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دانلود کتاب Miller's Anesthesia
دانلود کتاب بیهوشی میلر
مشخصات کتاب
Miller's Anesthesia
ویرایش: [9 ed.]
نویسندگان: Gropper Michael A.
سری:
ناشر: Elsevier Inc.
سال نشر: 2019
تعداد صفحات: [3337]
زبان: English
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فهرست مطالب
Cover 1 1 - The Scope of Modern Anesthetic Practice Introduction Forces That Will Change Practice (Fig. 1.1) Changing Patient Populations Changing Locations of Care Changes in the Anesthesia Workforce Increasing Costs of Care Increasing Focus on Safety and Quality New Opportunities and Challenges in Research Increasing Availability of Data Conclusions Acknowledgment References 2 2 - Anesthesia and Analgesia in the Global Context Introduction Section 1: Anesthesia and “Global Health” Scope and Scale of the Global Anesthesia, Surgery, and Pain Crises Global Burden of Surgical Disease Global Burden of Pain Disparities in Access, Affordability, and Safety Global Anesthesia, Surgery, and Pain Crises: Origins and Areas for Intervention Misperceptions and Limited Data Advocacy and Policy Workforce Shortages and Strategies for Expansion Infrastructure Challenges Inequities in Analgesia Section 2: Evolution of Anesthesia Care Models and Challenges Around the World Africa Uganda (Mary T. Nabukenya and Sarah Hodges) South Africa (Hyla Kluyts) North America Canada (Tyler Law) Mexico (Gerardo Prieto) United States (Ronald D. Miller and Adrian W. Gelb) Europe Norway (Jannicke Mellin-Olsen) Romania (Daniela Filipescu) Asia and The Middle East India (Bala Krishnan Kanni) Lebanon and The Middle East (Patricia Yazbeck) Pakistan (Fauzia Khan) China (Yugaung Huang) Vietnam (Thi Thanh Nguyen and Thang Cong Quyet) South America Paraguay (Rodrigo Sosa Argana) Colombia (Pedro Ibarra) Oceania Australia and New Zealand (Rob McDougall) Fiji and Pacific Island Nations (Sereima Bale) Section 3: Essentials for Practice in Resource-Constrained Settings Clinical and Technical Skills Global Health Competencies Conclusions Acknowledgments References Appendix 1 Links and Useful Resources References 3 3 - Perioperative Medicine Introduction The Anesthesiologist and Perioperative Medicine Perioperative Management Preoperative Assessment and Management Intraoperative (Intraprocedural) Management Postoperative Management Coordinated Perioperative Management Strategies Models of Perioperative Care Patient-Centered Medical Home Surgical Hospitalist Enhanced Recovery After Surgery Perioperative Surgical Home Conclusion References 4 4 - Informatics in Perioperative Medicine Introduction Computer Systems Computer Networks The Internet Information Security Standards for Healthcare Data Exchange Regulation of Electronic Data Exchange The Nature of Healthcare Information in the Anesthesia Encounter Development and Deployment of Anesthesia Information Management Systems Anatomy of an Anesthesia Information Management System Advantages of Implementation of an Anesthesia Information Management System Integration of Anesthesia Care Information with Operating Room Information Systems Development of Decision Support Tools Passive Decision Support Systems Active Decision Support Systems Impact of Decision Support in Anesthesia Care Integration with the Enterprise Electronic Health Record Billing System Interactions Challenges in Anesthesia Information Management System Implementation Additional Uses for Collected Data Use for Medical Research Measurement of Quality of Care Interactions of Electronic Devices with the Delivery of Anesthesia Care Conclusion Acknowledgment References 5 5 - Quality Improvement in Anesthesia Practice and Patient Safety Definition of Quality Aims of Quality in Health Care Deming’s System of Profound Knowledge Approaches to Quality Assessment Quality Assurance Versus Continuous Quality Improvement Frameworks for Improvement Model for Improvement Lean Methodology and Six Sigma The Value Framework in Health Care Quality Improvement Measures and Tools Process and Outcome Measures Analysis and Display of Quality Improvement Data Run Charts and Control Charts Failure Modes and Effects Analysis Putting It All Together: An Example Quality Improvement Project Dashboards and Scorecards Additional Quality Improvement Evaluation and Communication Tools Improvement Intervention Tools Daily Goals Sheet Checklists Briefings and Debriefings Sources of Quality Improvement Information Incident Reporting Published Literature National Initiatives and Quality Metrics Outcomes Research Internal or External Institutional Reviews Examples of Quality Improvement Programs Collaborative Programs Institute for Healthcare Improvement Breakthrough Series Collaboratives Comprehensive Unit-Based Program Challenges and Barriers to Quality Improvement Projects Related concepts: improvement science and implementation science The Future: Research, Education, and Ethics Summary Acknowledgments References 6 6 - Avoiding Patient Harm in Anesthesia: Human Performance and Patient Safety What this Chapter is About:An Overview Readers Will Learn WHAT THIS CHAPTER IS NOT ABOUT Human Performance and Patient Safety in Anesthesia: Why is this Important Nature of the Anesthesia Professional’s Operational Domain: A Dynamic and Complex Environment Anesthesiology by its Nature Involves Crises Criteria defining a complex and dynamic world Production Pressure Resulting in Asymmetry Between Safety and Production Nature of the Anesthesia Professional’s Work: Task Variation and Workload Management Procedural Tasks of Anesthesia Professionals and Related Vulnerabilities Preoperative Planning Induction Maintenance Phase of Anesthesia Emergence Pre-Use Checkout of Equipment/Anesthesia Machine Checkout Cognitive Tasks of Administering Anesthesia AND RELATED VULNERABILITIES Introduction of the Anesthesia Professional’s Core Cognitive Process Model Management and Coordination of the Core Cognitive Process: Supervisory Control and Resource Management Anesthesia Professional’s Workload and Methodologies to Measure It Assessing the Performance of Anesthesia Professionals Performance as a function of task density Performance as a Function of Teaching, Delegation, and Supervision Performance as a Function of Experience What are the practical implications of performance assessment in Anesthesia Benefits and Challenges of Assessing Performance Benefits of the Scientific Study of Tasks and Performance in Anesthesia Challenges of the Scientific Study of Tasks and Performance in Anesthesia Patient Safety on the Individual and Team Level Human Performance, Human Factors, and NonTechnical Skills Human Performance and Human Factors Human Factors and Nontechnical Skills Human Factors on the Individual Level Task Management Situation Awareness Decision Making Performance-Shaping Factors on the Individual Level Distractions and Interruptions in the Operating Room Sleep Deprivation and Fatigue Rest Breaks, Strategic Napping at Work, and Use of Caffeine Aging Anesthesiologists Illness and Drug Use Professionals’ Attitudes as a Crucial Part of Human Performance and Patient Safety Human Factors AT the Team Level Effective Communication and Delegation of Tasks Status and Hierarchy: Speaking Up Teamwork Leadership Patient Safety Strategies AT the Individual and Team Level: Crisis Resource Management and Other Training Curricula Crisis/Crew Resource Management Other Curricula for Team Training: TeamSTEPPS and Clinical Team Training Patient Safety on the Organizational Level Systems Thinking Human Failure: Human Error and Violations Active Errors Evolution and Investigation of Accidents: One Error is not the Cause of an Accident Evaluation of Errors and Accidents: Hindsight Bias—“I knew it all Along” and Outcome Bias—“No Harm no Foul” System Error Models: Normal Accident Theory and High Reliability Organization Theory Safety I and Safety II: Ensuring that as Few Things as Possible go Wrong or that as Many Things as Possible go Right… Resilience and Uncertainty Management: Safety is a Dynamic State, not all Risks can be Eliminated Normalization of Deviance and Flirting with the Margin Achieving High Reliabilty and System Thinking: Fundamental Elements for a Systematic Safety Approach Culture of Safety Organizational Learning Characteristics of Successful Incident Reporting Systems Continuous Training including simulation . A pocket card of the 15 CRM key points is shown in Fig. 6.17 Continuous Optimization of Safety-Relevant Structures and Processes The Bigger Picture: Patient Safety Efforts on the U.S. National and International Level Patient Safety Milestones and Movements Institutions Engaging in Patient Safety Raising the Awareness for Patient Safety Certified Education in Patient Safety for Health Care Professionals National and International Evaluation of the Benefits of Patient Safety Programs Patients for Patient Safety Conclusion and Outlook Acknowledgment References References 7 7 - Patient Simulation What This Chapter Is About: An Overview Readers will Learn What this Chapter is not About Simulation in Anesthesia: Why Is It Important Application of Simulation in Anesthesia and Health Care Use of Patient Simulation for Training and Education Use of Patient Simulation for System Probing and Protocol Testing Use of Patient Simulation for Testing Equipment and Supplies Use of Patient Simulation for Performance Assessment Use of Patient Simulation for Research Other Uses of Patient Simulation History, Development, and Types of Simulators and Simulation Simulation Fidelity and Classification of Simulators Sites of Simulation Dedicated Simulation Center Training and Probing Where Clinicians Work In Situ Simulation Peri-situ or Off-site Simulation Sequential Location Simulation Mobile Simulation: “Have Simulator, Will Travel” Simulation Team Training Participants: Who Should Be Trained and in What Composition Training Individuals Training Crews: Interprofessional Single-Discipline Team Training Training Teams: Interprofessional Multidiscipline Team Training Cross Training: Changing Roles EN-BLOC Training: Avoiding Sub-Threshold Training Effects Patient Simulation Timing: Announced in Advance Versus Unannounced in Advance Scopes of Simulation in Health Care: The 12 Dimensions of Simulation Crisis Resource Management (ACRM; CRM): Part of Modern Patient Simulation Team Training The Roots of Anesthesia Crisis Resource Management Training Anesthesia Crisis Resource Management Curricula Benefits of Crisis Resource Management-Based Simulation Training Anatomy of a Patient Simulation Team Training Exercise Scenario Design and Execution: Knowing the Learning Objectives and Making It Real Goal Oriented: Establishing Learning Objectives Cognitive Load Theory: Not too much, not too Little Constraints and Limitations of Scenario Design Ideas Scenario Design Templates AND Scenario Templates Reality Versus Realism Simulation Realism and Simulation Relevance in-Scenario Information and Guiding Debriefing: Heart and Soul of Patient Simulation Simulators (Devices) Don’t Teach Instruction Versus Facilitation—A New Way of Teaching Debriefing Techniques Use of Recorded Audio-Video Sequences in Debriefings Excursion: Debriefing Techniques For Discussion of Real Clinical Cases Excursion: Debriefing Techniques for Morbidity and Mortality Conferences Debriefing in Different Cultures Qualification and Certification of Simulation Instructors Tasks of Simulation Instructors—Learning Objectives for Simulation Instructor Courses Education, Training, AND Continuous Development of Simulation Instructors Instructor Education and Training Continuous Faculty Development Certification of Simulation Instructors Accreditation of Simulation Programs, Sites, and Centers Benefits, Effectiveness, and Ecological Validity of Simulation Training Benefits Effectiveness Ecological Validity of Patient Simulation: Is there Transferability to the Real World Cost of Patient Simulation and Simulation Centers Cost of Patient Simulation Cost of Simulation Centers Using Simulation for Assessment of Clinical Performance Benefits Of Simulation-Based Performance Assessment Pitfalls of Simulation-Based Performance Assessment Using Simulation for the Evaluation and Testing of Anesthesia Professionals Simulation Societies and Simulation Journals The Future of Patient Simulation in Anesthesia Appendix 7.1 Online Links and Useful Resources Acknowledgment References 8 8 - Ethical Aspects of Anesthesia Care Clinical Ethics Informed Consent and Informed Refusal Competence and Capacity Disclosure Legal Implications of Informed Consent Informed Refusal Special Issues in Informed Consent and Informed Refusal The Jehovah’s Witness Patient The Pediatric Patient and Other Patients With Impaired Competence Ethical Challenges of Preoperative Testing Routine Preoperative Testing Protocols Routine Preoperative Pregnancy and Human Immunodeficiency Virus Testing Ethics of Anesthesia Involving Pregnant Women Maternal-Fetal Conflicts Informed Consent in Laboring Women The Uncooperative Patient—Coercion and Restraint Truth Telling—Disclosure of Errors and Apology Advance Directives and Surrogate Decision Makers Medical Decisions That May Require a Court Order Do-Not-Attempt-Resuscitation Orders in the Operating Room End-of-Life Decision Making Withdrawal or Withholding of Medical Therapies Terminal Sedation Neuromuscular Blocking Drugs Implantable Cardiac Devices Physician-Assisted Suicide and Euthanasia Ethical Issues in Organ Transplantation Brain Death Donation after Cardiac Death Research Ethics Human Subject Research Children as Research Subjects Ethics of Animal Research Physician Participation in Executions Moral Integrity—can the Physician be a Conscientious Objector in Medicine References 9 9 - Consciousness, Memory, and Anesthesia Introduction Scientific and Clinical Importance Consciousness Definitions Subcortical Nuclei Regulating Arousal Brainstem Hypothalamus Role of the Thalamus Cortical-Subcortical Connectivity Cortical Connectivity and Dynamics Memory History and Terminology Organization and Function of Normal Memory Multiple Memory Systems Long-Term Potentiation, Synaptic Tagging, and the Consolidation Model of Memory Reconsolidation Phase Synchronization and Coupling Effects of Anesthetic Drugs on Declarative Memory Function in Humans Behavioral Studies of Retrograde Memory Effects Mathematical Modeling of Anesthetic Amnesia Anesthetic Effects on Attention and Arousal as Modulators of Encoding Neuroimaging Studies of Cortical Encoding Processes Neuroimaging Studies of Medial Temporal Lobe Function Studies of Cortical Event-Related Potentials Anesthetic Effects on Medial Temporal Lobe Plasticity Human and Nonhuman Studies of Anesthetic Effects on Fear Memory Systems The Amygdala-Dependent Fear System Studies of Anesthetic Effects on Fear Systems in Nonhumans Studies of Anesthetic Effects on Fear Systems in Humans Clinical Relevance Anesthetic Effects on Implicit Memory Function References 10 10 - Sleep Medicine Physiology Evolution Circadian Rhythms Sleep Stages and Sleep Cycles Neuroanatomy of Sleep Sleep-Promoting and Arousal Pathways How to Assess Sleep Questionnaires Actigraphy Respiratory Polygraphy Polysomnography Sleep Laboratory Testing Out-of-Center Testing Scoring of Sleep and Sleep Disordered Breathing Sleep and Breathing Respiratory Regulation During Sleep Sleep-Disordered Breathing Obstructive Sleep Apnea Central Sleep Apnea Obesity Hypoventilation Syndrome Sleep and Anesthesia: Two Unequal Twins Influencing Perioperative Medicine Clinical Picture of Sleep and Anesthesia Activation of Sleep-Promoting Pathways During Anesthesia Perioperative Interactions Between Anesthesia and Sleep Sleep-Disordered Breathing and Airway Patency During Anesthesia Perioperative Management in Patients with Sleep-Disordered Breathing Preoperative Screening Perioperative Management of Patients with Possible Sleep-Disordered Breathing Knowledge Gaps and Future Research Sleep and Sedation in the Intensive Care Unit Noise and Light Exposure Medication and Medical Procedures Sleep and Sedation in the Intensive Care Unit Pharmacological Treatment of Sleep Disturbances in Intensive Care Unit Patients Consequences of Sleep Disturbance in ICU Patients Perioperative Management of Other Sleep Disorders Narcolepsy Restless Legs Syndrome and Periodic Limb Movement Disorder Acknowledgment References 11 11 - Cerebral Physiology and the Effects of Anesthetic Drugs The Anatomy of the Cerebral Circulation Cerebrospinal Fluid Formation and Circulation Regulation of Cerebral Blood Flow Myogenic Regulation (Autoregulation) of Cerebral Blood Flow Chemical Regulation of Cerebral Blood Flow Cerebral Metabolic Rate Neurogenic Regulation of Cerebral Blood Flow Effects of Blood Viscosity on Cerebral Blood Flow Cardiac Output An Integrated Contemporary View of Cerebral Autoregulation Vasoactive Drugs Systemic Vasodilators Catecholamine Agonists and Antagonists Age Effects of Anesthetics on Cerebral Blood Flow and Cerebral Metabolic Rate Intravenous Anesthetic Drugs Barbiturates Propofol Etomidate Narcotics Benzodiazepines Droperidol Ketamine Lidocaine Inhaled Anesthetics Volatile Anesthetics Nitrous Oxide Muscle Relaxants Nondepolarizing Relaxants Succinylcholine Other Effects of Anesthetics on Cerebral Physiology Cerebrospinal Fluid Dynamics Blood-Brain Barrier Epileptogenesis Volatile Anesthetics Methohexital Ketamine Etomidate Propofol Narcotics Neonatal Anesthetic Neurotoxicity Cerebral Physiology in Pathologic States Cerebral Ischemia—Pathophysiologic Considerations Critical Cerebral Blood Flow Thresholds Models of Cerebral Ischemia Energy Failure and Excitotoxicity The Nature of Neuronal Death Timing of Neuronal Death Brain Protection Considerations Relevant to Complete Global Ischemia (Cardiac Arrest) Considerations Relevant to Focal (Incomplete) Ischemia Cerebral Ischemia: Influence of Physiologic Variables Anchor 1081 Summary of Anesthetics and Neuroprotection Deferring Elective Procedures After Stroke Chronic Arterial Hypertension Intracranial Hypertension Brain Tumors Coma and Epilepsy References 12 12 - Neuromuscular Physiology and Pharmacology Neuromuscular Transmission Morphology Quantal Theory Neuromuscular Junction Formation of Neurotransmitter at Motor Nerve Endings Nerve Action Potential Synaptic Vesicles and Recycling Process of Exocytosis Acetylcholinesterase Postjunctional Acetylcholine Receptors Synthesis and Stabilization of Postjunctional Receptors Basic Electrophysiology of Neurotransmission Drug Effects on Postjunctional Receptors Classic Actions of Nondepolarizing Muscle Relaxants Classic Actions of Depolarizing Muscle Relaxants Nonclassic and Noncompetitive Actions of Neuromuscular Drugs Desensitization Block Channel Block Phase II Block Biology of Prejunctional and Postjunctional Nicotinic Acetylcholine Receptors Postjunctional Conventional Acetylcholine Receptors in Muscle Versus Neuronal Acetylcholine Receptors in Muscle Maintenance of Mature Neuromuscular Junctions Re-Expression of Immature (Fetal) γ-Subunit and α7-Subunit Acetylcholine Receptors in Adult Life Prejunctional Acetylcholine Receptors Neuromuscular Junction at Extremes of Age Newborn Old Age References 13 13 - Respiratory Physiology and Pathophysiology Respiratory Physiology Is Central to the Practice of Anesthesia Pulmonary Physiology in Health Respiration in the Cell Transport of O2 in the