Affecting Block Height
Duration of the Block
Pharmacology
Technique
Monitoring of the Block
Epidural Anesthesia
Factors Affecting Epidural Block Height
Pharmacology
Technique
Combined Spinal-Epidural Anesthesia
Technique
Caudal Anesthesia
Pharmacology
Technique
Complications
Neurologic
Cardiovascular
Respiratory
Infection
Backache
Nausea and Vomiting
Urinary Retention
Pruritus
Shivering
Complications Unique to Epidural Anesthesia
Recent Advances in Ultrasonography
Questions of the Day
References
Chapter 18: Peripheral Nerve Blocks
Introduction
The Role of Regional Anesthesia
Preparation to Perform a Regional Nerve Block
Ultrasound Basics
Basic Ultrasound Physics
Echogenic Properties of Nerves and Tissue
Ergonomics and Transducer Manipulation
Regional Block Technique
Peripheral Nerve Catheters
Cervical Plexus Block
Upper Extremity Blocks
Brachial Plexus
Intercostobrachial Nerve Block
Lower Extremity Blocks
Femoral Nerve
Sciatic Nerve
Ankle Block
Chest and Abdomen Blocks
Intercostal Nerve Block
Transversus Abdominis Plane Block
Intravenous Regional Anesthesia (Bier Block)
Selection of Local Anesthetic
Characteristics of the Block
Risks
Questions of the Day
References
Chapter 19: Patient Positioning and Associated Risks
Physiologic Aspects of Positioning
General Positioning
Supine
Lithotomy
Lateral Decubitus
Prone
Sitting
Positioning for Robotic Surgery
Pressure Injuries
Bite Injuries
Peripheral Nerve Injuries
Ulnar Nerve
Brachial Plexus
Other Upper Extremity Nerves
Lower Extremity Nerves
Evaluation and Treatment of Perioperative Neuropathies
Perioperative Eye Injury and Visual Loss
Anesthesia Outside the Operating Room
Conclusion
Questions of the Day
References
Chapter 20: Anesthetic Monitoring
Introduction
Overview
Respiratory System
Oxygenation
Ventilation
Circulatory System
Measurement of the Electrocardiogram
Blood Pressure and Flow
Measures of Intravascular Volume Responsiveness
Central Venous Monitoring
Central Nervous System
Processed Electroencephalograph Monitoring
Minimum Alveolar Concentration Alert Monitoring
Intracranial Pressure Monitoring
Cerebral Oximetry
Peripheral Nervous System
Neuromuscular Monitoring
Temperature
Magnetic Resonance Imaging and Adverse Conditions
Monitors and Alarms
Questions of the Day
References
Chapter 21: Acid-Base Balance and Blood Gas Analysis
Definitions
Acids and Bases
Acidemia and Acidosis
Base Excess
Regulation of the Hydrogen Ion Concentration
Buffer Systems
Ventilatory Response
Renal Response
Analysis of Arterial Blood Gases
Blood Gas and pH Electrodes
Sampling
Temperature Correction
Oxygenation
Differential Diagnosis of Acid-Base Disturbances
Adverse Responses to Acidemia and Alkalemia
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Acidosis
Metabolic Alkalosis
Diagnosis
Other Information Provided by Analysis of Arterial Blood Gases and pH
Ventilation
Oxygenation
Cardiac Output Estimates
Questions of the Day
References
Chapter 22: Hemostasis
Primary Hemostasis
Secondary Hemostasis
Clotting Cascade and Propagation of the Clot
Control and Termination of Coagulation
Fibrinolysis
Diseases Associated with Bleeding
Inherited Coagulation Factor Deficiencies
Acquired Coagulation Factor Disorders
Treatment of Clotting Factor Deficiencies
Platelet Disorders
Diseases Associated with Thrombosis
Hereditary Hypercoagulable States
Acquired Hypercoagulable States
Treatment of Hypercoagulable States
Laboratory Evaluation of Hemostasis
Tests of Coagulation
Tests of Fibrinolysis
Tests of Platelet Function
Antithrombotics and Procoagulants
Antiplatelet Drugs
Anticoagulants
Procoagulants
Perioperative Management of Anticoagulation
