Miller’s Basics of Anesthesia

Cover
IFC
Half Title
Title
Copyright
Dedication
Contributors
Preface
Foreword
Contents
Section I - Introduction
1 - Scope of Anesthesia Practice
ANESTHESIOLOGY AS A MULTIDISCIPLI­NARY SPECIALTY
PERIOPERATIVE PATIENT CARE
ANESTHESIA WORKFORCE
TRAINING AND CERTIFICATION IN ANESTHESIOLOGY
QUALITY AND SAFETY
VALUE-BASED CARE
FUTURE OF ANESTHESIA CARE
Acknowledgment
REFERENCES
2 - LEARNING ANESTHESIA
COMPETENCIES, MILESTONES, AND ENTRUSTABLE PROFESSIONAL ACTIVITIES
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
Cognitive Load
REFERENCES
3 - Clinician Well-Being
DEFINING TERMS
Burnout
Resilience
Moral Injury
Well-Being
WHY WELL-BEING IS IMPORTANT
FACTORS AFFECTING CLINICIAN WELL-BEING
Individual Factors
Organizational Level
Societal Level
MENTAL HEALTH
Fatigue Mitigation
Substance Use Disorders
Depression
Suicide
INTERVENTIONS TO IMPROVE WELL-BEING
Personal Strategies
Systemic Approaches
Policies to Support Well-Being
REFERENCES
Section II - Pharmacology and Physiology
4 - Basic Pharmacologic Principles
PHARMACOKINETIC PRINCIPLES
Fundamental Pharmacokinetic Concepts
Volume of Distribution
Clearance
Front-End Kinetics
Compartmental Pharmacokinetic Models
Multicompartment Models
Back-End Kinetics
Biophase
PHARMACODYNAMIC PRINCIPLES
Potency and Efficacy
Anesthetic Drug Interactions
SPECIAL POPULATIONS
Influence of Obesity on Anesthetic Drugs
Propofol
Dosing Scalars for Propofol
Other Sedatives
Opioids
Remifentanil
Dosing Scalars
Fentanyl
Other Opioids
Inhaled Anesthetics
Influence of Increasing Age on Anesthetic Drug Pharmacology
SUMMARY
REFERENCES
5 - Clinical Cardiac and Pulmonary Physiology
HEMODYNAMICS
Arterial Blood Pressure
Physiologic Approach to Hypotension
Systemic Vascular Resistance
Cardiac Output
Heart Rate
Ejection Fraction and Stroke Volume
Preload
Frank–Starling Mechanism
Causes of Low Preload
Contractility
Afterload
CARDIAC REFLEXES
Autonomic Nervous System (Also See Chapter 6)
Baroreceptors
CORONARY BLOOD FLOW
PULMONARY CIRCULATION
Pulmonary Artery Pressure
Pulmonary Vascular Resistance
Hypoxic Pulmonary Vasoconstriction
Pulmonary Emboli
Arteriolar Thickening
Zones of the Lung
Pulmonary Edema
PULMONARY GAS EXCHANGE
Oxygen
Measurements of Oxygenation
Oxyhemoglobin Dissociation Curve
Arterial Oxygen Content
Multiwavelength Pulse Oximetry
Determinants of Alveolar Oxygen Partial Pressure
Venous Admixture
Intrapulmonary Shunt
Ventilation–Perfusion Mismatch
Diffusion Impairment
Venous Oxygen Saturation
Carbon Dioxide
Hypercapnia
Determinants of Arterial Carbon Dioxide Partial Pressure
Rebreathing
Increased Carbon Dioxide Production
Increased Dead Space
Hypoventilation
Differential Diagnosis of Increased Arterial Carbon Dioxide Partial Pressure
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
Identifying the Cause of Respiratory Failure
INTEGRATION OF THE HEART AND LUNGS
Supply and Delivery
Oxygen Delivery
Oxygen Extraction
Anemia
Metabolic Demand
Mechanical Relationships
REFERENCES
6 - Autonomic Nervous System
ANATOMY OF THE AUTONOMIC NERVOUS SYSTEM
The Sympathetic Nervous System
The Parasympathetic Nervous System
ADRENERGIC PHARMACOLOGY
Endogenous Catecholamines
Norepinephrine
Epinephrine
Dopamine
Synthetic Catecholamines
Isoproterenol
Dobutamine
Fenoldopam
Noncatecholamine Sympathomimetic Amines
Ephedrine
SELECTIVE α-ADRENERGIC RECEPTOR AGONISTS
α1-Adrenergic Agonists
Phenylephrine
α2-Adrenergic Agonists
Clonidine
Dexmedetomidine
β2-ADRENERGIC RECEPTOR AGONISTS
α-ADRENERGIC RECEPTOR ANTAGONISTS
Phenoxybenzamine
Prazosin
Yohimbine
β-ADRENERGIC ANTAGONISTS
Adverse Effects of β-Adrenergic Blockade
Specific β-Adrenergic Blockers
Propranolol
Metoprolol
Labetalol
Esmolol
CHOLINERGIC PHARMACOLOGY
Muscarinic Antagonists
Cholinesterase Inhibitors
REFERENCES
7 - Inhaled Anesthetics
HISTORY
CHEMICAL AND PHYSICAL PROPERTIES
Molecular Structures
Physical Properties
UPTAKE AND DISTRIBUTION IN THE BODY
Vaporizers
Anesthetic Circuit
Partition Coefficients
Gas Exchange
Concentration and Second Gas Effects
MINIMUM ALVEOLAR CONCENTRATION
MECHANISMS
Molecular Mechanisms
Neuronal Network Mechanisms
ORGAN SYSTEM EFFECTS
Central Nervous System
Cardiovascular System
Pulmonary System
Renal System
Hepatic System
Neuromuscular Function
UNIQUE ISSUES WITH NITROUS OXIDE
TOXICITY AND ADVERSE EVENTS
Postoperative Nausea and Vomiting
Malignant Hyperthermia
Developmental Neurotoxicity (also see Chapter 12)
Postoperative Cognitive Dysfunction
Cancer Recurrence and Morbidity
Reactions With Carbon Dioxide Absorbents (also see Chapter 15)
METABOLISM, ELIMINATION, AND RECOVERY
ENVIRONMENTAL CONSIDERATIONS (ALSO SEE CHAPTER 49)
REFERENCES
8 - Intravenous Anesthetics
WHY INTRAVENOUS ANESTHETICS?
