Ebook Basic clinical anesthesia: Part 2

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(BQ) Part 2 book “Basic clinical anesthesia” has contents: Cardiac anesthesia, vascular anesthesia, thoracic anesthesia, ambulatory anesthesia, hepatic and gastrointestinal diseases, endocrine diseases, pediatric anesthesia, the elderly patient,… and other contents.

Part IV Specialty Anesthesia 26 Cardiac Anesthesia Mahesh Sardesai Cardiac anesthesiology encompasses the perioperative management of patients undergoing surgery on the heart and great vessels, as well as an increasing variety of transcatheter and other nonsurgical procedures Cardiovascular disease is the leading cause of death in the United States and other industrialized nations, and it comprises an increasing share of the disease burden in the developing world Accordingly, the fundamental principles of cardiac anesthesiology are essential not only for cardiac surgery itself, but also for the care of patients with various degrees of cardiovascular compromise undergoing noncardiac procedures Therefore, optimum anesthetic care of these patients requires familiarity with cardiovascular physiology, diagnostic evaluation, transesophageal echocardiography (TEE), cardiopulmonary bypass (CPB), cardiac surgical techniques, and cardiac perioperative care Cardiovascular Physiology The underlying principle of perioperative management in any patient is to maintain adequate oxygen delivery to sustain the metabolic requirements of vital organs and peripheral tissues The ultimate goal of any cardiac surgical intervention is to provide conditions that promote adequate tissue perfusion with as little cardiopulmonary burden as possible Blood Pressure Tissue perfusion depends on systemic blood pressure and local vascular resistance Local vascular resistance is determined by local vasomotor tone Systemic blood pressure, clinically measured with a noninvasive blood pressure cuff or an indwelling arterial catheter, is expressed as mean arterial pressure (MAP), M Sardesai, M.D., M.B.A (*) Department of Anesthesiology, UPMC Shadyside Hospital, 5230 Centre Avenue Suite 205, Pittsburgh, PA 15232, USA e-mail: sardesaimp@upmc.edu normally between 70 and 100 mmHg normally between 70 and 100 mmHg Pulsatile flow from cyclic cardiac contractions generates a pulse pressure, the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP) The five main physiologic parameters that contribute to blood pressure are heart rate, rhythm, contractility, preload, and afterload Understanding these five parameters is essential to developing a clinical framework for hemodynamic management (Table 26.1) At normal resting heart rates, MAP can be estimated from measurements of SBP and DBP: MAP » SBP + DBP 3 However, at high heart rates, changes in the shape of the arterial pulse pressure curve cause MAP to approach the mean of SBP and DBP. Systemic blood pressure depends on a contribution from the heart, cardiac output (CO), and a contribution from the systemic vasculature, systemic vascular resistance (SVR): MAP = CO ´ SVR Cardiac Output Cardiac output is the volume of blood pumped by the heart into the peripheral circulation every minute Normal CO is approximately 5–6 L/min in a 70 kg adult male Cardiac index (CI), equal to CO divided by body surface area (BSA), is a normalized value that allows comparison of CO among people of differing body habitus (normal CI = 2.5–4.2 L/min/ m2) CO is normally identical between the right and left sides of the heart, but certain congenital abnormalities and traumatic injuries can cause the two sides of the heart to eject different amounts of blood per cardiac cycle CO is equal to the product of heart rate (HR) and stroke volume (SV): CO = HR ´ SV CI = CO / BSA P.K Sikka et al (eds.), Basic Clinical Anesthesia, DOI 10.1007/978-1-4939-1737-2_26, © Springer Science+Business Media New York 2015 311 312 M Sardesai Table 26.1 Overview of physiologic determinants of systemic blood pressure Heart rate Colloquial Clinical Fundamental Monitoring methods Rhythm Colloquial Clinical Fundamental Monitoring methods Contractility Colloquial Clinical Fundamental Monitoring methods Preload Colloquial Clinical Fundamental Monitoring methods Afterload Colloquial Clinical Fundamental Monitoring methods SA node Pulse rate, heartbeats per minute Periodicity or frequency of contraction Intactness of nodal function and innervation ECG, pulse waveforms Beat pattern, ECG tracing Regularity of contraction Intactness of cardiac conduction system Peripheral pulse, ECG, pulse waveforms Heart function, ejection fraction Magnitude of contraction, change in pressure Increase in intraventricular pressure during contraction, change in myocyte length TEE, pulse pressure, cardiac contractions on surgical field Ventricular volume, dilation, volume status Chamber volume at end diastole Maximum myocyte stretch TEE, venous distension, distension of heart on surgical field Arterial squeeze, vascular tightness Resistance faced by myocardium Work performed by myocyte PA catheter, TEE (by excluding other causes of hypotension) Heart Rate Heart rate represents the periodic impulses from the native pacemaker function of the heart’s conduction system Spontaneous, rhythmic depolarization of cells in the sinoatrial (SA) node generates impulses that are conducted through the atrioventricular (AV), the bundle of His, and the network of Purkinje fibers in the ventricles, thus spurring a coordinated cardiac contraction (Fig 26.1) The spontaneous nodal function of the heart is modulated by the autonomic nervous system Sympathetic stimulation (β-receptors) from upper thoracic spinal nerves increases HR, while parasympathetic stimulation (cholinergic receptors) from the vagus nerve (cranial nerve X) decreases HR. A mild reduction in HR can improve CO by providing more diastolic time for greater ventricular filling, but more significant decreases in HR will lead to a decrease in CO AV node Ventricular muscle Atrial muscle Bundle of His Left and right bundle branches Purkinje fibers Fig 26.1 Conduction system of the heart Heart Rhythm While heart rate measures the periodicity or frequency of cardiac contraction, rhythm measures the regularity or pattern of contraction Abnormal conduction leads to irregular heart rhythms, or arrhythmias Irregular rhythms can decrease CO by reducing diastolic filling time or by impeding the ability of the heart to contract in an efficient, coordinated fashion Overall, then, HR represents the intactness of nodal function and autonomic innervation of the heart, while rhythm represents the intactness of the cardiac conduction system Stroke Volume Stroke volume is the net amount of blood ejected by the heart per cardiac cycle, equal to the difference between end- diastolic volume (EDV) and end-systolic volume (ESV) During systolic contraction, shortening of cardiac myocytes generates a force that increases pressure inside the left ventricle Once this pressure exceeds DBP, the aortic valve opens, allowing ejection of blood from the left ventricle into the aorta The force of this myocardial contraction is called contractility The percentage of ventricular blood volume that is ejected during a single contraction, an indirect yet clinically useful measure of contractility, is called the ejection fraction (EF) Unlike SV, EF does not change with body habitus Healthy individuals typically have an EF of 55–70 % Stroke volume is affected by preload, afterload, contractility, valvular dysfunction, and wall-motion abnormalities EF = (EDV - ESV) / EDV = SV / EDV 26 Cardiac Anesthesia 313 Stroke volume Stroke volume Increased contractility Heart failure Afterload End-diastolic volume Normal during excercise Normal at rest Normal heart Moderate failure Severe failure Heart failure Cardiogenic shock Fig 26.3 Relationship between stroke volume and afterload Fig 26.2 Relationship between stroke volume and end-diastolic volume (Frank–Starling law) Preload EDV (or preload) is the maximum volume of the heart during the cardiac cycle It is the point at which the myocardium is maximally stretched prior to contraction and sarcomeres in the cardiac myocytes are the longest The amount of muscle stretch in the myocardium at EDV is called preload Surrogate measures of preload include central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), and left atrial pressure (LAP) According to the Frank–Starling mechanism, small increases in preload can improve the contractile function of the heart, resulting in increased SV with relatively little change in EF (Fig 26.2) Preload is dependent upon venous return, the blood volume, and the distribution of blood volume (posture, intrathoracic pressure) This is appreciated clinically as a “volume responsive” heart, a situation in which volume administration improves forward blood flow and systemic blood pressure As intraventricular volume increases further, additional increases in preload cause smaller increases in stroke volume Changes in ventricular compliance affect the end-diastolic pressure (EDP) A poorly compliant (“stiff”) ventricle will not expand easily with increased preload, leading to increased EDP and potentially detrimental venous congestion On the other hand, in a very compliant ventricle, as in a patient with dilated cardiomyopathy, increases in preload not lead to appreciable increases in EDP and may fail to improve SV adequately Afterload The resistance that must be overcome by the ventricle with each contraction is called afterload On a fundamental level, afterload is the work performed by the myocardium, or the force the myocardium must generate to propel blood a certain distance CO is inversely related to afterload Clinically, SVR is the principal determinant of afterload (Fig 26.3) SVR (normal 900–1,500 dyn/s/cm5) can be calculated from other hemodynamic measurements: ( ) SVR dynes / s / cm = 80 ´ ( MAP mmHg - CVP mmHg ) CO ( L / ) According to the Hagen–Poiseuille law, laminar blood flow through vessels is inversely proportional to the fourth power of vessel radius Although capillaries are the narrowest vessels in the entire circulation, the presence of millions of capillaries in parallel minimizes their aggregate contribution to SVR. Instead, the compliance of large arterioles plays the largest role in determining ventricular afterload Coronary Circulation The heart is supplied by two coronary arteries, left and right, arising from the aorta (Figs 26.4 and 26.5) They run on the surface of the heart and are, therefore, called epicardial arteries The right coronary artery (RCA) branches into the right marginal artery and the posterior descending artery and supplies the right atrium, right ventricle, bottom portion of 314 M Sardesai Aorta Superior vena cava Pulmonary valve Pulmonary artery Pulmonary veins Left atrium Right atrium Mitral valve Tricuspid valve Aortic valve Left ventricle Right ventricle Inferior vena cava Fig 26.4 Blood flow through the heart Superior