Questions of the Day
References
Chapter 23: Fluid Management
Background
Overview of Fluid and Electrolyte Physiology
Perioperative Fluid Balance
Fluid Replacement Solutions
Crystalloids
Colloids
Crystalloids Versus Colloids
Perioperative Fluid Strategies
Intraoperative Fluids
Monitoring Adequacy of Fluid Replacement
Questions of the Day
References
Chapter 24: Blood Therapy
Blood Therapy Procedures
Crossmatch
Emergency Transfusion
Type and Screen
Blood Storage
Decision to Transfuse
Patient Blood Management
Monitoring for Blood Loss
Monitoring for Inadequate Perfusion and Oxygenation of Vital Organs
Monitoring for Transfusion Indicators (Especially Hemoglobin Concentration)
Blood Components
Packed Red Blood Cells
Platelets
Fresh Frozen Plasma
Cryoprecipitate
Complications of Blood Therapy
Transmission of Infectious Diseases
Noninfectious Hazards of Transfusion
Metabolic Abnormalities
Hypothermia
Coagulation
Transfusion Reactions
Autologous Blood Transfusions
Predeposited Autologous Donation
Intraoperative and Postoperative Blood Salvage
Normovolemic Hemodilution
Conclusions and Future Directions
Questions of the Day
References
Section IV: Special Anesthetic Considerations
Chapter 25: Cardiovascular Disease
Coronary Artery Disease
Patient History
Electrocardiogram
Risk Stratification Versus Risk Reduction
Perioperative Cardiac Risk Reduction Therapy
Management of Anesthesia
Postoperative Care
Valvular Heart Disease
Mitral Stenosis
Mitral Regurgitation
Aortic Stenosis
Aortic Regurgitation
Mitral Valve Prolapse
Disturbances of Cardiac Conduction and Rhythm
Heart Block
Sick Sinus Syndrome
Ventricular Premature Beats
Ventricular Tachycardia
Preexcitation Syndromes
Prolonged QT Interval Syndrome
Artificial Cardiac Pacemakers
Essential Hypertension
Management of Anesthesia
Preoperative Evaluation
Induction of Anesthesia
Maintenance of Anesthesia
Postoperative Management
Congestive Heart Failure
Management of Anesthesia
Hypertrophic Cardiomyopathy
Management of Anesthesia
Pulmonary Hypertension and Cor Pulmonale
Management of Anesthesia
Cardiac Tamponade
Management of Anesthesia
Aneurysms of the Aorta
Management of Anesthesia
Cardiopulmonary Bypass
Components of the Cardiopulmonary Bypass Circuit
Monitoring During Cardiopulmonary Bypass
Myocardial Preservation
Management of Anesthesia
Discontinuation of Cardiopulmonary Bypass
Off-Pump Coronary Artery Bypass Graft Surgery
Questions of the Day
References
Chapter 26: Congenital Heart Disease
Fundamental Pathophysiology in Congenital Heart Disease
Left-to-Right Shunts
Right-to-Left Shunts
Mixing Lesions
Eisenmenger Syndrome
Obstructive Lesions
Perioperative Management
History and Physical Examination
Preparation for Surgery
Induction of Anesthesia
Maintenance of Anesthesia
Cardiopulmonary Bypass
Postoperative Care
Questions of the Day
References
Chapter 27: Chronic Pulmonary Disease and Thoracic Anesthesia
Introduction
History
Physical Examination
Laboratory Examination
Asthma
Clinical Presentation
Management of Anesthesia
Chronic Obstructive Pulmonary Disease
Clinical Presentation
Perioperative Management
Interstitial Lung Disease
Cystic Fibrosis
Obstructive Sleep Apnea
Clinical Presentation
Treatment of Obstructive Sleep Apnea
Preoperative Evaluation of Patients With Obstructive Sleep Apnea
Perioperative Management
Postoperative Management
Obesity Hypoventilation Syndrome
Pulmonary Hypertension
Pathophysiology
Preoperative Evaluation
Management of Anesthesia
Anesthesia for Lung Resection
Preoperative Assessment for Pulmonary Resection
Smoking Cessation
Assessment of the Patient With Lung Cancer