GABAA RECEPTOR AGONISM
PROPOFOL
Physical Properties and Pharmacokinetics
Continuous Intravenous Infusion
Pharmacodynamics
Central Nervous System
Cardiovascular System
Respiratory System
Other Effects
Clinical Uses
Induction and Maintenance of General Anesthesia
Sedation
Antiemetic
Alternative Formulations
BARBITURATES
Pharmacokinetics and Pharmacodynamics
Central Nervous System
Cardiovascular System
Respiratory System
Side Effects
Clinical Uses
Induction of Anesthesia
Neuroprotection
BENZODIAZEPINES
Pharmacokinetics and Pharmacodynamics
Central Nervous System
Cardiovascular System
Respiratory System
Side Effects
Clinical Uses
Preoperative Medication and Sedation
Induction of Anesthesia
Suppression of Seizure Activity
Remimazolam
KETAMINE
Pharmacokinetics and Pharmacodynamics
Central Nervous System
Cardiovascular System
Respiratory System
Clinical Uses
Induction and Maintenance of Anesthesia
Analgesia
Treatment of Major Depression
ETOMIDATE
Pharmacokinetics and Pharmacodynamics
Central Nervous System
Cardiovascular System
Respiratory System
Endocrine System
Clinical Uses
DEXMEDETOMIDINE
Pharmacokinetics and Pharmacodynamics
Central Nervous System
Cardiovascular System
Respiratory System
Immune System
Clinical Uses
ACKNOWLEDGMENTS
References
9 - Opioids
BASIC PHARMACOLOGY
Structure and Activity
Mechanism
Metabolism
CLINICAL PHARMACOLOGY
Pharmacokinetics (also see Chapter 4)
Pharmacodynamics
Therapeutic Effects
Adverse Effects
Drug Interactions
Special Populations
Hepatic Failure
Kidney Failure
Gender
Age (also see Chapter 35)
Obesity
Unique Features of Individual Opioids
Codeine
Morphine
Fentanyl
Alfentanil
Sufentanil
Remifentanil
Opioid Agonist-Antagonists and Pure Antagonists
Tramadol
Buprenorphine
Nalbuphine
Naloxone/Naltrexone
CLINICAL APPLICATION
Common Clinical Indications
Rational Drug Selection and Administration
EMERGING DEVELOPMENTS
Opioid Abuse Epidemic
Multimodal General Anesthesia (and Opioid-Free Anesthesia)
Biased mu-Receptor Agonists
ACKNOWLEDGMENT
REFERENCES
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
Central Nervous System Toxicity
Cardiovascular System Toxicity
Lipid Resuscitation
Local Tissue Toxicity
Allergic Reactions
Cross-Sensitivity
Documentation
SPECIFIC LOCAL ANESTHETICS
Amino Esters
Procaine
Tetracaine
Chloroprocaine
Amino Amides
Lidocaine
Mepivacaine
Prilocaine
Bupivacaine
Single Enantiomers
Stereochemistry
Ropivacaine
Levobupivacaine
Topical Local Anesthetics
Tumescent Local Anesthesia
Systemic Local Anesthetics for Acute and Chronic Pain
WHEN LOCAL ANESTHESIA FAILS
FUTURE LOCAL ANESTHETICS
CONCLUSIONS
Acknowledgments
REFERENCES
11 - Neuromuscular Blocking and Reversal Agents
INTRODUCTION
Clinical Uses
Choice of Neuromuscular Blocking Agent
THE NEUROMUSCULAR JUNCTION
Prejunctional Receptors and Release of Acetylcholine
Postjunctional Receptors
Extrajunctional Receptors
STRUCTURE–ACTIVITY RELATIONSHIPS
DEPOLARIZING NEUROMUSCULAR BLOCKING AGENTS: SUCCINYLCHOLINE
Characteristics of Blockade
Pharmacodynamics
Metabolism
Atypical Plasma Cholinesterase
Adverse Side Effects
Cardiac Dysrhythmias
Hyperkalemia
Myalgia
Increased Intraocular Pressure and Increased Intracranial Pressure
Increased Intragastric Pressure
Trismus
NONDEPOLARIZING NEUROMUSCULAR BLOCKING AGENTS
Pharmacokinetics
Pharmacodynamic Responses
Adverse Effects
Cardiovascular Effects
Critical Illness Myopathy and Polyneuropathy
Hypersensitivity Reactions
Long-Acting Nondepolarizing Neuromuscular Blocking Agent: Pancuronium
Intermediate-Acting Nondepolarizing Neuromuscular Blocking Agents
Vecuronium
Rocuronium
Atracurium
Cisatracurium
Short-Acting Nondepolarizing Neuromuscular Blocking Agent: Mivacurium
MONITORING THE EFFECTS OF NONDEPOLARIZING NEUROMUSCULAR BLOCKING AGENTS
Antagonism of Residual Neuromuscular Block
Anticholinesterases
Determinants of Speed and Adequacy of Recovery
Adverse Effects
Dosing
Pharmacokinetics and Pharmacodynamics
Selective Relaxant Binding Agents: Sugammadex
SUMMARY
ACKNOWLEDGMENT
REFERENCES
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
Pathologic Apoptosis
Impeded Neurogenesis
Altered Dendritic Development
Aberrant Glial Development
Anesthetic Effects on Spinal Cord
Neuroinflammation and Alzheimer-Related Neuropathology
Neurocognitive Function
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
REFERENCES
Section III - Preoperative Preparation and Intraoperative Management
13 - Preoperative Evaluation
HISTORY AND PHYSICAL EXAMINATION
PREOPERATIVE EVALUATION OF COMMON COEXISTING DISEASES
Neurologic
Parkinson Disease
Cardiovascular
Coronary Artery Disease
Hypertension
The Patient Receiving Anticoagulant Therapy
The Patient Receiving Antiplatelet Therapy
Pulmonary
Renal
Liver
Endocrine
Diabetes Mellitus
Hematologic
Infectious Disease
Surgical Site Infection
Infective Endocarditis
Geriatrics
Frailty
PREOPERATIVE TESTING
Rationale for Selective Testing
Pregnancy Testing
Preoperative Transfusion Testing
RISK ASSESSMENT
ASA Physical Status
MEDICATION MANAGEMENT
NPO GUIDELINES
INFORMED CONSENT FOR ANESTHESIA
PREOPERATIVE EVALUATION CLINICS
Enhanced Recovery Pathways
Preoperative Optimization
Inpatient Preoperative Evaluation
Acknowledgment
REFERENCES
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
ACKNOWLEDGMENT
REFERENCES
15 - Anesthesia Delivery Systems
THE ANESTHESIA WORKSTATION
FUNCTIONAL ANATOMY OF THE ANESTHESIA WORKSTATION
Gas Supply System
High-Pressure Section
Auxiliary E-Cylinder Inlet
Intermediate-Pressure Section
Gas Pipeline Inlet: Central Gas Supply Source
Oxygen Flush Valve
Pneumatic Safety Systems
Auxiliary Oxygen Flowmeter
Low-Pressure Section
Flow Control Assemblies
Proportioning Systems
Vaporizer Mount and Interlock System
Anesthetic Vaporizers
Physics
Modern Vaporizer Types
Variable Bypass Vaporizers
Desflurane Dual-Gas Blender
Cassette Vaporizers
Injection-Type Vaporizers
ANESTHETIC BREATHING CIRCUITS
Circle Breathing Systems
Fresh Gas Inlet
Unidirectional Valves
Corrugated Breathing Circuit Tubing
Y-Piece
Adjustable Pressure-Limiting Valve
Anesthesia Reservoir Bag or “Breathing Bag”
Carbon Dioxide Absorbent
Additional Components of the Circle Breathing Systems
Filters and Heat and Moisture Exchangers
Heated Humidifiers
Inspired Oxygen Concentration Monitor
Flow Sensors
Breathing Circuit Pressure Sensors
Circle System Function
Mapleson Breathing Systems
Self-Inflating Manual Resuscitators
ANESTHESIA VENTILATORS
Bellows Ventilators
Mechanically Driven Piston Ventilators
Other Anesthesia Ventilator Systems
Target-Controlled Inhalational Anesthesia