Blood Transport of Co2 in the Blood Oxygenation in the Pulmonary Artery Ventilation Alveolar Ventilation Dead Space Ventilation Static Lung Volumes—Functional Residual Capacity Respiratory Mechanics Compliance of the Respiratory System Resistance of the Respiratory System Airways Tissue Inertia or Acceleration of Gas and Tissue Distribution of Inspired Gas Airway Closure Diffusion of Gas Perfusion Distribution of Lung Blood Flow Distribution of Blood Flow in the Lung: the Effect of Gravity Distribution of Blood Flow in the Lung: Influence of Factors Not Related to Gravity Hypoxic Pulmonary Vasoconstriction Clinical Assessment of Lung Function Spirometry—Total Lung Capacity and Subdivisions Diffusing Capacity (DLCO)—Diffusion Across Alveolar-Capillary Membranes Surface Area Membrane Thickness Pressure Gradient Molecular Weight and Solubility Intraoperative Respiratory Events Respiratory Function During Anesthesia Lung Volume and Respiratory Mechanics During Anesthesia Lung Volume Compliance and Resistance of the Respiratory System Atelectasis and Airway Closure During Anesthesia Prevention of Atelectasis During Anesthesia Positive End-Expiratory Pressure Recruitment Maneuvers Minimizing Gas Resorption Maintenance of Muscle Tone Atelectasis Following Surgery Airway Closure Distribution of Ventilation and Blood Flow During Anesthesia Distribution of Ventilation Distribution of Lung Blood Flow Hypoxic Pulmonary Vasoconstriction Ventilation-Perfusion Matching During Anesthesia Dead Space, Shunt, and Ventilation-Perfusion Relationships CO2 Elimination Oxygenation Factors that Influence Respiratory Function During Anesthesia Spontaneous Breathing Increased Oxygen Fraction Body Position Age Obesity Preexisting Lung Disease Regional Anesthesia Causes of Hypoxemia and Hypercapnia Hypoventilation Ventilation-Perfusion Mismatch Effect of on CO2 Elimination Impaired Diffusion Right-to-Left Shunt Respiratory Function During One-Lung Ventilation Pneumoperitoneum Lung Function After Cardiac Surgery Protective Ventilation Postoperative Physiotherapy Intraoperative Hyperoxia Effect of Sleep on Respiration References 14 14 - Cardiac Physiology Physiology of the Intact Heart CARDIAC CYCLE Electrical Events and the Electrocardiogram Mechanical Events Ventricular Structure and Function Ventricular Structure Ventricular Function Cardiac Output Cellular Cardiac Physiology Cellular Anatomy Cardiomyocyte Structure and Function Excitation System Excitation-Contraction Coupling Contractile System Control of Cardiac Function Neural Regulation of Cardiac Function Hormones Affecting Cardiac Function Sex Steroid Hormones and the Heart Cardiac Reflexes Baroreceptor Reflex (Carotid Sinus Reflex) Chemoreceptor Reflex Bainbridge Reflex Bezold-Jarisch Reflex Valsalva Maneuver Cushing Reflex Oculocardiac Reflex Acknowledgment References 15 15 - Gastrointestinal Physiology and Pathophysiology Introduction Gastrointestinal Anatomy and Function Transit Time in Health and Disease Methods of Evaluating Colonic Motility The Effects of General Anesthesia on Bowel Function Effect of Opioids on Bowel Function Effect of Open Abdominal Surgery, Ischemia, Stomas, and Bowel Anastomosis on Gastrointestinal Physiology and Function Gastrointestinal System Nociception Abdominal Viscera Innervation Celiac Plexus Anatomy Abdominal Visceral Pain Visceral Pain Treatment Visceral Pain Block Techniques Visceral/Celiac PLEXUS Block Intraperitoneal Regional Anesthesia or Peritoneal Lavage Celiac Plexus Block—Posterior and Trans-Crural Approach Celiac Plexus Block—Anterior Approach Endoscopic Ultrasound-Guided Celiac Plexus Block Technical Aspects of Visceral Plexus Blocks Complications of Visceral Pain Blocks Indications for a Visceral Pain Block Post-Laparatomy Pain Relief Cancer Pain Effects of Regional Anesthesia on Gastrointestinal Physiology Effect on Gastrointestinal Motility and Postoperative Ileus Effect on Enteric Anastomosis Dehiscence Effect on Nutrition Effect on Postoperative Nausea and Vomiting Effect on Gastrointestinal Blood Flow and Volume Enhanced Recovery After Surgery for Gastrointestinal Procedures— Physiologic Basis Physiologic Basis of Eras Perioperative Pain Control Preoperative Carbohydrate Loading and Early Postoperative Feeding Temperature Control Nasogastric Tubes Bowel Preparation Drains Fluid Management Mobilization and Early Ambulation Acknowledgment References 16 16 - Hepatic Physiology, Pathophysiology, and Anesthetic Considerations Surgical Anatomy, Hepatic Blood Flow, and the Biliary Tree Cellular Anatomy Liver Lobule and Acinus Hepatocytes Hepatic Stellate Cells Myeloid Cells Lymphocytes Hepatic Physiology Drug Metabolism Protein Metabolism Carbohydrate Metabolism Lipid Metabolism Bile and Enterohepatic Circulation Role of the Liver in Coagulation Heme Metabolism, Bilirubin, and Porphyrias Hepatic Regulation of Hormones Evaluation of the Liver Clinical Assessment Standard Laboratory Tests Detection of Hepatocellular Injury Aminotransferases Lactate Dehydrogenase Glutathione-S-Transferase Detection of Cholestatic Disorders Alkaline Phosphatase Serum Bilirubin Assessment of Hepatic Protein Synthesis Serum Albumin Prothrombin Time Testing for Diagnosis of Specific Diseases Testing in Management and Prognosis of Liver Disease Noninvasive Serum Testing for Fibrosis Quantitative Liver Tests Measurement of Hepatic Blood Flow Clearance Techniques Indicator Dilution Techniques Direct Measurements Radiologic Methods Hepatic Pathophysiology Cholestatic Disease Primary Biliary Cholangitis Primary Sclerosing Cholangitis Cirrhosis Ascites Renal Failure and Hepatorenal Syndrome Hepatic Encephalopathy Pulmonary Complications Hepatocellular Carcinoma Hepatic Effects of Anesthetic Agents Inhalational Anesthetics Nonhepatic Surgery in Patients With Liver Disease Anesthetic Considerations for Procedures Involving the Liver Strategies for Minimizing Blood Loss Low Central Venous Pressure Other Approaches to Reduce Blood Loss Anesthetic Management Enhanced Recovery After Surgery and Liver Resection Acknowledgment References 17 17 - Renal Anatomy, Physiology, Pharmacology, and Evaluation of Function Introduction Organization of the Kidney The Nephron The Renal Tubules Formation of Urine Glomerular Filtration Mediator Control of the Glomerular Filtration Rate The Dopaminergic System Adenosine Nitric Oxide Renal Tubular System Physiology The Loop of Henle Distal Tubules and Macula Densa Collecting Tubules Collecting Ducts Renal Autoregulation Autoregulation of Renal Blood Flow The Myogenic Mechanism of the Renal Blood Flow Autoregulation Tubuloglomerular Feedback Maintenance of Plasma Osmolality Definition Regulation of Osmolality Role of Proximal Tubules and Loop of Henle Medullary Interstitium Vasa Recta The Role of Urea Renal Control of Intravascular Volume Hypovolemia Hypervolemia Clinical Tests for Renal Function46,47 Urine Output Creatinine Blood Urea Nitrogen Renal Clearance Techniques Measurement of Tubular Function Effect of Anesthetics on Renal Function Effects of Mechanical Ventilation on Renal Function Induced Hypotension Acknowledgment References 18 18 - Basic Principles of Pharmacology Introduction Fundamental Pharmacokinetic Concepts Volume of Distribution Clearance Physiologic Model for Clearance Hepatic Biotransformation Pharmacokinetic Models Physiologic Models Compartmental Models Zero Versus First-Order Kinetics One-Compartment Model Multicompartment Models Special Interests in Anesthetic Pharmacokinetics Front-End Kinetics Back-End Kinetics Hysteresis Pharmacodynamic Principles Potency and Efficacy Effective Versus Lethal Doses Anesthetic Drug Interactions Drug Displays Special Populations Influence of Obesity on Anesthetic Drugs Propofol Opioids Remifentanil Dosing Scalars Remifentanil Kinetic Models for Target-Controlled Infusions Fentanyl Other Opioids Inhaled Anesthetics Influence of Age on Anesthetic Drug Pharmacology Summary References 19 19 - Inhaled Anesthetics: Mechanisms of Action History The Unified Paradigm of Anesthetic Theories Minimum Alveolar Concentration―A Bridge Between Past and Present Shift From Lipid- to Protein-Centered Mechanisms Diversity of Potential Anesthetic Targets Anesthesia: A Composite Neuropharmacologic State Integrated Effects on Central Nervous System Function Immobility Unconsciousness Learning and Memory Sedation Identification of Molecular Sites of Anesthetic Action Criteria for Identifying Sites Relevant to Anesthesia Physicochemical Properties of Anesthetic Binding Sites From Model Proteins to Receptors Molecular Targets of Inhaled Anesthetics Ligand-Gated ION Channels Potentiation of Inhibitory GABAA and Glycine Receptors Inhibition of Excitatory Acetylcholine and Glutamate Receptors Voltage-Gated and other ION Channels Na+ Channels Ca2+ Channels K+, HCN, and TRP Channels Intracellular Signaling Mechanisms G-Protein–Coupled Receptors Protein Phosphorylation Gene Expression Cellular Mechanisms Neuronal Excitability Presynaptic Versus Postsynaptic Effects on Synaptic Transmission Simple Circuits and Complex Networks Simple Circuit Phenomena Synaptic Plasticity Spontaneously Active Circuits Rhythms and Simulations δ-Rhythms and Other Slow Rhythms θ-Rhythms γ-Rhythms Models and Simulations Research Strategies for the Future Pharmacologic Approaches Agonists, Antagonists, and Experimental Anesthetics Nonimmobilizers Photoreactive Anesthetics Genetic Approaches Whole-Organism Genetics Molecular Genetics Knockout and Knockin Animals Forward and Population Genetics Functional Imaging and High-Density Electroencephalography Summary References 20 20 - Inhaled Anesthetic Uptake, Distribution, Metabolism, and Toxicity Introduction Uptake and Distribution of Inhaled Anesthetics Biophysical Properties of Inhaled Anesthetics: Partial Pressure, Hydrophobicity, and Partition Coefficients Anesthetic Delivery, Uptake, and Distribution: a Multicompartmental Model Upstream and Downstream Compartments and Anesthetic Transfer: Bulk Flow and Pressure Gradients Rate of Wash-In of the Circuit: Equilibration Between Vaporizer and Circuit Equilibration Between Circuit and Pulmonary Airspace The Alveolar Anesthetic Concentration Alveolar Uptake of Anesthetic into Pulmonary Blood Other Factors That Affect the Rate of Rise of Palv Distribution of Anesthetic into Tissues The Mixed Venous Anesthetic Partial Pressure Synthesis of the Model and Inhaled Anesthetic Induction: PK/PD Pharmacodynamic Effects of Anesthetics on Uptake and Distribution The Effect of Nitrous Oxide on Gas-Filled Spaces Recovery from Anesthesia Similarities and Differences to Induction Context Sensitive Recovery from Anesthesia Percutaneous and Visceral Anesthetic Loss Effect of the Anesthetic Circuit Clearance via Metabolism of Anesthetics Additional Considerations and Possibilities Diffusion Hypoxia Metabolism and Toxicity of Inhaled Anesthetics Biotransformation of Inhaled Anesthetics Biotransformation in the Liver Halothane Hepatotoxicity Biotransformation in Kidneys Fluoride-Associated Nephrotoxicity Anesthetic Degradation in Carbon Dioxide Absorbents Sevoflurane, Compound A, and Renal Toxicity Carbon Monoxide and Heat Nitrous Oxide, Vitamin B12, and Homocysteine Anchor 818 Inhaled Anesthetics and Neurotoxicity Inhaled Anesthetics and Environmental Effects Global Warming Effects Ozone Depletion Exposure to Waste Anesthetic Gases Xenon and Other Noble Gases References 21 21 - Pulmonary Pharmacology and Inhaled Anesthetics Introduction Inhaled Anesthetics Asthma and Bronchospasm Overview Physiology of Bronchial Smooth Muscle Role of Calcium Histamine Adrenergic Receptors Effects of Inhaled Anesthetics Effects of Inhaled Anesthetics on Bronchomotor Tone in Humans and the Work of Breathing Mechanisms of Action of Volatile Anesthetics Mucociliary Function and Surfactant Normal Mucociliary Function Effects of Inhaled Anesthetics on Mucociliary Function Effects of Inhaled Anesthetics on Surfactant Pulmonary Vascular Resistance Regulation of Pulmonary Vascular Tone Mechanisms of Hypoxic Pulmonary Vasoconstriction Inhaled Anesthetics and Hypoxic Pulmonary Vasoconstriction Effects of Volatile Anesthetics on Pulmonary Vasculature in Humans Control of Respiration Components of the Respiratory Regulatory System Central Chemoreception Central Pattern Generator Integration of Peripheral Inputs Respiratory Motor Output and Upper Airway Patency Effects of Inhaled Anesthetics on Resting Ventilation Effects of Inhaled Anesthetics on Chemoreflexes Effects of Inhaled Anesthetics on the Hypercapnic Ventilatory Response Effects of Volatile Anesthetic on the Hypoxic Ventilatory Response In Humans Effects of Inhaled Anesthetics on Respiratory Muscle Activity Effects of Inhaled Anesthetics on the Upper Airway Effects of Inhaled Anesthetics on Defensive Airway Reflexes Inhaled Anesthetics and Acute Lung Injury Pathophysiology of Sepsis-Induced Acute Lung Injury Effects of Inhaled Anesthetics on Experimental Sepsis-Induced Acute Lung Injury Inhaled Anesthetics and Ventilator-Induced Lung Injury Inhaled Anesthetics and Lung Ischemia-Reperfusion Clinical Evidence Nonvolatile Inhaled Agents Nitrous Oxide Sedative and Analgesic Effects Gas Volume Expansion Nausea And Vomiting Pulmonary Hypertension Potential Neurotoxicity of Nitrous Oxide Xenon Speed of Emergence and Postoperative Cognitive Dysfunction with Xenon Intraoperative Hemodynamics and Postoperative Outcome Use of Xenon in Critical Care Postoperative Nausea and Vomiting Airway Resistance Apnea Comparison of Nitrous Oxide and Xenon Summary Acknowledgment References 22 22 - Inhaled Anesthetics: Delivery Systems Functional Anatomy of the Anesthesia Workstation Gas Supply System High-Pressure Section Intermediate-Pressure Section Low-Pressure Section Vaporizer Mount and Interlock System Anesthetic Vaporizers Physics Modern Vaporizer Types Anesthetic Breathing Circuits Circle Breathing Systems Mechanical Components of the Circle Breathing System Sensors Potential Circle System Problems Carbon Dioxide Absorbers Interactions of Inhaled Anesthetics With Absorbents Mapleson Breathing Systems Bain Circuit Self-Inflating Manual Resuscitators Anesthesia Ventilators Classification Pneumatically Driven Bellows Ventilator Mechanically Driven Piston Ventilator Maquet FLOW-i Anesthesia System With Volume Reflector Dräger Anesthesia Systems With Turbine Ventilators Target-Controlled Inhalational Anesthesia Fresh Gas Flow Compensation and Fresh Gas Decoupling Scavenging Systems Classifications and Components Hazards Checking Your Anesthesia Workstation 2008 Recommendations for Pre-Anesthesia Checkout Procedures Item 1: Verify Auxiliary Oxygen Cylinder and Self-Inflating Manual Ventilation Device Are Available and Functioning Item 2: Verify Patient Suction Is Adequate to Clear the Airway Item 3: Turn on Anesthesia Delivery System and Confirm That AC Power Is Available Item 4: Verify Availability of Required Monitors and Check Alarms Item 5: Verify That Pressure Is Adequate on the Spare Oxygen Cylinder Mounted on the Anesthesia Machine Item 6: Verify That Piped Gas Pressures Are 50 psig or Higher Item 7: Verify That Vaporizers Are Adequately Filled and, If Applicable, That the Filler Ports Are Tightly Closed Item 8: Verify That No Leaks Are Present in the Gas Supply Lines Between the Flowmeters and the Common Gas Outlet Item 9: Test Scavenging System Function Item 10: Calibrate, or Verify Calibration of, the Oxygen Monitor and Check the Low Oxygen Alarm Item 11: Verify Carbon Dioxide Absorbent Is Not Exhausted Item 12: Breathing System Pressure and Leak Testing Item 13: Verify That Gas Flows Properly Through the Breathing Circuit During Both Inspiration and Exhalation Item 14: Document Completion of Checkout Procedures Item 15: Confirm Ventilator Settings and Evaluate Readiness to Deliver Anesthesia Care (Anesthesia Time Out) Additional Comments Pertaining to the ASA’s Pre-Anesthesia Checkout Procedure Recommendations (2008) Automated Anesthesia Machine Checkout Procedures Machine-Embedded Preanesthesia Machine Checkout Checklists Developing a Local Preanesthesia Machine Checkout Checklist Acknowledgment References References 23 23 - Intravenous Anesthetics Propofol History Physicochemical Characteristics Pharmacokinetics Pharmacodynamics Effects on the Central Nervous System Effects on the Respiratory System Effects on the Cardiovascular System Other Effects Uses Induction and Maintenance of Anesthesia Sedation Side Effects and Contraindications Barbiturates History Physicochemical Characteristics Chemistry and Formulation Structure-Activity Relationships Pharmacokinetics Metabolism Pharmacology Mechanism of Action Effects on Cerebral Metabolism (Also see Chapter 57) Pharmacodynamics Effects on the Central Nervous System Effects on the Respiratory System Effects on the Cardiovascular System Other Effects Uses Induction and Maintanance of Anesthesia Dosing Contraindications Benzodiazepines Introduction Physicochemical Characteristics Pharmacokinetics Remimazolam (CNS 7056) Pharmacodynamics Effects on the Central Nervous System Effects on the Respiratory System Effects on the Cardiovascular System Drug Interactions Pharmacokinetic Drug Interactions Pharmacodynamic Drug Interaction Uses Premedication Sedation Induction and Maintenance of Anesthesia Nausea and Vomiting Prophylaxis Side Effects and Contraindications Flumazenil Physicochemical Characteristics Pharmacokinetics Pharmacodynamics Uses and Doses Side Effects and Contraindications Phencyclidines (Ketamine) History Physicochemical Characteristics Pharmacokinetics Pharmacodynamics Effects on the Central Nervous System Effects on the Respiratory System Effects on the Cardiovascular System Uses Induction and Maintenance of Anesthesia Pain Management Sedation Doses and Routes of Administration Side Effects and Contraindications Etomidate History Physicochemical Characteristics Pharmacokinetics Pharmacodynamics Effects on the Central Nervous System Effects on the Respiratory System Effects on the Cardiovascular System Endocrine Effects Uses Induction of Anesthesia Treatment in Hypercortisolemia Side Effects Novel Etomidate Derivatives Dexmedetomidine History Physicochemical Characteristics Metabolism and Pharmacokinetics Pharmacology Effects on the Central Nervous System Sedation Analgesia Central Nervous System Protection and Other Central Nervous System Effects Effects on the Respiratory System Effects on the Cardiovascular System USES Intensive Care Unit Droperidol History Pharmacokinetics Pharmacodynamics Effects on the Central Nervous System Effects on the Respiratory System Effects on the Cardiovascular System Uses Summary Acknowledgment References References 24 24 - Opioids Introduction Pharmacology of Opioids CLASSIFICATION OF OPIOID COMPOUNDS BASIC STUDIES ON OPIOID RECEPTORS Genetic Variations Which Influence Opioid Effects Endogenous Opioid Peptides Intracellular Signal Transduction Mechanism of Opioid Receptors Biased Agonism Mechanism of Opioid Analgesia Brain Spinal Cord Peripheral Mechanism Acupuncture Mechanism of Mood Alterations and Rewarding Properties Analysis of Knockout Mice Actions of Opioids on Targets Other than Opioid Receptors Physiologic Role of Nociceptin/Orphanin FQ Neurophysiologic Effects of Opioids Characteristics of The Analgesic Action of Opioids Effects of Opioids on Consciousness Hallucination Electroencephalography Evoked Responses Cerebral Blood