Vena Cava Aorta Pulmonary Artery Left Atrium Right Coronary In people in whom the posterior descending artery arises from the RCA are right dominant (65 %), from the CA are left dominant (25 %), and both from the RCA and CA are codominant (10 %) Deoxygenated blood is returned to the chambers of the heart via coronary veins These veins converge to form the coronary venous sinus, which in turn drains into the right ventricle The anatomic region of heart most likely associated with the specific coronary arterial supply is: • Inferior-Right coronary artery • Anteroseptal-Left anterior descending artery • Anteroapical-Left anterior descending (distal) artery • Anterolateral-Circumflex artery • Posterior-Right coronary artery The two coronary arteries are end arteries, and because they are narrow are prone to atherosclerosis Average coronary blood flow is 250 ml/min Myocardial blood flow is closely linked with oxygen demand, which is about 8–10 ml of O2/min/100 g The myocardium extracts about 65 % of oxygen in the arterial blood compared with other tissues (25 %) The coronary arteries autoregulate coronary blood flow between perfusion pressures of 50–120 mmHg Increases in heart rate cause decreased coronary perfusion This is because the heart gets its blood supply during diastole, and any increase in heart rate decreases diastolic time Coronary perfusion pressure (CPP) is a balance between the diastolic blood pressure and the left ventricular end-diastolic pressure and can be calculated as: CPP = Diastolic blood pressure – LVEnd diastolic pressure Circumflex Preoperative Management Right Atrium Left Anterior Descending Left Ventricle Right Ventricle Inferior Vena Cava Fig 26.5 Coronary circulation both ventricles, and back of the septum The left main coronary artery (LCA) branches into the circumflex artery and the left anterior descending artery (LAD) and supplies: • Circumflex artery (CA)—supplies blood to the left atrium and side and back of the left ventricle • Left anterior descending artery (LAD)—supplies the front and bottom of the left ventricle and the front of the septum Patient Assessment Typically in elective cardiac surgery, and even in many emergency cases, the surgical diagnosis and operative plan have been established in advance by history, physical examination, and diagnostic testing The patient presenting for heart surgery, by definition, has compromised cardiopulmonary function and has probably already suffered some degree of damage to other organs The fundamental paradox of cardiac surgery is that the planned operation increases the risk of further damage to other organ systems, yet the operation itself presumably represents the best chance to “optimize” the patient’s overall condition The substantial logistical and economic resources called upon by a cardiac operation impose additional pressure to develop a perioperative risk management strategy without postponing or canceling surgery Therefore, the goal of preoperative evaluation should be to clarify any preexisting conditions known to be associated 26 Cardiac Anesthesia with an increased risk of perioperative morbidity and mortality Among these are: • Age greater than 60 years • Previous cardiac surgery • Significant obesity (body mass index greater than 35 kg/m2) • Systemic or pulmonary arterial hypertension • Acute coronary syndrome (ACS) • Congestive heart failure (CHF) • Diabetes mellitus • Peripheral vascular disease • Acute or chronic renal insufficiency • Chronic pulmonary disease • Neurological disease istory and Physical Examination H As with any other procedure, preoperative assessment for cardiac surgery begins with a careful history and physical examination The patient should be asked about any past or current symptoms of chest pain, fatigue, shortness of breath, orthopnea, nocturnal angina or dyspnea, light-headedness, syncope, or palpitations The time course and progression of symptoms should be determined, with particular emphasis on whether symptoms occur at rest or with exertion It can be especially illuminating to identify symptoms in the context of the patient’s baseline lifestyle and level of activity For example, a patient may struggle to identify symptoms in unambiguous clinical terms but may easily describe related lifestyle changes, such as a reduced capacity to perform required job duties or abandonment of a favorite recreational activity Physical examination should obviously include auscultation of the heart for rhythm and the presence of any 315 murmurs Consultation with the primary physician or cardiologist can help delineate the progression of valvular lesions and decide if further evaluation is needed Softer midsystolic murmurs (grade or lower) that are asymptomatic and are not associated with other findings are generally thought to reflect increased flow velocity and require no further workup However, echocardiography is recommended in patients with louder or symptomatic midsystolic murmurs Other systolic murmurs, diastolic murmurs, and continuous murmurs reflect pathology and require echocardiography The degree of CHF should be assessed in terms of both American Heart Association (AHA) objective criteria as well as New York Heart Association (NYHA) functional capacity (Table 26.2) The patient’s tolerated level of exertion, measured in metabolic equivalents (MET), can provide a relative measure of perioperative risk (Table 26.3) Having cardiac surgery is a major life event by any measure, and caregivers need to be sensitive to the immense emotional burden faced by patients and their loved ones In the preoperative period, the anesthesiologist must balance the desire for a thorough assessment and honest discussion of perioperative risks with the need to avoid placing undue psychological (and, in turn, physiologic) stress on the patient A candid explanation of the anesthesia team’s active role in the operating room—monitoring the patient continuously and providing the diagnostic and physiologic support necessary to allow the surgeon the freedom to concentrate on the technical aspects of the operation itself—can be both informative and reassuring At the same time, many patients view the prospect of heart surgery as a signal to reconsider their Table 26.2 New York Heart Association (NYHA) functional classification, and American Heart Association (AHA) objective assessment of heart function NYHA class I II III IV AHA class A B C D Functional capacity in patients with cardiac disease No symptoms and no limitation of physical activity (ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or angina) Mild symptoms and slight limitation of physical activity (comfortable at rest, ordinary physical activity results in fatigue, palpitation, dyspnea, or angina) Moderate symptoms and marked limitation of physical activity (comfortable at rest, less-than-ordinary activity causes fatigue, palpitation, dyspnea, or angina) Severe symptoms and severe limitation of physical activity (inability to carry on any physical activity without discomfort, symptoms of heart failure or angina may be present even at rest, bed-bound patients) Objective assessment No objective evidence of cardiovascular disease Objective evidence of minimal cardiovascular disease Objective evidence of moderately severe cardiovascular disease Objective evidence of severe cardiovascular disease Examples A patient with minimal or no symptoms but a large pressure gradient across the aortic valve or severe left main coronary artery exclusion is classified as NYHA class I, AHA class D A patient with severe angina but normal coronary arteries on angiography is classified as NYHA class IV, AHA class A 316 M Sardesai Table 26.3 Approximate metabolic equivalents of task (MET) for various activities One MET represents metabolic oxygen consumption of 3.5 ml kg−1 min−1 MET 7 Good Activity Sleeping or sitting stationary Activities of daily living: eating, dressing, bathing, using the toilet Writing, desk work Walking indoors or around the house Light housework: changing bed sheets, dusting, washing dishes Brisk walking 1–2 blocks on level ground Climbing 1–2 flights of stairs or walking uphill Gardening and lawn work: raking leaves, weeding, pushing a mower Sexual relations Moderate housework: vacuuming, sweeping floors, carrying groceries Heavy housework: scrubbing floors, lifting and moving heavy furniture Jogging or running Swimming, cycling, vigorous sports own health-related behaviors and commit to improving them afterwards The preoperative discussion offers a valuable opportunity for the anesthesiologist to reinforce this process by encouraging healthy lifestyle changes that will also reduce future anesthetic risk, such as smoking cessation and weight management ations in patients with asthma or other chronic obstructive pulmonary disease (COPD) include the frequency of symptoms, time since the last attack, compliance with medications, and any previous need for intubation Preoperative oxygen saturations, blood gases, pulmonary function tests, and chest imaging can be useful Any history of smoking, current or remote, should be elicited Even if undiagnosed, Concomitant Diseases some degree of obstructive sleep apnea can be presumed in Patients scheduled for cardiac surgery frequently present morbidly obese patients or those who present with snoring with multiple comorbid conditions, which may arise either or daytime somnolence Any use of supplemental oxygen independently or as a result of their compromised cardiac sta- or positive airway pressure therapy should be determined tus Reviewing the patient’s list of prescription and over-the- to help guide intraoperative and postoperative ventilation counter medications can quickly reveal coexisting conditions strategies that should be considered when developing a perioperative Airway management plan If the physical examination suggests a difficult airway, and Cardiovascular especially if an awake intubation is anticipated, preparations Coronary artery disease often occurs in concert with cere- should be made for adequate topicalization, sedation, and brovascular and peripheral vascular disease Any history antihypertensive therapy during intubation If there is eviof previous stroke or transient ischemic attack, along with dence of poor dentition or abscesses in a patient scheduled any residual neurologic defects, should be ascertained for valve surgery, preoperative dental consultation and tooth Auscultation of the carotid arteries for bruits and review extraction may be indicated to prevent the development of of any carotid Doppler studies can reveal the severity of prosthetic valve endocarditis occlusive disease, which increases the risk of perioperative cerebrovascular complications Claudication, paresthesias, Diabetes Mellitus and venostasis changes suggest the presence of significant Diabetes mellitus is a major risk factor for coronary artery peripheral vascular disease Peripheral pulses should be pal- disease and an independent