Fresh Gas Flow Compensation and Fresh Gas Decoupling
SCAVENGING SYSTEMS
CHECKING YOUR ANESTHESIA WORKSTATION
Item 1: Verify Auxiliary Oxygen Cylinder and Self-Inflating Manual Ventilation Device Are Available and Functioning (Daily)
Item 2: Verify Patient Suction Is Adequate to Clear the Airway (Every Case)
Item 3: Turn On Anesthesia Delivery System and Confirm That AC Power Is Available (Daily)
Item 4: Verify Availability of Required Monitors and Check Alarms (Every Case)
Item 5: Verify That Pressure Is Adequate on the Spare Oxygen Cylinder Mounted on the Anesthesia Machine (Daily)
Item 6: Verify That Piped Gas Pressures Are 50 psig or Higher (Daily)
Item 7: Verify That Vaporizers Are Adequately Filled and, If Applicable, That the Filler Ports Are Tightly Closed (Every Case)
Item 8: Verify That No Leaks Are Present in the Gas Supply Lines Between the Flowmeters and the Common Gas Outlet (Daily)
Item 9: Test Scavenging System Function (Daily)
Item 10: Calibrate, or Verify Calibration of, the Oxygen Monitor and Check the Low Oxygen Alarm (Daily)
Item 11: Verify Carbon Dioxide Absorbent Is Not Exhausted (Every Case)
Item 12: Perform Breathing System Pressure and Leak Testing (Every Case)
Item 13: Verify That Gas Flows Properly Through the Breathing Circuit During Both Inspiration and Exhalation (Every Case)
Item 14: Document Completion of Checkout Procedures
Item 15: Confirm Ventilator Settings and Evaluate Readiness to Deliver Anesthesia Care (Anesthesia Time-Out)
Acknowledgment
REFERENCES
16 - AIRWAY MANAGEMENT
ANATOMY AND PHYSIOLOGY OF THE UPPER AIRWAY
Nasal Cavity
Oral Cavity and Pharynx
Larynx
Trachea
AIRWAY ASSESSMENT
History and Anatomic Examination
Physical Examination Findings
Oropharyngeal Space
Thyromental/Sternomental Distance
Atlanto-occipital Extension/Cervical Spine Mobility
Body Habitus/Other Examination Findings
Cricothyroid Membrane
Additional Airway Investigations
AIRWAY MANAGEMENT TECHNIQUES
Facemask Ventilation
Preoxgenation
Managing Inadequate Facemask Ventilation
Supraglottic Airways
Laryngeal Mask Airways (LMAs)
LMA Unique
LMA Fastrach
LMA ProSeal/LMA Supreme
LMA Flexible
Air-Q Intubating Laryngeal Airways
i-gel Supraglottic Airways
Endotracheal Intubation
Rapid-Sequence Induction of Anesthesia With Cricoid Pressure
Difficult Airway Management
Direct Laryngoscopy
Choice of Direct Laryngoscope Blade
Video Laryngoscopy
GlideScope
C-MAC
McGrath Scope
Endotracheal Tube Stylets, Introducers, and Airway Exchange Catheters
Stylet
Gum Elastic Bougie
Frova Intubating Introducer
Aintree Intubation Catheter
Cook Airway Exchange Catheter
Flexible Fiber-Optic Endotracheal Intubation
Awake Fiber-Optic Endotracheal Intubation
Patient Preparation
Airway Anesthesia
Nose and Nasopharynx
Tongue and Oropharynx
Larynx and Trachea
Superior Laryngeal Nerve Block
Transtracheal Block
Fiber-Optic Intubation Techniques
Fiber-Optic Endotracheal Intubation After Induction of General Anesthesia
Endoscopy Mask
Rigid Fiber-Optic Intubating Stylets
INVASIVE AIRWAY ACCESS
Cricothyrotomy
Transtracheal Jet Ventilation
Retrograde Endotracheal Intubation
Endotracheal Extubation
COMPLICATIONS
Complications During Laryngoscopy and Endotracheal Intubation
Complications After Endotracheal Extubation
Airway Management in Infants and Children (Also See Chapter 34)
Airway Management Differences Between Infants and Adults
Managing the Normal Airway in Infants and Children
History
Physical Examination
Preanesthetic Medication and Parental Presence During Induction of Anesthesia
Induction of Anesthesia
Direct Laryngoscopy and Endotracheal Intubation
Airway Equipment
Nasal and Oral Airways
Supraglottic Airways
Laryngeal Mask Airways
Air-Q Intubating Laryngeal Airways
i-gel Supraglottic Airways
Endotracheal Tubes
Cuffed Versus Uncuffed Endotracheal Tubes
Microcuff Endotracheal Tubes
Stylets
Laryngoscopes
Video Laryngoscopy
GlideScope Video Laryngoscopes
C-MAC Video Laryngoscopes
McGrath MAC Video Laryngoscopes
Fiber-Optic Bronchoscopy
Managing the Difficult Airway in Infants and Children
Unexpected Difficult Airway
Expected Difficult Airway
Tracheal Extubation in Infants and Children
Deep Versus Awake Extubation
Postextubation Stridor
Obstructive Sleep Apnea
Laryngospasm
Extubation After a Difficult Intubation
Acknowledgment
REFERENCES
17 - 1Spinal, Epidural, and Caudal Anesthesia
PRINCIPLES
PRACTICE
EVIDENCE
ANATOMY
Spinal Nerves
Blood Supply
Anatomic Variations
MECHANISM OF ACTION
Drug Uptake and Distribution
Drug Elimination
PHYSIOLOGIC EFFECTS
Cardiovascular
Systemic Vascular Resistance
Cardiac Output
Central Nervous System
Respiratory
Gastrointestinal
Renal
INDICATIONS
Neuraxial Anesthesia
Neuraxial Analgesia
CONTRAINDICATIONS
Absolute
Relative
Neurologic
Myelopathy or Peripheral Neuropathy
Spinal Stenosis
Previous Spine Surgery
Multiple Sclerosis
Spina Bifida
Cardiac (Also See Chapter 26)
Aortic Stenosis or Fixed Cardiac Output
Hypovolemia
Hematologic
Thromboprophylaxis and Antithrombotic and Thrombolytic Therapy
Inherited Coagulopathy
Infection
SPINAL ANESTHESIA
Factors Affecting Block Height
Drug Factors
Baricity
Dose
Patient Factors
Procedure Factors
Duration of the Block
Pharmacology
Short- and Intermediate-Acting Local Anesthetics
Long-Acting Local Anesthetics
Spinal Additives
Hydrophilic Opioids
Lipophilic Opioids
Vasoconstrictors
α2-Agonists
Other Drugs
Technique
Preparation
Position
Projection and Puncture
Use of Ultrasonography
Special Spinal Techniques
Monitoring of the Block
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
Vasoconstrictors
Opioids
α2-Agonists
Other Drugs
Carbonation and Bicarbonate
Technique
Preparation
Position
Projection and Puncture
Paramedian Approach
Use of Ultrasonography
COMBINED SPINAL-EPIDURAL ANESTHESIA
Technique
CAUDAL ANESTHESIA
Pharmacology
Technique
COMPLICATIONS
Neurological
Paraplegia
Epidural Hematoma
Epidural Abscess
Post–Dural Puncture Headache
Total Spinal Anesthesia
Transient Neurological Symptoms
Cardiovascular
Hypotension
Bradycardia
Respiratory
Infection
Wrong-Route Drug Delivery
Backache
Nausea and Vomiting
Urinary Retention
Pruritus
Shivering
Complications Unique to Epidural Anesthesia
Intravascular Injection
Subdural Injection
REFERENCES
18 - Peripheral Nerve Blocks
INTRODUCTION
The Role of Regional Anesthesia
Preparation to Perform a Regional Nerve Block
Foundation of Knowledge
Patient and Surgeon Factors
Monitors and Equipment
Choice of Local Anesthetic
Regional Block Checklist
Risks and Prevention
Infection
Hematoma
Local Anesthetic Systemic Toxicity (Also See Chapter 10)