Flow and Cerebral Metabolic Rate Intracranial Pressure Neuroprotection Muscle Rigidity Neuroexcitatory Phenomena Pupil Size Thermoregulation and Shivering Pruritus Opioid-Induced Hyperalgesia Respiratory Effects of Opioids Effects on Airways Respiratory Depression Factors Affecting Opioid-Induced Respiratory Depression Cardiovascular Effects of Opioids Neurologic Mechanisms Cardiac Mechanisms Contractility Cardiac Rhythm Conduction Myocardial Ischemia Coronary Circulation Circulatory Reflexes Histamine Release Vascular Mechanisms Opioids in Shock Endocrinologic Effects of Opioids Stress Reduction and Outcome Opioid Tolerance Management of Opioid-Dependent Patients Renal and Urodynamic Effects of Opioids Effects of Opioids on Digestive Organs Effects on Gastrointestinal Tract Biliary and Hepatic Effects Nausea and Vomiting Other Opioid Effects Obstetrics Anaphylactoid Reactions Ocular Effects Immune Effects Cancer Progression Wound Healing Pharmacokinetics and Pharmacodynamics of Opioids Physicochemical Properties Pharmacokinetic Features of Individual Drugs Morphine Fentanyl Alfentanil Sufentanil Remifentanil Surrogate Measures of Opioid Potency Factors Affecting Pharmacokinetics and Pharmacodynamics of Opioids Age Body Weight Renal Failure Hepatic Failure Cardiopulmonary Bypass Acid-Base Changes Hemorrhagic Shock Genetic Variations in Opioid Metabolism Anesthetic Techniques Using Opioids Analgesia Sedation Balanced Anesthesia Fentanyl Alfentanil Sufentanil Remifentanil Total Intravenous Anesthesia Opioid-Based (High-Dose Opioid) Anesthesia for Cardiac Surgery Fentanyl Sufentanil Remifentanil Other Applications of Opioids Transdermal Therapeutic System Iontophoresis Transmucosal Drug Delivery Oral Controlled-Release Medications Extended-Release Epidural Morphine (DepoDur) Other Opioid Agonists Codeine Oxycodone Meperidine (Pethidine) Hydromorphone Levorphanol Methadone Oxymorphone Piritramide Tramadol Morphine-6-Glucuronide Agonist-Antagonist Opioid Compounds Pentazocine Butorphanol Buprenorphine Nalbuphine Dezocine Meptazinol Opioid Antagonists Naloxone Reversal of Respiratory Depression by Naloxone Other Applications of Naloxone Naltrexone Nalmefene Methylnaltrexone Naloxegol Drug Interactions With Opioids General Principles Sedative-Hypnotics Benzodiazepines Barbiturates Propofol Etomidate Ketamine Inhaled Anesthetics Muscle Relaxants Monoamine Oxidase Inhibitors Calcium Channel Blockers Magnesium Nonsteroidal Antiinflammatory Drugs Acetaminophen Gabapentinoids Antidepressants Diphenhydramine Local Anesthetics References 25 25 - Nonopioid Pain Medications Introduction Calcium Channel Blockers Gabapentin Pregabalin Zonisamide Ziconotide Levetiracetam Sodium Channel Blockers Lidocaine Mexiletine Carbamazepine Oxcarbazepine Lamotrigine Topiramate References 26 26 - Intravenous Drug Delivery Systems Introduction Pharmacodynamic Considerations The Biophase Direct-Effect Models Indirect-Effect Models Dose Implications of the Biophase Drug Potency Single Drugs Pharmacodynamic Drug Interactions Designing Dosing Regimens Bolus Dose Calculations Maintenance Infusion Rates Recovery From Anesthesia Displaying Pharmacologic Information Intravenous Infusion Devices and Technologies Manual Intravenous Infusion Computer-Controlled Drug Delivery Target-Controlled Infusion Devices Evaluation of Target-Controlled Infusion Delivery Model Selection for Target-Controlled Infusion: Adult Propofol Models Model Selection for Target-Controlled Infusion: Pediatric Propofol Models Model Selection for Target-Controlled Infusion: Opioids Rational Target Concentration Selection Benefits of Target-Controlled Infusion Plasma Versus Effect-Site Targeting Safety of Target-Controlled Infusion Patient-Controlled Analgesia and Sedation Closed-Loop Controlled Intravenous Drug Delivery Future Perspectives References 27 27 - Pharmacology of Neuromuscular Blocking Drugs History and Clinical Use Principles of Action of Neuromuscular Blocking Drugs at the Neuromuscular Junction Postjunctional Effects Prejunctional Effects Pharmacology of Succinylcholine Structure-Activity Relationships Pharmacokinetics and Pharmacodynamics Butyrylcholinesterase Activity Dibucaine Number and Atypical Butyrylcholinesterase Activity Side Effects Cardiovascular Effects Hyperkalemia Increased Intraocular Pressure Increased Intragastric Pressure Increased Intracranial Pressure Myalgia Masseter Muscle Rigidity Anaphylaxis Clinical Uses Interactions With Anticholinesterases Nondepolarizing Neuromuscular Blocking Drugs Structure-Activity Relationships Benzylisoquinolinium Compounds Steroidal Neuromuscular Blockers Asymmetric Mixed-Onium Fumarates and Analogues Potency of Nondepolarizing Neuromuscular Blocking Drugs Onset Duration of Action Clinical Management Varying Sensitivities of Different Muscle Groups Dosage General Dosage Guidelines Initial and Maintenance Dosage Neuromuscular Blocking Drugs and Tracheal Intubation Rapid Tracheal Intubation Metabolism and Elimination Steroidal Compounds Benzylisoquinolinium Compounds Asymmetric Mixed-Onium Fumarates Adverse Effects of Neuromuscular Blocking Drugs Autonomic Effects Drug Interactions and Other Factors Affecting Response to Neuromuscular Blockers Interactions Among Nondepolarizing Neuromuscular Blocking Drugs Interactions Between Succinylcholine and Nondepolarizing Neuromuscular Blocking Drugs Interactions With Inhaled Anesthetics Interactions With Antibiotics Temperature Interactions With Magnesium and Calcium Interactions With Lithium Interactions With Local Anesthetic and Antidysrhythmic Drugs Interactions With Antiepileptic Drugs Interactions With Diuretics Interactions With Other Drugs Special Populations Pediatric Patients Older Patients Obese Patients Severe Renal Disease Hepatobiliary Disease Burns Use of Neuromuscular Blocking Drugs and Weakness Syndromes in Critically Ill Patients Critical Illness Myopathy Critical Illness Polyneuropathy Clinical Implications Should Succinylcholine Be Used in Patients in the Intensive Care Unit Should Nondepolarizing Neuromuscular Blocking Drugs Be Used in Patients in the Intensive Care Unit Acknowledgment References References 28 28 - Reversal (Antagonism) of Neuromuscular Blockade History Antagonism of Neuromuscular Blockade: Current Management Practices Residual Neuromuscular Blockade Assessment of Residual Neuromuscular Blockade Definitions of Residual Neuromuscular Blockade Incidence of Residual Neuromuscular Blockade Adverse Effects of Residual Blockade Drugs Used to Antagonize (Reverse) Neuromuscular Blockade Anticholinesterase Reversal of Neuromuscular Blockade Mechanism of Action of Anticholinesterases Pharmacokinetic and Pharmacodynamic Properties of Anticholinesterases Factors Determining the Adequacy of Recovery Following Administration of Anticholinesterases Complications Associated With Inhibitors of Acetylcholinesterase Sugammadex Reversal of Neuromuscular Blockade Structure-Activity Relationships and Mechanism of Action Pharmacokinetics Pharmacodynamics Clinical Use of Sugammadex in Healthy Patients Clinical Use of Sugammadex in Pediatric and Older Adult Patients Clinical Use of Sugammadex in Special Patient Populations Side Effects and Drug Interactions Special Considerations Cysteine Reversal of Fumarate Neuromuscular Blocking Drugs References 29 29 - Local Anesthetics Basic Pharmacology Chemistry The Local Anesthetic Molecule Structure-Activity Relationships and Physicochemical Properties Lipophilic-Hydrophilic Balance Hydrogen Ion Concentration Anatomy of the Peripheral Nerve Structure of the Axonal Membrane Physiology of Nerve Conduction Mechanism of Action of Local Anesthetics (Pharmacodynamics) Active Form Electrophysiologic Effect of Local Anesthetics The Nature of the Local Anesthetic Binding Site Neurophysiologic Aspects of Phasic Inhibition Selective Block of Na+ Channel Isoforms Sodium Channel Isoforms and Their Contribution to Human Diseases Characterized by Pain or Pain Insensitivity Summary of Local Anesthetic Mechanisms Clinical Pharmacology General Considerations Anesthetic Potency Onset of Action Duration of Action Differential Sensory and Motor Blockade Factors Influencing Anesthetic Activity in Humans Dosage of Local Anesthetic Addition of Additives Site of Injection Carbonation and pH Adjustment of Local Anesthetics Mixtures of Local Anesthetics Pregnancy Choice of Local Anesthetic for Various Regional Anesthetic Procedures Infiltration Anesthesia Intravenous Regional Anesthesia Peripheral and Truncal Nerve Blockade Perineural and Plexus Infusions Central Neural Blockade Topical Anesthesia Tumescent Anesthesia Systemic Local Anesthetics for Postoperative Pain and Neuropathic Pain Pharmacokinetics Absorption Distribution Biotransformation and Excretion Pharmacokinetic Alterations by Patient Status Toxicity Systemic Toxicity Central Nervous System Toxicity Cardiovascular System Toxicity Comparative Cardiovascular Toxicity Chiral Local Anesthetics: Ropivacaine and Levobupivacaine Acidosis and Hypoxia Indirect Cardiovascular Effects Methemoglobinemia Allergies Local Tissue Toxicity Development of Prolonged-Duration and Sensory- or Nociceptive-Selective Local Anesthetics Slow-Release Formulations Site 1 Blockers Targeting of Specific Sodium Channel Isoforms Targeting of Nociceptive Fibers Biologic Mechanisms of Local Anesthetic Failure: Inflammation, Hyperalgesia, Tachyphylaxis, and Genetic Variants Conclusions Acknowledgment References 30 30 - Risk of Anesthesia Introduction Framework of Perioperative Risk Issues Related to Study Design Types of Studies Problems Inherent in Studying Anesthesia-Related Risk Studies of Anesthesia-Related Mortality Analysis of Intraoperative Cardiac Arrest Perioperative Mortality and Morbidity in Outpatient Surgery Use of Anesthesia Information Management Systems Other Approaches to Discern the Root Cause of Morbidity and Mortality Issues Associated with Anesthesia-Related Mortality Risks Related to Patient Characteristics Special Patient Groups Obstetrics Pediatrics Older Adults Risks Directly Related to the Anesthetic Drug Risks Related to Surgery Risks Related to the Location of Surgery and Postoperative Monitoring Risks Related to the Anesthesia Provider Improving Anesthesia Safety Summary References 31 31 - Preoperative Evaluation Evolution of Preanesthesia Evaluation Preoperative Evaluation Goals and Benefits of Preanesthesia Evaluation Clinical Examination During Preoperative Evaluation Components of The Medical History Assessment of Functional Capacity Physical Examination Frailty, Geriatric Conditions, and the Older Surgical Patient Geriatric-Focused Assessment in the Older Surgical Patient Function and Mobility Cognition Nutrition Frailty Additional Considerations Preoperative Optimization for Frail Geriatric Patients (Table 31.4) Decision Making for Surgery in Older Adults Preoperative Evaluation of Patients With Coexisting Disease Cardiovascular Disease Hypertension Ischemic Heart Disease Coronary Stents Heart Failure Murmurs and Valvular Abnormalities Infective Endocarditis Prophylaxis Rhythm Disturbances on the Preoperative Electrocardiogram Cardiovascular Implantable Electronic Devices Peripheral Artery Disease Pulmonary Disorders Asthma Chronic Obstructive Pulmonary Disease Restrictive Pulmonary Disorders Patients Scheduled for Lung Resection Obstructive Sleep Apnea Pulmonary Hypertension Smokers and Second-Hand Smoke Exposure Upper Respiratory Tract Infections Cystic Fibrosis Postoperative Pulmonary Complications Endocrine Disorders Diabetes Mellitus Thyroid Disease Parathyroid Disease Hypothalamic-Pituitary-Adrenal Disorders Multiple Endocrine Neoplasia Syndromes Pheochromocytoma Kidney Disease Contrast-Induced Nephropathy Hepatic Disorders Hepatitis Obstructive Jaundice Miscellaneous Liver Diseases Unexpected Elevated Liver Function Tests Cirrhosis Hematologic Disorders Anemia Sickle Cell Disease Glucose-6-Phosphate Dehydrogenase Deficiency Coagulopathies Neurologic Disease Cerebrovascular Disease Asymptomatic Carotid Bruit Seizure Disorder Multiple Sclerosis Aneurysms and Arteriovenous Malformations Parkinson Disease Neuromuscular Junction Disorders Muscular Dystrophies and Myopathies Central Nervous System Tumors Musculoskeletal and Connective Tissue Diseases Rheumatoid Arthritis Ankylosing Spondylitis Systemic Lupus Erythematosus Systemic Sclerosis Raynaud Phenomenon Inherited Connective Tissue Disorders Kyphoscoliosis Cancers and Tumors in Preoperative Patients Patients With Cancer Mediastinal Masses Von Hippel–Lindau disease Carcinoid Tumors Special Issues in Preoperative Evaluation Pseudocholinesterase Deficiency Malignant Hyperthermia Morbidly Obese Patients Patients with Transplanted Organs Patients with Allergies Human Immunodeficiency Virus Infection Patients With A History of Substance Abuse Breastfeeding Patients Patients With do Not Resuscitate Orders Preoperative Laboratory and Diagnostic Studies Complete Blood Count, Hemoglobin, and Hematocrit Renal Function Testing Liver Function Testing Coagulation Testing Urinalysis Pregnancy Test Sickle Cell Test Electrocardiogram Chest Radiograph Preoperative Risk Assessment Role of Specialized Testing in Preoperative Risk Assessment Preoperative Medication Management Planning for Anesthesia Preoperative Fasting Status Planning for Postoperative Pain Management Regulatory Issues Preoperative Evaluation Clinic Collaboration, Commitment, and Teamwork Role of the Medical Consultant in Preoperative Evaluation Structures and Activities of the Preoperative Evaluation Clinic Impact on Operating Room Efficiency and Outcomes Patient Satisfaction with Preoperative Evaluation Clinics Conclusion Acknowledgment References 32 32 - Anesthetic Implications of Concurrent Diseases Role of the Primary Care Physician or Consultant Diseases Involving the Endocrine System and Disorders of Nutrition Pancreatic Disorders Preoperative and Preprocedure Diabetes Mellitus Glucotoxicity Diabetes and Accelerated Physiologic Aging Other Conditions Associated With Diabetes Emergency Surgery Anticipated Newer Treatments of Diabetes Insulinoma and Other Causes of Hypoglycemia Disorders of Nutrition, Including Obesity Hyperlipoproteinemia, Hyperlipidemia, and Hypolipidemia Obesity Other Eating Disorders: Anorexia Nervosa, Bulimia, and Starvation Hyperalimentation (Total Parenteral or Enteral Nutrition) Adrenocortical Malfunction Physiologic Properties of Adrenocortical Hormones Adrenocortical Hormone Excess Adrenocortical Hormone Deficiency Patients Taking Steroids for Other Reasons Adrenal Cortex Function in Older Adults Adrenal Medullary Sympathetic Hormone Excess: Pheochromocytoma Hypofunction or Aberration in Function of the Sympathetic Nervous System (Dysautonomia) Thyroid Dysfunction Hyperthyroidism Thyroid Storm Hypothyroidism Thyroid Nodules and Carcinoma Disorders of Calcium Metabolism Hyperparathyroidism and Hypercalcemia Hypocalcemia Osteoporosis Pituitary Abnormalities Anterior Pituitary Hypersecretion Anterior Pituitary Hypofunction Posterior Pituitary Hormone Excess and Deficiency Diseases Involving the Cardiovascular System Hypertension Preoperative Administration of All Antihypertensive Drugs Ischemic Heart Disease Role of Coronary Artery Bypass Graft or Percutaneous Coronary Interventions Before Noncardiac Surgical Procedures Perioperative Risk Factors for Cardiac Morbidity and Mortality Preoperative and Preprocedure Therapy Valvular Heart Disease Preoperative Antibiotic Prophylaxis for Endocarditis Cardiac Valve Prostheses and Anticoagulant Therapy and Prophylaxis for Deep Vein Thrombosis Cardiac Conduction Disturbances: Cardiac Arrhythmias Disorders of the Respiratory and Immune Systems General Preoperative and Preprocedure Considerations Specific Diseases Pulmonary Vascular Diseases Infectious Diseases of the Lung Chronic Diseases of the Lung Anaphylaxis, Anaphylactoid Responses, and Allergic Disorders Other than Those Related to Lung Diseases and Asthma Primary Immunodeficiency Diseases Diseases of the Central Nervous System, Neuromuscular Diseases, and Psychiatric Disorders COMA Epileptic Seizures Back Pain, Neck Pain, and Spinal Canal Syndromes Demyelinating Diseases Metabolic Diseases Neuromuscular Disorders Down Syndrome Preoperative Prediction of Increased Intracranial Pressure During Neurosurgery Mental Disorders Renal Disease and Electrolyte Disorders Renal Disease Causes and Systemic Effects of Renal Disorders Patients With Insufficient but Functioning Kidneys Patients Undergoing Dialysis Drugs in Patients With Renal Failure Infectious Disease Electrolyte Disorders Hyponatremia and Hypernatremia Hypokalemia and Hyperkalemia Gastrointestinal and Liver Diseases Gastrointestinal Disease Preoperative Search for Diverse Associated Disorders in Gastrointestinal Disease Ulcerative Colitis and Carcinoid Tumors as Examples of Gastrointestinal Disease Affecting Other Systems Liver Disease Hematologic Disorders and Oncologic Disease Hematologic Disorders Sickle Cell Anemia and Related Hemoglobinopathies Cytoskeletal Anemias (Hereditary Spherocytosis and Elliptocytosis), Enzyme-Deficient Anemias, and Autoimmune Hemolytic Anemias Granulocytopenia Platelet Disorders Hemophilia and Related Clotting Disorders Oncologic Disease Patients Given Drug Therapy for Chronic and Acute Medical Conditions Antihypertensive Drugs Mood-Altering Drugs Antiarrhythmic Drugs Antibiotics Medications for Glaucoma References 33 33 - Anesthetic Implications of Complementary and Alternative Therapies Herbal Medicines Preoperative Assessment and Management Echinacea Ephedra Garlic Ginger Ginkgo Ginseng Green Tea Kava Saw Palmetto St. John’s wort Valerian Other Herbal Medicines Common Dietary Supplements Coenzyme Q10 Glucosamine and Chondroitin Sulfate Fish Oil Prebiotics and Probiotics Other Dietary Supplements Summary Acupuncture Mechanism and General Practice Acupuncture for Postoperative Nausea and Vomiting Deep Breathing Music Therapy Conclusion Acknowledgment References 34 34 - Patient Positioning and Associated Risks Physiologic Considerations of Positioning General Positioning Considerations Specific Positions Supine Variations of the Supine Position Complications of the Supine Position Lithotomy Lateral Decubitus Prone Sitting Robotic Surgery Peripheral Nerve Injury Ulnar Nerve Injury Brachial Plexus Injury Other Upper Extremity Nerve Injury Lower Extremity Nerve Injury Evaluation and Treatment of Perioperative Neuropathies Pressure Injuries Bite Injuries Anesthesia Outside the Operating Room Perioperative Visual Loss Retinal Ischemia: Branch and Central Retinal Artery Occlusion Clinical Findings Mechanisms of Retinal Ischemia Central Retinal Artery Occlusion Cardiac Surgery and Retinal Arterial Occlusion Branch Retinal Artery Occlusion Considerations in Head and Neck Surgery Prognosis, Treatment, and Prevention Ischemic Optic Neuropathy Mechanisms Blood Supply to the Optic Nerve Control of Blood Flow Histopathologic Findings Patient Characteristics in Perioperative Ischemic Optic Neuropathy Retrospective Case Series Spine Surgery Cardiac Surgery Controversies and Anesthesia Management Recommendations Prognosis, Treatment, and Prevention American Society of Anesthesiologists Advisories (Updated With 2019 Advisory) Visual Loss After Vitrectomy and Vitreal Gas Bubble Tamponade Conclusion Disclosure Acknowledgment References References 35 35 - Neuromuscular Disorders