Indications for Lung Isolation
Options for Lung Isolation
Airway Anatomy
Sizing a Double-Lumen Endobronchial Tube
Methods of Insertion of a Left-Sided DoubleLumen Tube
Positioning a Left-Sided Double-Lumen Tube
Right-Sided Double-Lumen Tube Indications
Positioning a Bronchial Blocker
Physiologic Considerations of One-Lung Ventilation in the Lateral Position
Conduct of Anesthesia
Approach to Intravenous Fluid Management
Approach to One-Lung Ventilation
Prediction of Intraoperative Hypoxia
Management of Hypoxia During One-Lung Ventilation
Conclusion of Surgery
Pain Management
Mediastinoscopy
Mediastinal Masses
Questions of the Day
References
Chapter 28: Renal, Liver, and Biliary Tract Disease
Renal Disease
Renal Blood Flow
Glomerular Filtration Rate
Humoral Mediators of Renal Function
Drug Clearance
Renal Function Tests
Pharmacology of Diuretics
Pathophysiology of End-Stage Renal Disease
Management of Anesthesia in Patients With End-Stage Renal Disease
Differential Diagnosis and Management of Perioperative Oliguria
Liver Disease
Hepatic Blood Flow
Intrinsic Determinants of Hepatic Blood Flow
Extrinsic Determinants of Hepatic Blood Flow
Glucose Homeostasis
Coagulation
Drug Metabolism
Heme Metabolism
Cholesterol and Lipid Metabolism
Protein Metabolism
Pathophysiology of End-Stage Liver Disease
Effects of Anesthesia and Surgery on the Liver
Management of Anesthesia in Patients With End-Stage Liver Disease
Induction and Maintenance of Anesthesia
Management of Coagulopathy
Postoperative Jaundice
Management of Anesthesia in Intoxicated Patients
Alcohol Withdrawal Syndrome
Diseases of the Biliary Tract
Management of Anesthesia
Questions of the Day
References
Chapter 29: Nutritional, Gastrointestinal, and Endocrine Disease
Nutritional Disorders
Morbid Obesity
Malnutrition
Gastrointestinal Disease
Inflammatory Bowel Disease
Gastroesophageal Reflux Disease
Endocrine Disorders
Diabetes Mellitus
Hyperthyroidism and Thyroid Storm
Hypothyroidism
Thyroid Surgery
Pheochromocytoma and Paraganglioma
Multiple Endocrine Neoplasia and Neuroendocrine Tumors
Adrenal Insufficiency and Steroid Replacement
Pituitary Apoplexy
Cushing Syndrome
Questions of the Day
References
Chapter 30: Central Nervous System Disease
Neuroanatomy
Neurophysiology
Regulation of Cerebral Blood Flow
Cerebral Metabolic Rate and Neurovascular Coupling
Cerebral Perfusion Pressure and Cerebral Autoregulation
Cerebrovascular Paco2 and Pao2 Reactivity
Effects of Anesthetics on Cerebral Blood Flow
Intracranial Pressure
Determinants of ICP and the Compensation for an Increased ICP
Effect of Anesthetics on Intracranial Pressure
Neuroprotection
Neurophysiologic Monitoring
Anesthesia for Neurosurgery
Preoperative Assessment
Monitoring
Induction of Anesthesia
Positioning
Maintenance of Anesthesia
Intracranial Pressure Reduction and Brain Relaxation
Ventilation Adjustment
Intravascular Fluid Management
Postoperative Care
Venous Air Embolism
Common Clinical Cases
Intracranial Mass Lesions
Intracranial Aneurysms
Arteriovenous Malformations
Carotid Disease
Questions of the Day
References
Chapter 31: Ophthalmology and Otolaryngology
Ophthalmology
Intraocular Pressure
Ophthalmic Medications
Oculocardiac Reflex
Preoperative Assessment
Anesthetic Options
Anesthesia Management of Specific Ophthalmic Procedures
Postoperative Eye Issues
Otolaryngology
Special Considerations for Head and Neck Surgery
Anesthesia Management of Specific Otolaryngology Procedures
Questions of the Day
References
Chapter 32: Orthopedic Surgery
Rheumatologic Disorders
Rheumatoid Arthritis
Ankylosing Spondylitis
Spine Surgery
Anesthetic Technique