Nerve Injury
Wrong-Sided 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
Interscalene Block
Supraclavicular Block
Infraclavicular Block
Axillary Block
Intercostobrachial Nerve Block
LOWER EXTREMITY BLOCKS
Femoral Nerve
Femoral Nerve Block
Adductor Canal and Saphenous Nerve Blocks
Sciatic Nerve
Proximal Sciatic Nerve Block
Popliteal Block of the 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
REFERENCES
19 - Patient Positioning and Associated Risks
PHYSIOLOGIC ASPECTS OF POSITIONING
GENERAL POSITIONING PRINCIPLES
Supine
Variations of the Supine Position
Complications
Lithotomy
Lateral Decubitus
Prone
Sitting
POSITIONING FOR ROBOTIC-ASSISTED 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
REFERENCES
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: CVP, PAP, and CO
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
MULTIFUNCTION DISPLAYS AND DECISION SUPPORT
REFERENCES
21 - POINT-OF-CARE ULTRASOUND
REVIEW OF ULTRASOUND PHYSICS
ULTRASOUND TRANSDUCERS
PREPARING FOR THE EXAMINATION
BASIC CARDIAC ULTRASOUND
Parasternal Long-Axis View
Parasternal Short-Axis View
Apical Four-Chamber View
Subcostal and Inferior Vena Cava Views
PULMONARY ULTRASOUND
Normal Lung Examination
Evaluation for Pneumothorax
Evaluation of Interstitial and Alveolar Patterns
Evaluation of the Pleural Space
ABDOMINAL ULTRASOUND
FAST Examination
Right Upper Quadrant View
Left Upper Quadrant View
Pelvic View
Gastric Ultrasound
CONCLUSIONS AND FUTURE DIRECTIONS
REFERENCES
22 - Acid–Base Balance and Blood Gas Analysis
DEFINITIONS
Acids and Bases
Acidemia and Acidosis
Base Excess
REGULATION OF THE HYDROGEN ION CONCENTRATION
Buffer Systems
Bicarbonate Buffer System
Hemoglobin Buffer System
Ventilatory Response
Renal Response
ANALYSIS OF ARTERIAL BLOOD GASES
Sampling
Temperature Correction
Alpha-Stat
pH-Stat
Oxygenation
DIFFERENTIAL DIAGNOSIS OF ACID–BASE DISTURBANCES
Adverse Responses to Acidemia and Alkalemia
Respiratory Acidosis
Compensatory Responses and Treatment
Respiratory Alkalosis
Compensatory Responses and Treatment
Metabolic Acidosis
Anion Gap
Nonanion Gap
Strong Ion Difference
Compensatory Responses and Treatment
Metabolic Alkalosis
Compensatory Responses and Treatment
Diagnosis
OTHER INFORMATION PROVIDED BY ANALYSIS OF ARTERIAL BLOOD GASES AND pH
Ventilation
Oxygenation
Alveolar Gas Equation
Alveolar-Arterial Gradient
Pao2/Fio2 Ratio
Cardiac Output Estimates
Fick Equation
Arteriovenous Difference
Lactate Measurements
REFERENCES
23 - Hemostasis
INTRODUCTION
NORMAL HEMOSTASIS
Vascular Endothelial Role in Hemostasis
Platelets and Hemostasis
Plasma-Mediated Hemostasis
Regulation of Coagulation
BLEEDING DISORDERS
Inherited Bleeding Disorders
Von Willebrand Disease
Hemophilias
Other Factor Deficiencies
Acquired Bleeding Disorders
Drug Induced
Vitamin K Deficiency
Liver Disease
Renal Disease
Disseminated Intravascular Coagulation
Cardiopulmonary Bypass–Associated Coagulopathy
Trauma-Induced Coagulopathy (also see Chapter 43)
Treatment of Bleeding Disorders
von Willebrand Disease
Hemophilia
Disseminated Intravascular Coagulation
Platelet Disorders
PROTHROMBOTIC STATES
Inherited Thrombotic Disorders
Factor V Leiden and Prothrombin Gene Mutation
Protein C and Protein S Deficiency
Acquired Thrombotic Disorders
Antiphospholipid Syndrome
Heparin-Induced Thrombocytopenia
Treatment of Thrombotic Disorders
Inherited Thrombophilias
Antiphospholipid Syndrome
Heparin-Induced Thrombocytopenia
LABORATORY EVALUATION OF HEMOSTASIS
Preoperative Evaluation
Laboratory-Based Measures of Coagulation
Prothrombin Time
Activated Partial Thromboplastin Time
Anti–Factor Xa Activity
Thrombin Time
Fibrinogen Level
Tests of Platelet Function
Platelet Count
Bleeding Time
Platelet Aggregometry
Point-of-Care Measures of Coagulation
Activated Clotting Time
Viscoelastic Measures of Coagulation
Platelet Function Analysis
ANTITHROMBOTIC AND PROCOAGULANT DRUGS
Antiplatelet Agents
Cyclooxygenase Inhibitors
P2Y12 Receptor Antagonists
GPIIb/IIIa Inhibitors
Anticoagulants
Vitamin K Antagonists
Unfractionated Heparin
Low-Molecular-Weight Heparin and Fondaparinux
Direct Thrombin Inhibitors
Direct Oral Anticoagulants
Thrombolytics
Procoagulant Drugs
Antifibrinolytics
Recombinant Factor VIIa
Prothrombin Complex Concentrate
Fibrinogen Concentrate
PERIOPERATIVE MANAGEMENT OF ANTI­THROMBOTIC THERAPY
Vitamin K Antagonists
Heparins
Antiplatelet Agents
Neuraxial Anesthesia and Anticoagulation
Emergent Reversal of Anticoagulants
CONCLUSION
Acknowledgment
REFERENCES
24 - FLUID MANAGEMENT
INTRODUCTION
PHYSIOLOGY OF FLUID BALANCE
FLUID REPLACEMENT SOLUTIONS
Crystalloids
Normal Saline
Balanced Crystalloid Solutions
Other Crystalloid Solutions
Colloids
Albumin
Synthetic Colloids
HEMODYNAMIC MONITORING FOR FLUID RESPONSIVENESS
PERIOPERATIVE FLUID STRATEGIES FOR OPTIMAL VOLUME STATUS
CONCLUSIONS
Acknowledgment
REFERENCES
25 - Blood Therapy
BLOOD BANKING ESSENTIALS
Whole-Blood Processing
Ensuring Donor–Recipient Compatibility
Blood Type
Antibody Screen
Crossmatch
Massive Transfusion/Emergency Release Protocols
Blood Storage
BLOOD COMPONENTS
Packed Red Blood Cells
Fresh Frozen Plasma
Cryoprecipitate
Platelets
PATIENT BLOOD MANAGEMENT AND THE DECISION TO TRANSFUSE RED BLOOD CELLS
Patient Blood Management
Monitoring for Blood Loss
Monitoring for Inadequate Perfusion and Oxygenation of Vital Organs
Monitoring for Transfusion Indicators
COMPLICATIONS OF BLOOD THERAPY
Transmission of Infectious Diseases
Noninfectious Hazards of Transfusion
Transfusion-Related Acute Lung Injury
Transfusion-Related Immunomodulation
Metabolic Abnormalities
Hydrogen Ions
Potassium
2,3-Diphosphoglycerate
Citrate
Hypothermia
Coagulopathy
Transfusion Reactions
Febrile Reactions
Allergic Reactions
Hemolytic Reactions
AUTOLOGOUS BLOOD TRANSFUSIONS
Predeposited Autologous Donation
Intraoperative Blood Salvage
Normovolemic Hemodilution
CONCLUSIONS AND FUTURE DIRECTIONS
REFERENCES
Section IV - Special Anesthetic Considerations
26 - Cardiovascular Disease
CORONARY ARTERY DISEASE
Prior Myocardial Infarction
Perioperative Risk Reduction Therapy/Medications
Monitoring (Also See Chapter 20)
Management of Anesthesia
VALVULAR HEART DISEASE
Mitral Stenosis
Management of Anesthesia
Mitral Regurgitation
Management of Anesthesia
Aortic Stenosis
Management of Anesthesia
Aortic Regurgitation
Management of Anesthesia
DISTURBANCES OF CARDIAC CONDUCTION AND RHYTHM
Heart Block
Cardiac Implantable Electronic Devices
HEART FAILURE
Management of Anesthesia
HYPERTROPHIC CARDIOMYOPATHY
Management of Anesthesia
PULMONARY HYPERTENSION