Including Malignant Hyperthermia and Other Genetic Disorders History Physiology and Pathophysiology of Excitation-Contraction Coupling and Malignant Hyperthermia Malignant Hyperthermia Is the Result of Abnormal Function of Muscle Calcium Release Units Ryanodine Receptors Voltage-Gated Calcium Channels: role of Cav1.1 Factors Other than Ryanodine Receptor Abnormalities Dantrolene Genetics Distribution of RyR1 Mutations Inheritance and Penetrance of Malignant Hyperthermia In Vitro Contracture Test and Caffeine Halothane Contracture Test Discordance Between Genetic and in Vitro Contracture Test/Caffeine/Halothane Contracture Tests Malignant Hyperthermia Testing Guidelines for Genetic Screening Fulminant Malignant Hyperthermia Anesthetic Triggering Nonanesthetic Malignant Hyperthermia Malignant Hyperthermia–Associated Syndromes Masseter Spasm (“Thiopental-Succinylcholine or Halothane-Succinylcholine Rigidity”) Core Myopathies King-Denborough Syndrome Diagnosis in the Operating Room and Postanesthesia Care Unit Treatment Anesthesia for Susceptible Patients Evaluation of Susceptibility Multiple Sclerosis Anesthetic Considerations Motor Neuron Disorders Anesthetic Considerations Guillain-Barré Syndrome Anesthetic Considerations Critical Illness Polyneuropathy and Critical Illness Myopathy Anesthetic Considerations Hereditary Motor-Sensory Neuropathies, including Charcot-Marie-Tooth Disease Anesthetic Considerations Duchenne Muscular Dystrophy and Becker Muscular Dystrophy Diagnosis and Differential Diagnosis Anesthetic Considerations Limb-Girdle Muscular Dystrophy Myotonic Dystrophy Anesthetic Considerations Myotonia Congenita Anesthetic Considerations Myotubular Myopathy Anesthetic Considerations Metabolic Myopathies Glycogen Storage Disease Type I Anesthesia Considerations Glycogen Storage Disease Type II (Acid Maltase Deficiency) Anesthetic Considerations Mitochondrial Myopathies Mitochondrial Myopathy, Encephalopathy, Lactic Acidosis, and Stroke-Like Episodes Myoclonic Epilepsy with Ragged Red Fibers Anesthetic Considerations Preoperative Evaluation Induction and Maintenance of Anesthesia Myasthenia Gravis Anesthetic Considerations Eaton-Lambert Myasthenic Syndrome Anesthetic Considerations Periodic Paralysis (Hyperkalemic, Hypokalemic, and Normokalemic) Anesthetic Considerations Summary Acknowledgment References References 36 36 - Cardiovascular Monitoring Introduction to Cardiovascular Monitoring: Focused Physical Examination Heart Rate and Pulse Rate Monitoring Electrocardiography Monitoring Electrocardiogram Lead Placement and Selection Standard Lead Systems Alternative Lead Systems Electrocardiogram Filter Selection Electrocardiogram Gain Selection Electrocardiogram Pacing Mode Electrocardiogram Displays and Recordings Electrocardiogram Artifacts Electrocardiogram Monitoring for Myocardial Ischemia Automated Real-Time ST-Segment Monitoring Electrocardiogram Criteria for Acute Myocardial Ischemia Blood Pressure Monitoring Indirect Measurement of Arterial Blood Pressure Manual Intermittent Techniques Automated Intermittent Techniques Complications of Noninvasive Blood Pressure Measurement Automated Continuous Techniques Direct Measurement of Arterial Blood Pressure Percutaneous Radial Artery Cannulation Alternative Arterial Pressure Monitoring Sites Complications of Direct Arterial Pressure Monitoring Technical Aspects of Direct Blood Pressure Measurement Natural Frequency, Damping Coefficient, and Dynamic Response of Pressure Monitoring Systems Pressure Monitoring System Components Transducer Setup: Zeroing and Leveling Normal Arterial Pressure Waveforms Arterial Blood Pressure Gradients Abnormal Arterial Pressure Waveforms Arterial Pressure Monitoring and Waveform Analysis for Prediction of Volume Responsiveness Central Venous Pressure Monitoring Central Venous Cannulation Choosing the Catheter, Site, and Method for Central Venous Cannulation Complications of Central Venous Pressure Monitoring Mechanical Complications of Central Venous Catheterization Thromboembolic Complications of Central Venous Catheterization Infectious Complications of Central Venous Catheterization Other Complications of Central Venous Catheterization Physiologic Considerations for Central Venous Pressure Monitoring Central Venous Pressure and Venous Return Central Venous Pressure and Cardiac Function Normal Central Venous Pressure Waveforms Abnormal Central Venous Pressure Waveforms Pulmonary Artery Catheter Monitoring Pulmonary Artery Catheter Insertion Complications of Pulmonary Artery Catheter Monitoring Normal Pulmonary Artery Pressures and Waveforms Abnormal Pulmonary Artery and Wedge Pressure Waveforms Physiologic Considerations for Pulmonary Artery Catheter Monitoring: Prediction of Left Ventricular Preload Pulmonary Artery Catheter-Derived Hemodynamic Variables Pulmonary Artery Catheterization: Indications and Outcome Controversy Special Types of Pulmonary Artery Catheters Mixed Venous Oximetry Pulmonary Artery Catheter Right Ventricular Ejection Fraction Pulmonary Artery Catheter Cardiac Output Monitoring Thermodilution Cardiac Output Monitoring Sources of Error in Thermodilution Cardiac Output Monitoring Continuous Thermodilution Cardiac Output Monitoring Transpulmonary Thermodilution Cardiac Output Lithium Dilution Cardiac Output Monitoring Other Methods For Monitoring Cardiac Output and Perfusion Esophageal Doppler Cardiac Output Monitoring Bioimpedance and Bioreactance Cardiac Output Monitoring Partial CO2 Rebreathing Cardiac Output Monitoring Pulse Contour Cardiac Output Monitoring Acknowledgment References 37 37 - Perioperative Echocardiography Introduction History of Perioperative Echocardiography Intraoperative Transesophageal Echocardiography Critical Care Echocardiography Principles of Ultrasound Ultrasound Modalities Strain and Strain-Rate Imaging Harmonic Imaging Contrast Echocardiography Three-Dimensional Image Acquisition Imaging Modes Two-Dimensional Multiplane Acquisition Real-Time Three-Dimensional Imaging Gated Acquisition Color Flow Doppler Quantitative Analysis Multiplanar Reformatting Advanced Applications Indications and Practice Guidelines Perioperative Transesophageal Echocardiography Critical Care Transesophageal Echocardiography Examination CONTRAINDICATIONS AND COMPLICATIONS Transesophageal Echocardiography Image Acquisition Probe Manipulation and Imaging Planes Basic Examination Comprehensive Examination Epicardial and Epiaortic Imaging Transthoracic Echocardiography Examination Transthoracic Echocardiography Image Acquisition Focused Cardiac Ultrasound Versus Limited Examination Comprehensive Examination Qualitative Assessment Ventricular Size and Function Left Ventricle Right Ventricle Valvular Function Quantitative Assessment Ventricular Size and Function Left Ventricle Right Ventricle Diastolic Function Valvular Function Stenosis Regurgitation Hemodynamic Measurements Cardiac Output Continuity Principle Bernoulli Equation Intracardiac Pressure Estimates Hemodynamic Failure and Shock Ventricular Dysfunction Severe Hypovolemia Left Ventricular Outflow Tract Obstruction Cardiac Tamponade Pulmonary Embolism Intraoperative Transesophageal Echocardiography - Noncardiac Surgery Monitoring Role Myocardial Ischemia Liver Transplantation Lung Transplantation Vascular Surgery/Endovascular Procedures Rescue Role Intraoperative Transesophageal Echocardiography - Cardiac Surgery Mitral Valve Repair Tricuspid Valve Repair Aortic Dissection Mechanical Circulatory Support (MCS) Durable Mechanical Circulatory Support Temporary Mechanical Circulatory Support Congenital Heart Surgery Other Surgical Procedures Intraprocedural Transesophageal Echocardiography- Structural Heart Interventions Transcatheter Aortic Valve Replacement Valve Sizing Intraprocedural Examination Transesophageal Echocardiography Versus Transthoracic Echocardiography Transcatheter Mitral Valve Repair Other Percutaneous Structural Heart Procedures Emerging Technologies Fusion Imaging Three-Dimensional Printing Artificial Intelligence/Machine Learning Perioperative Transthoracic Echocardiography and Focused Cardiac Ultrasound Critical Care Fluid Responsiveness Post-Cardiac Surgery Trauma and Resuscitation Other Clinical Applications Handheld Cardiac Ultrasound Miniature Tee Probes Training and Certification Knowledge Expectations and Training Certification Future Directions Acknowledgment References 38 38 - Implantable Cardiac Pulse Generators: Pacemakers and Cardioverter-Defibrillators Basic Cardiac Implantable Electronic Device Function Pacemakers Implantable Cardioverter-Defibrillators Cardiac Resynchronization Therapy Devices Perioperative Considerations Preoperative Assessment Preoperative Information Transfer Electromagnetic Interference Magnets Electromagnetic Interference Damage to the Cardiac Implantable Electronic Device Intraoperative Management Postoperative Management Emergency Protocol Specific Surgical Procedures Cardioversion Radiofrequency Ablation Lithotripsy Radiation Electroconvulsive Therapy Endoscopy Emerging Technologies Conclusions Acknowledgment References 39 39 - Neurologic Monitoring Monitoring Modalities Monitors of Adequacy of Nervous System Blood Flow Global Blood Flow Monitoring Techniques (Noninvasive) Tissue-Level Blood Flow Monitoring Techniques (Invasive) Tissue Partial Pressure of Oxygen Monitoring Monitors of Nervous System Function Electroencephalogram Evoked Potentials Reactions to Intraoperative Changes in Monitored Responses Clinical Applications of Neurologic Monitoring Neurovascular Surgery (Also See Chapters 56 And 57) Extracranial Neurovascular Surgery: Carotid Vascular Surgery (Monitors: Electroencephalogram, Somatosensory-Evoked Potentials, T... Intracranial Neurovascular Surgery (Monitors: Somatosensory-Evoked Potentials, Motor-Evoked Potentials) Supratentorial Intracranial Nonvascular Surgery (Monitors: Awake Patient, Electroencephalogram, Somatosensory-Evoked Potentials)... Seizure Focus Localization Surgery Motor Strip Localization Posterior Fossa Surgery (Monitors: Brainstem Auditory-Evoked Potentials, Cranial Nerve Monitoring, Somatosenory-Evoked Potential... Microvascular Decompression of Cranial Nerves V, VII, and IX Vestibular Nerve Schwannoma Other Posterior Fossa Neoplasms Spinal Column and Spinal Cord Surgery (Monitors: Somatosensory-Evoked Potentials, Motor-Evoked Potentials, Electromyogram, And B... Peripheral Nerve Surgery (Monitors: Electromyogram, Nerve Action Potential) Applications of Intraoperative Monitoring to Pediatric Patients Cardiopulmonary Bypass Intensive Care Applications of Neurologic Monitoring (Monitors: Electroencephalogram, Evoked Potentials, Transcranial Doppler, J... Continuous Electroencephalogram Monitoring Cerebral Ischemia Prognosis in Coma and Determination of Brain Death Nonsurgical Factors Influencing Monitoring Results Anesthesia and The Electroencephalogram Intravenous Anesthetic Drugs Inhaled Anesthetics Anesthesia and Sensory-Evoked Responses Volatile Anesthetics Intravenous Anesthetics Anesthesia and Motor-Evoked Potentials Pathophysiologic Effects on the Electroencephalogram Hypoxia Hypotension Hypothermia Hypercarbia and Hypocarbia Untoward Events Physiologic Factors Influencing Sensory-Evoked Responses Summary References References 40 40 - Monitoring the State of the Brain and Central Nervous System During General Anesthesia and Sedation Induction of General Anesthesia Physiologic Signs of Loss of Consciousness Electroencephalogram-Markers of Loss of Consciousness Maintenance of General Anesthesia: Physiologic Signs and the Nociceptive-Medullary-Autonomic Pathway Maintenance of General Anesthesia: Electroencephalogram-Based Indices of Level of Consciousness Bispectral Index Patient Safety Index Narcotrend Entropy End-Tidal Anesthetic CONCENTRATION Other Strategies for Monitoring Level of Consciousness Emergence From General Anesthesia Electroencephalogram-Based Indices and Return of Consciousness Physiologic Signs and Return of Consciousness Emerging Strategies for Monitoring the Brain States of General Anesthesia and Sedation Unprocessed Electroencephalogram and the Spectrogram Changes in Electroencephalogram Signatures with Aging Implications for Monitoring Anesthetic State Normalized Symbolic Transfer Entropy Closed-Loop Anesthetic Delivery Systems Monitoring Antinociception References References 41 41 - Respiratory Monitoring Overview of Respiratory Monitoring AMERICAN SOCIETY OF ANESTHESIOLOGISTS STANDARDS The Physical Examination Pulse Oximetry PHYSIOLOGIC FUNDAMENTALS MEASUREMENT PRINCIPLES Oximetry Pulse Oximetry LIMITATIONS AND SOURCES OF ERROR Pulse Oximeter Probes Mixed Venous Oxygen Saturation PHYSIOLOGIC FUNDAMENTALS MEASUREMENT PRINCIPLES APPLICATIONS AND INTERPRETATION Tissue Oxygenation CLINICAL APPLICATIONS Capnometry and Capnography GENERAL CONCEPTS MEASUREMENT PRINCIPLES TIME CAPNOGRAM VOLUME CAPNOGRAM Blood Gas Analysis PHYSIOLOGIC FUNDAMENTALS MEASUREMENT PRINCIPLES Effect of Temperature LIMITATIONS AND SOURCES OF ERRORS Monitoring Lung Flows, Volumes, and Pressures DYNAMIC RESPIRATORY MECHANICS STATIC RESPIRATORY MECHANICS WORK OF BREATHING AND MECHANICAL POWER MONITORING OF RESPIRATORY PRESSURES MONITORING OF RESPIRATORY FLOWS MONITORING OF RESPIRATORY VOLUME Plethysmographic Monitoring Respiratory Rate Monitoring: Apnea Monitoring Imaging for Respiratory Monitoring CHEST RADIOGRAPHY ULTRASONOGRAPHY ELECTRICAL IMPEDANCE TOMOGRAPHY Point of Care Tests Respiratory Monitoring in Special Conditions HIGH-FREQUENCY VENTILATION JET VENTILATION PATIENT TRANSPORT Automated Data Systems Additional Monitored Variables NITROGEN WASHOUT AND END-EXPIRATORY LUNG VOLUME TRANSCUTANEOUS MEASUREMENTS OF PARTIAL PRESSURES OF OXYGEN AND CARBON DIOXIDE LUNG WATER Imaging Techniques Indicator Dilution Methods References References 42 42 - Renal Pathophysiology and Treatment for Perioperative Ischemia and Nephrotoxic Injury Introduction and Acute Kidney Injury Definitions Pathophysiologic Processes of Ischemic Acute Kidney Injury RENAL RESPONSE TO HYPOPERFUSION: AUTOREGULATION AND DISTRIBUTION OF CARDIAC OUTPUT TO THE KIDNEYS Detection of Acute Kidney Injury LABORATORY TESTS OF SERUM AND URINE AS MARKERS OF RENAL FUNCTION NOVEL (EARLY) BIOMARKERS OF ACUTE KIDNEY INJURY New Filtration-Based Markers of Renal Dysfunction Biomarkers Reflecting Renal Tubular Cell Damage (Tubular Enzymuria) Biomarkers Reflecting Renal Tubular Cell Dysfunction (Tubular Proteinuria) Biomarkers Reflecting Renal Tubular Cell Response to Stress Preoperative Evaluation of Renal Function and Risk Stratification Perioperative Acute Kidney Injury: Mechanisms and Treatment REGIONAL ANESTHESIA EFFECTS OF INHALED ANESTHETICS EFFECTS OF INTRAVENOUS ANESTHETICS SPECIFIC PERIOPERATIVE PERTURBATIONS AND RENAL FUNCTION INTRAOPERATIVE MANAGEMENT FOR AKI PREVENTION: OXYGEN DELIVERY: BLOOD GAS, ACID-BASE BALANCE, AND HEMATOCRIT Perioperative Blood Pressure and Fluid Management EXCESSIVE INTRAVASCULAR VOLUME AND THE ABDOMINAL COMPARTMENT SYNDROME Nephrotoxins and Acute Kidney Injury Renal Replacement Therapy Summary Acknowledgment References References 43 43 - Neuromuscular Monitoring Principles of Peripheral Nerve Stimulation SUPRAMAXIMAL STIMULATION CALIBRATION IMPEDANCE SAFETY MARGIN Types of Peripheral Nerve Stimulation Basic Considerations STIMULATING ELECTRODES Sites of Nerve Stimulation and Different Muscle Responses NERVE-MUSCLE UNIT Patterns of Nerve Stimulation SINGLE-TWITCH STIMULATION TRAIN-OF-FOUR STIMULATION DOUBLE-BURST STIMULATION TETANIC STIMULATION POSTTETANIC COUNT STIMULATION Equipment Peripheral Nerve Stimulator Objective Monitors MECHANOMYOGRAPHY ELECTROMYOGRAPHY ACCELEROMYOGRAPHY KINEMYOGRAPHY CUFF PRESSURE MODALITY (CPM) COMPRESSOMYOGRAPHY PHONOMYOGRAPHY Evaluation of Recorded Evoked Responses NONDEPOLARIZING NEUROMUSCULAR BLOCK Intense Neuromuscular Block Deep Neuromuscular Block Moderate Neuromuscular Block Recovery from Neuromuscular Block DEPOLARIZING NEUROMUSCULAR BLOCK (PHASE I AND II BLOCKS) Use of Nerve Stimulators in Daily Clinical Practice PREPARATIONS BEFORE INDUCTION OF ANESTHESIA AND ADMINISTRATION OF THE NEUROMUSCULAR BLOCKING AGENT USE OF A NERVE STIMULATOR DURING INDUCTION OF ANESTHESIA USE OF A NERVE STIMULATOR DURING SURGERY USE OF A NERVE STIMULATOR DURING REVERSAL OF NEUROMUSCULAR BLOCK When to Use a Peripheral Nerve Stimulator Acknowledgment References References 44 44 - Airway Management in the Adult Introduction ALGORITHMS FOR MANAGEMENT OF THE DIFFICULT AIRWAY The American Society of Anesthesiologists Algorithm Other Difficult Airway Algorithms Human Factors and Cognitive Aids Functional Airway Anatomy NASAL CAVITY ORAL CAVITY PHARYNX LARYNX TRACHEA AND BRONCHI Airway Assessment TRADITIONAL METRICS NEW MODALITIES Physiologic Concepts for Airway Management PREOXYGENATION APNEIC OXYGENATION PULMONARY ASPIRATION OF GASTRIC CONTENTS AIRWAY REFLEXES AND THE PHYSIOLOGIC RESPONSE TO INTUBATION OF THE TRACHEA Anesthesia for Airway Management AIRWAY MANAGEMENT AFTER THE INDUCTION OF GENERAL ANESTHESIA Standard Intravenous Induction with Neuromuscular Blockade Rapid-Sequence Induction and Intubation Inhalational Induction of Anesthesia Intravenous Induction Without Neuromuscular Blocking Drugs AIRWAY MANAGEMENT IN AN AWAKE (NON-ANESTHETIZED) PATIENT Mask Ventilation Supraglottic Airways LARYNGEAL MASK AIRWAY LMA Classic LMA ProSeal LMA Supreme NEWER LMA MODELS OTHER PERILARYNGEAL SEALERS CUFFLESS ANATOMICALLY PRESHAPED SEALERS CUFFED PHARYNGEAL SEALERS Tracheal Intubation ENDOTRACHEAL TUBES ENDOTRACHEAL TUBE INTRODUCERS OROTRACHEAL VERSUS NASOTRACHEAL INTUBATION DIRECT LARYNGOSCOPY Preparation and Positioning Technique Nasotracheal Intubation Technique Confirmation of Endotracheal Tube Placement Securing the Endotracheal Tube INDIRECT LARYNGOSCOPY Flexible Intubation Scopes Rigid Indirect Laryngoscopes Lighted Optical Stylets Video Laryngoscopes Lighted Stylets RETROGRADE INTUBATION DOUBLE-LUMEN TUBES AND BRONCHIAL BLOCKERS COMBINATION TECHNIQUES Tracheal Intubation Through a Supraglottic Airway Device Combined Direct Laryngoscopy Techniques Combined Video-Assisted Laryngoscopy Techniques Combined Retrograde Intubation Techniques Emergency Front of Neck Access TRANSTRACHEAL JET VENTILATION CRICOTHYROTOMY Extubation of the Trachea GENERAL CONSIDERATIONS FOR EXTUBATION OF THE TRACHEA EXTUBATION AND REINTUBATION OF THE DIFFICULT AIRWAY Dissemination of Critical Airway Information Summary References References 45 45 - Spinal, Epidural, and Caudal Anesthesia Principles Practice Historical Perspectives Anatomy BLOOD SUPPLY Anatomic Variations NERVE ROOTS CEREBROSPINAL FLUID EPIDURAL SPACE Mechanism of Action DRUG UPTAKE DRUG DISTRIBUTION DRUG ELIMINATION Physiologic Effects CARDIOVASCULAR Stroke Volume Heart Rate Coronary Blood Flow Treatment CENTRAL NERVOUS SYSTEM RESPIRATORY Pregnancy Obesity (also see Chapter 58) GASTROINTESTINAL RENAL Indications NEURAXIAL ANESTHESIA NEURAXIAL ANALGESIA Contraindications ABSOLUTE RELATIVE Neurologic Cardiac (also see Chapter 54) Hematologic Infection Spinal Anesthesia FACTORS AFFECTING BLOCK HEIGHT Drug Factors Patient Factors Procedure Factors DURATION PHARMACOLOGY Short- and Intermediate-Acting Local Anesthetics Long-Acting Local Anesthetics Spinal Additives Technique SPECIAL SPINAL TECHNIQUES Continuous Spinal Anesthesia Unilateral Spinal Anesthesia and Selective Spinal Anesthesia BLOCK MONITORING 