predictor of perioperative morpated, particularly in locations where arterial line placement bidity and mortality Because of accompanying autonomic is anticipated neuropathy, diabetics have an increased risk of hemodynamic lability and asymptomatic (silent) myocardial Pulmonary ischemia, thereby increasing overall cardiovascular risk The thoracotomy incision incumbent with cardiac surgery, Delayed gastric emptying, also associated with autonomic as well as CPB itself, increases the risk of postsurgical pul- neuropathy, can also complicate airway management A monary complications Thoroughly assessing the patient’s preoperative serum glycosylated hemoglobin (HbA1c) level baseline pulmonary status can help predict the need for can help characterize the quality of glycemic control in the prolonged postoperative ventilation Important consider- months preceding surgery and identify those patients in 26 Cardiac Anesthesia need of more aggressive perioperative and postoperative glycemic control Renal Patients with even early stages of renal dysfunction experience increased morbidity from cardiac surgery Many factors incumbent to cardiac surgery, such as large crystalloid fluid loads from CPB, hyperkalemic cardioplegia solutions, and variable or prolonged periods of systemic hypoperfusion, can adversely affect renal function Severe renal impairment, especially when combined with anemia and metabolic acidosis, can compromise myocardial function when weaning the patient from CPB. Baseline urine production in patients with renal dysfunction should be assessed, as urine output is often used in cardiac surgery as an indicator of renal function Liver Severe liver dysfunction increases the risk of severe bleeding complications from surgery Any clinical signs of impaired clotting, such as delayed wound healing, epistaxis, or gum bleeding, should raise concern about severely reduced production of clotting factors Preoperative administration of vitamin K or fresh frozen plasma may be warranted, keeping in mind that the added fluid load can worsen CHF and left ventricular dysfunction Elective surgery should be delayed in patients with acute hepatitis until serum liver function tests normalize Laboratory Tests Reviewing the cardiac surgical assessment and previous diagnostic tests is essential, both to assess the patient’s overall medical condition and to understand more fully the planned operation Previous surgical records may provide evidence of potential complicating factors, such as unanticipated difficult airway management or adverse events Past surgical records are particularly important for repeat cardiac surgery A chest radiograph can show the distance between the cardiac silhouette and the sternum, which can help judge the likely difficulty of sternotomy and intrathoracic surgical dissection Other imaging modalities, such as computer tomography (CT) or cardiac magnetic resonance imaging (MRI), can delineate intrathoracic anatomy and highlight potential dangers for sternotomy, such as a dilated aortic root or previous coronary bypass grafts in close proximity or adherent to the sternum Important preoperative laboratory tests include serum hemoglobin and hematocrit, platelet count, blood urea nitrogen and creatinine levels, coagulation profiles, and liver function tests The preoperative electrocardiogram (ECG) should be examined for signs of myocardial ischemia, prior myocardial infarction, and abnormal conduction Stress echocardiography, myocardial perfusion studies, and cardiac catheterization can provide valuable information about 317 v alvular abnormalities, global and segmental left ventricular function, areas of induced ischemia, pulmonary hypertension, and right ventricular dysfunction (cor pulmonale) For patients scheduled for coronary artery bypass grafting (CABG), cardiac catheterization can define coronary anatomy and help determine the number and location of planned bypass grafts Preoperative Medications Antihypertensives Primary or essential hypertension is common in patients having cardiac surgery and is a major concern for risk assessment and stratification Chronic hypertension can lead to left ventricular hypertrophy, decreased ventricular compliance, renal insufficiency or failure, and neurologic symptoms progressing to infarction After excluding secondary causes of increased blood pressure (e.g., renal disease, pheochromocytoma, or certain drugs), one should assess the typical range of blood pressures within the patient normally lives without symptoms Patients are typically advised to delay elective surgery until blood pressure is controlled to a normal range, but altered cerebral autoregulation may make normotension undesirable Untreated primary hypertension that appears to resolve spontaneously (“pseudonormotension”) may actually represent myocardial compromise or progression of valvular stenosis and pose a risk of cardiovascular collapse with minimal anesthetic exposure or surgical stress In general, patients on antihypertensive medications should continue such medications throughout the perioperative period to maintain blood pressure homeostasis at the time of surgery, though diuretics should not be given the day of surgery to minimize hypovolemia In particular, withdrawal of β-blockers and clonidine can lead to rebound hypertension Preoperative nitrates and digoxin should also be continued Calcium channel blockers may have renal protective effects in patients undergoing surgery involving aortic crossclamping, but their myocardial depressant and vasodilator effects can accentuate hypotension during anesthetic induction Refractory hypotension during and after CPB can also occur with ACE inhibitors and angiotensin II receptor antagonists Nonetheless, the apparent renal protective benefit of these agents warrants their continuation perioperatively while treating intraoperative hypotension with appropriate vasoconstrictor therapy Antidiabetics Diabetics undergoing cardiac surgery require serial monitoring of serum glucose levels Patients should be instructed to withhold their usual nutritional insulin on the day of surgery Similarly, oral diabetes medication should be held in the morning of the surgery Inpatients awaiting surgery may 318 require scheduled insulin therapy to achieve preoperative glycemic control The intraoperative humoral stress response can cause increased cortisol levels and decreased production of insulin, both of which can lead to hyperglycemia Intraoperative glycemic control is achieved most efficiently with a continuous intravenous infusion protocol rather than intermittent intravenous boluses or subcutaneous injections An insulin protocol should be started perioperatively for diabetic patients undergoing cardiac surgery, as well as for nondiabetics who have repeated serum glucose values ≥180 mg/dL. Maintaining glycemic control (120–180 mg/dL) prior to and during cardiac surgery is associated with reduced mortality, decreased neurologic injury, lower incidence of wound infections, and decreased length of hospital stay Tighter glucose control strategies (such as 90–120 mg/dL) have not been demonstrated to lead to superior outcomes While mild hyperglycemia appears to be well tolerated in most patients, hypoglycemia is an unambiguously undesirable complication of intensive insulin infusion therapy Accordingly, overly aggressive intraoperative glucose control may be counterproductive, especially if it distracts from other patient care responsibilities Anticoagulants Patients on chronic anticoagulant therapy (e.g., aspirin, heparin, or warfarin) or who have been recently exposed to thrombolytic agents pose a particular challenge The preoperative evaluation should pay particular attention to the usage, dosage regimen, indications, and cessation intervals of these drugs Ideally, such medications should be stopped several days prior to surgery to minimize postoperative bleeding complications, but these benefits should be weighed against the patient-specific risks of stopping ongoing anticoagulant therapy, such as in-stent restenosis or thromboembolism Warfarin (Coumadin) should be stopped days prior to surgery or until a normal or near-normal INR is reached Similarly, PTT or thrombin clotting time can help verify adequate blood clotting function after discontinuing dabigatran (Pradaxa, a direct thrombin inhibitor) or rivaroxaban (Xarelto, a direct factor Xa inhibitor) Patients at high risk of thrombosis may need to be admitted to the hospital preoperatively for bridging therapy More urgent surgery may require administration of some combination of vitamin K and fresh frozen plasma, depending on the patient’s level of anticoagulation and the urgency of surgery Aspirin irreversibly inhibits platelet cyclooxygenase, rendering platelets inactive Thienopyridines such as clopidogrel (Plavix) and prasugrel (Effient) also irreversibly inhibit platelet response for the life of the platelet A newer ADP receptor/P2Y12 inhibitor, ticagrelor (Brilinta), is an allosteric antagonist that provides reversible platelet blockade Patients with newly diagnosed ACS may be started on dual antiplatelet therapy (aspirin and clopidogrel) to prevent further dis- M Sardesai ease progression One may suspect that discontinuing antiplatelet therapy would predispose the patient to thrombotic complications, particularly in patients with drug- eluting stents However, studies suggest that discontinuing antiplatelet therapy a few days before surgery is actually associated with reductions in bleeding, transfusion requirements, and rates of reoperation, with no significant increase in rates of myocardial infarction, stroke, or postoperative death Preoperative discontinuation of aspirin is also reasonable in high-risk patients, such as those who refuse blood transfusion (Jehovah’s Witnesses) and those with limited sources of allogeneic blood products due to antibodies Patients presenting for urgent or emergent cardiac surgery may have received doses of glycoprotein IIb/IIIa receptor antagonists during cardiac catheterization Antiplatelet effects last approximately 24–48 h for abciximab (ReoPro), 4–8 h for tirofiban (Aggrastat), and 2–4 h for eptifibatide (Integrilin) Even in nonelective surgery, a delay of or days can help reduce intraoperative bleeding risk while minimizing thrombotic risk Laboratory tests of platelet inhibition, such as PFA-100 or thromboelastography (TEG), can be helpful in deciding whether to delay surgery If surgery cannot be postponed, the increased intraoperative bleeding may necessitate acute reversal of therapy, alterations in heparin dosing for CPB, large transfusions of blood products (including platelets), or administration of procoagulant agents (such as activated factor VII) Herbals The preoperative review of medications should not neglect over-the-counter medications, herbal remedies, nutritional supplements, and other nontraditional therapies, as they can have important implications for anesthetic