Awareness
Blood Conservation During Spine Surgery
Positioning
Intraoperative Spinal Cord Monitoring
Vision Loss
Surgery in the Sitting Position
Fractured Hip
Anesthetic Technique
Total Joint Replacement
Total Hip Replacement
Total Knee Replacements and Tourniquets
Deep Venous Thrombosis and Thromboembolism Prophylaxis
Questions of the Day
References
Chapter 33: Obstetrics
Physiologic Changes in Pregnant Women
Cardiovascular System Changes
Pulmonary System Changes
Gastrointestinal Changes
Nervous System Changes
Renal Changes
Hepatic Changes
Physiology of the Uteroplacental Circulation
Uterine Blood Flow
Placental Exchange
Stages of Labor
Anatomy of Labor Pain
Methods of Labor Analgesia
Nonpharmacologic Techniques
Systemic Medications
Neuraxial (Regional) Analgesia
Neuraxial Techniques
Preoperative Assessment
Timing and Placement of Epidural
Epidural Technique
Combined Spinal-Epidural Technique
Epidural and Combined Spinal-Epidural Dosing and Delivery Techniques
Spinal Labor Analgesia
Contraindications of Neuraxial Anesthesia
Complications of Regional Anesthesia
Systemic Toxicity and Excessive Blockade
Hypotension
Increased Core Temperature
Other Nerve Blocks for Labor
Paracervical Block
Pudendal Block
Anesthesia for Cesarean Delivery
Spinal Anesthesia
Epidural Anesthesia
Combined Spinal-Epidural Anesthesia
General Anesthesia
Abnormal Presentations and Multiple Births
Multiple Gestations
Abnormal Presentations
Hypertensive Disorders of Pregnancy
Preeclampsia
Hemorrhage in Pregnant Women
Placenta Previa
Massive Hemorrhage
Abruptio Placentae
Uterine Rupture
Retained Placenta
Uterine Atony
Placenta Accreta
Amniotic Fluid Embolism
Anesthesia for Nonobstetric Surgery During Pregnancy
Avoidance of Teratogenic Drugs
Avoidance of Intrauterine Fetal Hypoxia and Acidosis
Prevention of Preterm Labor
Management of Anesthesia
Laparoscopic Surgery
Diagnosis and Management of Fetal Distress
Key Evaluation Components
Fetal Heart Rate Categories
Evaluation of the Neonate and Neonatal Resuscitation
Cardiopulmonary Resuscitation
Questions of the Day
References
Chapter 34: Pediatrics
Developmental Physiology
Respiratory System
Cardiovascular System
The Renal System
The Hematologic System
Pharmacologic Differences
Pharmacokinetics
Hepatic Metabolism
Renal Excretion
Pharmacology of Inhaled Anesthetics
Fluids and Electrolytes
Intraoperative Fluid Administration
Glucose Administration
Transfusion Therapy
Maximum Allowable Blood Loss
Transfusion of Blood Products
Antifibrinolytics
Recombinant Factor VIIa
Pediatric Airway
Airway Assessment
Airway Management Techniques
Difficult Pediatric Airway
Anesthetic Considerations
Preoperative Evaluation and Preparation
Perioperative Considerations
The Postanesthesia Care Unit
Medical and Surgical Diseases Affecting the Neonate
Necrotizing Enterocolitis
Abdominal Wall Defects: Gastroschisis and Omphalocele
Tracheoesophageal Fistula
Congenital Diaphragmatic Hernia
Patent Ductus Arteriosus
Retinopathy of Prematurity
Myelomeningocele
Pyloric Stenosis
Special Anesthetic Considerations
Anesthesia for the Former Premature Infant
Anesthesia for Remote Locations
Ex-Utero Intrapartum Therapy Procedure and Fetal Surgery
Anesthetic Neurotoxicity and Neuroprotection in the Developing Brain
Questions of the Day
References
Chapter 35: Elderly Patients
Why Geriatric Anesthesiology Is Important
Morbidity and Mortality Rates
Age-Related Physiologic Changes
Cardiovascular Changes
Pulmonary Changes
Metabolic and Renal Changes
Changes in Basal Metabolic Rate
Central Nervous System Changes
Perioperative Care in the Elderly
Medications
Intraoperative Monitoring