Management of Anesthesia
CARDIAC TAMPONADE
Management of Anesthesia
ANEURYSMS OF THE AORTA
Management of Anesthesia
CARDIOPULMONARY BYPASS
Acknowledgments
REFERENCES
27 - Chronic Pulmonary Disease
INTRODUCTION
History
Physical Examination
Laboratory Examination
Chest Imaging
Spirometry
Gas Exchange
ASTHMA
Clinical Presentation
Management of Anesthesia
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Clinical Presentation
Carbon Dioxide Retention (Baseline Paco2 >45 mm Hg)
Right Ventricular Dysfunction
Bullae
Flow Limitation
Perioperative Management
INTERSTITIAL LUNG DISEASE
CYSTIC FIBROSIS
OBSTRUCTIVE SLEEP APNEA (ALSO SEE CHAPTER 48)
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
Objective Assessment of Pulmonary Function
Respiratory Mechanics
Lung Parenchymal Function
Cardiopulmonary Interaction
Ventilation-Perfusion Scintigraphy
Preoperative Cardiac Assessment
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 Double-Lumen 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
REFERENCES
28 - Renal, Liver, and Biliary Tract Disease
RENAL DISEASE
Renal Blood Flow
Glomerular Filtration Rate
Humoral Mediators of Renal Function
Renin–Angiotensin–Aldosterone System
Prostaglandins
Arginine Vasopressin
Atrial Natriuretic Peptide
Drug Clearance
Renal Function Tests
Serum Creatinine
Blood Urea Nitrogen
Creatinine Clearance
Proteinuria
Urine Indices
Newer Tests of Renal Function
Pharmacology of Diuretics
Thiazide Diuretics
Loop Diuretics
Osmotic Diuretics
Aldosterone Antagonists
Dopamine and Fenoldopam
Pathophysiology of End-Stage Renal Disease
Cardiovascular Disease
Metabolic Disease
Anemia and Abnormal Coagulation
Differential Diagnosis and Management of Perioperative Oliguria
Prerenal Oliguria
Intrinsic Renal Disease
Postrenal Oliguria
Postoperative Acute Kidney Injury
Management of Anesthesia in Patients With End-Stage Renal Disease
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
Cardiovascular Complications
Portal Hypertension
Pulmonary Complications
Hepatic Encephalopathy
Impaired Drug Binding
Ascites
Renal Dysfunction and Hepatorenal Syndrome
Effects of Anesthesia and Surgery on the Liver
Impact of Anesthetics on Hepatic Blood Flow
Volatile Anesthetic–Induced Hepatic Dysfunction
Management of Anesthesia in Patients With End-Stage Liver Disease
Preoperative Evaluation of Liver Disease
Intraoperative Management
Management of Coagulopathy
Postoperative Jaundice
DISEASES OF THE BILIARY TRACT
Bile Metabolism and Secretion
Pathophysiology of the Biliary Tract
Management of Anesthesia for Biliary Tract Surgery
Laparoscopic Cholecystectomy
REFERENCES
29 - Nutritional, Gastrointestinal, and Endocrine Disease
NUTRITIONAL DISORDERS
Obesity
Perioperative Considerations
Bariatric Surgery
Malnutrition
Perioperative Considerations
GASTROINTESTINAL DISORDERS
Inflammatory Bowel Disease
Perioperative Considerations
Gastroesophageal Reflux Disease
Perioperative Considerations
ENDOCRINE DISORDERS
Diabetes Mellitus
Perioperative Considerations
Thyroid Disease
Hypothyroidism
Perioperative Considerations
Hyperthyroidism and Thyroid Storm
Perioperative Considerations
Thyroidectomy Postoperative Complications
Parathyroid Disease
Perioperative Considerations
Adrenal Cortex Dysfunction
Mineralocorticoid Excess
Glucocorticoid Excess
Adrenal Insufficiency
Pheochromocytoma and Paraganglioma
Perioperative Considerations
Pituitary Gland Dysfunction
Acromegaly
Prolactinoma
Hypopituitarism
Syndrome of Inappropriate Antidiuretic Hormone Secretion
Central Diabetes Insipidus
Neuroendocrine Tumors
Carcinoid Tumor
REFERENCES
30 - CENTRAL NERVOUS SYSTEM DISEASE
NEUROANATOMY
Supratentorial and Infratentorial Compartments
Cerebral Vasculature
Cranial Nerves
Blood–Brain Barrier
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 Anesthetic Agents on CBF (Also See Chapters 7 and 8)
INTRACRANIAL PRESSURE AND BRAIN RELAXATION
Determinants of ICP and the Compensation for an Elevated ICP
Effect of Anesthetic Agents on ICP
NEUROPROTECTION
NEUROPHYSIOLOGIC MONITORING
ANESTHESIA FOR NEUROSURGERY
Preoperative Assessment
Monitoring
Induction of Anesthesia
Positioning (Also See Chapter 19)
Maintenance of Anesthesia
ICP Reduction and Brain Relaxation
Ventilation Adjustment
Fluid Management
Blood Product Administration and Anticoagulant Management
Emergence From Anesthesia and Postoperative Care
Venous Air Embolism
COMMON CLINICAL CASES
Intracranial Mass Lesions
Intracranial Aneurysms
Arteriovenous Malformations
Carotid Disease
REFERENCES
31 - Ophthalmology and Otolaryngology
Ophthalmology
Intraocular Pressure
Factors That Influence Intraocular Pressure
Anesthetic Drugs and Intraocular Pressure
Ophthalmic Medications
Oculocardiac Reflex
Preoperative Assessment
Anesthetic Options
Needle-Based Ophthalmic Regional Anesthesia
Cannula-Based Ophthalmic Regional Anesthesia
Topical Ophthalmic Regional Anesthesia
Anesthesia Management of Specific Ophthalmic Procedures
Retina Surgery
Glaucoma
Strabismus Surgery
Nausea and Vomiting
Malignant Hyperthermia
Traumatic Eye Injuries
Postoperative Eye Issues
Corneal Abrasion
Acute Glaucoma
Postoperative Visual Loss
OTOLARYNGOLOGY
Special Considerations for Head and Neck Surgery
The Difficult Airway (Also See Chapter 16)
Laryngospasm
Upper Respiratory Infections
Epistaxis
Obstructive Sleep Apnea (Also See Chapter 48)
Airway Fires
Anesthesia Management of Specific Otolaryngology Procedures
Ear Surgery
Nitrous Oxide
Facial Nerve Monitoring
Epinephrine
Emergence
Postoperative Nausea and Vomiting (Also See Chapter 39)
Myringotomy and Tube Insertion
Tonsillectomy and Adenoidectomy
Tonsillar Bleeding After Tonsillectomy and Adenoidectomy
Epiglottitis
Foreign Body in Airway
Nasal and Sinus Surgery
Cochlear Implant Surgery
Endoscopic Surgery
Laser Surgery
Neck Dissection Surgery
Postoperative Complications
Thyroid and Parathyroid Surgery
Parotid Surgery
Facial Trauma
REFERENCES
32 - Orthopedic Surgery
RHEUMATOLOGIC DISORDERS
Rheumatoid Arthritis
Airway and Cervical Spine Changes
Atlantoaxial Subluxation
Subaxial Subluxation
Superior Migration of the Odontoid
The Trachea in Rheumatoid Arthritis
Ankylosing Spondylitis
SPINE SURGERY
Anesthetic Technique
Awareness
Blood Conservation During Spine Surgery
Positioning
Intraoperative Spinal Cord Monitoring
Transcranial Motor Evoked Potentials
Electromyograms
Wake-Up Test
Conclusion of the Case
Vision Loss
SURGERY IN THE SITTING POSITION
FRACTURED HIP
Anesthetic Technique
TOTAL JOINT REPLACEMENT
Tranexamic Acid in Orthopedics
Total Hip Replacement
Total Knee Replacements and Tourniquets