care For example, ephedra (ma huang) is a sympathomimetic compound that can complicate hemodynamic management, while ginseng and gingko biloba can inhibit platelet aggregation Patients may be reluctant to mention taking these substances unless specifically asked about them Because complementary therapies are not consistently regulated for origin, content, and purity, all such drugs should preferably be stopped at least days prior to surgery Cardiac Implantable Electronic Devices Cardiac implantable electronic devices consist of permanent pacemakers, which supplement or replace the heart’s native conduction system, and implantable cardioverter defibrillators (ICDs), which provide tachycardia therapy Approximately three million people worldwide currently live with a pacemaker In the United States alone, roughly one million people have a pacemaker, and nearly 200,000 new pacemakers are implanted annually Pacemakers and 26 Cardiac Anesthesia 319 ICDs are implanted for a wide variety of conduction disorders and ischemic conditions (Table 26.4) The increasingly widespread use of these devices presents special challenges for perioperative management In addition to evaluating and optimizing coexisting conditions, preoperative evaluation of a patient with an implanted device should include determining the type of device, indication for placement, and currently programmed settings (Table 26.5) This information can frequently be obtained from the patient (wallet card) or the physician managing the device A chest radiograph can help determine the device type by showing the number and location of pacing electrodes and shock coils Also, the generator may also be identified by a radiopaque manufacturer logo and serial number Locating the coronary sinus lead on a biventricular pacemaker or ICD can help avoid dislodgment during central line placement Nonetheless, interrogation with a programming console remains the only reliable means of evaluating assessing device settings and predicted battery life Under ideal circumstances, all patients with a pacemaker or ICD should undergo preoperative device interrogation, not only to determine proper function but also to facilitate proper intraoperative management Table 26.4 Indications for cardiac implantable electronic device implantation Permanent pacemaker Sinus node disease Atrioventricular node disease Long QT syndrome Hypertrophic cardiomyopathy Dilated cardiomyopathy Implantable cardioverter defibrillator (ICD) Ventricular tachycardia, fibrillation Post-myocardial infarction with EF ≤30 % Cardiomyopathy with EF ≤35 % Long QT syndrome Hypertrophic cardiomyopathy Awaiting ventricular assist device or heart transplant by the anesthesia team However, this may not be possible in all situations, such as in emergency surgery Electromagnetic interference (EMI) from surgical electrocautery can be detected by the device and interfere with its normal function Monopolar electrocautery (Bovie) creates an arc of electrical current from the single handheld electrode to the adhesive return pad; this current can threaten any electrical device or metallic implant in its path In contrast, bipolar electrocautery confines the current between the two handheld electrodes and is preferable in these patients If monopolar electrocautery is required for the operation, then the return pad should be placed in a location that prevents the electrical arc from crossing the device generator and leads All patients with ICDs should have antitachycardia therapy disabled prior to surgery with monopolar electrocautery The sheer variety of devices and programming modes currently available makes formulaic preoperative management difficult For example, it is commonly assumed that a magnet will convert a pacemaker to asynchronous pacing and disable antitachycardia therapy when applied to an ICD. However, magnet effects vary significantly depending on the manufacturer, model, and even specific device settings Even when indicated, magnet placement is an unreliable technique for changing device therapy Obesity, perspiration, patient movement, surgical positioning, and other implanted devices can interfere with proper magnet contact; loss of contact may not be readily apparent to the clinician, as the pacing function of the device would not be changed The anesthesia team should test the magnet’s effect prior to the start of surgery, paying close attention to whether the preprogrammed asynchronous pacing rate is sufficient, particularly in patients with compromised myocardial function Postoperatively, any device that was reprogrammed prior to surgery should be interrogated and reset appropriately Table 26.5 Generic codes for cardiac implantable electronic devices Pacemaker Position I Chambers paced Position II Chambers sensed Position III Response to sensing Position IV Programmability O = None A = Atrium V = Ventricle D = Dual (A + V) O = None A = Atrium V = Ventricle D = Dual (A + V) O = None I = Inhibited T = Triggered D = Dual (T + I) O = None R = Rate modulation Position III Tachycardia detection Position IV (or Pacemaker Code) Antibradycardia pacing chambers E = Electrocardiogram H = Hemodynamic O = None A = Atrium V = Ventricle D = Dual (A + V) Implantable cardioverter defibrillator (ICD) Position I Position II Shock chambers Antitachycardia pacing chambers O = None O = None A = Atrium A = Atrium V = Ventricle V = Ventricle D = Dual (A + V) D = Dual (A + V) Position V Multisite pacing O = None A = Atrium V = Ventricle D = Dual (A + V) Index propofol cardiovascular effects, 131–132 central nervous system effects, 132–133 dosage and uses, 133 drug distribution, 132 mechanism of action, 131 respiratory effects, 132 side effects, 133 thiopental, 5, 133–134 Intravenous regional block (IVRB), 299 Intubating laryngeal mask airway (ILMA)., 590 Invasive blood pressure monitoring indication and contraindications, 71 normal arterial pulse waveform, 72 radial artery pressures, 72 Invasive positive pressure ventilation airway pressure release ventilation, 558 assist-control ventilation, 556 continuous mandatory ventilation, 556, 557 ETT, 556 inverse ratio ventilation, 558 O2 toxicity, 556 positive end-expiratory pressure, 558 pressure control ventilation, 557 pressure support ventilation, 557–558 synchronized intermittent mandatory ventilation, 556 tracheostomy, 556 types, 556 Irefin, S., 23–44 Iron-deficiency anemia, 109 Ischemic heart disease, 519 CAD, 339 coronary perfusion, 338–339 IABP, 339–340 Isoflurane, arousal pathway, 121 asthma, 376 blood–gas partition coefficients of, 124 cardiovascular effects, 125–126 EEG, 80 gas–tissue partition coefficients of, 124 hepatic effects, 126 MAC of, 125 metabolism, 124 mitral regurgitation, 340–342 neurological protection, 342 neurologic effects, 125 OPCAB, 338 properties of, 60, 127–128 renal function, 447–448 respiratory effects, 126 vaporizers, 60, 62–63 J Jackson, 54 Jackson, D.J., 131–138 Jackson-Rees circuit, 55, 56 Janssen, P., Jaw protrusion test, 25 Joy, M.A., 101–114 K Katz, J.A., 363–394 Kava kava, 654 697 Ketamine ambulatory care setting, 419 anti-inflammatory properties, 138 cardiovascular effects, 137 central nervous system effects, 137 chronic kidney disease, 453 induction dose of, 136 IOP, 485 MAC/TIVA, 21–22 mechanism of action, 136–137 nondepolarizing neuromuscular blocking agents, 137 pain management, 279 respiratory effects, 137 septic patient, 441 Ketoacidosis signs and symptoms, 462 treatment, 463 Kirstein, A., Klippel-Feil, 24 Knee surgery ACL repairs, 300 knee arthroscopy, 300 TKA, 300, 301 Koller, C., Kopyeva, T., 23–44, 575–584 Korotkoff, N., Krakowski, J.C., 139–149 Kuhn, F., Kwoh, 627 L Labat, Labetalol, 180, 516 Lack system, 56 Lambert-Eaton myasthenic syndrome (LEMS), 380, 477 Langston, K.D., 609–614 Laparoscopic surgery anesthetic considerations, 437 CO2 embolism, 438 physiologic changes cardiovascular, 436–437 renal, 437 respiratory, 437 Laryngeal mask airways (LMAs), 26, 617 airway control, 19 and aspiration risk, 32 cLMA, 31, 32 insertion technique, 32 pulmonary aspiration, 603 types of, 31 Laryngeal surgery, 493 Left internal mammary artery (LIMA), 327 Left-sided DLT advantages, 382 algorithm, 383 insertion technique, 383 malpositioned tube, 384 size, 382, 383 Lemmon, W., LEMS See Lambert-Eaton myasthenic syndrome (LEMS) Levobupivacaine, 193, 194, 508, 512 Lidocaine, 191, 220 Ligda, K.O., 483–487, 647–651 Li, P., 623–626 698 Liver bariatric surgery FRC and CV, 439 induction, 440 maintenance, 440 monitoring, 440 OSA, 439 oxygen consumption and carbon dioxide production, 439 patients position, 440 prevalence, 438 routine awake extubation, 438 Roux-en-Y gastric bypass, 438 CTP system, 433 emergency abdominal surgery, 440–441 end-stage liver disease ascites, 434 cardiovascular disease, 433 coagulation defects, 434 electrolyte abnormalities, 433–434 endocrine, 434 hepatic encephalopathy, 435 hepatorenal syndrome, 434 management, 435 portal hypertension, 434 pulmonary dysfunction, 433 functional anatomy, 431 function tests, 431 hepatic lobule, 431, 432 history and physical examination, 431 indicators, 432 laparoscopic surgery (see Laparoscopic surgery) MELD score, 433 physiology, 431 transplantation anhepatic phase, 435 dissection phase, 435 neohepatic/reperfusion phase, 436 preoperative preparation, 435 Liver function tests (LFTs), 12, 433 LMAs See Laryngeal mask airways (LMAs) Local anesthetics (LA) allergic reactions, 189 amide local anesthetics (see Amide local anesthetics) bicarbonate, 194 cardiac toxicity, 189 chemical structure of, 187 classification of, 189 clonidine, 194 cocaine, compounding of, 194 cytotoxicity of, 188 dosages and duration of action, 186 epidural anesthesia, 228 epinephrine, 194 ester local anesthetics, 190 history of, labor epidural analgesia, 508, 509 mechanism of action, 186 methemoglobinemia, 189 nasotracheal FOB intubation, 40 nerve conduction myelinated axon, 185, 186 nerve cell, anatomy of, 185, 186 peripheral nerve fiber types, 185, 187 sodium channel, 185, 186 sodium–potassium ATPase pump, 185, 186 Index neurotoxicity of, 188–189 opioids, 189 orotracheal FOB intubation, 40–41 peripheral nerve blockade, 167, 244 phenylephrine, 194 properties of, 187–188 spinal anesthesia, 220 topical anesthesia, 193 Local infiltration analgesia (LIA), 301 Lofgren, Lonchena, T., 643–645 Long, C.W., Loop diuretics clinical applications/implications in anesthesiology, 170–171 mechanism of action, 170 side effects, 170 Lorazepam, 13, 147, 559 Loulmet, D., 627 Low back pain, 290291 Lower extremity nerve blockade ankle block, 249 femoral nerve block, 244 innervation of, 244 lumbar plexus block, 245, 246 popliteal sciatic nerve block, 247 sciatic nerve block, 246 Lower motor neurons (LMNs) lesions ALS,475 cerebrovascular disease, 476–477 CMT, 475–476 Friedreich’s ataxia, 475 multiple sclerosis, 475 signs, 471, 472 Lumbar plexus blockade, 245–246, 302 Lundquist, M MAC See Minimum alveolar concentration (MAC); Monitored anesthesia care (MAC) Macewan, W., Macintosh laryngoscopy blades, 35, 37 Macintosh, R., Magill, E., 56 Magill, I., Magill’s circuit, 56, 57 Magnetic resonance imaging (MRI), 277, 317, 425–426 Mallampati airway classification, 25 Mangione, M.P., 89–99 Mannitol, 400 clinical applications/implications in anesthesiology, 171 mechanism of action, 134 side effects, 171 TBI, 410, 619 Manrique-Espinel, A.M., 203–206 MAP See Mean arterial pressure (MAP) Mapleson breathing systems, 90–92 Mapleson, W.W., 54 Marfan’s syndrome, 536 Marijuana (Cannabis sativa), 639–640 Massive blood transfusion complications, 108 definition, 107 indications, 107 patient monitoring, 107 resuscitation, 107–108 Index Maximum voluntary ventilation (MVV), 369 McAffee, R., 159–162 McGill Pain Questionnaire (MPQ), 269 McHugh, S.M., 165–168 Mean arterial pressure (MAP), 69, 131, 311, 357, 398, 400 Medical gases cylinder supply, 49, 50 heliox, 50 medical air, 50 nitrous oxide, 50 oxygen, 49–50 physics governing gas storage, 46, 48 pipeline supply, 48–49 xenon, 50 Megaloblastic anemia, 109 Melatonin, 654 Melzack, 267 Memorial Delirium Assessment Scale, 600 Meng, L., 603–608 Meperidine, 146, 273, 506 Mepivacaine, 188, 192 Merskey, H., 265 Messmer, K., 200 Metabolic equivalent of task (MET), 8, 315, 316 Methadone, 145, 280, 532 Methicillin-resistant Staphylococcus aureus (MRSA), 649 Methylnaltrexone, 147, 274 Methylprednisolone, 161, 282, 475, 561 Metoclopramide, 161 Metoprolol, 180 Metro, D.G., 165–168 Microdialysis catheters (MDCs), 405 Midazolam, 147–149, 419, 533 Miller laryngoscopy blades, 35, 37 Miller, R., Millikan, G., Milrinone, 182, 334 Mini Mental-State Examination (MMSE), 600 Minimum alveolar concentration (MAC), 1, 119, 124–125, 643 Mivacurium, 154 MND See Motor neuron diseases (MND) Model for End-Stage Liver Disease (MELD) score, 433 Monitored anesthesia care (MAC), 418 airway management, 21 conscious sedation, 21 drugs, 21–22 indications, 20 monitoring, 20 patient positioning, 19 postoperative care/discharge criteria, 22 preanesthetic examination and evaluation, 20 Montoya, M.I., 197–201 Moon, T.S., 297–306 Moore, F., 89 Morphine, 137, 139, 145, 200, 508, 564 Morphine-3-glucoronide (M3G), 145 Morphine-6-glucoronide (M6G), 145 Morris, L., Morton, W.T.G., 3, 119 Motor evoked potentials (MEPs), 81, 536, 625 Motor neuron diseases (MND) causes, 471–472 denervation, 471 LMN lesions ALS, 475 cerebrovascular disease, 476–477 699 CMT, 475–476 Friedreich’s ataxia, 475 multiple sclerosis, 475 signs, 472 UMN lesions ALS, 475 cerebrovascular disease, 476–477 CMT, 475–476 Friedreich’s ataxia, 475 multiple sclerosis, 475 signs, 472 SMA, 472–473 spinal cord injury, 473–474 syringomyelia, 474 Motor neuron pathway, 471, 472 MND (see Motor neuron diseases (MND)) muscular lesions malignant hyperthermia, 478–479 muscular dystrophy, 478 myotonia, 478 neurological diseases Alzheimer’s disease, 480 critical illness polyneuropathy/myopathy, 481–482 GBS, 480–481 Parkinsonism, 479–480 seizure disorder, 481 NMJ CMS, 477 LEMS, 477 myasthenia gravis, 477–478 MPS See Myofascial pain syndrome (MPS) MRI See Magnetic resonance imaging (MRI) Muscle relaxants chronic pain, 279, 280 curare, depolarizing muscle relaxants, 152–153 neuromuscular transmission, physiology of, 151 nondepolarizing muscle relaxants (see Nondepolarizing muscle relaxants) succinylcholine, Mushin, W., 54 Music therapy, 655 Myasthenia gravis (MG), 477–478, 555 Myocardial infarction (MI) causes, 562 classification, 562 diagnosis, 563–564 management, 564 risk factors, 563 Myocardial ischemia, 339, 340, 583 beta-blockers, 179 ECG, 75, 76 EPI, 177 nicotine, 639 nitroglycerin, 175 TEE, 87, 321, 322 Myofascial pain syndrome (MPS), 290 N Naidu, R.K., 265–295 Nalbuphine, 146, 281, 506, 507, 509 Naloxone, 140, 147, 274, 638 Naltrexone, 146 Nasopharyngeal airways, 28 National Board of Echocardiography (NBE), 322 700 National Heart Lung and Blood Institute (NHLBI), 375, 587 National Institute for Occupational Safety and Health (NIOSH), 65, 661 NE See Norepinephrine (NE) Near-infrared spectroscopy (NIRS), 405 Necrotizing enterocolitis (NEC), 537 Neostigmine epidural anesthesia, 228 neuromuscular blockade, reversal of, 156 PONV, 582, 605 spinal anesthesia, 221 Nerve injury eye injury, 633 patient position lateral decubitus position, 634–635 lithotomy position, 633–634 prone position, 634, 635 reverse Trendelenburg position, 633 sitting position, 634, 635 supine position, 633, 634 Trendelenburg position, 633, 634 peripheral nerve injury brachial plexus, 631, 632 lower extremity nerve injury, 632 lumbosacral nerve root, 631, 632 prevention, 632 radial and median nerve injuries, 632 spinal cord, 631, 632 ulnar nerve injury, 631–632 Neubert, L., 123–129 Neu, M., Neuraxial analgesia delayed gastric emptying, 509 excessive motor blockade, 510 failed analgesia, 509 high/total spinal anesthesia, 510 hypotension, 509 intravascular injection and systemic toxicity, 510 labor analgesia, 509 nausea and vomiting, 509 neurological complications, 510 PDPH, 510 pruritis, 509 respiratory depression, 510 shivering, 509 urinary retention, 509 Neuraxial anesthesia anticoagulants and, 230–231 asthma, 516 cardiovascular effects, 214 epidural anesthesia (see Epidural anesthesia) gastrointestinal effects, 215 labor analgesia, 507 prior spine surgery, patients with, 230 PVD, 360, 361 renal and urinary tract, 215 respiratory effects, 214–215 spinal anesthesia (see Spinal anesthesia) Neuroanesthesia AVM, 413 cellular physiology, 397 cerebral aneurysm surgery, 412–413 cerebral blood flow autonomic innervation, 397–398 cerebral vasculature, 398 circle of Willis, 397–398 metabolic-perfusion coupling, 398 Index PaCO2 reactivity, 398 PaO2 reactivity, 398 cerebral monitoring diagnose secondary brain injury, 406 guide therapy, 405 intracranial pressure monitoring, 405 neural pathway monitoring, 406 predict functional recovery, 405 regional perfusion monitoring, 406 S100B, 405 tissue oxygenation monitoring, 405–406 cerebral perfusion,397 cerebral physiology (see Cerebral physiology) craniotomy, 406–408 intracranial pressure adequate ventilation, 401 barbiturate coma, 401 causes, 399, 401 clinical signs, 399, 401 cranial vault, 399 CSF circulation, 399 head elevation, 400 hyperosmolar therapy, 400 hyperventilation, 400–401 intracranial elastance, 400 Monro–Kellie hypothesis, 399 sedation and analgesia, 401 seizures, 401 steroid therapy, 401 surgical interventions, 402 vasodilation, 399, 401 neurophysiologic monitoring tests, 397 normal CMRO2, 397 psychiatric disorder, 482–483 subarachnoid hemorrhage, 411 TBI (see Traumatic brain injury (TBI)) Neurokinin (NK1) receptor antagonists, 161–162, 659 Neuroleptic malignant syndrome, 483 Neuromuscular blockade affecting factors, 155 depolarizing muscle relaxants, 151 neuromuscular transmission, physiology of, 151, 152 nondepolarizing muscle relaxants (see Nondepolarizing muscle relaxants) peripheral nerve stimulator, 155–156 reversal agents atropine, 157 edrophonium, 156–157 glycopyrrolate, 157 L-cysteine, 157 neostigmine, 156 sugammadex, 157 Neuromuscular-blocking drugs (NMBD), 78, 406, 643 Neuromuscular junction (NMJ) CMS, 477 LEMS, 477 myasthenia gravis, 477–478 Neuromuscular monitoring, 78–79 Neuromuscular relaxants See Muscle relaxants Neuropathic pain, 268, 293, 294 Neurophysiologic monitoring BAEPs, 81 bispectral index, 80 electroencephalograph, 80 MEPs, 81 Index SSEPs, 80–81 visual evoked potentials, 81 Nicardipine, 181 Nifedipine, 180 Nil per oral (NPO), 13 Nimodipine, 181, 405, 412 NIPPV See Noninvasive positive pressure ventilation (NIPPV) Nitrates hydralazine, 176 nitroglycerin, 175–176 nitroprusside, 176 Nitroglycerin (NTG), 175–176, 564, 639 Nitrous oxide (N2O), 50 history of, 3, properties of, 127 NMBD See Neuromuscular-blocking drugs (NMBD) NMJ See Neuromuscular junction (NMJ) Nociceptive pain, 268 Nondepolarizing muscle relaxants acetylcholine, 151 atracurium, 154 cisatracurium, 154 gantacurium, 155 mivacurium, 154 pancuronium, 154 pharmacologic paralysis, 151 rocuronium, 152–154 vecuronium, 154 Nonintubation airway management mask ventilation technique assessment of, 29 contraindications and complications, 29–30 face mask, characteristics of, 28 one-provider technique, 29, 30 prerequisites for, 28–29 two-provider technique, 29, 30 uses, 28 oxygen delivery systems high-flow nasal cannulas, 28 nasal cannulas, 27 nonrebreathing masks, 28 partial rebreathing masks, 27–28 simple face masks, 27 Venturi masks, 28 pharyngeal airways, 28, 29 supraglottic airway devices (see Supraglottic airway devices (SADs)) Noninvasive blood pressure (NIBP) monitoring arterial digital photoplethysmography, 70 arterial tonometry, 70 auscultatory method, 69–71 automated oscillonometer, 71 complications, 69 cuff size, 69 Noninvasive positive pressure ventilation (NIPPV), 336, 555–556 Non-operating room anesthesia (NORA) cardiology procedures cardioversion, 428–429 coronary angiography, 429 diagnostic imaging, 429 endoscopic procedures, 427–429 ICU, 429 locations, 423 patient selection, 423 radiation oncology procedures, 428 radiologic procedures CT scan, 426 701 interventional neuroradiology, 426–427 IR, 424–425 MRI, 425–426 Nonsteroidal anti-inflammatory drugs (NSAIDs) acetaminophen, 166–167 acute pain, 271 angioedema, 495–496 cardiac surgery, 337 chronic pain, 277 CKD, 454 clinical uses, 164–165 COX enzymes, 165 COX-2 inhibitors, 166 side effects, 166 NORA See Non-operating room anesthesia (NORA) Norepinephrine (NE), 177–178, 278 Novikov, M., 101–114 NSAIDs See Nonsteroidal anti-inflammatory drugs (NSAIDs) NTG See Nitroglycerin (NTG) Numerical Rating Scale (NRS), 269 O Obesity classification, 587, 588 clinical manifestations, 587, 588 intraoperative care, 591 obstetric anesthesia anesthesia considerations, 517–518 labor and delivery effects, 517 physiologic changes, 517 prevalence, 517 pathophysiology cardiovascular system, 587–588 endocrine system, 588–589 gastrointestinal system, 588 renal system, 589 respiratory system, 588 postoperative care, 591–592 preoperative assessment airway evaluation, 589–590 anesthetic plan, 590 aspiration prophylaxis, 590 cardiovascular system evaluation, 589 equipment, 590 monitoring, 590 respiratory system evaluation, 589 vascular access, 590 Obstetric anesthesia asthma continuous lumbar epidural analgesia, 517 inhaled beta-adrenergic agonists, 517 medical management, 517 neuraxial anesthesia, 517 pregnancy effects, 516 symptoms, 516 cardiac disease acquired heart disease (see Acquired heart disease) congenital heart disease, 520–521 incidence, 519 maternal cardiac arrest, 521 cesarean section aspiration prophylaxis, 511 epidural anesthesia, 512–513 fasting guidelines, 511 general anesthesia, 513 spinal anesthesia, 511–512 702 Obesity (cont.) chloroform, diabetes mellitus anesthesia considerations, 519 GDM, 518 glucose tolerance, 518 implications, 518 management, 518–519 fetal monitoring antepartum assessment, 504 intrapartum assessment, 504–505 intrapartum fetal resuscitation, 505 hypertensive disorders (see