Choice of Anesthesia
General Anesthesia
Monitored Anesthesia Care
Neuraxial Anesthesia
Postoperative Care
Pain
Postoperative Neurologic Events
Reduction of Perioperative Risk
Medications to Avoid in the Geriatric Population
Summary
Questions of the Day
References
Chapter 36: Organ Transplantation
Considerations for Organ Transplantation
Kidney Transplantation
Preoperative Assessment
Intraoperative Management
Postoperative Management
Liver Transplantation
Preoperative Assessment
Intraoperative Management
Postoperative Management
Heart Transplantation
Preoperative Evaluation
Intraoperative Management
Postoperative Management
Lung Transplantation
Preoperative Evaluation
Intraoperative Management
Postoperative Management
Pancreas Transplantation
Conclusions
Questions of the Day
References
Chapter 37: Outpatient Anesthesia
Introduction
Outpatient Anesthesia Is Different
Outpatient Anesthesia Is Patient-Centered
Defining the Value of Ambulatory Care
Selection
Patient
Practitioner
Procedure
Place (Surgical Facility)
The Perioperative Journey of an Ambulatory Surgical Patient
An Itinerary for Success
Preoperative Phase: Days to Weeks Before Surgery
Preoperative Phase: Day(s) Before Surgery
Preoperative Phase: Day of Surgery
Intraoperative Phase: Anesthesia Techniques
Postoperative Phase: Beginning of Recovery
Postoperative Phase: Discharging Patients Home
Postoperative Phase: Postdischarge Issues
Outcomes
Conclusion
Questions of the Day
Special Mention
References
Chapter 38: Anesthesia for Procedures in Non–Operating Room Locations
Characteristics of Nora Locations
Importance of Communication
Standard of Care and Equipment
Safety and Concerns in Radiology Suites
Radiation Safety Practices
Monitoring the Radiation Dose
Adverse Reactions to Contrast Materials
Magnetic Resonance Imaging
MRI Safety Considerations
Monitoring Issues in MRI Suites
Compatible Equipment
Anesthesia for Noninvasive Imaging Procedures
Physiologic Monitoring
Oxygen Administration
Pharmacologically Induced Sedation
Management of Anesthesia for Computed Tomography
Management of Anesthesia for MRI
Interventional Radiology
Interventional Neuroradiology
Body Interventional Radiology
Endoscopy and Endoscopic Retrograde Cholangiopancreatography
Anesthesia Evaluation and Management
Challenges and Complications
Catheter-Based Cardiology Procedures
Adult Cardiac Catheterization
Electrophysiology Studies
Structural Heart Disease Intervention
Pediatric Studies
Challenges and Complications
Electroconvulsive Therapy
Electrically Induced Seizures
Anesthesia Evaluation
Psychotropic Medications
Induction of Anesthesia and Seizure
Physiologic Responses to Seizure and Treatment
Questions of the Day
References
Section V: The Recovery Period
Chapter 39: Postanesthesia Recovery
Admission to the Postanesthesia Care Unit
Early Postoperative Physiologic Disorders
Upper Airway Obstruction
Loss of Pharyngeal Muscle Tone
Residual Neuromuscular Blockade
Laryngospasm
Airway Edema
Obstructive Sleep Apnea
Management of Airway Obstruction
Monitoring Airway Patency During Transport
Hypoxemia in the Postanesthesia Care Unit
Alveolar Hypoventilation
Decreased Alveolar Partial Pressure of Oxygen
Ventilation-to-Perfusion Mismatch and Shunt
Increased Venous Admixture
Decreased Diffusion Capacity
Pulmonary Edema in the Postanesthesia Care Unit
Postobstructive Pulmonary Edema
Transfusion-Related Acute Lung Injury
Oxygen Supplementation
Oxygen Delivery
Continuous Positive Airway Pressure and Noninvasive Positive-Pressure Ventilation
Hemodynamic Instability
Systemic Hypertension
Systemic Hypotension
Myocardial Ischemia