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 EPIDURAL TECHNIQUE Preparation Position Projection and Puncture Paramedian Approach Combined Spinal-Epidural TECHNIQUE Caudal Anesthesia PHARMACOLOGY TECHNIQUE Complications NEUROLOGIC Paraplegia Cauda Equina Syndrome Epidural Hematoma Nerve Injury Arachnoiditis Post–Dural Puncture Headache Transient Neurologic Symptoms CARDIOVASCULAR Hypotension Bradycardia Cardiac Arrest (also see Chapter 87) RESPIRATORY INFECTION BACKACHE NAUSEA AND VOMITING URINARY RETENTION PRURITUS SHIVERING WRONG ROUTE ADMINISTRATION COMPLICATIONS UNIQUE TO EPIDURAL ANESTHESIA Intravascular Injection Subdural Injection COMPLICATIONS UNIQUE TO COMBINED SPINAL-EPIDURALS Outcomes Recent Advances ULTRASOUND Acknowledgment References References 46 46 - Peripheral Nerve Blocks and Ultrasound Guidance for Regional Anesthesia Introduction Techniques for Localizing Neural Structures PARESTHESIA TECHNIQUES PERIPHERAL NERVE STIMULATION Ultrasound Guidance FUNDAMENTAL ASSUMPTIONS AND ARTIFACTS Transducer Selection, Manipulation, and Modes of Imaging Needle Tip Visibility Approaches to Regional Block With Ultrasound REGIONAL BLOCK TECHNIQUES Cervical Plexus Blocks Clinical Applications Superficial Cervical Plexus Brachial Plexus Blocks BRACHIAL PLEXUS ANATOMY Interscalene Blocks Ultrasound-Guided Technique Side Effects and Complications Ultrasound-Guided Technique Side Effects and Complications Indications Ultrasound-Guided Technique Shoulder Block (Suprascapular Nerve Plus Axillary [Circumflex] Nerve Block)42 Side Effects and Complications INFRACLAVICULAR BLOCKS AXILLARY BLOCKS Trunk Blocks INTERCOSTAL NERVE BLOCKS Clinical Applications Intercostal Block Technique Alternative Techniques Side Effects and Complications TRANSVERSUS ABDOMINIS PLANE BLOCKS ILIOINGUINAL AND ILIOHYPOGASTRIC NERVE BLOCKS Indications Side Effects and Complications Lower Extremity Blocks LOWER EXTREMITY ANATOMY FEMORAL NERVE BLOCKS Fascia Iliaca (Modified Femoral Nerve) Blocks SAPHENOUS NERVE BLOCKS ABOVE THE KNEE (INCLUDING ADDUCTOR CANAL BLOCK) Indications Anatomy Technique Side Effects and Complications SAPHENOUS NERVE BLOCKS BELOW THE KNEE Indications Anatomy Technique Side Effects and Complications SCIATIC NERVE BLOCKS IN THE POPLITEAL FOSSA ALTERNATIVE APPROACHES TO SCIATIC NERVE BLOCK NERVE BLOCKS AT THE ANKLE Tibial Nerve Technique Side Effects and Complications INTRAVENOUS REGIONAL ANESTHESIA (OR BIER BLOCK) Introduction and Clinical Applications Technique (Upper Extremity) Prerequisites Extremity Exsanguination and Tourniquet Inflation Tourniquet Deflation Comments Complications Continuous Catheter Techniques TESTING THE CATHETER SECURING THE CATHETER Choice of Local Anesthetic Complications and Safety Training Summary and Conclusions Acknowledgments References References 47 47 - Perioperative Fluid and Electrolyte Therapy Physiology FLUID COMPARTMENTS PHYSICOCHEMICAL LAWS GOVERNING FLUID AND ELECTROLYTE MOVEMENT Diffusion Osmosis Osmolality Tonicity Oncotic Pressure FLUID COMPARTMENT BARRIERS AND DISTRIBUTION Cell Membrane Carrier Proteins Vascular Endothelium PHYSIOLOGIC CONTROL OF OVERALL FLUID BALANCE Acute Disturbances in Circulating Volume Long-Term Control of Circulating Intravascular Volume ELECTROLYTE PHYSIOLOGY Sodium Physiology Potassium Physiology Calcium Physiology Magnesium Physiology Phosphate Physiology Chloride Physiology ACID-BASE DISTURBANCES AND FLUID THERAPY Hyperchloremic Acidosis Bicarbonate Administration Fluid Pharmacology CRYSTALLOIDS Saline Solutions Balanced Crystalloid Solutions Dextrose Solutions COLLOIDS Semisynthetic Colloids Human Plasma Derivatives Clinical Fluid and Electrolyte Management PATHOPHYSIOLOGIC FLUID ALTERATIONS IN THE PERIOPERATIVE PHASE Preoperative Intraoperative Postoperative ASSESSMENT AND TREATMENT OF PERIOPERATIVE FLUID AND ELECTROLYTE IMBALANCE Intravascular Volume Electrolyte Imbalance Sodium Disorders Calcium Disorders Magnesium Disorders Phosphate Disorders PRACTICAL MANAGEMENT OF PERIOPERATIVE FLUID THERAPY Quantity of Fluid Appropriate Fluid Selection Saline-Based or Balanced Solutions Special Considerations Patient Factors Surgical Factors References References 48 48 - Perioperative Acid-Base Balance Introduction—Why Is Acid-Base Balance Important? What Are Acids and Bases? What Determines the Acidity or Alkalinity of a Solution? STRONG IONS WEAK ACID “BUFFER” SOLUTIONS CARBON DIOXIDE FACTORS INDEPENDENTLY INFLUENCING WATER DISSOCIATION Acid-Base Abnormalities RESPIRATORY ACID-BASE ABNORMALITIES Respiratory Alkalosis Respiratory Acidosis METABOLIC ACID-BASE DISTURBANCES Regulation of Acid-Base Balance Analytic Tools Used in Acid-Base Chemistry THE DESCRIPTIVE (CO2-BICARBONATE [BOSTON]) APPROACH ANION GAP APPROACH THE SEMI-QUANTITATIVE (BASE DEFICIT/EXCESS [COPENHAGEN]) APPROACH STEWART APPROACH Acid-Base Problems in Perioperative and Critical Care Medicine RESPIRATORY ACIDOSIS AND ALKALOSIS Metabolic Acidosis and Alkalosis METABOLIC ACIDOSIS LACTIC ACIDOSIS Ketoacidosis Renal Acidosis Hyperchloremic Acidosis Perioperative Metabolic Alkalosis ACID-BASE DISTURBANCES IN CRITICAL ILLNESS TREATING ACID-BASE DISTURBANCES Summary Acknowledgment References References 49 49 - Patient Blood Management: Transfusion Therapy Evolution and Recent History of Blood Transfusion Therapy THE 1960S THE 1970S THROUGH THE 1980S 1990S THROUGH THE 2000S 2010 TO THE PRESENT Blood Procurement SOURCE OF DONORS TRANSFUSION-TRANSMISSIBLE INFECTIONS Posttransfusion Hepatitis Cytomegalovirus Zika Virus Other Transfusion-Associated Infectious Diseases BIOCHEMICAL CHANGES IN STORED BLOOD CHANGES IN OXYGEN TRANSPORT CLINICAL IMPLICATIONS: DURATION OF BLOOD STORAGE Blood Component Therapy: Indications for Transfusion ALLOGENEIC (HOMOLOGOUS) BLOOD ADDITIONAL BLOOD TRANSFUSIONS Measurement of Blood Loss Determination of Hemoglobin Concentration Preoperative Anemia Liberal Versus Restrictive Transfusion Strategy General Conclusions PLATELET CONCENTRATES FRESH FROZEN PLASMA CRYOPRECIPITATE MASSIVE TRANSFUSION AND TRANSFUSION RATIOS Synthetic Oxygen-Carrying Substances HB-BASED OXYGEN CARRIERS Autologous Blood PREOPERATIVE AUTOLOGOUS DONATION ACUTE NORMOVOLEMIC HEMODILUTION INTRAOPERATIVE CELL SALVAGE Clinical Studies POSTOPERATIVE CELL SALVAGE Compatibility Testing GENERAL PRINCIPLES ABO-RH TYPING ANTIBODY SCREENING CROSSMATCHING ELECTRONIC CROSSMATCH Maximal Surgical Blood Order Schedule Emergency Transfusion TYPE-SPECIFIC, PARTIALLY CROSSMATCHED BLOOD TYPE-SPECIFIC, UNCROSSMATCHED BLOOD TYPE O RH-NEGATIVE (UNIVERSAL DONOR), UNCROSSMATCHED BLOOD Fresh Whole Blood Complications COAGULATION ABNORMALITIES THROMBOCYTOPENIA LOW LEVELS OF FIBRINOGEN AND FACTORS V AND VIII DISSEMINATED INTRAVASCULAR COAGULATION–LIKE SYNDROME DIAGNOSIS AND TREATMENT OF A HEMORRHAGIC DIATHESIS AFTER BLOOD TRANSFUSIONS Citrate Intoxication and Hyperkalemia Temperature Acid-Base Abnormalities Transfusion Reactions HEMOLYTIC TRANSFUSION REACTION Signs and Symptoms Treatment DELAYED HEMOLYTIC TRANSFUSION REACTION (IMMUNE EXTRAVASCULAR REACTION) TRANSFUSION-RELATED ACUTE LUNG INJURY TRANSFUSION ASSOCIATED CIRCULATORY OVERLOAD NONHEMOLYTIC TRANSFUSION REACTIONS OTHER ADVERSE EFFECTS OF BLOOD TRANSFUSION Transfusion-Associated Graft-Versus-Host Disease Transfusion-Related Immunomodulation OTHER NONINFECTIOUS RISKS OF BLOOD TRANSFUSIONS Leukoreduction and Irradiation of Blood Transfusions GENERAL CONSIDERATIONS IRRADIATED BLOOD PRODUCTS Informed Consent Acknowledgment References References 50 50 - Patient Blood Management: Coagulation Introduction Normal Hemostasis VASCULAR ENDOTHELIAL ROLE IN HEMOSTASIS PLATELETS AND HEMOSTASIS PLASMA-MEDIATED HEMOSTASIS Extrinsic Pathway of Coagulation Intrinsic Pathway of Coagulation Common Pathway of Coagulation Intrinsic Anticoagulant Mechanisms Disorders of Hemostasis EVALUATION OF BLEEDING DISORDERS INHERITED BLEEDING DISORDERS Von Willebrand Disease Hemophilias ACQUIRED BLEEDING DISORDERS Drug Induced Liver Disease Renal Disease Disseminated Intravascular Coagulation CARDIOPULMONARY BYPASS-ASSOCIATED COAGULOPATHY TRAUMA-INDUCED COAGULOPATHY PROTHROMBOTIC STATES INHERITED THROMBOTIC DISORDERS ACQUIRED THROMBOTIC DISORDERS Antiphospholipid Syndrome HEPARIN-INDUCED THROMBOCYTOPENIA MONITORING COAGULATION COMMON LABORATORY-BASED MEASURES OF COAGULATION Prothrombin Time Activated Partial Thromboplastin Time Anti-Factor Xa Activity Platelet Count and Bleeding Time COMMON POINT-OF-CARE MEASURES OF COAGULATION Activated Clotting Time Heparin Concentration Measurement Viscoelastic Measures of Coagulation Platelet Function Monitors Antithrombotics, Thrombolytics, and Procoagulant Drugs ANTIPLATELET AGENTS Cyclooxygenase Inhibitors Aspirin NONSTEROIDAL ANTIINFLAMMATORY DRUGS P2Y12 RECEPTOR ANTAGONISTS GLYCOPROTEIN IIB/IIIA INHIBITORS ANTICOAGULANTS Vitamin K Antagonists Unfractionated Heparin Low Molecular Weight Heparin and Fondaparinux Direct Thrombin Inhibitors Direct Oral Anticoagulants THROMBOLYTICS PROCOAGULANT DRUGS Antifibrinolytics Factor Replacements Perioperative Management of Anticoagulation VITAMIN K ANTAGONISTS HEPARINS ASPIRIN NEURAXIAL ANESTHESIA AND ANTICOAGULATION Emergent Reversal of Anticoagulants VITAMIN K ANTAGONISTS DIRECT THROMBIN INHIBITORS EMERGING AGENTS Conclusion Acknowledgment References References 51 51 - MANAGEMENT OF THE PATIENT WITH CHRONIC PAIN Introduction PHYSIOLOGICAL CHANGES IN PERSISTENT PAIN Excitatory Mechanisms Inhibitory Mechanisms Translation of Basic Research CLINICAL DEFINITIONS, PREVALENCE, AND CLASSIFICATION OF CHRONIC PAIN Definitions Prevalence Classification Biopsychosocial Concept of Chronic Pain INTERDISCIPLINARY MANAGEMENT OF CHRONIC PAIN Psychology Physical Therapy Occupational Therapy Anesthesiology Drugs Used for Chronic Pain OPIOIDS NONSTEROIDAL ANTIINFLAMMATORY DRUGS AND ANTIPYRETIC ANALGESICS SEROTONERGIC DRUGS ANTIEPILEPTIC DRUGS ANTIDEPRESSANTS TOPICAL ANALGESICS OTHER ANALGESICS AND ADJUVANTS DEVELOPMENT OF NOVEL ANALGESICS Interventional Methods used for Chronic Pain DIAGNOSTIC NERVE BLOCKS THERAPEUTIC NERVE BLOCKS Cancer Pain Non-Cancer-Associated Pain CONTINUOUS CATHETER TECHNIQUES Cancer Pain Non-Cancer-Associated Pain STIMULATION TECHNIQUES Perioperative Management of Patients with Chronic Pain CHARACTERISTICS OF CHRONIC PAIN PATIENTS IN THE PERIOPERATIVE PERIOD CHRONIC USE OF ANALGESICS AND ADJUVANT DRUGS DEPENDENCE, ADDICTION, AND PSEUDOADDICTION MANAGEMENT AND PRACTICAL RECOMMENDATIONS Preoperative Evaluation (also see Chapter 31) Perioperative Management Postoperative Regional Anesthesia Postoperative Intravenous Opioids Perioperative Transdermal Opioids Acknowledgment References References 52 52 - Palliative Medicine What Is Palliative Medicine? DEFINITION PRIMARY VERSUS SPECIALIST PALLIATIVE MEDICINE HISTORY OF PALLIATIVE MEDICINE WHY IS PALLIATIVE MEDICINE NEEDED? WHY IS PALLIATIVE MEDICINE IMPORTANT TO ANESTHESIOLOGISTS? GLOBAL PALLIATIVE CARE PALLIATIVE CARE TEAM Where Is Palliative Care Delivered? INPATIENT PALLIATIVE CARE TEAMS Outcomes With Palliative Care Teams When to Consult Palliative Care Teams Palliative Care in the Surgical Intensive Care Unit Trigger Criteria in the Surgical Intensive Care Unit OUTPATIENT PALLIATIVE CARE Differences Between Hospice Care and Palliative Care HOSPICE CARE IN THE UNITED STATES Who Is Eligible for Hospice Care? Recipients of Hospice Care Outcomes of Hospice Care PALLIATIVE CARE AND ANESTHESIOLOGISTS Surgery in Seriously Ill Patients Communicating Surgery Risk in Seriously Ill Patients Anesthetic Concerns in the Patient Receiving Palliative Care PREOPERATIVE CONSIDERATIONS INTRAOPERATIVE CONCERNS ANESTHETIC CHOICE AND CANCER POSTOPERATIVE COURSE Communication ADVANCE CARE PLANNING OUTCOMES OF ADVANCE CARE PLANNING PHYSICIAN COMMUNICATION SKILLS TRAINING PHYSICIAN COMMUNICATION SKILLS The Surgical “Contract” WHAT DO FAMILIES CONSIDER IMPORTANT IN END-OF-LIFE COMMUNICATION? SPIRITUALITY AT THE END OF LIFE COMMUNICATION FRAMEWORKS Family Meetings Breaking Bad News Responding to Emotion Requests for Nondisclosure Time-Limited Trials RESUSCITATION STATUS Outcomes of Cardiopulmonary Resuscitation Resuscitation Status Discussions Perioperative Limitations on Treatment Prognosis DISEASE TRAJECTORIES PROGNOSTIC TOOLS Congestive Heart Failure Dementia Chronic Obstructive Pulmonary Disease Liver Disease Renal Disease SYMPTOM MANAGEMENT Alternative Routes of Drug Delivery Pain Bone Pain Neuropathic Pain Pain in the Intensive Care Unit OPIOID USE Interventional Pain Management at the End of Life NAUSEA AND VOMITING Nausea and Vomiting Related to Chemotherapy and Radiation Therapy BOWEL OBSTRUCTION ARTIFICIAL HYDRATION AND NUTRITION DYSPNEA DEPRESSION AND ANXIETY IN THE PATIENT RECEIVING PALLIATIVE CARE DELIRIUM AT THE END OF LIFE BLEEDING IN THE PATIENT RECEIVING PALLIATIVE CARE The Dying Process WITHDRAWAL OF LIFE SUPPORT Outcomes of Withdrawal of Life Support Paralytic Drugs in the Withdrawal of Life Support PEDIATRIC HOSPICE CARE AND PALLIATIVE CARE Characteristics of the Pediatric Palliative Care Population Symptom Management in Pediatric Palliative Care References References 53 53 - Anesthesia for Thoracic Surgery Introduction PREOPERATIVE EVALUATION OF THE THORACIC SURGERY PATIENT (SEE CHAPTER 31) PERIOPERATIVE COMPLICATIONS ASSESSMENT OF RESPIRATORY FUNCTION RESPIRATORY MECHANICS Lung Parenchymal Function Cardiopulmonary Interaction Ventilation Perfusion Scintigraphy Combination of Tests Concomitant Medical Conditions CARDIAC DISEASE Ischemia Arrhythmia Congestive Heart Failure Pulmonary Hypertension AGE RENAL DYSFUNCTION CHRONIC OBSTRUCTIVE PULMONARY DISEASE Respiratory Drive Nocturnal Hypoxemia Right Ventricular Dysfunction Bullae Flow limitation Auto-Positive End-Expiratory Pressure PREOPERATIVE THERAPY OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE PHYSIOTHERAPY PRIMARY THORACIC TUMORS Non–Small-Cell Lung Cancer Squamous Cell Carcinoma Adenocarcinoma Large-Cell Undifferentiated Carcinoma Small-Cell Lung Cancer Carcinoid Tumors Pleural Tumors ASSESSMENT OF THE PATIENT WITH LUNG CANCER POSTOPERATIVE ANALGESIA PREMEDICATION SUMMARY OF THE INITIAL PREOPERATIVE ASSESSMENT FINAL PREOPERATIVE ASSESSMENT Difficult Endobronchial Intubation Prediction of Desaturation During One-Lung Ventilation Assessment for Repeat Thoracic Surgery Intraoperative Monitoring OXYGENATION CAPNOMETRY Invasive Hemodynamic Monitoring ARTERIAL LINE CENTRAL VENOUS PRESSURES PULMONARY ARTERY CATHETERS FIBEROPTIC BRONCHOSCOPY CONTINUOUS SPIROMETRY TRANSESOPHAGEAL ECHOCARDIOGRAPHY Other Monitoring Technology Indirect Cardiac Output Lung Isolation DOUBLE-LUMEN ENDOTRACHEAL TUBES Size Selection Methods of Insertion RIGHT-SIDED DOUBLE-LUMEN ENDOBRONCHIAL TUBES Positioning of Double-Lumen Tubes Problems Related to Double-Lumen Tubes BRONCHIAL BLOCKERS Wire-Guided Endobronchial Blocker (Arndt Blocker) Cohen Endobronchial Blocker Fuji Uniblocker EZ-Blocker Complications Related to the Bronchial Blockers Difficult Airways and One-Lung Ventilation Lung-Isolation Techniques in Patients With a Tracheostomy in Place POSITIONING Position Change Neurovascular Complications Physiologic Changes in the Lateral Position . Significant changes in ventilation develop between the lungs when the patient is placed in the lateral position.130 The compli... . Gravity has some effect on distribution of pulmonary blood flow. In the lateral position, the blood flow to the dependent lung... Anesthetic Management FLUID MANAGEMENT TEMPERATURE PREVENTION OF BRONCHOSPASM CORONARY ARTERY DISEASE Management of One-Lung Ventilation HYPOXEMIA INTRAOPERATIVE POSITION Hypoxic Pulmonary Vasoconstriction CHOICE OF ANESTHETIC CARDIAC OUTPUT Ventilation Strategies During One-Lung Ventilation RESPIRATORY ACID-BASE STATUS POSITIVE END-EXPIRATORY PRESSURE TIDAL VOLUME VOLUME-CONTROL VERSUS PRESSURE-CONTROL VENTILATION Prediction of Hypoxemia During One-Lung Ventilation PREOPERATIVE VENTILATION-PERFUSION SCAN SIDE OF OPERATION TWO-LUNG OXYGENATION PREOPERATIVE SPIROMETRY Treatment of Hypoxemia During One-Lung Ventilation PHARMACOLOGIC MANIPULATIONS INTERMITTENT REINFLATION OF THE NONVENTILATED LUNG PARTIAL VENTILATION METHODS MECHANICAL RESTRICTION OF PULMONARY BLOOD FLOW HYPOXEMIA PROPHYLAXIS BILATERAL PULMONARY SURGERY Anesthetic Management for Common Surgical Procedures FLEXIBLE FIBEROPTIC BRONCHOSCOPY Anesthetic Management RIGID BRONCHOSCOPY Anesthetic Management MEDIASTINOSCOPY Anesthetic Management ENDOBRONCHIAL ULTRASOUND-GUIDED BIOPSY Pulmonary Surgery MINIMALLY INVASIVE THORACOSCOPIC SURGERY ANESTHETIC TECHNIQUE Lobectomy SLEEVE LOBECTOMY Pneumonectomy EXTRAPLEURAL PNEUMONECTOMY SLEEVE PNEUMONECTOMY Limited Pulmonary Resections: Segmentectomy and Wedge Resection Anesthetic Management for Specific Surgical Procedures ESOPHAGEAL SURGERY Esophagectomy . Transthoracic esophagectomy is commonly a two-phase procedure. The first phase involves a laparotomy performed with the patien... . Airway management is done with an SLT. Apart from this, anesthetic management is essentially the same as for a transthoracic a... . Minimally invasive esophagectomy involves the use of laparoscopic, thoracoscopic, and/or robotic surgical approaches. For a la... Esophageal Surgery for Benign Disease . Although most patients with gastroesophageal reflux have a hiatal hernia, most patients with a hiatal hernia do not have signi... . Chronic reflux of acidic gastric contents can lead to ulceration, inflammation, and eventually stricture of the esophagus. The... . There are multiple causes of esophageal perforation, including foreign bodies, endoscopy, bougienage, traumatic tracheal intub... . Achalasia is a disorder in which there is a lack of peristalsis of the esophagus and a failure of the lower esophageal sphinct... . Esophagorespiratory tract fistula in an adult is most often due to malignancy. Occasionally, the fistula is benign, and may be... . Zenker diverticulum is actually a diverticulum of the lower pharynx. It arises from a weakness at the junction of the thyropha... Anesthesia for Tracheal Resection BRONCHIECTASIS/LUNG ABSCESS/EMPYEMA Anesthetic Management BRONCHOPLEURAL FISTULA Anesthetic Management Blebs, Bullae, Cysts, and Pneumatoceles BLEBS BULLAE CYSTS PNEUMATOCELE Lung Transplantation ANESTHESIA FOR THE PATIENT AFTER LUNG TRANSPLANTATION LUNG VOLUME REDUCTION Pulmonary Hemorrhage PULMONARY ARTERY CATHETER-INDUCED HEMORRHAGE During Weaning from Cardiopulmonary Bypass Posttracheostomy Hemorrhage Pulmonary Thromboendarterectomy Bronchopulmonary Lavage Mediastinal Masses MANAGEMENT Thymectomy for Myasthenia Gravis NONINTUBATED THORACIC SURGERY EXTRACORPOREAL MEMBRANE OXYGENATION Postoperative Management ENHANCED RECOVERY AFTER SURGERY EARLY MAJOR COMPLICATIONS Respiratory Failure Cardiac Herniation Postoperative Analgesia SYSTEMIC ANALGESIA Opioids Nonsteroidal Antiinflammatory Drugs Ketamine Dexmedetomidine Intravenous Lidocaine Gabapentinoids LOCAL ANESTHETICS/NERVE BLOCKS Intercostal Nerve Blocks Epidural Analgesia Paravertebral Block Ultrasound-Guided Blocks POSTOPERATIVE PAIN MANAGEMENT PROBLEMS Shoulder Pain Postthoracotomy Neuralgia and Chronic Incisional Pain MANAGEMENT OF OPIOID TOLERANT PATIENTS References References 54 54 - Anesthesia for Cardiac Surgical Procedures Cardiovascular Disease in the 21st Century AGE, GENDER, AND RACE GENETIC INFLUENCES IN CARDIAC DISEASE Approach to Anesthesia for the Adult Cardiac Patient PREOPERATIVE EVALUATION, PREPARATION, AND