Hypertensive disorders) labor analgesia adjuvants, 509 hydrotherapy, 506 hypnosis, 506 inhalational analgesia, 506 intradermal water injection, 506 local anesthetic agents, 508, 509 lumbar epidural block, 508–509 neuraxial analgesia, 509–510 neuraxial anesthesia, 507 opioids, 508 parenteral opioids, 506–507 PCEA, 509 remifentanil, 507 spinal epidural block, 508 systemic analgesia, 506 TENS, 506 labor physiology pain effects, 506 stages, 505–506 maternal hemorrhage AFE, 524 antepartum hemorrhage, 521–523 fetal surgery, 525 IUFD, 525–526 nonobstetric surgery, 524–525 postpartum hemorrhage, 522–524 obesity anesthesia considerations, 517–518 labor and delivery effects, 517 physiologic changes, 517 prevalence, 517 physiologic changes airway changes, 501 aortocaval compression, 502 cardiovascular system, 502 endocrine system, 503 gastrointestinal system, 503 hematologic system, 502–503 musculoskeletal system, 503–504 nervous system, 504 placental function and drug transfer, 504 renal system, 503 respiratory system, 501–502 uteroplacental blood flow, 504 Obstructive airway diseases asthma desflurane, 376 intraoperative bronchospasm, 376 isoflurane, 376 lidocaine, 376 pathologic features, 374 preoperative preparation, 375 Index prevalence, 374 sevoflurane, 376 signs and diagnosis, 374–375 treatment, 324–325 COPD anesthetic considerations, 377–378 BODE index, 377 chronic bronchitis, 376, 377 emphysema, 376, 377 estimation, 377 GOLD classification, 377 MMRC, 377 prevalence, 376 Obstructive sleep apnea (OSA) bariatric surgery, 438–439 body mass index, 379 comorbidity, 379 ENT surgery, 497 impaired glucose metabolism, 379 incidence, 379 postoperative complications, 379 prevalence, 379 regional anesthesia, 379 O’Connor, J., 657–659 Off-pump coronary artery bypass grafting (OPCAB) epicardial stabilization devices, 337 functional safety net, 338 inhaled agent/total intravenous anesthesia, 338 isoflurane, 338 keyhole cardiac surgery, 337 neuraxial techniques, 338 operating room setup, 337 physiologic effects, 337 prevalence, 337 single and double-bypass surgery, 337 Ohmeda Link-25 proportion-limiting control system, 51, 52 Ondansetron, 160, 606 OPCAB See Off-pump coronary artery bypass grafting (OPCAB) Open reduction and internal fixation (ORIF), 234, 302 Operating room (OR) chemical dependency, 664 fire safety, 662–663 HBV infection, 662 HCV, 662 information systems, 668 laser safety, 663 latex sensitivity, 662 management case scheduling, 669 effective operational management, 669 emergent case management, 669 operational decisions, 667 OR time, 668–669 strategic and tactical decisions, 667 NIOSH safety recommendations, 661, 662 performance metrics, 668 psychological stress, 663–664 radiation safety, 661–662 work hours and sleep disturbance, 664 Ophthalmic surgery anesthetic considerations adverse effects, 485, 486 general anesthesia, 485 monitored anesthesia care, 485 ocular injuries, 485–486 regional anesthesia, 485 Index intraocular gas expansion surgery, 486 intraocular pressure anatomy, 483–484 glaucoma, 485 hypoxia and hypercarbia, 485 intravenous acetazolamide, 485 ketamine, 485 non-depolarizing muscle relaxants, 485 succinylcholine, 485 oculocardiac reflex, 483, 484 retinal detachment surgery, 486 strabismus surgery, 486 traumatic open eye injury, 486 Opioids, 419, 638 acute pain managing side effects, 274 opioid conversion, 274–275 PCA, 275 pharmacologic agents, 271, 272 routes of administration, 272 analgesia, 142 antagonists, 146 cardiovascular stability, 143 chronic pain, 275–276 cough reflex suppression, 143 definition, 141 endogenous opioids, 139 epidural anesthesia, 228 fully synthetic opioids, 139 labor analgesia, 508 miosis, 143 mixed agonist–antagonists, 146 natural opium alkaloids, 139 opioid agonists alfentanil, 146 fentanyl, 145–146 hydromorphone, 145 meperidine, 146 methadone, 145 morphine, 145 remifentanil, 146 sufentanil, 146 opioid partial agonists, 146 peripheral opioid antagonists, 147 pharmacodynamics, 141 pharmacogenetics, 142 pharmacokinetics elimination, 141 lipophilicity, 141 pKa, 141 protein binding, 140–141 route of administration, 140 receptor subtypes, physiologic effects of, 141 respiratory depression, 143 sedation and anxiolysis, 142–143 semisynthetic opioids, 139 side effects and toxicity cardiovascular effects, 144 euphoria, 144 gastrointestinal and urinary effects, 144 hormonal effects, 144 immune modulation, 144 muscle rigidity and proconvulsant activity, 144 nausea and vomiting, 144 paradoxical response, 144 respiratory depression, 143 sedation and cognitive impairment, 143 703 thermoregulation, inhibition of, 144 tolerance, dependence, and withdrawal, 144–145 spinal anesthesia, 221 structure–activity relationships, 147 Optimal external laryngeal manipulation (OELM), 35 Oravitz, T.M., 175–183 Orebaugh, S.L., 139–149 Oropharyngeal airways, 28 Orthopedic surgery FES, 304–305 foot and ankle surgery, 303 hand and forearm surgery, 299 hip surgery, 301–303 infection prevention, 305 knee surgery, 300–301 regional anesthesia, 303–304 shoulder surgery anesthetic considerations, 298 beach chair and lateral decubitus position, 297–298 postoperative pain management, 300–301 thromboprophylaxis, 305–306 tourniquets, 304 OSA See Obstructive sleep apnea (OSA) Oscillonometer, 70, 71 Osmotic diuretics, 171 Oxygen failure protection device (OFPD), 51 Oxygen ratio monitor controller (ORMC), 51 P Packed red blood cells (PRBCs), 102 PACs See Pulmonary artery catheters (PACs) PACU See Postanesthesia care unit (PACU) Pain management acute pain (see Acute pain) cancer pain (see Cancer pain) central modulation, 267 chronic pain (see Chronic pain) CRPS, 292–293 gate control theory, 267 low back pain, 290–292 myofascial pain, 290 pain, definition of, 265 pain pathways ascending pathway, 266 descending pathway, 266–267 nociception, 265 peripheral sensation, 265, 266 peripheral modulation, 267 phantom limb pain, 293 post-herpetic neuralgia, 293 trigeminal neuralgia, 293 types of, 267–268 Palonosetron, 160, 605–606 Pancuronium, 154 Parathyroid disorders hyperparathyroidism bilateral neck exploration, 466 complications, 466–467 diagnosis, 466 minimally invasive parathyroidectomy, 466 primary hyperparathyroidism, 466 secondary hyperparathyroidism, 466 symptoms and signs, 466 tertiary hyperparathyroidism, 466 treatment, 466 hypoparathyroidism, 467 704 Patient-controlled analgesia (PCA), 598 acute pain, 272, 273 postoperative pain management, 300–301 Patient-controlled epidural analgesia (PCEA), 275, 509 PDIs See Phosphodiesterase inhibitors (PDIs) PDPH See Postdural puncture headache (PDPH) Peak expiratory flow (PEF), 369, 374, 517 Pediatric anesthesia adenotonsillectomy, 535–536 children resuscitation, 542–544 congenital cardiac disease left-sided obstructive lesions, 546 left to right shunt lesions, 545 right-sided obstructive lesions, 545–546 Down syndrome/trisomy 21, 534–535 epiglottitis vs croup, 535 foreign body aspiration, 535 neonatal emergency CDH, 538–539 gastroschisis, 539–540 NEC, 537 neural tube defects, 540–541 omphalocele, 539–540 pyloric stenosis, 540 TEF, 537–538 neonates resuscitation, 543 PACU complications, 536–537 pain management caudal epidural anesthesia, 541–542 neuraxial blockade, 541 peripheral nerve blocks, 542 spinal anesthesia, 542 pediatric scoliosis correction, 536 pharmacology inhalational agents, 532 intravenous induction agents, 532 non-depolarizing neuromuscular blocking agents, 533 opioids, 532–533 succinylcholine, 533 physiology cardiovascular, 529–531 hematological, 530–531 pediatric airway, 531 preterm neonate, 531–532 renal, 531 respiratory, 529, 530 temperature regulation, 531 preoperative preparation, 533–534 tonsillectomy, 535–536 upper respiratory tract infection, 534 urological procedures, 536 PEEP See Positive end-expiratory pressure (PEEP) Peripheral nerve blockade (PNB) benefits of, 534 brachial plexus (see Brachial plexus) cervical plexus block preparation technique, 242–243 side effects, 243 surface anatomy, landmarks, and procedure, 243 complications of, 234 contraindications, 234 digital and metacarpal nerve block, 242 intravenous regional anesthesia, 242 local anesthetics for, 244 lower extremity nerve blockade (see Lower extremity nerve blockade) Index surgical procedure, 234 ultrasound-guided techniques (see Ultrasound-guided peripheral nerve blockade) Peripheral nerve stimulator, 155–156 Peripheral vascular disease (PVD) endovascular repair, 361 general anesthesia, 361 neuraxial anesthesia, 361 normal and diseased artery, 361 open vascular repair, 361 postoperative management, 361–362 regional anesthesia, 361 Perlas, A., 604 Perphenazine, 160 Pham, T.M., 265–295 Phantom limb pain, 293 Pharyngeal airways, 28 Phenobarbital, 4–5, 481 Phenylephrine, 40, 178–179, 194, 360 Pheochromocytoma, 469–470 Phosphodiesterase inhibitors (PDIs), 181–182 Pickwickian syndrome, 439 Pin Index Safety System (PISS), 49 Planinsic, R.M., 627–629 Platelets, 102–103 thrombocytopenia, 111 von Willebrand disease, 112 PNB See Peripheral nerve blockade (PNB) Poiseuille’s Law, 617 Polycythemia, 109, 110, 588 PONV See Postoperative nausea and vomiting (PONV) Pope, E., Popliteal sciatic nerve blockade, 247–248, 261–262 Positive end-expiratory pressure (PEEP), 376, 438, 556, 558, 591 Postanesthesia care unit (PACU), 20, 424 airway management AEC, 579 cuff leak test, 579 endotracheal extubation, 579 expanding neck hematoma, 579–580 hypoventilation, 578 hypoxemia, 578 obstruction, 577–578 arrhythmias, 583 bypass/discharge criteria delay discharge, 576 factors, 577 fast-tracking, 577 oral intake and voiding, 575 regional anesthesia, 576 scoring system, 575 delayed emergence, 582 delirium, 583–584 hemodynamic management APH, 580 hypotension and shock, 581 hypothermia, 583 myocardial ischemia, 583 nausea and vomiting, 582–583 oliguria and urinary retention, 583 pain, 583 patient monitoring, 575, 576 perioperative nerve injuries, 583 volume responsiveness, 581–582 Postdischarge nausea and vomiting (PDNV), 161, 604–605 Postdural puncture headache (PDPH), 222, 510 Index Post-herpetic neuralgia (PHN), 288, 293 Postoperative nausea and vomiting (PONV), 582–583 ambulatory anesthesia, 420 antiemetics, 161 anticholinergics, 161 corticosteroids, 161 dopamine antagonists, 160–161 histamine (H1) blockers, 161 neurokinin receptor antagonists, 161–162 serotonin 5HT3 receptors, 160 cosmetic surgery, 659 definition, 659 electroacupuncture and acupressure, 162 emetogenic trigger avoidance, 162 etomidate, 135–136 foot and ankle surgery, 303 IMPACT trial, 608 incidence, 604 physiology of, 259 prophylaxis, 420 propofol, 133 risk factors, 159, 605 Postoperative visual loss (POVL), 625 Postpartum hemorrhage abnormal placentation, 523 coagulopathy, 524 hematomas, 524 lacerations, 524 placenta, 524 uterine atony, 522 uterine inversion, 524 Potassium-sparing diuretics, 171 Preemptive analgesia, 300 Preoperative evaluation allergies and social habits, 10 ASA classifications, 14 basic preoperative evaluation, 7, cardiac evaluation