Cardiac Dysrhythmias
Delirium
Risk Factors
Management
Emergence Agitation
Renal Dysfunction
Oliguria
Intra-Abdominal Hypertension
Rhabdomyolysis
Contrast Nephropathy
Body Temperature and Shivering
Mechanism
Treatment
Postoperative Nausea and Vomiting
High-Risk Patients
Prevention and Treatment
Delayed Awakening
Treatment
Discharge Criteria
Questions of the Day
References
Chapter 40: Perioperative Pain Management
Common Terminology
Pain Services
Neurobiology of Pain
Nociception
Modulation of Nociception
Preemptive and Preventive Analgesia
Opioid-Induced Hyperalgesia
Multimodal Approach to Perioperative Recovery
Analgesic Delivery Systems
Patient-Controlled Analgesia
Systemic Therapy
Oral Administration
Intravenous Administration
Subcutaneous Administration
Transdermal/Iontophoretic Administration
Transmucosal Administration
Neuraxial Analgesia
Intrathecal Administration
Epidural Administration
Side Effects of Neuraxial Analgesic Drugs
Surgical Site (Incision) Infiltration
Intra-Articular Administration
Intrapleural Analgesia
Peripheral Nerve Block
Techniques
Adjuvant Drugs
Regional Analgesia
Catheter Versus Single-Shot Techniques
Paravertebral Blocks
Transversus Abdominis Plane Block
Questions of the Day
References
Section VI: Consultant Anesthetic Practice
Chapter 41: Critical Care Medicine
Respiratory Failure
Mechanical Ventilation
Noninvasive Positive-Pressure Ventilation
Weaning From Mechanical Ventilation and Tracheal Extubation
Acute Respiratory Distress Syndrome
Tracheostomies
Shock
Hypovolemic Shock
Cardiogenic Shock
Vasodilatory Shock
Hemodynamic Monitoring
Sepsis
Acute Renal Failure
Epidemiology
Diagnosis
Treatment
Dialysis
Pain and Sedation
Analgesia
Sedation
Sedation Interruption
Other Topics in Critical Care
Delirium
Nutrition
Glucose Control
Prophylaxis
Hospital-Acquired Infections
ICU Staffing and Organization
Questions of the Day
References
Chapter 42: Anesthesia for Trauma
Introduction
Background
Physiology in Trauma
Initial Management
Prearrival Preparation
Trauma Bay
Adjuncts and Investigations
Definitive Care and Transport
Decision Making in Trauma
Intraoperative Management
Phase 1: Uncontrolled Hemorrhage
Phase 2: Controlled Hemorrhage
Phase 3: Restoration of Physiology
Special Groups
Traumatic Brain Injury
Spinal Cord Injury
Burns
Extremes of Age
Trauma in Pregnancy
Care for Trauma Patients in Non-OR Settings
Questions of the Day
References
Chapter 43: Human-Induced and Natural Disasters
Disaster Types and Nomenclature
Epidemiology
Disaster Preparation and Response
Phases of a Disaster
Mass Casualty Events
Role of the Anesthesia Provider
Triage of Victims
Prehospital Care
Hospital Care
Nuclear Exposure
Chemical and Biologic Terrorism
Decontamination
Personal Protective Equipment
Infectious Disease Disasters and Pandemics
Cyber Attacks and High Altitude Electromagnetic Pulse Events
Postdisaster Syndromes Surveillance
Recovery
Questions of the Day
References
Chapter 44: Chronic Pain Management
Classification of Chronic Pain
Multidisciplinary Pain Management
Common Pain Syndromes
Low Back Pain
Neuropathic Pain
Musculoskeletal Pain
Cancer-Related Pain
Pharmacologic Management of Chronic Pain
Acetaminophen and Nonsteroidal Antiinflammatory Drugs
Antidepressants
Anticonvulsants
Opioids
Interventional Pain Therapies
Epidural Injection of Steroids
Facet Blocks and Radiofrequency Treatment
Sympathetic Blocks
Spinal Cord Stimulation
Intrathecal Drug Delivery
Summary
Questions of the Day
References
Chapter 45: Cardiopulmonary Resuscitation
Basic Life Support
Recognition
Early Cardiopulmonary Resuscitation
Early Defibrillation
