Miller’s Basics of Anesthesia

Description

Long regarded as the undisputed leading text of its kind, Miller’s Basics of Anesthesia provides comprehensive yet concise coverage of both basic science and clinical topics in anesthesiology. Under the experienced editorial leadership of Dr. Manuel C. Pardo, Jr., the 8th Edition has been meticulously updated to reflect the latest advances in practice and important aspects of contemporary anesthesia care, including pathophysiology, pharmacology, regional anesthesia, anesthetic management, and special problems and patient groups. It remains the first learning resource of choice for anesthesia providers, including anesthesia residents and fellows, medical students, and student registered nurse anesthetists, and is also a valuable review tool for practitioners undergoing maintenance of certification or recertification. Features a reader-friendly format with color-coded section tabs, easy-to-read chapters, and a concise writing style, along with color patterns in every chapter for quick navigation. Contains new chapters on Clinician Well-Being, Perioperative Point-of-Care Ultrasound, Environmental Impact of Anesthetics, and Perioperative Medicine. Covers key topics such as anesthesia neurotoxicity, palliative care, sleep medicine, trauma, and much more. Includes high-quality images that offer a detailed visual understanding of complex topics, while numerous figures and tables condense material for easier retention and review. Shares the knowledge and experience of renowned anesthesia expert Dr. Manuel C. Pardo, Jr. and a team of more than 80 global contributing authors. Serves both as an initial learning resource and a useful tool for solidifying the essential “must know” information and reviewing core knowledge for maintenance of certification. Enhanced eBook version included with purchase. Your enhanced eBook allows you to access all of the text, figures, and references from the book on a variety of devices. 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