active cardiac conditions, algorithm, 7, clinical risk factors, functional capacity, 8, need for surgery, surgical risk, 7–8 chronic kidney disease, 10 endocrine, 10 family history, 10 gastrointestinal, 10 goals of, 7, laboratory testing, 11–12 liver disease, 10 medications, 10–11 neurological, 10 NPO guidelines, 13 physical examination, 11 pregnancy test, 10 premedication, 12–13 prior anesthetic history, 10 pulmonary aspiration, 13 pulmonary evaluation, Pretransfusion testing type and cross, 101 type and screen, 101 Priestly, J., Prilocaine, 191–193 Procaine, 190 705 Promethazine, 160 Prophylactic antibiotic, 305 Propofol, cardiovascular effects, 131, 132 central nervous system effects, 132–133 dosage and uses, 133 drug distribution, 132 mechanism of action, 131, 132 respiratory effects, 132 side effects, 133 Propranolol, 179 Protamine, 183, 200, 334–335 Psychiatric disorders, 482 Psychogenic pain, 268 Pulmonary artery catheters (PACs), 91, 551 cardiac output, 86–87 contraindications, 85 indications, 85 normal cardiac parameters, 86 pressure tracing, 85 Pulmonary aspiration clinical signs, 603–604 gastric contents, regurgitation of, 13 prevention, 14, 604 risk factors, 14, 603–604 treatment, 604 Pulmonary dysfunction, 433 Pulmonary embolism (PE), 305 blood clots, 564 clinical signs, 564 diagnosis, 564 management, 564 Pulmonary function tests (PFTs), 12, 623 Pulmonary vascular resistance (PVR), 126, 351 Pulse oximetry, 74–75 PVD See Peripheral vascular disease (PVD) Q Qualitative Sensory Testing (QST), 277 Quick connectors, 48 Quincke, H., R RA See Regional anesthesia (RA) RAAS See Renin–angiotensin–aldosterone system (RAAS) Radial artery catheterization Allen test, 72 arterial waveform, 74 complications, 74 insertion site, 73 natural frequency and damping, 73–74 technique of, 72 zeroing transducer, 74 Radiofrequency lesioning (RFL), 285, 292, 295 Rapid Infusion Catheter (RIC™), 617 Rapid sequence induction and intubation (RSII), 42–43 Rapid sequence intubation (RSI) technique, 19, 458, 604 Recombinant activated factor VII (RVII), 103, 105 Rees, 54 Referred pain, 268, 290 Regional anesthesia (RA) acute kidney injury, 453 acute pain, 275 Alzheimer’s disease, 480 706 Regional anesthesia (RA) (cont.) ambulatory surgeries, 418 asthma, 376 Bier block, 242 cancer pain, 295 carotid artery stenosis, 358 cesarean section, 511 COPD, 376–377 cosmetic surgery, 657 elderly patients, 598 endotracheal intubation, 33 epinephrine, 177 heat loss, phases of, 76 history of, hyperparathyroidism, 466 hyperthyroidism, 464 hypothyroidism, 465 motor neuron diseases, 471 obesity, 590 ophthalmic surgery, 485, 486 orthopedic surgery advantages, 303 complications, 316 hip fracture surgery, 301–302 shoulder surgery, 297 OSA, 379, 497 pediatric neuraxial anesthesia, 541 peripheral nerve injuries, 631 prilocaine, 191–192 pulmonary embolism, 564 PVD, 360–361 TURP syndrome, 455 ultrasound-assisted peripheral nerve blockade, 253 Remifentanil, 146 ambulatory surgical patients, 420 bariatric surgery patients, 440 characteristics of, 141 cosmetic surgery, 657 FOB intubation, 40 labor analgesia, 507 MAC/TIVA, 21 MEPs, 81 PCA, 273 pediatric anesthesia, 532–533 Renal and urinary tract diseases acute kidney injury AKIN criteria, 448 biomarkers, 450–451 BUN, 450 characteristics, 448 creatinine, 450 intrinsic failure, 448, 449 parameters, 449 prerenal and postrenal failure, 448, 449 prevention, 449, 450 RIFLE criteria, 448 risk factors, 448 urine output, 450 anesthetic management barbiturates, 453 benzodiazepines, 448, 453 etomidate, 453 inhalational agents, 453, 454 ketamine, 453 muscle relaxants, 453, 454 opioids, 448, 452, 453 Index propofol, 453 succinylcholine, 453, 454 cardiopulmonary bypass surgery, 448 CKD, 451–452 genitourinary system, 443, 445 regional anesthetic techniques, 448 renal physiology ANP, 447 autonomic system, 446–447 autoregulation, 446 feedback mechanisms, 444 GFR, 446 nephron structure and function, 445 prostaglandins, 447 RAAS, 446 sevoflurane, 447 urologic procedures autonomic hyperreflexia, 457 cystoscopy, 454 ESWL, 455–456 laparoscopic techniques, 457 laser lithotripsy, 456 lateral flexed position, 454 lithotomy position, 454 radical cystectomy, 456 radical nephrectomy, 456 radical prostatectomy, 456 renal transplantation, 451, 457–458 robotic techniques, 457 Trendelenberg position, 454 TURP, 454–455 ureteroscopy, 454 Renin–angiotensin–aldosterone system (RAAS), 93, 446 Residency requirements ACGME requirements, 671 clinical anesthesia (CA) years career pathway, 672 case types, 673 mandatory rotations residents, 672 perioperative rotations, 673 surgical subspecialty rotations, 673 duty hour requirements, 671–672 education program, 673 fellowship training, 674 performance evaluations, 673 scholarly activity, 673–674 Respiratory depression, 143, 221 Respiratory syncytial virus (RSV), 648, 662 Resti, J.P., 671–674 Reticular activating system (RAS), 119 Retinopathy of prematurity (ROP), 531, 558 Right-angle endotracheal tubes (RAE), 34 Right atrial pressure (RAP), 84 Ring, J., 200 Robertshaw, F., Robin, P., 24 Robotic surgery advantages, 627, 628 carbon dioxide insufflation, 628 da Vinci robotic system, 627–628 disadvantages, 627, 628 emergence and neuromuscular blockade, 628 history, 627 muscle paralysis, 628 patient positioning, 628 robot position, 628 Index Rocuronium, 152–154 allergic reactions, 199 cesarean section, 513 CKD, 454 drug interactions, 204 end-stage liver disease, 435 pediatric anesthesia, 533–534 Romeo, R.C., 631–635 Ropivacaine, 192–193 ambulatory anesthesia care, 418 cesarean section, 513 dosages and duration of, 186 epidural anesthesia, 228 labor analgesia, 508, 509 PCEA, 275 peripheral nerve blockade, 244 popliteal sciatic nerve block, 261 spinal anesthesia, 220 TKA patients, 301 Ross, F.J., 661–664 Ross, S.M., 197–201 Rovenstein, RSII See Rapid sequence induction and intubation (RSII) Rubin, K.P., 431–441 S SADs See Supraglottic airway devices (SADs) SAH See Subarachnoid hemorrhage (SAH) Sardesai, M., 311–351 Saw palmetto (SP), 654 Schizophrenia, 483 Sciatic nerve blockade, 246, 247, 259–262 Scopolamine, 161 Alzheimer’s disease, 480 ambulatory anesthesia care, 420 cardiac anesthesia, 324, 346 elderly patients, 559 PONV, 161, 420, 606 preoperative premedication, 12–13 Seizure disorder causes, 481 focal/partial seizures, 481 generalized tonic-clonic seizure, 481 petit mal seizures, 481 Selective serotonin reuptake inhibition (SSRIs), 278, 482 Semisynthetic opioids, 139 Sensitive oxygen ratio controller (S-ORC), 51 Serotonin 5HT3 receptors, 159–160 Serotonin norepinephrine reuptake inhibitors (SNRIs), 278 Serturner, 145 Severe acute respiratory syndrome (SARS), 650 Sevoflurane ambulatory care setting, 419 asthma, 376 blood–gas partition coefficients of, 124 carbon dioxide absorption, 59 CKD, 454 elderly patients, 559 exposure to, 661 gas–tissue partition coefficients of, 124 inhalational induction, 18 labor analgesia, 506 MAC, 125, 142 metabolism, 124 musculoskeletal effects, 127 myringotomy and tympanostomy tube placement, 489 707 neurophysiology, 402 pediatric anesthesia, 532, 535 properties of, 60, 128 renal function, effect on, 127, 447–448 tracheal resection, 392 vaporizer, 59–63 Shaffer, E.G., 653–655 Shires, T., 89 Shock bradycardia, 554 classification, 550 clinical signs, 550, 552 critical care, 549–551 excessive sedation, 553 management strategy blood pressure, 552 cardiac abnormality/dysfunction, 552–553 fluid and vasopressors, 552–553 interventions, 553 lactic acidosis, 552 monitoring CVP, 551 hemodynamic parameters, 552 PAC, 551 pathophysiology, 549–550 stage I progression, 549 stage II progression, 549–550 stage III progression, 550 stage IV progression, 550 tachycardia, 554 Sickle cell disease (SCD), 109 SID See Strong ion difference (SID) Siggaard-Andersen, O., 610 Sikka, P.K., 3–5, 17–22, 461–470, 549–573 Simpson, J.Y., 3, Singh, A., 45–67 Singh, P.M., 45–67 Single-shot technique, 301, 511 Sinha, A., 123–129, 417–421, 593–600 Sleep apnea, SMA See Spinal muscle atrophy (SMA) Smith, K., 627–630 Smoking, 9, 380–381, 639 Snow, J., 3, Sodium nitroprusside (SNP), 176 Somatosensory evoked potentials (SSEPs), 80, 536, 625 Spinal anesthesia, administration of, 219 alpha-2 agonists, 221 baricity, 219 contraindications for, 216 vs epidural anesthesia, 213 failed blocks, 222 hemodynamic collapse, 222 infection, 222 local anesthetics, 219–220 midline and paramedian approach, 218 neostigmine, 221 neurologic complications, 222 opioids, 221 patient positioning and anatomic landmarks, 217–218 PDPH, 222 preoperative evaluation and consent, 216 progression of blockade, 215–216 spinal needles, 217 vasoconstrictors, 221 Spinal muscle atrophy (SMA), 472–473 708 Spine surgery intraoperative care and monitoring, 625 patient position Andrews frame, 624 complications, 624–625 Jackson table and Wilson frame, 624 Mayfield pins, 624 POVL, 625 preoperative evaluation airway assessment, 623 osteoarthritis, 623–624 respiratory system, 623 spinal cord perfusion, 623 spinal shock, 626 succinylcholine-induced hyperkalemia, 626 wake-up test, 625 Spirometers, 63 Spironolactone, 170, 172, 564 Spoerel, 56 SSEPs See Somatosensory evoked potentials (SSEPs) Standard bicarbonate concentration (SBC), 610 Stemland, C., 529–546 Stewart, P.A., 612 Stiff joint syndrome, 519 St John’s wort (Hypericum perforatum), 482, 654 Strong ion difference (SID) free water change contraction alkalosis, 613–614 dilutional acidosis, 613 hyperchloremia, 614 hypochloremia, 614 unidentified anions, 614 Sturgill, E.L., 151–157 Subarachnoid hemorrhage (SAH) medical management, 411–412 pathophysiology, 411 prognostic factors, 411 risk factors, 411 size and location, 411 Subramaniam, K., 355–362 Substance abuse acute intoxication, 637 anesthesiologists, 640 club drugs, 640 CNS depressant alcohol, 637–638 characteristics, 638 opioids, 638 CNS stimulants amphetamine, 638–639 cocaine, 638–639 tobacco and marijuana, 639–640 dissociative drugs, 640 emergent consultation, 640 hallucinogens, 640 history and physical examination, 637 inhalants, 640 Succinylcholine, amyotrophic lateral sclerosis, 474 burns, 571, 572 cerebrovascular accident, 476 cesarean section, 513 chemical structure, 152 dosage and uses, 153 endotracheal tube, insertion of, 19 end-stage liver disease, 435 Index hyperkalemia, 95 IOP, 485 laryngospasm, 498 LEMS, 477 LMN lesions, 474 malignant hyperthermia, 479 metabolism, 153, 203 motor neuron diseases, 471 muscular dystrophies, 478 myasthenia gravis, 477 neuromuscular blockade, 156 neurophysiology, 402 pediatric patients, 533 pyloric stenosis, 540 renal disease, 454 side effects, 153 spinal cord injury, 473, 625–626 traumatic open eye injury, 486 UMN lesions, 472 Sufentanil characteristics of, 141, 146 epidural anesthesia, 227 labor analgesia, 508 PCA, 273 pediatric anesthesia, 532 spinal anesthesia, 221 Sugammadex, 157 Sullivan, E.A., 203–206 Supine hypotension syndrome, 502 Supraglottic airway devices (SADs) classification of, 31 complications, 31 