Deep Venous Thrombosis and Thromboembolism Prophylaxis
REFERENCES
33 - Obstetrics
PHYSIOLOGIC CHANGES IN PREGNANT WOMEN
Cardiovascular System Changes
Intravascular Fluid and Hematology
Cardiac Output
Systemic Vascular Resistance
Aortocaval Compression
Echocardiography Changes
Compensatory Responses and Anesthetic Implications
Pulmonary System Changes
Upper Airway
Minute Ventilation and Oxygenation
Lung Volumes
Anesthetic Implications
Gastrointestinal Changes
Anesthetic Implications
Nervous System Changes
Renal Changes
Hepatic Changes
PHYSIOLOGY OF THE UTEROPLACENTAL CIRCULATION
Uterine Blood Flow
Placental Exchange
Fetal Uptake
Characteristics of the Fetal Circulation
STAGES OF LABOR
ANATOMY OF LABOR PAIN
METHODS OF LABOR ANALGESIA
Nonpharmacologic Techniques
Systemic Medications
Opioids (also see Chapter 9)
Nitrous Oxide (also see Chapter 7)
Neuraxial (Regional) Analgesia
Local Anesthetics
Neuraxial Opioids
NEURAXIAL TECHNIQUES
Preoperative Assessment
Timing and Placement of Epidural
Epidural Technique (also see Chapter 17)
Combined Spinal Epidural and Dural Puncture Epidural Techniques
Neuraxial Dosing and Delivery Techniques
Spinal Labor Analgesia
CONTRAINDICATIONS OF NEURAXIAL ANESTHESIA
COMPLICATIONS OF NEURAXIAL ANESTHESIA
Systemic Toxicity and Excessive Blockade (also see Chapter 10)
Treatment
Hypotension
Increased Core Temperature
ANESTHESIA FOR CESAREAN DELIVERY
Spinal Anesthesia
Epidural Anesthesia
Combined Spinal Epidural Anesthesia
General Anesthesia
Induction Drugs (also see Chapter 8)
Neuromuscular Blocking Drugs and Reversal Agents (also see Chapter 11)
Maintenance of Anesthesia
ABNORMAL PRESENTATIONS AND MULTIPLE BIRTHS
Multiple Gestations
Abnormal Presentations
Breech Presentation
Shoulder Dystocia
HYPERTENSIVE DISORDERS OF PREGNANCY
Preeclampsia
Intrapartum Management
Magnesium
Antihypertensives
Neuraxial Analgesia Considerations
HEMORRHAGE IN PREGNANT WOMEN
Placenta Previa
Massive Hemorrhage
Abruptio Placentae
Uterine Rupture
Retained Placenta
Uterine Atony
Placenta Accreta Spectrum
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
DIAGNOSIS AND MANAGEMENT OF FETAL DISTRESS
Overview
Key Evaluation Components
Uterine Contractions
Baseline FHR
Variability
Accelerations
Decelerations
FHR Categories
EVALUATION OF THE NEONATE AND NEONATAL RESUSCITATION
REFERENCES
34 - Pediatrics
DEVELOPMENTAL PHYSIOLOGY
Respiratory System
Lung Development
Chest Wall and Respiratory Muscles
Respiratory Variables
Factors Affecting Respiration
Breathing Patterns
Cardiovascular System
Fetal Circulation
Neonatal Myocardium
Autonomic Innervation of the Heart
Newborn Cardiovascular Assessment
Renal System
Hematologic System
PHARMACOLOGIC DIFFERENCES
Pharmacokinetics
Hepatic Metabolism
Renal Excretion
Pharmacology of Inhaled Anesthetics
Effect of Shunt on Inhaled Induction of Anesthesia
Minimum Alveolar Concentration
FLUIDS AND ELECTROLYTES
Intraoperative Fluid Administration
Replacement of Preoperative Fluid Deficits
Maintenance Fluids
Ongoing Fluid Losses
Treatment of Hypovolemia
Glucose Administration
TRANSFUSION THERAPY
Maximum Allowable Blood Loss
Transfusion of Blood Products
Packed Red Blood Cells
Platelets
Fresh Frozen Plasma
Cryoprecipitate and Fibrinogen Concentrate
Antifibrinolytics
Recombinant Factor VIIa
PEDIATRIC AIRWAY
Airway Assessment
Airway Management Techniques
Difficult Pediatric Airway
ANESTHETIC CONSIDERATIONS
Preoperative Evaluation and Preparation
Preoperative Laboratory Testing
Recent Upper Respiratory Tract Infection
Preoperative Fasting Guidelines
Premedication
Perioperative Considerations
Thermoregulation and Heat Loss
Monitoring (Also See Chapter 20)
Routes of Induction of Anesthesia
Maintenance of Anesthesia
Emergence
Pain Management (Also See Chapter 40)
Regional Anesthesia (Also See Chapters 17 and 18)
The Postanesthesia Care Unit (Also See Chapter 39)
Airway Monitoring
Postoperative Nausea and Vomiting
Emergence Agitation and Delirium
Pain Control
Discharge Criteria
Behavioral Recovery
MEDICAL AND SURGICAL DISEASES AFFECTING THE NEONATE
Necrotizing Enterocolitis
Clinical Manifestations
Medical and Surgical Treatment
Management of Anesthesia
Abdominal Wall Defects: Gastroschisis and Omphalocele
Medical and Surgical Treatment
Management of Anesthesia
Tracheoesophageal Fistula
Surgical Approaches
Anesthetic Management
Congenital Diaphragmatic Hernia
Management of Anesthesia
Patent Ductus Arteriosus
Management of Anesthesia
Retinopathy of Prematurity
Management of Anesthesia
Myelomeningocele
Management of Anesthesia
Pyloric Stenosis
Management of Anesthesia
CONGENITAL HEART DISEASE
Left-to-Right Shunts
Right-to-Left Shunts
Obstructive Lesions
Transposition of the Great Arteries
Single-Ventricle Lesions
Conclusion
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
REFERENCES
35 - GERIATRICS
INTRODUCTION
THE PHYSIOLOGIC CHANGES OF AGING
Cardiovascular System
Pulmonary System
Renal System
Nervous System
Gastrointestinal System
Hematologic System
PHARMACOLOGIC CONSIDERATIONS
Pharmacology of Specific Anesthetic Medications in the Elderly
Volatile Anesthetics
Propofol
Etomidate
Ketamine
Benzodiazepines
Opioids
Dexmedetomidine
Acetaminophen
Nonsteroidal Antiinflammatory Drugs
Local Anesthetics
Neuromuscular Blocking Agents
PREOPERATIVE ASSESSMENT AND RISK MANAGEMENT
INTRAOPERATIVE CONSIDERATIONS
POSTOPERATIVE MANAGEMENT
Acute Pain
Hypoxemia
Fluid Management
CHRONIC PAIN IN THE ELDERLY
PERIOPERATIVE NEUROCOGNITIVE DISORDERS
Postoperative Delirium
Postoperative Neurocognitive Disorders
SUMMARY
Acknowledgment
REFERENCES
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
CONCLUSION
REFERENCES
37 - Outpatient Anesthesia
INTRODUCTION
Ambulatory Anesthesia Settings
Non–Operating Room Anesthesia
Office-Based Anesthesia
PATIENT SELECTION
SURGERIES AND PROCEDURES
PREOPERATIVE EVALUATION
Obstructive Sleep Apnea (also see Chapter 48)
Obesity
Chronic Kidney Disease
Implanted and Other Medical Devices
Difficult Airway Management
Substance Use Disorders
ANESTHETIC TECHNIQUES
POSTOPERATIVE CARE
QUALITY IMPROVEMENT
ADVANCES AND NEW TRENDS IN OUTPATIENT ANESTHESIA
CONCLUSION
REFERENCES
38 - Anesthesia for Procedures in NonOperating 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 CT
Management of Anesthesia for MRI
INTERVENTIONAL RADIOLOGY
Interventional Neuroradiology
Anesthesia Choice
Access and Monitoring
Arterial Blood Pressure Management
Management of Neurologic and Procedural Crises
Body Interventional Radiology
Anesthesia Evaluation and Management
Transjugular Intrahepatic Portosystemic Shunt