MONITORING Heart and Vascular System Central Nervous System Monitoring Renal System Endocrine System Hematologic System Unique Hematologic Considerations in Cardiac Surgery INDUCTION OF ANESTHESIA AND THE PREBYPASS PERIOD Premedication Induction of Anesthesia The Pre-Cardiopulmonary Bypass Period Onset of Cardiopulmonary Bypass WEANING FROM CARDIOPULMONARY BYPASS The “CVP” Mnemonic TERMINATION OF CARDIOPULMONARY BYPASS CHEST CLOSURE TRANSPORT TO THE INTENSIVE CARE UNIT Phase 1: Equipment and Technology Handover Phase 2: Information Handover Phase 3: Questions and Discussion THE POSTBYPASS PERIOD: COMMON PROBLEMS AFTER CARDIOPULMONARY BYPASS Awareness Cardiovascular Decompensation (Low Cardiac Output Syndrome) Right Heart Failure Right Ventricular Dysfunction or Failure Vasoplegia Dysrhythmias Hypertension Renal Insufficiency Central Nervous System Dysfunction Respiratory Insufficiency Metabolic Disturbances Pain Bleeding and Coagulopathy Cardiopulmonary Bypass CIRCUITRY AND EQUIPMENT Blood Tubing Venous Reservoirs Arterial Pumps Heat Exchanger Oxygenator Arterial Line Filter SEQUENCE OF EVENTS Circuit Selection and Priming Anticoagulation Cannulation Initiation and Maintenance of Cardiopulmonary Bypass Myocardial Protection Weaning and Termination of Cardiopulmonary Bypass OTHER ISSUES Temperature Blood Gas Management Inflammatory Response to Cardiopulmonary Bypass Modification of Surgical Techniques or Perfusion Techniques Perfusion Technology Pharmacologic Strategies DEEP HYPOTHERMIC CIRCULATORY ARREST LEFT HEART BYPASS CARDIOPULMONARY SUPPORT AND EXTRACORPOREAL MEMBRANE OXYGENATION CIRCUITS Specific Cardiovascular Disease States CORONARY ARTERY DISEASE Pathophysiology of Coronary Disease On-Pump Coronary Artery Bypass Grafting Surgery Off-Pump Coronary Artery Bypass Surgery, Minimally Invasive Coronary Artery Bypass Surgery, and Hybrid Coronary Revascularizatio... CARDIAC VALVE LESIONS Mitral Valve Disease Anatomy of the Mitral Valve Mitral Stenosis Aortic Valve Disease Aortic Stenosis Aortic Regurgitation Other Valvular Disease Structural Heart Procedures HEART FAILURE Medical Management of Heart Failure Surgical Management of Heart Failure CARDIOMYOPATHIES Hypertrophic Cardiomyopathy Cardiac Transplantation CONGENITAL HEART DISEASE IN ADULTS Background and Current Perspective Preoperative Anesthetic Considerations Intraoperative Anesthetic Considerations OTHER CARDIAC PROCEDURES Surgical Ablation of Atrial Fibrillation Pericardial Tamponade and Constrictive Pericarditis Constrictive Pericarditis Cardiac and Aortic Trauma Ischemic and Other Emergencies in the Cardiac Catheterization Laboratory Procedures in the Hybrid Operating Room GENERAL CONSIDERATIONS HYBRID OPERATING ROOM Acknowledgment References References 55 55 - Anesthesia for Correction of Cardiac Arrhythmias Historical Perspectives Scope of Cardiac Arrhythmias Normal Cardiac Rhythm Cardiac Arrhythmias INDICATIONS FOR CORRECTION OF CARDIAC ARRHYTHMIAS Permanent Pacing Resynchronization Therapy PREOPERATIVE EVALUATION ANESTHETIC CONSIDERATIONS Pacemakers Monitored Anesthesia Care General Anesthesia Implantable Cardioverter-Defibrillator PREOPERATIVE EVALUATION ANESTHETIC CONSIDERATIONS Monitored Anesthesia Care General Anesthesia EXTRACTION OF DEVICES POSTOPERATIVE CARE Correction of Cardiac Arrhythmias With Ablation Therapy ANESTHETIC CONSIDERATIONS Future Trends References References 56 56 - Anesthesia for Vascular Surgery Preoperative Evaluation COEXISTING DISEASE PERIOPERATIVE AND LONG-TERM CARDIAC OUTCOMES GUIDELINE‐BASED APPROACH CARDIAC RISK ASSESSMENT Clinical Risk Indices Noninvasive Diagnostic Cardiac Testing Cardiac Catheterization and Prophylactic Revascularization ASSESSMENT OF PULMONARY FUNCTION ASSESSMENT OF RENAL FUNCTION PERIOPERATIVE Β-ADRENERGIC BLOCKER THERAPY PERIOPERATIVE STATIN THERAPY PERIOPERATIVE DUAL ANTIPLATELET THERAPY Abdominal Aortic Reconstruction NATURAL HISTORY AND SURGICAL MORTALITY Abdominal Aortic Aneurysm Aortoiliac Occlusive Disease Renal and Visceral Arterial Insufficiency AORTIC CROSS CLAMPING Hemodynamic and Metabolic Changes RENAL FUNCTION AND PROTECTION THERAPEUTIC STRATEGIES AORTIC UNCLAMPING ANESTHETIC MANAGEMENT Intraoperative Monitoring Cell Salvage Anesthetic Drugs and Techniques Temperature Control THORACOABDOMINAL AORTIC SURGERY ETIOLOGY AND CLASSIFICATION MORBIDITY AND MORTALITY PREOPERATIVE PREPARATION AND MONITORING ANESTHETIC MANAGEMENT Simple Aortic Cross Clamping Left Heart Bypass Deep Hypothermic Circulatory Arrest Anesthetic Technique Spinal Cord Ischemia and Protection Renal Ischemia and Protection Coagulation and Metabolic Management Endovascular Aortic Repair Surgery HISTORY OF ENDOVASCULAR AORTIC REPAIR ADVANCEMENTS IN STENT-GRAFT DEVICES ANESTHETIC MANAGEMENT Spinal Cord Blood Supply Anesthesia Roadmap for EVARs CHOICE OF ANESTHESIA Radiation Safety Renal Protection Vascular Access and Blood Loss Temperature Control Spinal Cord Protection POTENTIAL COMPLICATIONS Early and Late Complications Endoleaks Postimplantation Syndrome Hybrid Arch Repairs ANESTHETIC MANAGEMENT OF HYBRID ARCH REPAIRS Carotid Endarterectomy INDICATIONS PERIOPERATIVE MORBIDITY AND MORTALITY PREOPERATIVE ASSESSMENT ANESTHETIC MANAGEMENT General Anesthesia Regional and Local Anesthesia Regional Versus General Anesthesia Carbon Dioxide and Glucose Management NEUROLOGIC MONITORING AND CEREBRAL PERFUSION Carotid Artery Stump Pressure Regional Cerebral Blood Flow Electroencephalography Somatosensory Evoked Potentials Transcranial Doppler Ultrasonography Cerebral Oxygenation POSTOPERATIVE CONSIDERATIONS Endovascular Treatment of Carotid Disease: Carotid Artery Stenting Lower Extremity Revascularization PERIPHERAL ARTERY DISEASE PERIOPERATIVE MANAGEMENT OF ANTIPLATELETS AND ANTICOAGULANT IN PAD PATIENTS Single Antiplatelet Therapy in Symptomatic Peripheral Artery Disease Dual Antiplatelet Therapy in Symptomatic Peripheral Artery Disease OPEN BYPASS SURGERIES AND ANESTHESIA MANAGEMENT ENDOVASCULAR TREATMENT OF PERIPHERAL ARTERIAL DISEASE Acknowledgment References References 57 57 - Anesthesia for Neurologic Surgery and Neurointerventions Recurrent Issues in Neuroanesthesia CONTROL OF INTRACRANIAL PRESSURE AND BRAIN RELAXATION PNEUMOCEPHALUS VENOUS AIR EMBOLISM Detection of Venous Air Embolism Which Patients Should Have a Right Heart Catheter? Which Vein Should Be Used for Right Heart Access? Positioning the Right Heart Catheter Paradoxical Air Embolism Transpulmonary Passage of Air Nitrous Oxide MONITORING INTRAVENOUS FLUID MANAGEMENT Which Colloid Solutions Should Be Used? GLUCOSE MANAGEMENT HYPOTHERMIA EMERGENCE FROM ANESTHESIA SELECTION OF ANESTHETICS MANAGEMENT OF PACO2 Hypocapnia-Induced Cerebral Ischemia Duration of Hypocapnia-Induced Reduction in Cerebral Blood Flow MANAGEMENT OF ARTERIAL BLOOD PRESSURE STEROIDS OSMOTHERAPY AND DIURETICS Mannitol Hypertonic Saline Diuretic Combinations ANTICONVULSANTS POSITIONING General Considerations Supine Semilateral Lateral Prone Sitting . The properly positioned patient is more commonly in a modified recumbent position as shown in Fig. 57.8 rather than truly sitt... . Hypotension should be avoided. Prepositioning hydration, compressive stockings, and slow, incremental adjustment of table posi... . There have been sporadic reports of upper airway obstruction after posterior fossa procedures in which swelling of pharyngeal ... . The sitting position has been implicated as a cause of rare instances of unexplained postoperative quadriplegia. It has been h... Specific Procedures SUPRATENTORIAL TUMORS Preoperative Preparation Monitoring Management of Anesthesia ANEURYSMS AND ARTERIOVENOUS MALFORMATIONS Preoperative Evaluation Anesthetic Technique Monitoring Special Considerations for Specific Aneurysms Arteriovenous Malformations HEAD INJURY Intubating the Trachea of a Head-Injured Patient The Cervical Spine Anesthetic Technique Monitoring Hypothermia POSTERIOR FOSSA PROCEDURES Brainstem Stimulation Balloon Compression of the Trigeminal Ganglion TRANSSPHENOIDAL SURGERY Preoperative Evaluation Monitoring Anesthetic Technique Diabetes Insipidus AWAKE CRANIOTOMY AND SEIZURE SURGERY Presurgical Evaluation Anesthesia for Electroencephalogram Electrode Placement Preanesthetic Evaluation and Preparation Anesthetic Technique STEREOTACTIC PROCEDURES NEUROENDOSCOPIC PROCEDURES NEUROINTERVENTIONAL PROCEDURES ANESTHETIC TECHNIQUE ACUTE THROMBECTOMY Tumors and Arteriovenous Malformations Intracranial Aneurysms Stent-Assisted Revascularization or Stent-Assisted Aneurysm Coil Embolization CEREBROSPINAL FLUID SHUNTING PROCEDURES Anesthetic Management Pediatric Ventriculoperitoneal Shunts PEDIATRIC NEUROSURGERY SPINAL SURGERY References References 58 58 - Anesthesia for Bariatric Surgery Obesity as a Disease METABOLIC SYNDROME OBSTRUCTIVE SLEEP APNEA—HYPOPNEA SYNDROME Nonsurgical Management of Obesity BEHAVIORAL INTERVENTIONS AND MODIFICATION PHARMACOTHERAPY FOR WEIGHT LOSS ALTERNATIVE PHARMACOLOGIC OPTIONS IMPLANTED ELECTRICAL STIMULATORS Surgical Management of Obesity OPERATIVE PROCEDURES RESTRICTIVE PROCEDURES MALABSORPTIVE PROCEDURES MINIMALLY INVASIVE PROCEDURES HEALTH BENEFITS OF BARIATRIC SURGERY Anesthetic Management of the Bariatric Surgical Patient PREOPERATIVE EVALUATION INTRAOPERATIVE CARE Patient Positioning Airway Management Anesthetic Drugs and Dosing Induction of Anesthesia POSTOPERATIVE MANAGEMENT MANAGEMENT OF COMPLICATIONS Considerations for Management of the Obese Patient Presenting for Nonbariatric Surgery References References 59 59 - Anesthesia and the Renal and Genitourinary Systems Innervation of the Genitourinary System KIDNEY AND ABDOMINAL URETER BLADDER AND URETHRA PROSTATE AND PROSTATIC URETHRA PENIS AND SCROTUM TESTES Renal Blood Flow Anesthesia for Patients With Renal Disease EVALUATION OF RENAL FUNCTION GLOMERULAR FUNCTION Glomerular Filtration Rate Blood Urea Nitrogen Creatinine and Creatinine Clearance TUBULAR FUNCTION Concentration Protein Glucose ADDITIONAL DIAGNOSTIC TESTS Urinalysis and Appearance Urine and Serum Electrolytes With Blood Gases Imaging Studies IMPORTANT PATHOPHYSIOLOGIC MANIFESTATIONS OF CHRONIC RENAL FAILURE Hypervolemia Acidemia Hyperkalemia Cardiac and Pulmonary Manifestations Hematologic Manifestations EFFECTS OF DRUGS IN PATIENTS WITH REDUCED RENAL FUNCTION Opioids Inhaled Anesthetics Intravenous Anesthetics Muscle Relaxants and Their Antagonists Vasopressors and Antihypertensive Drugs ACUTE KIDNEY INJURY AND HEMODIALYSIS PERIOPERATIVE MANAGEMENT OF PATIENTS WITH ACUTE KIDNEY INJURY Dialysis Nondialytic Management Renal and Genitourinary Procedures TRANSURETHRAL RESECTION OF THE PROSTATE Pathophysiology of Prostate Hyperplasia Surgical Procedures Irrigation Solutions Anesthetic Considerations for Transurethral Resection of the Prostate Morbidity and Mortality After Transurethral Resection of the Prostate COMPLICATIONS OF TRANSURETHRAL RESECTION OF THE PROSTATE Absorption of Irrigating Solution Excessive Circulatory Volume, Hyponatremia, and Hypoosmolarity Glycine Toxicity Ammonia Toxicity Bladder Perforation Transient Bacteremia and Septicemia Hypothermia Bleeding and Coagulopathy Treatment of Transurethral Resection of Prostate Syndrome Laser Resection, Plasma Vaporization, Microwave Ablation, and Aquablation of the Prostate URETEROSCOPIC LITHOTRIPSY AND PERCUTANEOUS NEPHROLITHOTRIPSY EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY Biomechanical Effects of Shock Wave Therapy Anesthetic Choices for Lithotripsy Newer Generations of Lithotripters Contraindications Open Radical Surgery in Urology Radical Nephrectomy Radical Cystectomy Radical Prostatectomy Comparison of Anesthetic Techniques for Radical Prostatectomy Robotic and Laparoscopic Surgery in Urology Robotic-Assisted Radical Prostatectomy Robotic-Assisted Radical Cystectomy With Diversion LAPAROSCOPIC NEPHRECTOMY Robotic-Assisted Partial Nephrectomy Urogenital Pain Syndromes and Treatment POSTOPERATIVE PAIN AND TREATMENT Inflammatory Pain Neuropathic Pain Postoperative Urinary Retention Enhanced Recovery After Surgery CHRONIC POSTSURGICAL PAIN Perioperative Management Considerations ACUTE OR CHRONIC NONMALIGNANT PAIN Benign Renal Masses Polycystic Kidney Disease NEPHROLITHIASIS INFECTIOUS RENAL DISEASE INTERSTITIAL CYSTITIS NEURALGIAS CHRONIC PROSTATITIS PRIAPISM CHRONIC PELVIC PAIN IN WOMEN TESTICULAR PAIN MEDICATIONS NERVE BLOCKS AND NEUROMODULATION CANCER-RELATED PAIN Pediatric Tumors Renal Cell Carcinoma Bladder Cancer Prostate Cancer Uterine and Cervical Cancer Neurolysis Intrathecal Medications Acknowledgment References References 60 60 - Anesthesia for Abdominal Organ Transplantation Kidney Transplantation INDICATIONS FOR KIDNEY TRANSPLANTATION PATHOPHYSIOLOGY OF END-STAGE RENAL DISEASE ANESTHESIA FOR KIDNEY TRANSPLANTATION: PREOPERATIVE EVALUATION Day of Surgery ANESTHESIA FOR KIDNEY TRANSPLANT: INTRAOPERATIVE MANAGEMENT ANESTHESIA FOR KIDNEY TRANSPLANT: POSTOPERATIVE MANAGEMENT ORGAN MATCHING AND ALLOCATION ANESTHESIA FOR PATIENTS AFTER KIDNEY TRANSPLANTATION Pancreas Transplantation INDICATIONS FOR PANCREAS AND KIDNEY-PANCREAS TRANSPLANTATION PATHOPHYSIOLOGY OF PANCREATIC INSUFFICIENCY ANESTHESIA FOR PANCREAS TRANSPLANTATION: PREOPERATIVE EVALUATION ANESTHESIA FOR PANCREAS TRANSPLANTATION: INTRAOPERATIVE MANAGEMENT ANESTHETIC MANAGEMENT OF PANCREAS TRANSPLANTATION: POSTOPERATIVE MANAGEMENT ORGAN MATCHING AND ALLOCATION ANESTHESIA FOR PATIENTS AFTER PANCREAS TRANSPLANTATION Liver Transplantation INDICATIONS FOR LIVER TRANSPLANTATION TRENDS IN LIVER TRANSPLANTATION PATHOPHYSIOLOGY AND EVALUATION FOR LISTING Cardiovascular Complications Pulmonary Complications Renal Dysfunction Hepatic Encephalopathy Ascites Varices Hemostasis OBESITY AND SARCOPENIA SURGICAL PROCEDURE Preoperative Considerations . The allocation policy in the United States, adopted by many programs worldwide, uses MELD scores to prioritize allocation of g... Intraoperative Management Preanhepatic Stage Anhepatic Stage Neohepatic Stage Management of Transfusion, Hemostasis, and Coagulation Postoperative Care ACUTE LIVER FAILURE LIVING DONOR LIVER TRANSPLANTATION PEDIATRIC LIVER TRANSPLANTATION ORGAN MATCHING AND ALLOCATION ANESTHESIA FOR PATIENTS AFTER LIVER TRANSPLANTATION INTESTINAL, LIVER-INTESTINAL, AND MULTIVISCERAL TRANSPLANT Background Surgical Procedures Preoperative Assessment Intraoperative Management Postoperative Care Conclusion POSTABDOMINAL TRANSPLANTATION COMPLICATIONS Surgical Complications Infection Immunosuppression Malignancy Long-Term Survival Conclusions References References 61 61 - Anesthesia for Organ Procurement Introduction Management of Organ Donors After Declaration of Neurologic Death PATHOPHYSIOLOGIC CHANGES WITH NEUROLOGIC DEATH CARDIOVASCULAR RESPONSES TO NEUROLOGIC DEATH RESPIRATORY RESPONSES TO NEUROLOGIC DEATH ENDOCRINE, METABOLIC, AND STRESS RESPONSES TO NEUROLOGIC DEATH Donation After Circulatory (Cardiac) Death Extended Criteria Donor Management of Organ Donors Before Procurement CARDIOVASCULAR MANAGEMENT PULMONARY MANAGEMENT TEMPERATURE HORMONES, STEROIDS, ELECTROLYTES, AND GLYCEMIC CONTROL DONOR MANAGEMENT GOALS Management of Donors After Circulatory Death Management of Organ Donor During Procurement Surgery Management of Living Organ Donors LIVING KIDNEY DONOR LIVING LIVER DONOR LIVING LUNG DONOR ISCHEMIA-REPERFUSION INJURY Organ Preservation and Management After Procurement References References 62 62 - Anesthesia for Obstetrics Physiologic Changes During Pregnancy and Delivery CARDIOVASCULAR CHANGES Physical Examination and Cardiac Studies Intravascular Volume Cardiac Output Systemic Vascular Resistance Aortocaval Compression RESPIRATORY SYSTEM CHANGES The Upper Airway Ventilation and Oxygenation Lung Volumes GASTROINTESTINAL CHANGES HEPATIC AND BILIARY CHANGES RENAL CHANGES HEMATOLOGIC CHANGES Coagulation NEUROLOGIC CHANGES Uteroplacental Physiology UTERINE BLOOD FLOW PLACENTAL EXCHANGE Oxygen Transfer Drug Transfer FETAL CIRCULATION AND PHYSIOLOGY Labor Progress LABOR AND FETAL MONITORING CONTRACTION MONITORING FETAL HEART RATE TRACING FETAL HEART RATE CATEGORIES Labor Analgesia NONPHARMACOLOGIC LABOR PAIN MANAGEMENT CONSIDERATIONS FOR PHARMACOLOGIC TREATMENT OF PAIN IN LABOR SYSTEMIC MEDICATIONS INHALED ANALGESIA NEURAXIAL ANALGESIA Neuraxial Analgesia and Progress of Labor Timing of Placement Epidural Analgesia Spinal Analgesia Combined Spinal-Epidural Analgesia Dural Puncture Epidural Neuraxial Analgesic Medications Administration Techniques Contraindications of Neuraxial Anesthesia OTHER REGIONAL NERVE BLOCKS Anesthesia Considerations for Operative Delivery Anesthesia for Cesarean Delivery MATERNAL RISKS AND CONSIDERATIONS SPINAL ANESTHESIA EPIDURAL ANESTHESIA COMBINED SPINAL-EPIDURAL ANESTHESIA GENERAL ANESTHESIA Induction of Anesthesia: Intravenously Administered Drugs Muscle Relaxants Maintenance of General Anesthesia Postcesarean Pain Control and Recovery Complications of Regional Anesthesia POSTDURAL PUNCTURE HEADACHE EPIDURAL HEMATOMA NEUROLOGIC INJURY LOCAL ANESTHETIC SYSTEMIC TOXICITY TOTAL SPINAL BLOCK OTHER COMPLICATIONS Maternal Comorbidities HYPERTENSIVE DISORDERS COAGULOPATHIES OBESITY CARDIAC DISEASE ANTICOAGULATION PULMONARY DISEASE NEUROLOGIC DISORDERS OPIOID DEPENDENCE Anesthesia for Malpresentation and External Cephalic Version Obstetric Emergencies MATERNAL MORTALITY OBSTETRIC HEMORRHAGE Placenta Previa and Accreta Vasa Previa Placental Abruption Uterine Rupture Uterine Atony Management of Massive Obstetric Hemorrhage AMNIOTIC FLUID EMBOLISM SHOULDER DYSTOCIA OTHER OBSTETRIC EMERGENCIES ADVANCED CARDIAC LIFE SUPPORT IN PREGNANCY Nonobstetric Surgery During Pregnancy PERIOPERATIVE CONSIDERATIONS ANESTHETIC TOXICITY PERIOPERATIVE FETAL HEART RATE MONITORING ANESTHETIC MANAGEMENT POSTOPERATIVE PAIN CONTROL SPECIFIC SURGICAL TECHNIQUES Laparoscopy Trauma Cardiac Surgery Neurosurgery Acknowledgment References References 63 63 - Anesthesia for Fetal Surgery and Other Fetal Therapies Indications, Procedures,and Outcomes ANEMIA AND INTRAUTERINE TRANSFUSION CONGENITAL HEART DEFECTS OBSTRUCTIVE UROPATHY Twin Reversed Arterial Perfusion Sequence TWIN-TO-TWIN TRANSFUSION SYNDROME AMNIOTIC BAND SYNDROME CONGENITAL DIAPHRAGMATIC HERNIA MYELOMENINGOCELE SACROCOCCYGEAL TERATOMA CONGENITAL PULMONARY LESIONS Preoperative Assessment and Counseling Intraoperative Management and Considerations FETAL PHYSIOLOGY AND MONITORING FETAL ANESTHESIA, ANALGESIA, AND PAIN PERCEPTION MANAGEMENT OF MINIMALLY INVASIVE PROCEDURES MANAGEMENT OF OPEN PROCEDURES Postoperative Management and Considerations Management of Ex Utero Intrapartum Treatment Procedure Conclusions and Future Considerations References References 64 64 - Anesthesia for Orthopedic Surgery Preoperative Evaluation EPIDEMIOLOGY AND DEMOGRAPHICS OF ORTHOPEDIC SURGERY CARDIOVASCULAR COMORBIDITIES Coronary Artery Disease Other Cardiac Comorbidities FRAILTY NEUROLOGIC COMORBIDITIES THROMBOEMBOLIC DISEASE PULMONARY, RENAL, HEMATOLOGIC, ENDOCRINE DISEASES, AND NUTRITIONAL STATUS COMPLICATIONS AND OUTCOME Special Considerations for Conditions Leading to Orthopedic Surgery OSTEOARTHRITIS RHEUMATOID ARTHRITIS ANKYLOSING SPONDYLITIS ACHONDROPLASIA Orthopedic Procedures in Children with Special Conditions JUVENILE IDIOPATHIC ARTHRITIS OSTEOGENESIS IMPERFECTA CEREBRAL PALSY SPINA BIFIDA DUCHENNE MUSCULAR DYSTROPHY ARTHROGRYPOSIS MULTIPLEX CONGENITA Perioperative Management of the Orthopedic