Ancillary Devices and Alternative Techniques
Adult Advanced Cardiac Life Support
Monitoring Cardiopulmonary Resuscitation
Airway Management
Algorithms
Medications
Pediatric Advanced Cardiovascular Life Support
Circulation
Airway
Defibrillation
Drugs
Postresuscitation Care
Acute Coronary Syndrome
Hemodynamic Goals
Neurologic Monitoring
Targeted Temperature Management
Blood Glucose Control
Prognosis
Special Perioperative Considerations
Anaphylaxis
Gas Embolism
Local Anesthetic Systemic Toxicity
Cardiovascular Collapse From Neuraxial Anesthesia
Systems of Care
Questions of the Day
References
Chapter 46: Operating Room Management
Perioperative Leadership
Anesthesiology Staffing
Operating Room Efficiency
Operating Room Utilization
Operating Room Throughput and Turnover Time
Questions of the Day
References
Additional Resources
E-only Material
Chapter 47: Awareness Under Anesthesia
Incidence
Etiology and Risk Factors for Intraoperative Awareness
Psychological Sequelae
Prevention of Awareness
Brain Function Monitoring
Asa Practice Advisory on Intraoperative Awareness and Brain Function Monitors
Medicolegal Sequelae of Awareness
Data From the Anesthesia Closed Claims Project
Summary
Questions of the Day
References
Chapter 48: Quality and Patient Safety in Anesthesia Care
Definitions: Quality Versus Safety
Specific Approaches to Anesthesia Safety
Learning From Experience
Adoption of Specialty-Wide Standards
Patient Safety–Focused Programs
From Safety to Quality: Making Anesthesia Both Safer and Better
Process Measures
Structural Measures
Outcome Measures
Tools for Improving Local Outcomes
Structured Quality Improvement Programs: FADE, PDSA, and DMAIC
Multidisciplinary Process Improvement: Root Cause Analysis, “Never Events,” and Failure Mode Effects Analysis
Summary
Questions of the Day
References
Chapter 49: Palliative Care
Introduction
What Is Hospice?
Hospice and Palliative Medicine Subspecialty
Anesthesiologists’ Contribution to Palliative Care
What Do Palliative Care Teams Do?
Palliative Care in the Intensive Care Unit
Withdrawal of Life Support
Spirituality in Serious Illness
Palliative Care and Pain
Use of Opioids at the End of Life
Cancer Pain
Noncancer Pain
Challenges in the Palliative Care Patient
Identifying Palliative Care and Hospice Patients
Prognosis
Communication
Perioperative Management of the Palliative Care Patient
Advance Directives
Decision-Making Capacity
Surrogate Decision Makers
How to Approach Perioperative DNR Conversations
Conclusion
Questions of the Day
References
Chapter 50: Sleep Medicine and Anesthesia
Introduction
Human Sleep
General Anesthesia
Other Arousal States
Sleep and Anesthesia: How Different Are They?
Functional Neuroanatomy of Sleep and Arousal Pathways
Sleep-disordered Breathing or Sleep-Related Breathing Disorders
Obstructive Sleep Apnea (OSA)
Pathophysiology of Upper Airway Collapse in OSA
Clinical Diagnostic Criteria
Polysomnography and Portable Devices
Prevalence of OSA in the General and Surgical Population
OSA and Comorbid Conditions
Surgery and OSA Severity
OSA and Postoperative Complications
Clinical Pathways and Principles of Perioperative Management
Conclusion
Questions of the Day
References
Chapter 51: New Models of Anesthesia Care: Perioperative Medicine, the Perioperative Surgical Home, and Population Health
Growth and Expansion of Anesthesia Practice
Changing Health Care Landscape
Workforce Changes Affecting the Models of Anesthesia Care
New Payment Models
Transitions From Anesthesiology to Perioperative Medicine
Implications of New Models of Care on Anesthesia Training Programs
Conclusion
Questions of the Day
References