Challenges: Hemostasis and Anticoagulation
ENDOSCOPY AND ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
Anesthesia Evaluation and Management
Challenges and Complications
CATHETER-BASED CARDIOLOGY PROCEDURES
Adult Cardiac Catheterization
Electrophysiology Studies
Catheter-Based Ablation
Cardiac Implantable Electronic Devices
Cardioversion
Structural Heart Disease Intervention
Pediatric Studies
Challenges and Complications
ELECTROCONVULSIVE THERAPY
Electrically Induced Seizures
Anesthesia Evaluation
Psychotropic Medications
Management of Anesthesia and Seizure
Physiologic Responses to Seizure and Treatment
Side Effects
REFERENCES
Section V - The Recovery Period
39 - Postanesthesia Recovery
ADMISSION TO THE POSTANESTHESIA CARE UNIT
EARLY POSTOPERATIVE PHYSIOLOGIC CHANGES
UPPER AIRWAY OBSTRUCTION
Loss of Pharyngeal Muscle Tone
Residual Neuromuscular Blockade
Laryngospasm
Airway Edema or Hematoma
Obstructive Sleep Apnea (also see Chapter 48)
DIFFERENTIAL DIAGNOSIS OF ARTERIAL HYPOXEMIA IN THE PACU (also see Chapter 5)
Alveolar Hypoventilation
Decreased Alveolar Partial Pressure of Oxygen
Ventilation-Perfusion Mismatch and Shunt
Increased Venous Admixture
Decreased Diffusion Capacity
PULMONARY EDEMA IN THE PACU
Postobstructive Pulmonary Edema
Transfusion-Related Acute Lung Injury
MONITORING AND TREATMENT OF HYPOXEMIA
Oxygen Supplementation
Limitations of Pulse Oximetry
Oxygen Delivery Systems (also see Chapter 41)
Continuous Positive Airway Pressure
Noninvasive Positive-Pressure Ventilation
HEMODYNAMIC INSTABILITY
Systemic Hypertension
Systemic Hypotension
Hypovolemic Shock
Distributive Shock
Cardiogenic Shock
Extracardiac/Obstructive Shock
Myocardial Ischemia
Low-Risk Patients
High-Risk Patients
Cardiac Arrhythmias
Tachyarrhythmias
Bradyarrhythmias
Treatment
RENAL DYSFUNCTION
Oliguria
Intravascular Volume Depletion
Postoperative Urinary Retention
Contrast Nephropathy
Intraabdominal Hypertension
Rhabdomyolysis
POSTOPERATIVE HYPOTHERMIA AND SHIVERING
Mechanism
Treatment
POSTOPERATIVE NAUSEA AND VOMITING
Prevention and Treatment
DELIRIUM
Risk Factors
Prophylaxis and Management
Emergence Agitation
DELAYED AWAKENING
Treatment
DISCHARGE CRITERIA
POSTANESTHESIA SCORING SYSTEMS
REFERENCES
40 - Perioperative Pain Management
COMMON TERMINOLOGY
In-Hospital (Inpatient) Pain Service
NEUROBIOLOGY OF PAIN
Nociception
Modulation of Nociception
Preventive Analgesia
Multimodal Approach to Perioperative Recovery
Opioid-Induced Hyperalgesia
Opioid-Sparing Versus Opioid-Free Techniques
ANALGESIC DELIVERY SYSTEMS
Patient-Controlled Analgesia
SYSTEMIC THERAPY
Oral Administration
Intravenous Administration
Subcutaneous Administration
Transmucosal Administration
Perioperative Management of Buprenorphine
NEURAXIAL ANALGESIA (also see Chapter 17)
Intrathecal Administration
Epidural Administration
Side Effects of Neuraxial Analgesic Drugs
Most Common Side Effects
Anticoagulants
Infection
SURGICAL SITE (INCISION) INFILTRATION
INTRAARTICULAR ADMINISTRATION
PARAVERTEBRAL BLOCKS
PERIPHERAL NERVE BLOCK
Techniques
Adjuvant Drugs
REGIONAL ANALGESIA
Catheter Versus Single-Shot Techniques
Upper Extremity
Lower Extremity
TRANSVERSUS ABDOMINIS PLANE BLOCK
REFERENCES
Section VI - Consultant Anesthetic Practice
41 - Critical Care Medicine
ICU DEFINITIONS, INTERPROFESSIONAL CARE, AND PHYSICIAN STAFFING
ORGAN FAILURE AND SUPPORT
Neurologic: Encephalopathy and Delirium
Cardiovascular: Shock
Hypovolemic Shock
Clinical Manifestations
Treatment
Cardiogenic Shock
Clinical Manifestations
Treatment
Mechanical Circulatory Support
Intraaortic Balloon Pump
Extracorporeal Membrane Oxygenation
Ventricular Assist Devices
Impella
Obstructive Shock
Clinical Manifestations
Treatment
Distributive Shock
Sepsis and Septic Shock
Clinical Manifestations
Treatment
Anaphylactic Shock
Clinical Manifestations
Treatment
Neurogenic Shock
Clinical Manifestations
Treatment
Hemodynamic Monitoring
Arterial Catheter
Central Venous Catheter
Pulmonary Artery Catheter
Noninvasive Cardiac Output Monitors
Point-of-Care Ultrasonography
Pulmonary: Respiratory Failure
Hypoxemic Respiratory Failure
ARDS
Treatment
Hypercapnic Respiratory Failure
Respiratory Support
Supplemental Oxygen
Noninvasive Positive-Pressure Ventilation
Mechanical Ventilation
Weaning From Mechanical Ventilation
Criteria for Weaning Trial
Oxygenation
Ventilation
Respiratory Mechanics
Other Criteria
Weaning Strategies
Tracheotomies
Gastrointestinal: Nutrition
Renal: Acute Kidney Injury
Epidemiology
Diagnosis
Treatment
Dialysis
Fluid Status Assessment
Infectious Disease: Hospital-Acquired Infections
Catheter-Associated Urinary Tract Infection
Ventilator-Associated Pneumonia
Catheter-Related Bloodstream Infection
Endocrine: Glucose Management
Prophylaxis
Venous Thromboembolism
Gastrointestinal Prophylaxis
A-F BUNDLE
A: Assess, Prevent, and Manage Pain
B: Both SAT and SBT
C: Choice of Sedation and Analgesia
D: Delirium: Assess, Prevent, and Manage
E: Early Mobility
F: Family Engagement and Empowerment
ACKNOWLEDGMENT
REFERENCES
42 - Perioperative Medicine
INTRODUCTION
THE PERIOPERATIVE MEDICINE CONSULTANT
IMPROVING PERIOPERATIVE OUTCOMES AND OPERATIONALIZING PERIOPERATIVE MEDICINE
VALUE-ADDED PREOPERATIVE SCREENING AND TESTING
MEDICAL MANAGEMENT OF THE MOST COMMON COMORBIDITIES
Anemia
Nutritional Optimization
Smoking Cessation
Glycemic Control (also see Chapter 29)
Obstructive Sleep Apnea and Chronic Obstructive Pulmonary Disease (also see Chapters 48 and 27)
Prehabilitation
Physical Exercise Regimen
PSYCHOLOGICAL STATE: ASSESSMENT AND INTERVENTIONS
COGNITIVE SCREENING AND INTER­VENTIONS (also see Chapter 35)
HEALTH LITERACY AND SHARED DECISION MAKING
OTHER OPPORTUNITIES TO IMPROVE PERI­O­PERATIVE OUTCOMES
FUTURE DIRECTIONS IN PERIOPERATIVE MEDICINE: SOCIAL DETERMINANTS OF HEALTH
REFERENCES
43 - Anesthesia for Trauma
INTRODUCTION
Background
Physiology in Trauma
INITIAL MANAGEMENT
Prearrival Preparation
Universal Organization/Preparation
Patient-Specific Preparation
Prearrival Briefing
Trauma Bay
Primary Survey
Airway and Oxygenation (Also See Chapter 16)
Management of the Airway and Trauma
Preoxygenation (Administration of Oxygen Before Induction of Anesthesia)
Fasting
Altered Physiology
Hemodynamic Status
Anesthetic Drug Choices
Manual In-Line Stabilization
Choice of Laryngoscope
Failed Endotracheal Intubation Drills
Posttracheal Intubation Care
Special Groups
Circulation and Hemorrhage
Disability
Exposure
Adjuncts and Investigations
Definitive Care and Transport
Setting Priorities: What Is Next?