Patient SPECIAL CONSIDERATIONS Antifibrinolytic Drugs Fat Embolism Syndrome Bone-Cement Implantation Syndrome ORTHOPEDIC TRAUMA Pelvic Fractures Femur Fractures Tibia Fractures Upper Extremity Fractures Extremity Replantation UPPER EXTREMITY SURGERIES Hand Surgery Shoulder and Elbow Surgery LOWER EXTREMITY SURGERY Knee and Hip Arthroscopy Hip and Knee Arthroplasties Foot and Ankle Surgery Anesthesia for Spine Surgery PREOPERATIVE ASSESSMENT SPINAL TRAUMA COMMON SPINAL PROCEDURES INTRAOPERATIVE NEUROPHYSIOLOGIC MONITORING PERIOPERATIVE VISUAL LOSS POSTOPERATIVE PAIN AFTER SPINAL SURGERY Acknowledgment References References 65 65 - Geriatric Anesthesia Organ-Specific Age-Related Physiologic and Pathologic Changes CARDIOVASCULAR SYSTEM Vascular Changes With Age Myocardium Cardiac Valves Sympathetic and Autonomic System RESPIRATORY SYSTEM RENAL SYSTEM GASTROINTESTINAL AND HEPATIC SYSTEMS MUSCULOSKELETAL SYSTEM CENTRAL NERVOUS SYSTEM Preoperative Assessment COGNITIVE ASSESSMENT AND DELIRIUM RISK FUNCTIONAL/FRAILTY SCREENING PALLIATIVE CARE POLYPHARMACY DEPRESSION AND ALCOHOL SCREENING CAPACITY/ADVANCED DIRECTIVES/EXPECTATIONS/SUPPORT Capacity Shared Decision Making/Expectations Intraoperative Management Considerations for Older Adults Postoperative Concerns Outcomes Acknowledgment References References 66 66 - Anesthesia for Trauma Introduction EPIDEMIOLOGY MODERN TRAUMA SYSTEMS AND REGIONALIZATION Prioritizing Trauma Care PREHOSPITAL TRIAGE BLUNT VERSUS PENETRATING TRAUMA ADVANCED TRAUMA LIFE SUPPORT INJURY PATTERNS PROMPTING URGENT OPERATIVE INTERVENTION Anesthesia in War and Austere Conditions Emergency Airway Management INDICATIONS APPROACH TO ENDOTRACHEAL INTUBATION PROPHYLAXIS AGAINST PULMONARY ASPIRATION OF GASTRIC CONTENTS PROTECTION OF THE CERVICAL SPINE PERSONNEL ANESTHETICS AND INDUCTION OF ANESTHESIA NEUROMUSCULAR BLOCKING DRUGS ADJUNCTS TO ENDOTRACHEAL INTUBATION FACIAL AND PHARYNGEAL TRAUMA THE FIELD PLACED AIRWAY Resuscitation from Hemorrhagic Shock PATHOPHYSIOLOGY OF HEMORRHAGIC SHOCK ACUTE TRAUMATIC COAGULOPATHY ASSESSMENT OF THE HEMOSTATIC SYSTEM GENERAL APPROACH TO RESUSCITATION Phase 1: Uncontrolled Hemorrhage . In the setting of trauma, “permissive” rather than “deliberate” hypotension is controversial and has been the focus of numerou... . As discussed earlier, management of the early coagulopathy associated with trauma must be incorporated into the overall phase ... Phase 2, Controlled Hemorrhage Phase 3, Restoration of Physiology RESUSCITATION FLUIDS RESUSCITATION EQUIPMENT Trauma to the Central Nervous System TRAUMATIC BRAIN INJURY AND CONCOMITANT TRAUMA MANAGEMENT OF INTRACRANIAL PRESSURE IN THE OPERATING ROOM SPINAL CORD INJURY INTRAOPERATIVE MANAGEMENT OF SPINAL CORD INJURY Orthopedic and Soft Tissue Trauma SPECIFIC ORTHOPEDIC CONDITIONS SOFT TISSUE TRAUMA Other Traumatic Injuries HEAD AND NECK SURGERY CHEST INJURIES: PULMONARY CHEST INJURIES: TRAUMATIC AORTIC INJURY CHEST INJURIES: RIB FRACTURES CHEST INJURIES: CARDIAC INJURY ABDOMINAL INJURY Selected Patient Populations TRAUMA AND PREGNANCY PEDIATRIC TRAUMA PATIENTS OLDER TRAUMA PATIENTS JEHOVAH’S WITNESS PATIENTS Postoperative Care EMERGENCE AND TRACHEAL EXTUBATION ACUTE PAIN MANAGEMENT Summary Acknowledgment References References 67 67 - Prehospital Care for Medical Emergencies and Trauma Background BASIC VERSUS ADVANCED LIFE SUPPORT AND BEYOND BASIC LIFE SUPPORT ADVANCED LIFE SUPPORT, INTENSIVE CARE–LEVEL PREHOSPITAL CARE Emergency Medical Technician and Paramedic-Based Emergency Medical Service Systems Primary Survey and Initial Assessment at the Scene MONITORS POINT OF CARE ULTRASOUND Out-of-Hospital Cardiac Arrest ACUTE CORONARY SYNDROME PREHOSPITAL DIAGNOSIS AND ELECTROCARDIOGRAPHY PREHOSPITAL TREATMENT AND FIBRINOLYSIS MECHANICAL CIRCULATORY SUPPORT Prehospital Extracorporeal Cardiac Life Support Respiratory Distress EVALUATION MANAGEMENT Neurologic Injury and Head Injury TRAUMATIC BRAIN INJURY SPINAL CORD INJURY ACUTE STROKE MANAGEMENT SEIZURE ALTERED MENTAL STATUS Prehospital Trauma TRIAGE SCENE SECURITY PRIMARY AND SECONDARY SURVEYS STAY AND PLAY SCOOP AND RUN FURTHER CONSIDERATIONS BALANCED RESUSCITATION HEMORRHAGE CONTROL ANTIFIBRINOLYTICS TOURNIQUETS RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA FUTURE DIRECTIONS AND CHALLENGES TRAUMA TRIAGE Point-of-Care Diagnostics Overdose/Toxicology/Environmental Exposure EVALUATION MANAGEMENT ENVIRONMENTAL EXPOSURES Horizons in Prehospital Care Acknowledgment References References 68 68 - Biological, Natural, and Human-Induced Disasters: The Role of the Anesthesiologist Introduction Section 1: Natural Disasters EARTHQUAKES TORNADOES TSUNAMI HURRICANES Section 2: Acts of Terrorism SEPTEMBER 11, 2001 ATTACKS MASS SHOOTINGS BOSTON MARATHON BOMBING Section 3: Chemical, Biological, Radiological, and Nuclear Warfare HISTORICAL ASPECT OF CHEMICAL, BIOLOGICAL, RADIOLOGICAL, AND NUCLEAR WARFARE CHEMICAL, BIOLOGICAL, RADIOLOGICAL, OR NUCLEAR HAZARDS DEFINED Chemical Biological Radiological and Nuclear Weapons and Effects Mass Casualty Situations and Chemical, Biological, Radiological, or Nuclear Attacks Incident Management During a Chemical, Biological, Radiological, or Nuclear Attack and Personal Protective Equipment Decontamination Summary of Chemical, Biological, Radiological, or Nuclear Section Section 4: Epidemic and Pandemic Infectious Outbreaks PANDEMIC INFLUENZA A SEVERE ACUTE RESPIRATORY SYNDROME MIDDLE EAST RESPIRATORY SYNDROME EBOLA VIRUS DISEASE PERSONAL PROTECTION Acknowledgment References References 69 69 - Anesthesia for Ophthalmic Surgery Overview of Ophthalmic Anesthesia OCULAR ANATOMY OCULOCARDIAC REFLEX INTRAOCULAR PRESSURE OPHTHALMIC DRUGS OPHTHALMIC PROCEDURES Preoperative Evaluation LABORATORY STUDIES CARDIOVASCULAR EVALUATION ANTICOAGULATION Orbital Blocks RETROBULBAR BLOCK PERIBULBAR BLOCK SUB-TENON BLOCK FACIAL NERVE BLOCK LOCAL ANESTHETIC SOLUTIONS FOR REGIONAL TECHNIQUES Monitored Anesthesia Care MONITORED ANESTHESIA CARE FOR CATARACT SURGERY UNDER TOPICAL ANESTHESIA MONITORED ANESTHESIA CARE FOR OPHTHALMIC SURGERY WITH AN ORBITAL BLOCK SPECIAL CONSIDERATIONS IN MONITORED ANESTHESIA CARE General Anesthesia Anesthesia for Pediatric Ophthalmology GLAUCOMA STRABISMUS RETINOPATHY OF PREMATURITY Postoperative Considerations in Ophthalmic Surgery Ophthalmic Emergencies OPEN GLOBE AND FULL STOMACH Anesthesia-Related Eye Injuries Acknowledgment ?Complete references available online at expertconsult.com References References 70 70 - Anesthesia for Otolaryngologic and Head-Neck Surgery Synopsis of Ear, Nose, and Throat Anatomy Preoperative Evaluation for Ear, Nose, and Throat Surgery Airway Management in Otolaryngology Airway Disorders in Otolaryngology ANGIOEDEMA ACUTE EPIGLOTTITIS RETROPHARYNGEAL ABSCESS LUDWIG ANGINA AIRWAY TUMORS, POLYPS, AND GRANULOMAS LARYNGEAL PAPILLOMATOSIS Anesthesia for Panendoscopy Otolaryngologic Trauma Nasal Surgery Tonsillectomy and Adenoidectomy Endoscopic Sinus Surgery Thyroid and Parathyroid Surgery Airway Fires Ear Surgery Parotid and Other Salivary Gland Surgery Sleep Apnea Surgery Zenker Diverticulum Anesthesia for Surgical Airways: Cricothyrotomy and Tracheostomy Neck Dissection and Laryngectomy Maxillary, Mandibular, and Temporomandibular Joint Surgery Ear, Nose, and Throat Laser Surgery Phonosurgery Head and Neck Flap Reconstructive Surgery Stridor and Heliox Anesthesia for Face Transplantation Acknowledgment References References 71 71 - Anesthesia for Robotic Surgery What Is a Robot? Why Is the Robot Preferred? When Is the Robot Used? Future Applications of Robotic Surgery ROBOTICALLY ASSISTED INTUBATION ROBOTIC SURGERY PHYSIOLOGY Insufflation With CO2 Pulmonary Vasoconstriction Cerebral Vascular Effects Systemic Effects of Hypercapnia Physiologic Changes Associated With Patient Positioning CARDIOVASCULAR EFFECTS INTRAOCULAR EFFECTS URINARY OUTPUT Types of Robotic Surgery UROLOGIC PROCEDURES Robotic-Assisted Retropubic Prostatectomies Robotic-Assisted Radical Cystectomy Robotic-Assisted Nephrectomy GYNECOLOGIC SURGERY Robotic-Assisted Hysterectomy Other Gynecological Surgeries General Surgery Otolaryngology TONSILLECTOMY HEAD AND NECK DISSECTION CARDIAC (SEE ALSO CHAPTER 54 ANESTHESIA FOR CARDIAC SURGICAL PROCEDURES) Mitral Valve Replacement Coronary Artery Bypass Grafting ROBOTIC-ASSISTED THORACOSCOPIC SURGERY (SEE ALSO CHAPTER 53 ANESTHESIA FOR THORACIC SURGERY) Summary Acknowledgment References References 72 72 - Ambulatory (Outpatient) Anesthesia Introduction Benefits of Ambulatory Surgery Facilities for Ambulatory Surgery HOSPITAL INTEGRATED HOSPITAL SELF-CONTAINED FREESTANDING OFFICE-BASED Patient Selection Criteria SURGICAL FACTORS MEDICAL FACTORS Obstructive Sleep Apnea Age Cardiovascular Disease SOCIAL FACTORS Preoperative Assessment THE ROLE OF PREOPERATIVE ASSESSMENT MECHANISMS AND TIMING OF PREOPERATIVE ASSESSMENT PREOPERATIVE INVESTIGATION Patient Preparation PROVISION OF INFORMATION PREOPERATIVE FASTING PREMEDICATION Management of Anxiety Anxiolytic Premedication Analgesic Premedication Prophylactic Antiemetics Antacid and Gastrokinetic Premedication Anesthetic Techniques CHOICE OF TECHNIQUE GENERAL ANESTHESIA INTRAVENOUS ANESTHESIA Propofol INHALED ANESTHETICS Sevoflurane Desflurane ANESTHETIC ADJUVANTS Nitrous Oxide Opioid Analgesics Nonopioid Analgesia Cardiovascular Drugs Neuromuscular Blocking Drugs AIRWAY MANAGEMENT REGIONAL ANESTHESIA Spinal Anesthesia New Drugs for Ambulatory Spinal Anesthesia Epidural Anesthesia Intravenous Regional Anesthesia Other Local and Regional Anesthetic Techniques SEDATION Choice of Sedatives Midazolam Propofol Potential New Sedatives Analgesic Adjuvants Delivery of Sedation Monitoring Depth of Anesthesia Recovery from Ambulatory Anesthesia EARLY RECOVERY SECOND-STAGE RECOVERY FAST-TRACK RECOVERY Postoperative Pain MULTIMODAL ANALGESIA RESCUE ANALGESIA PAIN MANAGEMENT AT HOME Managing Opioid Complications Local Anesthetic Administration at Home Postoperative Nausea and Vomiting RISK ASSESSMENT AND STRATEGIES ANTIEMETIC AGENTS First-Generation Drugs Serotonin 5-HT3 Receptor Antagonists Steroids Neurokinin-1 Antagonists MANAGING PERSISTENT NAUSEA AND VOMITING Special Areas OFFICE-BASED PRACTICE ANESTHESIA IN REMOTE LOCATIONS Home Readiness and Beyond PATIENT INFORMATION CRITERIA FOR DISCHARGE AFTERCARE AND FOLLOW-UP Follow-Up and Outcome Measures Adverse Effects After Ambulatory Surgery Patient Satisfaction With Ambulatory Surgery ?Complete references available online at expertconsult.com References References 73 73 - Non-Operating Room Anesthesia Overview: Defining Non-Operating Room Anesthesia—What It Is and How We Got Here NOVEL CHARACTERISTICS OF NORA CASES UNIQUE OBSTACLES: FROM PHYSICAL ENVIRONMENT TO THE MEDICINE–ANESTHESIOLOGY CULTURE GAP FINANCIAL AND OPERATIONAL CONSTRAINTS EFFECTS OF PAYMENT SYSTEMS OPERATIONAL CONSTRAINTS Transitional Priorities for Anesthesiologists Outside of the Operating Room DEFINING INTERDISCIPLINARY SAFETY IN NON-OPERATING ROOM LOCATIONS: STANDARDIZATION, RELIABILITY, AND COMMUNICATION OTHER GENERAL CONSIDERATIONS FOR NORA CARE Continuous Learning Culture of Accountability and Responsibility Support for Teamwork Structure Effective Communication and Flow of Information NON-OPERATING ROOM ANESTHESIA LOCATIONS: SOME LOGISTICAL ISSUES Sites of Care Supplies and Equipment MONITORING IN NON-OPERATING ROOM ANESTHESIA LOCATIONS PREPROCEDURAL EVALUATION FOR NON-OPERATING ROOM ANESTHESIA CASES OTHER CONSIDERATIONS Specific Procedure-Related Issues GASTROINTESTINAL PROCEDURES IN THE ENDOSCOPY SUITE Reimbursement Constraints Esophagogastroduodenoscopy Sigmoidoscopy and Colonoscopy Endoscopic Retrograde Cholangiopancreatography NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY: THE NEXT FRONTIER? Interventional Pulmonary Procedures COMMON BRONCHOSCOPIC PROCEDURES Novel Anesthetic Concerns Anesthesiology for Image-Guided Interventions: Evolution of a New Interface Diagnostic and Therapeutic Interventions: New Challenges EQUIPMENT LAYOUT Radiation Exposure Contrast Material Bleeding VASCULAR INTERVENTIONAL PROCEDURES BILIARY AND HEPATIC INTERVENTIONS GASTROINTESTINAL AND GENITOURINARY INTERVENTIONS PERCUTANEOUS INTERVENTIONS FOR ONCOLOGY Procedures Guided by Computed Tomography, Positron Emission Tomography, and Magnetic Resonance Imaging COMPUTED TOMOGRAPHY Computed Tomography–Guided Biopsies Computed Tomography–Guided Therapeutic Interventions Catheter Drainage Computed Tomography–Guided Ablation Computed Tomography–Guided Injections for Pain Management POSITRON EMISSION TOMOGRAPHY AND POSITRON EMISSION TOMOGRAPHY COMPUTED TOMOGRAPHY MAGNETIC RESONANCE–GUIDED INTERVENTIONS Physical Constraints of Magnetic Resonance Imaging Suites Magnetic Resonance Imaging–Guided Interventions Image-Guided Procedures for Specialty Areas: Neuroradiology and Interventional Cardiology Procedures in the Neuroradiology Suite GENERAL CONSIDERATIONS FOR ANESTHESIOLOGISTS IN THE INTERVENTIONAL SUITE ENDOVASCULAR TREATMENT OF CEREBRAL ANEURYSMS ENDOVASCULAR TREATMENT OF ARTERIOVENOUS MALFORMATIONS Interventional Neuroradiology: Acute Stroke Treatments Interventional Cardiology Procedures: General Considerations for the Electrophysiology and Catheterization Laboratories THE ELECTROPHYSIOLOGY LABORATORY ENVIRONMENT: UNIQUE CHALLENGES FOR ANESTHESIOLOGISTS Room Configuration and Equipment Layout Anesthesiologists in the Electrophysiology Laboratory DIAGNOSTIC ELECTROPHYSIOLOGY STUDIES CATHETER ABLATION ELECTROPHYSIOLOGIC DEVICES Implantable Cardioverter-Defibrillators Pacemakers Anesthesiologists in the Catheterization Laboratory PERCUTANEOUS CORONARY INTERVENTIONS INTRAAORTIC BALLOON PUMPS AND PERCUTANEOUS VENTRICULAR ASSIST DEVICES PERCUTANEOUS CLOSURE OF SEPTAL DEFECTS PERIPHERAL ARTERIAL DISEASE PERCUTANEOUS VALVE REPAIR AND REPLACEMENT PERCUTANEOUS MITRAL VALVE REPAIR Percutaneous Aortic Valve Replacement (Transcatheter Aortic Valve Replacement) Common Complications and Remedies . A number of vascular problems can occur during insertion and removal of the introducer sheath. Vascular dissection or perforat... . Transvenous pacing is used to establish rapid ventricular pacing and a near-zero cardiac output state during ballooning of the... . Patients respond idiosyncratically to balloon valvuloplasty; new-onset aortic insufficiency may require significant support an... . Embolization into the aorta can occur as a result of ejection because of inadequate pacer capture or inappropriately high depl... . Coronary occlusion is a potential problem if calcium or native aortic valve tissue occludes a coronary ostium. Prior coronary ... . Cardiovascular collapse during transfemoral procedures may require cardiopulmonary support. Institutional variability exists r... . Acute stroke is potentially detectable with unilateral changes in cerebral oximetry readings. The higher stroke rate of cohort... Interventional Echocardiography Anesthesiologists as Co-Proceduralists—The Road Ahead The Road Ahead: Toward a Comprehensive Strategy SOME ADDITIONAL CONSIDERATIONS Operational Effectiveness Costs, Uniqueness, and Value-Added Strategic Positioning Financial Silos and Teamwork Sustainable Strategy: Key Points Acknowledgment References References 74 74 - Clinical Care in Extreme Environments: Physiology at High Altitude and in Space Introduction to Altitude and Explanation of Hypobaric Hypoxia and Its Effect on Physiologic Performance Physiologic Responses to Hypoxia/Acclimatization CARDIOVASCULAR RESPONSES RESPIRATORY RESPONSES RENAL AND ENDOCRINE CHANGES CENTRAL NERVOUS SYSTEM GASTROINTESTINAL Altitude Illness ACUTE MOUNTAIN SICKNESS HIGH-ALTITUDE CEREBRAL EDEMA High-Altitude Pulmonary Edema CHRONIC MOUNTAIN SICKNESS COMORBIDITY AT ALTITUDE CHILDREN PREGNANCY GENERAL PRINCIPLES ANESTHETIC EQUIPMENT GENERAL ANESTHESIA REGIONAL ANESTHESIA APPLICATION TO FLIGHT, INCLUDING AIR TRANSPORT OF CRITICALLY UNWELL PATIENTS Space Medicine INTRODUCTION TO SPACE EXPLORATION AND MEDICINE RISK OF DISEASE AMONG ASTRONAUTS DURING SPACE TRAVEL The Environmental Challenges Posed by Spaceflight EXTREME ACCELERATIONS/DECELERATIONS RADIATION ISOLATION, CONFINEMENT, SLEEP DISTURBANCE, AND OTHER PSYCHOLOGICAL CHALLENGES DECOMPRESSION AND CHANGING OXYGEN CONCENTRATIONS MICROGRAVITY Cardiovascular Physiology During Space Flight Pulmonary Physiology During Space Flight Musculoskeletal Physiology During Space Flight Central Nervous System and Psychological Challenges During Space Flight The Effect of Spaceflight on Other Physiologic Systems (Including the Immune and Gastric Systems) Potential Medical Scenarios During Manned Space Missions Thoughts and Considerations for Anesthetic Provision in Space GENERAL PRINCIPLES PREOPERATIVE PERIOD General Anesthesia in Space Regional Anesthesia in Space References References 75 75 - Clinical Care in Extreme Environments: High Pressure, Immersion, Drowning, Hypo- and Hyperthermia Introduction Physiology of Immersion ACUTE EFFECTS OF IMMERSION PROLONGED IMMERSION AND RESCUE IMMERSION PULMONARY EDEMA Drowning DEFINITION PREVALENCE PATHOPHYSIOLOGY RESCUE AND RESUSCITATION HOSPITAL CARE Circulation and Renal support Neuroresuscitation OUTCOME OF DROWNING PREVENTION Hypothermia PHYSIOLOGY OF HYPOTHERMIA CLINICAL CONSIDERATIONS TREATMENT OF HYPOTHERMIA HYPOTHERMIA OUTCOME Hyperthermia PHYSIOLOGY OF HYPERTHERMIA CLINICAL SCENARIOS TREATMENT OF HYPERTHERMIA HYPERTHERMIA OUTCOME Effects of Increased Gas Pressure HISTORY INCREASED BAROMETRIC PRESSURE EFFECTS INCREASED PARTIAL PRESSURE OF OXYGEN ELEVATION OF INERT GAS PARTIAL PRESSURE ELEVATION OF ABSOLUTE PRESSURE High-Pressure Nervous Syndrome Pressure Reversal of Anesthesia EFFECTS OF HYPERBARIC EXPOSURE ON DRUG DISPOSITION Hyperbaric Oxygen Therapy RATIONALE FOR HYPERBARIC TREATMENT OF SELECTED ACUTE CLINICAL ENTITIES Carbon Monoxide Poisoning Gas Embolism and Decompression Sickness Acute Infections Support of Arterial Oxygenation in Therapeutic Lung Lavage Maintenance of Oxygen Transport in Severe Anemia Crush Injury Central Retinal Artery Occlusion and Central Retinal Vein Occlusion Idiopathic Sudden Sensorineural Hearing Loss THERAPEUTIC SYSTEMS HYPERBARIC TREATMENT SCHEDULES SIDE EFFECTS OF HYPERBARIC OXYGEN THERAPY Oxygen Toxicity Inert Gas Uptake Barotrauma PRACTICAL ASPECTS OF HYPERBARIC THERAPY Middle Ear Pressure Equilibration Pulmonary Pressure Equilibration Patient Monitoring Intravenous Fluid Administration Blood Gas Assessment and Ventilator Management Other Medical Devices Atmosphere Control Fire Hazards Evaluation of a Patient for Safety of Hyperbaric Oxygen Treatment Delivery of Anesthesia at Increased Ambient Pressure . Inhaled anesthesia of any type can pollute the enclosed chamber atmosphere with anesthetic gases, which may exert pharmacologi... . The increased ambient pressure in a hyperbaric chamber allows nitrous oxide to be used at partial pressures exceeding its MAC.... . The effect of a volatile anesthetic on a patient is proportional not to the alveolar concentration but to the partial pressure... . Intravenous anesthetics behave similarly and are unlikely to be affected within the usual clinical range of ambient pressure (... . Regional anesthesia is likely to be both safe and effective in a hyperbaric environment by avoiding the requirement for mechan... FUTURE DIRECTIONS IN HYPERBARIC OXYGEN THERAPY Preoperative Hyperbaric Oxygenation Stroke Acute Traumatic Brain Injury Summary References References 