LMA (see Laryngeal mask airways (LMAs)) uses and advantages, 30 Sword, B., Sydenham, T., 355 Systemic inflammatory response syndrome (SIRS), 441, 554 Systemic vascular resistance (SVR), 126, 311, 345, 502 Systolic blood pressure (SBP), 69, 70 Systolic pressure variation (SPV), 91 T Tail, D., TBI See Traumatic brain injury (TBI) TEE See Transesophageal echocardiography (TEE) TEF See Tracheoesophageal fistula (TEF) Temperature monitoring, 77 Terrell, R., Teter, C., Tetracaine ester agents, 189–191 orotracheal FOB intubation, 40 spinal anesthesia, 220, 542 TAC, 193 Tetracaine, adrenaline, and cocaine (TAC), 193 Tetralogy of Fallot (TOF), 520, 545, 546 Tetzlaff, J.E., 185–194 THA See Total hip arthroplasty (THA) Thiazide diuretics clinical applications/implications in anesthesiology, 170–171 mechanism of action, 171 side effects, 171 Thiopental, cardiovascular effects, 134 central nervous system effects of, 132, 134 Index cesarean section, 513 hyperthyroidism, 464 MAC/TIVA, 21–22 mechanism of action, 134 neurophysiology, 402 pharmacokinetics properties of, 132 properties of, 134–135 respiratory effects, 134 Thoracic anesthesia alveolar oxygen tension, 370 anatomy, 363–365 BPF, 392 Co2 transport, 372 CPB, 393 flow-volume loop, 369 functions, 365 HPV, 370–371 lung transplantation, 393 lung volumes closing capacity, 369 FEV, 369 forced vital capacity, 369 FRC, 368 MVV, 369 PEF, 369 mediastinoscopy, 391–392 mixed venous oxygen saturation, 371 obstructive airway diseases (see Obstructive airway diseases) off-bypass, 393 OSA body mass index, 379 comorbidity and postoperative complications, 379 impaired glucose metabolism, 379 incidence, 379 prevalence, 379 regional anesthesia, 379–380 oxygen transport, 371 peripheral chemoreceptors, 365, 366 physiologic dead space, 369 pulmonary compliance, 366 pulmonary hypertension, 378–379 respiratory centers, 365 restrictive lung diseases, 378 sensors, 365–366 thoracic surgery (see Thoracic surgery) thoracoscopic surgery, 392 tracheal resection, 392–393 ventilation-perfusion alveolar pressure, 372 high V/Q and dead space, 373–374 pulmonary artery, 372, 373 pulmonary venous pressures, 372, 373 venous admixture, 373 work of breathing airway resistance, 218 anesthetized COPD patient, 366, 367 awake patient, 366, 367 helium-O2 gas mixture, 368 Reynolds number, 368 Thoracic surgery anesthesia management balanced-drainage system, 388 excessive positive pressure, 388 induction, 386 maintenance, 387 positioning, 387 709 lungs separation anatomic considerations, 381–382 bronchial blockers (see Bronchial blockers (BB)) indications, 382 left-sided DLT (see Left-sided DLT) right-sided DLT, 384, 387 one-lung ventilation disadvantage, 389 iatrogenic right-to-left intrapulmonary shunt, 388, 389 lateral decubitus position, 388 lung mechanics, 389 management, 390 postoperative care, 391 preoperative assessment arterial blood gas analysis, 380 chest radiography, 380 CT scans and MRI, 380 non-small cell carcinomas, 380 resectability, 381 small cell carcinomas, 380 smoking cessation, 380–381 pulmonary complications, 391 Thrombocytopenia, 105, 110–113, 181, 434, 514 Thromboprophylaxis, 305–306 Thyroid disorders hyperthyroidism anesthetic considerations, 464 causes, 464 clinical manifestations, 463 complications, 464–465 diagnosis, 464 thyroid hormone secretion, 464 thyroid storm, 465 treatment, 464 hypothyroidism, 465 Tic douloureux, 293 Time-weighted average (TWA), 65 TIVA See Total intravenous anesthesia (TIVA) Tobacco (Nicotiana tabacum L.), 639–640 Tolvaptan, 172 Tom, M., 233–250, 253–262 Topical anesthesia cocaine, 190 EMLA, 193 TAC, 193 tetracaine, 190 Total body water (TBW), 89 Total hip arthroplasty (THA), 302–303 Total intravenous anesthesia (TIVA), 657 definition, 21 drugs, 21–22 indications for, 21 postoperative care/discharge criteria, 22 Total knee arthroplasty (TKA) choice of anesthesia, 300 postoperative pain management, 300–301 Total parenteral nutrition (TPN), 99 Tourniquets, 110, 304 Tracheoesophageal fistula (TEF), 537–538 Train of four (TOF), 43, 79, 156 Transcutaneous electrical nerve stimulation (TENS), 270, 291, 506 Transesophageal echocardiography (TEE), 18 bite block, 322 complication rate, 322 comprehensive examination, 320–321 contraindications, 321, 322 710 Transesophageal echocardiography (TEE) (cont.) indications, 320 NBE, 322 patient monitoring, 87 preoperative CT scan, 322 probe insertion and manipulation, 320–322 Transforaminal epidural steroid injection, 283 Transfusion medicine blood disorders (see Blood disorders) blood substitutes, 114 complications acute hemolytic reaction, 105 allergic reactions, 106 bacterial contamination, 106 delayed hemolytic reaction, 105 febrile nonhemolytic reactions, 106 human error, 105 immunosuppression, 265 metabolic abnormalities, 106 TRALI, 106 cryoprecipitate, 103 erythropoietin, 103 fresh frozen plasma, 102 HIT, 113 massive blood transfusion, 107–108 perioperative blood conservation, 103–104 perioperative transfusion criteria, 104–105 platelet disorders, 110–112 platelets, 102–103 PRBCs, 102 pretransfusion testing, 101 RVII, 103 Transfusion-related acute lung injury (TRALI), 106 Transient ischemic attack (TIA), 358, 476 Transient neurological symptoms (TNS), 188–189, 191 Transurethral resection of the prostate (TURP), 454–455 Trauma abdomen injury, 620 airway, 616–617 AirTraq® laryngoscope, 616 blind nasal intubation, 616–617 Bullard and lighted stylette, 616 coughing and bucking, 616 fiber-optic intubation, 616 Glascow coma scale, 616 Glidescope®, 616 MAIS and cricoid pressure, 616 11-step examination, 616 supraglottic devices, 617 burn injuries, 620–621 circulation ABC score, 618 ETIC, 618 hypotensive resuscitation, 618 intraosseous (IO) access, 617 isotonic sodium chloride solution, 617 lethal triad, 618 management, 618 massive transfusion, 618 mortality rates, 617 Poiseuille’s Law, 617 PRBC:plasma:platelet ratio, 618 RIC™, 617 Ringer’s lactate solution, 617 epidemiology, 615 extremities injury, 620 Index head injury, 619 initial examination, 615–616 ISS calculation, 616 neck injury, 619 spine injury, 619 thorax injury, 619–620 Traumatic brain injury (TBI) classification, 409 clinical signs, 409 evaluation, 408 FOUR score, 409 GCS, 409 intraoperative management, 409–410 pathophysiology, 408 preoperative management, 409 treatment, 410 Triamterene, 171 Tricyclic antidepressants (TCA), 278, 482 Trifluoroethyl vinyl ether, Trigeminal neuralgia, 287, 293 Tuberculosis (TB), 650 Tuffier, T., Tuohy, E., Turnbull, J.H., 211–231 Turner, 24 TURP See Transurethral resection of the prostate (TURP) U Ultrasound-guided peripheral nerve blockade axillary blockade, 257 femoral nerve blockade, 259 infraclavicular blockade, 256 interscalene blockade, 233–234 popliteal sciatic nerve blockade, 261–262 sciatic nerve blockade, 246–247 supraclavicular blockade, 255–256 Upper extremity nerve blockade brachial plexus (see Brachial plexus) digital and metacarpal nerve block, 242 innervation of, 253 intravenous regional anesthesia, 242 Upper lip bite test (ULBT), 25 Upper motor neurons (UMNs) lesions ALS, 475 cerebrovascular disease, 476–477 CMT, 475–476 Friedreich’s ataxia, 474 multiple sclerosis, 475 signs, 471, 472 SMA, 472–473 spinal cord injury, 473 syringomyelia, 474 V Valerian, 654 Vallejo, M.C., 501–529 Valvular heart disease, 520 aortic insufficiency, 343 aortic stenosis, 343–344 hemodynamic management, 345 mitral regurgitation anesthetic management, 341 arrhythmias and thrombus formation, 341 bacterial infective endocarditis, 340 Index cardiogenic shock, 340 Ehlers–Danlos syndrome, 536 Frank–Starlin mechanism, 340 IABP support and placement, 341 Marfan syndrome, 340 myocardial ischemia/infarction, 340 regurgitant fraction, 341 rheumatic fever, 340 vasodilators, 341 mitral stenosis, 342 Vaporizers Aladin cassette vaporizer, 62–63 classification of, 60 desflurane vaporizer, 62 heat of vaporization, 59 saturated vapor pressure, 59 vaporizer output, 60–62 working principle of, 63 Varicella zoster virus (VZV), 647 Vascular surgery abdominal aortic aneurysm anesthetic management, 356–357 cross clamping and unclamping, 357 graft repair, 355–356 postoperative management, 357–358 symptoms, 356 carotid artery stenosis cardiovascular protection, 360 general anesthesia, 359–360 neurologic protection, 360 normal carotid arteries, 358, 359 plaque formation, 358, 359 postoperative management, 360 regional anesthesia, 361 symptoms, 358 carotid artery stenting, 360 endovascular aortic repair, 358 peripheral vascular disease, 360–361 preoperative evaluation, 355 Vasoconstrictors end-stage liver disease, 435 epidural anesthesia, 227 nasal and sinus surgery, 490 nasotracheal FOB intubation, 40 nasotracheal intubation, 38 ropivacaine, 192–193 spinal anesthesia, 220 Vasodilators aortic insufficiency, 343 Eisenmenger’s syndrome, 521 711 mitral regurgitation, 340–341 pulmonary hypertension, 376, 519 PVR, 345 restrictive lung diseases, 378 Vecuronium dosing and administration of, 154 muscle relaxation, 419 Venable, Ventilation-perfusion (V/Q) alveolar pressure, 372 high V/Q and dead space, 373–374 pulmonary artery, 373, 374 pulmonary venous pressures, 372, 373 venous admixture, 373 Venturi masks, 27 Verapamil, 96, 181 Videolaryngoscopy, 26, 38 Visceral edema, 441 Visual Analog Scale (VAS), 269 Visual evoked potentials (VEP), 80, 81 Vitamin E, 11, 111, 654 Vitamin K deficiency, 112, 434, 532 von Mering, J., Von Willebrand disease (vWD), 105, 112, 524 W Wall, 267 Warner, M.A., 632 Warren, J., Waters, J.H., 609–614 Waters, R., Wells, C., 587–592, 643–645 Wells, H., Wernicke–Korsakoff syndrome, 637, 638 Wertheim, White, S., Wrist surgery, 299 X Xenon, 50, 128 Y Yemen, T.A., 529–546 Z Zeus robotic surgical system, 627 ... Adenosine 0 .25 –10 mcg/kg/min, 1 2 ml of 20 –40 mcg/ml as bolus 0 .25 –10 mcg/kg/min 0.5 mg/kg bolus over min, 50–300 mcg/kg/min infusion 5 20 mg 2 10 mg 4 20 mg 1–5 mg 0 .25 –0.5 mg bolus, 2. 5–15 mg/h... 2. 5–15 mg/h infusion 0.001–0.1 mcg/kg/min, 2 10 mcg bolus 0.01–0.1 mcg/kg/min or 1–16 mcg/min 2 20 mcg/kg/min 2 20 + mcg/kg/min 5 25 mg bolus 20 –60 mcg/min, 40 20 0 mcg bolus 0.375–0.75 mcg/kg/min, 50... BSA P.K Sikka et al (eds.), Basic Clinical Anesthesia, DOI 10.1007/978-1-4939-1737 -2_ 26, © Springer Science+Business Media New York 20 15 311 3 12 M Sardesai Table 26 .1 Overview of physiologic

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Ebook Basic clinical anesthesia: Part 2

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Preface

Contents

Contributors

Part I: The Basics

1: History of Anesthesia

Inhalational Anesthetic Agents

The Story of Nitrous Oxide

Intravenous Anesthetics

Airway and the Anesthesia Machine

Local and Regional Anesthesia

Further Reading

2: Preoperative Evaluation

Preoperative System Review

Cardiovascular

Pulmonary

Neurological

Renal

Hepatic

Endocrine

Gastrointestinal

Pregnancy

Family History

Prior Anesthetic History

Allergies and Social Habits

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