Local Care Versus Transfer
Decision Making in Trauma
Leadership and Followership
Graded Assertiveness
INTRAOPERATIVE MANAGEMENT
Phase 1: Uncontrolled Hemorrhage
Damage Control Resuscitation
Access for Intravascular Resuscitation
Phase 2: Controlled Hemorrhage
Viscoelastic Testing
Phase 3: Restoration of Physiology
Anesthetics
SPECIAL CONSIDERATIONS
Traumatic Brain Injury
Spinal Cord Injury
Burns
Burn Severity
Estimating Burn Surface Area
Types of Burns: Thermal, Chemical, and Electrical
Fluid Management
Airway (Also See Chapter 16)
Pain (Also See Chapter 40)
Inhalation
Infection
Escharotomies
Transfer of Burn Patients
Extremes of Age
Pediatric Trauma (Also See Chapter 34)
Special Considerations
Geriatric Trauma (Also See Chapter 35)
Special Considerations
Trauma in Pregnancy
Causes of Trauma
Anatomy of Injury
Special Considerations
Maternal Physiology
Aortocaval Compression
Maternal Airway
Anti-D Immunoglobulin
Radiation Exposure
Fetal Monitoring
Delivery
Specific Differential Diagnoses (Also See Chapter 33)
Care for Trauma Patients in Non-OR Settings
Acknowledgment
REFERENCES
44 - Chronic Pain Management
INTRODUCTION
CHRONIC PAIN FOUNDATIONS
Terminology
Epidemiology
Pathophysiology
PAINFUL CONDITIONS: SPINE
Lower Back Pain: An Overview
Lumbosacral Spine Pain: Axial Pain Generators
Lumbosacral Radiculopathy
Lumbar Spinal Stenosis
PAINFUL CONDITIONS: NEUROPATHIC PAIN
Peripheral Neuropathy
Complex Regional Pain Syndrome
PAINFUL CONDITIONS: CHRONIC POSTSURGICAL PAIN
PAIN CONDITIONS: ADDITIONAL GENERATORS
PSYCHOLOGICAL TREATMENT PILLAR: CATASTROPHIZING
PHYSICAL MEDICINE TREATMENT PILLAR
PHARMACOLOGIC TREATMENT PILLAR
Nonopioid Analgesics
Opioid Analgesics (Also See Chapter 9)
PROCEDURAL TREATMENT PILLAR
Epidural Steroid Injections
Facet Injections
Sympathetic Blockade
NEUROMODULATION: ADVANCED INTERVENTIONAL PAIN MEDICINE
SUMMARY
ACKNOWLEDGMENT
REFERENCES
45 - Cardiopulmonary Resuscitation
INTRODUCTION
EVIDENCE BASED
PRINCIPLES OF MANAGEMENT
Basic Life Support
Recognition
Cardiopulmonary Resuscitation
Defibrillation
Alternative Techniques and Ancillary Devices
Adult Advanced Cardiovascular Life Support
Resuscitation Team Management
Monitoring Cardiopulmonary Resuscitation
Airway Management
Management of Specific Arrhythmias
Bradycardia
Tachycardia
Pulseless Arrest
Ventricular Fibrillation/Ventricular Tachycardia
Asystole/Pulseless Electrical Activity
Medication Administration
Pediatric Advanced Life Support
Circulation
Airway and Ventilation Management
Defibrillation
Medications
Post-resuscitation Care and Neuroprognostication
Acute Coronary Syndrome
Pulmonary and Hemodynamic Goals
Neurologic Monitoring
Targeted Temperature Management
Blood Glucose Control
Special Perioperative Considerations
Anaphylaxis
Gas Embolism
Local Anesthetic Systemic Toxicity (LAST) (Also See Chapter 10)
Cardiovascular Collapse From Neuraxial Anesthesia
Cardiac Arrest in Pregnancy
Debriefing
Systems of Care
REFERENCES
46 - Quality and Patient Safety in Anesthesia Care
INTRODUCTION
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 Approaches: FADE, PDSA, and DMAIC
Multidisciplinary Process Improvement: Root Cause Analysis, “Never Events,” and Failure Mode Effects Analysis
SUMMARY
REFERENCES
47 - 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
Inpatient Palliative Care Consults
Hospice Consults
Outpatient Palliative Care Consults
Prognosis
Physician Estimate
Disease Trajectories
Prognostic Tools
Functional Status
Communication
Physician Tendencies in Addressing Difficult Topics
Patient and Family Wishes About Communicating Prognosis
Frameworks for Communicating Difficult Information
Discussing Code Status
Time-Limited Trials
Identifying the Imminently Dying Patient
PERIOPERATIVE MANAGEMENT OF THE PALLIATIVE CARE PATIENT
Advance Directives
Decision-Making Capacity
Surrogate Decision Makers
How to Approach Perioperative DNR Conversations
Recommendations From the American Society of Anesthesiologists
Recommendations From the American College of Surgeons and the Association of periOperative Registered Nurses
Hospice Patients Who Present for Surgery
CONCLUSION
REFERENCES
48 - Sleep Medicine and Anesthesia
INTRODUCTION
BASIC SLEEP PHYSIOLOGY
GENERAL ANESTHESIA
OTHER AROUSAL STATES
SLEEP AND ANESTHESIA STATES
FUNCTIONAL NEUROANATOMY OF SLEEP AND AROUSAL PATHWAYS
SLEEP-DISORDERED BREATHING OR SLEEP-RELATED BREATHING DISORDERS
OBSTRUCTIVE SLEEP APNEA
Pathophysiology of Upper Airway Collapse in Obstructive Sleep Apnea
Clinical Diagnostic Criteria
Polysomnography and Portable Devices
Prevalence of OSA in the General and Surgical Populations
OSA and Comorbid Conditions
Surgery and OSA Severity
OSA and Perioperative Complications
Clinical Pathways and Principles of Perioperative Management
Preoperative Assessment (Also See Chapter 13)
Patients With Diagnosed OSA
Patients With Suspected OSA
Perioperative Risk Mitigation Strategies
Postoperative Disposition of OSA Patients
CONCLUSION
REFERENCES
49 - Anesthesia and Environmental Health
HEALTH, HEALTH CARE, AND CLIMATE CHANGE
ENVIRONMENTAL IMPACT OF ANESTHESIA GASES
OCCUPATIONAL HAZARDS OF INHALED ANESTHETICS
LOW-FLOW ANESTHESIA
CLOSED-CIRCUIT ANESTHESIA
CO2 ABSORBENTS
WASTE ANESTHETIC GAS SCAVENGING SYSTEMS
ENVIRONMENTAL IMPACT OF PROPOFOL
DRUG WASTE
ENVIRONMENTAL IMPACT OF OPERATING ROOM PRACTICES
Waste
Reusable versus Single-Use Equipment
Reusable versus Single-Use Textiles
Reusable Breathing Circuits
Energy Efficiency
SUMMARY
REFERENCES
Index
IBC