76 76 - REGIONAL ANESTHESIA IN CHILDREN Introduction Relevant Differences Between Children and Adults ANATOMIC DIFFERENCES Change in Body Size Resulting From the Growth Process Delayed Ossification of Bones and Fusion of Sacral Vertebrae Development of Curvature of the Spine Loose Attachment of Fasciae and Fluidity of Epidural Fat Delayed Myelinization of Nerve Fibers PAIN PERCEPTION PHARMACOLOGY OF LOCAL ANESTHETICS AND ADDITIVES Local Anesthetics Local Fixation Systemic Absorption and Distribution Opioids Other Additives PHYSIOLOGIC FACTORS PSYCHOLOGICAL FACTORS Indications, Contraindications, and Complications INDICATIONS Anesthetic Indications Intraoperative and Postoperative Analgesia and Procedural Pain Management of Nonsurgical Pain Chronic Pain Relief and Palliative Care Nonanalgesic Indications CONTRAINDICATIONS AND LIMITATIONS Absolute Contraindications to Neuraxial Blocks Absolute Contraindications to Peripheral Nerve Block Procedure Patients at Risk for Compartment Syndrome Hemoglobinopathies Bone and Joint Deformities Preexisting Neurologic Disorders or Diseases COMPLICATIONS Local Complications Systemic Complications Epidemiology Selection of Materials and Anesthetic Solution SELECTION OF BLOCK PROCEDURE SELECTION OF EQUIPMENT SELECTION OF DRUG Anatomic Identification in Regional Anesthesia MANUAL APPROACHES Electrical Stimulation Ultrasound Techniques Safety, Precautions and Discharge Criteria ACCEPTABLE ENVIRONMENTS FOR PERFORMING A REGIONAL BLOCK SEDATION AND GENERAL ANESTHESIA PATIENT MONITORING AND SAFETY PRECAUTIONS DURING THE BLOCK PROCEDURE Monitoring and Anesthesia Chart Technique of Injection Assessment of the Block POSTOPERATIVE MONITORING IN THE RECOVERY ROOM DISCHARGE CRITERIA AFTER SINGLE-SHOT PROCEDURES MANAGEMENT OF CONTINUOUS REGIONAL TECHNIQUES Neuraxial Blocks CAUDAL ANESTHESIA Ultrasound Guidance for Caudal Block Placement Anatomy of the Sacral Hiatus Technique EPIDURAL ANESTHESIA Anatomy and Physiology Indications and Contraindications Techniques SPINAL ANESTHESIA Anatomy and Physiology Indications and Contraindications Technique Drugs and Doses Adverse Effects and Complications Upper Extremity Conduction Blocks ANATOMIC CONSIDERATIONS CERVICAL BRACHIAL PLEXUS BLOCKS Interscalene Approach Parascalene Approach SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK INFRACLAVICULAR BRACHIAL PLEXUS BLOCKS Infraclavicular Approaches Midclavicular Approaches Paracoracoid Approaches Ultrasound-Guided Infraclavicular Block Axillary Approach DISTAL CONDUCTION BLOCKS Elbow and Forearm Approaches DIGITAL BLOCKS Lower Extremity Conduction Blocks LUMBAR PLEXUS NERVE BLOCKS Anatomic Considerations Psoas Compartment Block (Direct Lumbar Plexus Block) Femoral Nerve Block Fascia Iliaca Compartment Blocks Other Lumbar Plexus Nerve Blocks SCIATIC NERVE BLOCKS Anatomic Considerations Indications and Contraindications Proximal Sciatic Nerve Blocks Popliteal Sciatic Approach Metatarsal Blocks Truncal Blocks PERIPHERAL BLOCKS FOR ABDOMINAL WALL SURGERY Rectus Sheath and Paraumbilical Block Rectus Sheath Block Ilioinguinal and Iliohypogastric Nerve Blocks Transversus Abdominis Plane Block Ilioinguinal Nerve Block Transversus Abdominis Plane Block PERIPHERAL BLOCKS FOR PENILE SURGERY Penile Block Pudendal Nerve Block INTERCOSTAL NERVE BLOCK THORACIC PARAVERTEBRAL SPACE BLOCK OTHER NERVE BLOCKS OF THE TRUNK ERECTOR SPINAE PLANE BLOCKS Face, Head, and Neck Nerve Blocks NERVE BLOCK OF THE FACE Anatomic Considerations Superficial Trigeminal Nerve Blocks Suprazygomatic Approach to Maxillary Nerve Mandibular Nerve Block Block of the Nose: Nasociliary Nerve Block and External Nasal Nerve Block Nerve Blocks of the External Ear Nerve Block of the Head Nerve Block of the Neck Other Procedures INTRAVENOUS REGIONAL ANESTHESIA Intradermal Wheals Wound Infiltration Acknowledgment References References 77 77 - Pediatric Anesthesia Physiologic Considerations INTRAUTERINE DEVELOPMENT NEONATAL AND INFANT PHYSIOLOGY Cardiovascular System Respiratory System The Kidneys The Liver Gastrointestinal System Hematology and Coagulation System Central Nervous System Thermoregulation Pharmacology DEVELOPMENTAL PHARMACOLOGY Body Composition Protein Binding Clearance Pharmacodynamic Differences INHALED ANESTHETICS Potency of Inhaled Anesthetics in Children Pharmacokinetics of Inhaled Anesthetics in Children Halothane Sevoflurane Isoflurane Desflurane Nitrous Oxide Xenon Emergence Agitation and Delirium INTRAVENOUS GENERAL ANESTHETICS Propofol Total Intravenous Anesthesia in Children Thiopental Ketamine Etomidate Α2 AGONISTS Clonidine Dexmedetomidine OPIOIDS Morphine Codeine Meperidine Fentanyl Alfentanil Sufentanil Remifentanil Tramadol MUSCLE RELAXANTS AND REVERSAL AGENTS Succinylcholine Nondepolarizing Muscle Relaxants Sugammadex THE IMPACT OF ANESTHESIA ON THE DEVELOPING BRAIN Animal data Translating the Animal Data to Humans Human Study Outcomes Results From Studies That Look at Specific Developmental Disorders Perioperative Management PREOPERATIVE EVALUATION The Child With an Upper Respiratory Tract Infection PERIOPERATIVE ANXIETY IN CHILDREN PREOPERATIVE FASTING ANESTHESIA INDUCTION AIRWAY MANAGEMENT AND VENTILATION Airway Management The Child With Stridor Ventilation Strategies EQUIPMENT AND MONITORING SAFETY ISSUES FLUID MANAGEMENT Regional Anesthesia and Analgesia Important Pediatric Anesthesia Scenarios NEONATAL ANESTHESIA ANESTHESIA FOR SPECIFIC NEONATAL SURGICAL PROCEDURES Meningomyelocele Omphalocele and Gastroschisis Tracheoesophageal Fistula Congenital Diaphragmatic Hernia ANESTHESIA FOR SPECIFIC SURGICAL PROCEDURES IN INFANTS Pyloric Stenosis Infant Inguinal Hernia Repair Cleft Lip and Palate ANESTHESIA FOR SPECIFIC PROCEDURES AND CONDITIONS IN OLDER CHILDREN Anterior Mediastinal Mass Inhaled Foreign Body Tonsillectomy and Obstructive Sleep Apnea Muscle Biopsy Child With Developmental Disability Acknowledgment References References 78 78 - Anesthesia for Pediatric Cardiac Surgery Unique Features of Pediatric Cardiac Anesthesia PHYSIOLOGIC CONSIDERATIONS AND MATURATIONAL FEATURES OF THE PEDIATRIC PATIENT CONGENITAL HEART DISEASE Physiologic Approach to Congenital Heart Disease Anesthetic Management PREOPERATIVE MANAGEMENT Anesthetic Evaluation Concurrent Medications and Drug Interactions INTRAOPERATIVE MANAGEMENT Operating Room Preparation Physiologic Monitoring Special Monitoring Induction and Maintenance of Anesthesia Cardiopulmonary Bypass DIFFERENCES BETWEEN ADULT AND PEDIATRIC CARDIOPULMONARY BYPASS Volume of Priming Solutions Temperature Hemodilution BLOOD GAS MANAGEMENT INITIATION OF CARDIOPULMONARY BYPASS PUMP FLOW RATES SPECIAL TECHNIQUES Deep Hypothermic Circulatory Arrest Regional Cerebral Perfusion Glucose Regulation Renal Effects Pulmonary Effects STRESS RESPONSE AND CARDIOPULMONARY BYPASS DISCONTINUATION OF CARDIOPULMONARY BYPASS ULTRAFILTRATION SPECIFIC PROBLEMS ENCOUNTERED IN DISCONTINUING CARDIOPULMONARY BYPASS Left Ventricular Dysfunction Right Ventricular Dysfunction Pulmonary Artery Hypertension Anticoagulation, Hemostasis, and Blood Conservation Postoperative Management POSTOPERATIVE NEUROPSYCHOLOGIC MORBIDITY MECHANICAL ASSIST DEVICES Anesthesia for Heart and Lung Transplantation Anesthesia for Closed-Heart Operations Anesthesia for Interventional or Diagnostic Cardiac Procedures TRANSCATHETER TECHNIQUE FOR ATRIAL SEPTAL DEFECT CLOSURES TRANSCATHETER VENTRICULAR SEPTAL DEFECT CLOSURES ANGIOPLASTY OF BRANCH PULMONARY ARTERY STENOSIS BALLOON VALVULOTOMIES COIL EMBOLIZATION VALVE PROSTHESES EMERGENT PROCEDURES ENDOMYOCARDIAL BIOPSY CARDIAC CATHETERIZATION OF PATIENTS SUPPORTED BY EXTRACORPOREAL MEMBRANE OXYGENATION Adult Congenital Heart Disease EPIDEMIOLOGY AND CLASSIFICATION CONSIDERATIONS IN THE CARE OF PATIENTS WITH ADULT CONGENITAL HEART DISEASE SPECIFIC LESIONS WITH UNIQUE CONSIDERATIONS FOR ADULT CONGENITAL HEART DISEASE Tetralogy of Fallot Fontan Circulations Transposition of the Great Arteries Pediatric Cardiac Electrophysiology DIAGNOSTIC EVALUATION Cardiac Event Monitoring Insertable Cardiac Recorders RADIOFREQUENCY ABLATION OF ACCESSORY PATHWAYS Intraatrial Reentrant Tachycardia Arrhythmias and Sudden Cardiac Death IMPLANTATION OF PACEMAKERS AND DEFIBRILLATORS Advances in Resynchronization Therapy Anesthesia for Noncardiac Surgery INFECTIVE ENDOCARDITIS PROPHYLAXIS: AMERICAN HEART ASSOCIATION GUIDELINES MAGNETIC RESONANCE IMAGING OF THE HEART Offsite Anesthesia in Cardiac Surgery Patients Acknowledgment References References 79 79 - Pediatric and Neonatal Critical Care Relationship Between the Intensive Care Unit and the Operating Room Family Partnered Care in the Pediatric Intensive Care Unit Disclosure of Medical Errors Organization of the Pediatric Intensive Care Unit Cardiovascular System STRUCTURAL AND FUNCTIONAL DEVELOPMENT DEVELOPMENT OF THE CIRCULATION DEVELOPMENT OF AUTONOMIC CONTROL OF THE CIRCULATION MYOCARDIAL METABOLISM Common Cardiovascular Disease States CONGENITAL HEART DISEASE ACUTE CIRCULATORY FAILURE IN CHILDREN (SHOCK AND SEPSIS) Shock Classification of Shock Diagnosis of Shock Compensatory Mechanisms Therapy and Outcomes Cardiovascular Pharmacology EPINEPHRINE Dopamine Vasopressin Isoproterenol Dobutamine Norepinephrine Milrinone Levosimendan Nesiritide Digitalis Calcium Bicarbonate Therapy Vasodilators Nicardipine Sodium Nitroprusside Hydralazine Tolazoline and Phentolamine Prostaglandin E1 Nitric Oxide Disorders of Cardiac Rhythm HYPERTENSION Neonatal Resuscitation INITIAL ASSESSMENT OF THE FETUS AT BIRTH ONGOING ASSESSMENT CLEARING THE AIRWAY TEMPERATURE CONTROL OXYGEN VENTILATION PNEUMOTHORAX ENDOTRACHEAL INTUBATION CARDIAC COMPRESSIONS MEDICATIONS Epinephrine Naloxone DETECTION OF HYPOVOLEMIA TREATMENT OF HYPOVOLEMIA OTHER CAUSES OF HYPOTENSION MECONIUM COLOR RESUSCITATION EQUIPMENT PEDIATRIC CARDIAC ARREST AND RESUSCITATION Phases of Resuscitation PREARREST NO FLOW/LOW FLOW Airway-Breathing-Circulation or Circulation-Airway-Breathing POSTARREST/RESUSCITATION Interventions During the Cardiac Arrest (No Flow) and Cardiopulmonary Resuscitation (Low Flow) AIRWAY AND BREATHING CIRCULATION: OPTIMIZING BLOOD FLOW DURING LOW FLOW CARDIOPULMONARY RESUSCITATION: PUSH HARD, PUSH FAST CHEST COMPRESSION DEPTH COMPRESSION/VENTILATION RATIOS DUTY CYCLE CIRCUMFERENTIAL VERSUS FOCAL STERNAL COMPRESSIONS OPEN-CHEST CARDIOPULMONARY RESUSCITATION MEDICATIONS USED TO TREAT CARDIAC ARREST Vasopressors Antiarrhythmic Medications POST-RESUSCITATION INTERVENTIONS Temperature Management Glucose Control Blood Pressure Management Post-resuscitation Myocardial Dysfunction NEUROMONITORING QUALITY OF CARDIOPULMONARY RESUSCITATION EXTRACORPOREAL MEMBRANE OXYGENATION-CARDIOPULMONARY RESUSCITATION Ventricular Fibrillation and Ventricular Tachycardia in Children ANTIARRHYTHMIC MEDICATIONS: LIDOCAINE AND AMIODARONE PEDIATRIC AUTOMATED EXTERNAL DEFIBRILLATORS WHEN SHOULD CARDIOPULMONARY RESUSCITATION BE DISCONTINUED? Respiratory System STRUCTURAL AND FUNCTIONAL DEVELOPMENT: AGE-DEPENDENT VARIABLES Airways and Alveoli Pulmonary Circulation Biochemical Development Respiratory Transition: Placenta to Lung Mechanics of Breathing Lung Compliance Versus Age Chest Wall Upper Airway Closing Capacity Resistive Forces Control of Breathing Oxygen Transport: Oxygen Loading and Unloading RESPIRATORY FAILURE MONITORING OF RESPIRATORY FUNCTION RESPIRATORY FAILURE HYPOVENTILATION SYNDROMES IN CHILDREN WITH NORMAL LUNGS Primary Pulmonary Alveolar or Interstitial Disorders Obstructive Airway Disease RESPIRATORY CARE PEDIATRIC ACUTE RESPIRATORY DISTRESS SYNDROME PRINCIPLES OF LUNG PROTECTIVE STRATEGIES: LIMITING VENTILATOR ASSOCIATED LUNG INJURY ADJUVANT THERAPIES FOR ACUTE RESPIRATORY DISTRESS SYNDROME Prone Positioning Surfactant Therapy Corticosteroids Nitric Oxide Extracorporeal Membrane Oxygenation ADJUNCTIVE PHARMACOLOGIC THERAPY: SEDATIVES AND ANALGESICS WEANING FROM MECHANICAL VENTILATION RESPIRATORY DISORDERS Laryngotracheobronchitis (Croup) Epiglottitis Bronchiolitis Cystic Fibrosis Bronchopulmonary Dysplasia Sleep Apnea Foreign Body Aspiration Upper Airway Obstruction and Meningomyelocele ASTHMA Asthma Therapy Pulmonary Hypertension CENTRAL NERVOUS SYSTEM Functional Postnatal Neurologic Development Assessment of Neurologic Function Laboratory Assessment of Neurologic Function Traumatic Brain Injury Cerebral Perfusion Pressure and Cerebral Blood Flow Respiratory Management in the Brain Injured Child Hypoxic-Ischemic Encephalopathy Hydrocephalus Tumors Status Epilepticus in Children Renal System ENDOCRINE SYSTEM Adrenal Axis Congenital Adrenal Hyperplasia Pheochromocytoma Iatrogenic Chronic Adrenal Insufficiency Anterior Pituitary Diabetes Insipidus Syndrome of Inappropriate Secretion of Antidiuretic Hormone Pancreas/Insulin GASTROINTESTINAL SYSTEM Structural and Functional Development of the Intestine Development of the Liver Congenital Malformations Enteral and Parenteral Nutrition for the Critically Ill Child Hematology Oncology Leukostasis Tumor Lysis Syndrome Mediastinal Mass IMMUNITY AND INFECTION Empiric Antibiotic Coverage Prevention of Health Care–Associated Infections Ventilator-Associated Pneumonia Catheter-Associated Blood Stream Infections Urinary Tract Infection Infections in the Newborn PEDIATRIC TRAUMA Prenatal and Perinatal Injuries Trauma in Children Child Abuse Ingestion Injury Transport of the Critically Ill Child Acknowledgment References References 80 80 - THE POSTANESTHESIA CARE UNIT Admission to the Postanesthesia Care Unit The Standards for Postanesthesia Care Early Postoperative Physiologic Changes Transport to the Postanesthesia Care Unit Upper Airway Obstruction LOSS OF PHARYNGEAL MUSCLE TONE RESIDUAL NEUROMUSCULAR BLOCKADE LARYNGOSPASM EDEMA OR HEMATOMA OBSTRUCTIVE SLEEP APNEA Management of Upper Airway Obstruction Differential Diagnosis of Arterial Hypoxemia in the Postanesthesia Care Unit ALVEOLAR HYPOVENTILATION DECREASED ALVEOLAR OXYGEN PRESSURE VENTILATION-PERFUSION MISMATCH AND SHUNT INCREASED VENOUS ADMIXTURE DECREASED DIFFUSION CAPACITY Pulmonary Edema POSTOBSTRUCTIVE PULMONARY EDEMA TRANSFUSION-RELATED ACUTE LUNG INJURY TRANSFUSION-ASSOCIATED CIRCULATORY OVERLOAD (TACO) Monitoring and Treatment of Hypoxemia OXYGEN SUPPLEMENTATION LIMITATIONS OF PULSE OXIMETRY Oxygen Delivery Systems SUPPLEMENTAL OXYGEN CONTINUOUS POSITIVE AIRWAY PRESSURE NONINVASIVE POSITIVE-PRESSURE VENTILATION Hemodynamic Instability SYSTEMIC HYPERTENSION SYSTEMIC HYPOTENSION Hypovolemic (Decreased Preload) Distributive (Decreased Afterload) Cardiogenic (Intrinsic Pump Failure) Extracardiac/Obstructive Shock Myocardial Ischemia: Evaluation and Treatment EVALUATION TREATMENT Cardiac Arrhythmias TACHYCARDIA BRADYCARDIA ATRIAL ARRHYTHMIAS VENTRICULAR ARRHYTHMIAS TREATMENT Renal Dysfunction OLIGURIA Intravascular Volume Depletion Postoperative Urinary Retention CONTRAST NEPHROPATHY INTRAABDOMINAL HYPERTENSION RHABDOMYOLYSIS Postoperative Hypothermia and Shivering MECHANISM TREATMENT CLINICAL EFFECTS Postoperative Nausea and Vomiting PREVENTION AND TREATMENT Delirium RISK FACTORS PROPHYLAXIS AND MANAGEMENT Emergence Excitement Delayed Awakening Discharge Criteria POSTANESTHESIA SCORING SYSTEMS Infection Control Postoperative Management of Patients Undergoing Transcatheter Aortic Valve Replacement and Transcatheter Mitral Valve Repair Immediate Postoperative Care of Craniotomies Potentially Devastating Visual Complications CORNEAL ABRASIONS POSTOPERATIVE VISION LOSS Future Considerations INTENSIVE CARE OUTPATIENT PROCEDURES Summary Acknowledgment References References 81 81 - Acute Postoperative Pain Fundamental Considerations PAIN PATHWAYS AND THE NEUROBIOLOGY OF NOCICEPTION ACUTE AND CHRONIC EFFECTS OF POSTOPERATIVE PAIN Acute Effects Chronic Effects Preventive Analgesia Multimodal Approach to Perioperative Recovery/Enhanced Recovery after Surgery Treatment Methods Systemic Analgesic Techniques OPIOIDS Advantages and Characteristics Intravenous Patient-Controlled Analgesia NON-OPIOIDS Nonsteroidal Antiinflammatory Agents Acetaminophen Gabapentinoids KETAMINE Tramadol Regional Analgesic Techniques Single-Dose Neuraxial Opioids Continuous Epidural Analgesia Analgesic Drugs Location of Catheter Insertion Side Effects of Neuraxial Analgesic Drugs Patient-Controlled Epidural Analgesia Benefits of Epidural Analgesia Risks With Epidural Analgesia Peripheral Regional Analgesia Truncal Blocks Intraarticular and Local Infiltration Analgesia OTHER TECHNIQUES POSTOPERATIVE ANALGESIA IN SPECIAL POPULATIONS OPIOID-TOLERANT PATIENTS: PATIENTS WITH PREEXISTING PAIN PEDIATRIC PATIENTS OBESITY, OBSTRUCTIVE SLEEP APNEA, AND SLEEP INPATIENT PAIN SERVICES Acknowledgment References References 82 82 - Cognitive Dysfunction and Other Long-Term Complications of Surgery and Anesthesia Introduction Nomenclature, Diagnosis, and Measurement NOMENCLATURE Preexisting Cognitive Impairment Delirium Postoperative Cognitive Dysfunction Cognitive Concern Activities of Daily Living Assessment Objective Testing MEASUREMENT AND DIAGNOSIS OF PERIOPERATIVE NEUROCOGNITIVE DISORDERS Assumptions Underlying Assessment of Postoperative Cognitive Dysfunction/Perioperative Neurocognitive Disorder Cognitive Decline Outcome Criteria Issues Associated With Repeated Testing Summary Risk Factors, Informed Consent, and Perioperative Management RISK FACTORS INFORMED CONSENT PREOPERATIVE MANAGEMENT Intraoperative Management TYPE OF ANESTHESIA DEXMEDETOMIDINE KETAMINE INTRAOPERATIVE BRAIN MONITORING BLOOD PRESSURE CONTROL Postoperative Management PAIN MANAGEMENT Mechanisms and Biomarkers AMYLOIDOPATHY CELL AND MOLECULAR STUDIES ANIMAL STUDIES HUMAN STUDIES AMYLOIDOPATHY SUMMARY TAUOPATHY CELL AND MOLECULAR STUDIES ANIMAL STUDIES HUMAN STUDIES TAUOPATHY SUMMARY CALCIUM DYSREGULATION CELL AND MOLECULAR STUDIES ANIMAL AND HUMAN STUDIES CALCIUM SUMMARY NEUROINFLAMMATION CELL AND MOLECULAR STUDIES ANIMAL STUDIES HUMAN STUDIES NEUROINFLAMMATION SUMMARY Summary CLOSING COMMENTS Acknowledgment References References 83 83 - CRITICAL CARE ANESTHESIOLOGY Introduction HISTORY OF CRITICAL CARE MEDICINE AND THE ROLE OF ANESTHESIA INTENSIVISTS Intensive Care Unit Structure and Management CAPACITY, UTILIZATION, AND COST STRUCTURE AND STAFFING PATTERNS IN THE INTENSIVE CARE UNIT MANAGEMENT AND QUALITY IMPROVEMENT Acute Respiratory Distress Syndrome and Lung Protective Ventilation ACUTE RESPIRATORY DISTRESS SYNDROME “BABY LUNG” LUNG PROTECTIVE VENTILATION PERMISSIVE HYPERCAPNIA VENTILATION MODES IN ACUTE RESPIRATORY DISTRESS SYNDROME POSITIVE END-EXPIRATORY PRESSURE AND OPEN LUNG STRATEGIES POSITIVE END-EXPIRATORY PRESSURE OPEN LUNG STRATEGIES Esophageal Manometry, Transpulmonary Pressures, and Positive End-Expiratory Pressure Decremental Positive End-Expiratory Pressure Trials Recruitment Maneuvers PRONE POSITIONING SELF-INDUCED LUNG INJURY NEUROMUSCULAR BLOCKADE NONINVASIVE POSITIVE-PRESSURE VENTILATION AND HIGH-FLOW NASAL CANNULA SUMMARY OF EVIDENCE-BASED VENTILATION IN ARDS AND FUTURE RESEARCH MANAGEMENT OF PAIN AND AGITATION Sepsis and Shock INFECTION, SYSTEMIC INFLAMMATORY RESPONSE SYNDROME, AND SEPSIS SEPTIC SHOCK SURVIVING SEPSIS CAMPAIGN HEMODYNAMIC SUPPORT IN SEPTIC SHOCK Hemodynamic Resuscitation in Shock END-ORGAN PERFUSION Urine Output Lactate Standard Base Deficit Other Tissue-Specific Perfusion Markers CARDIAC OUTPUT Pulmonary Artery Catheter, Thermal Dilution Transpulmonary Thermal Dilution or Lithium Dye Dilution Pulse Contour Analysis ELECTRICAL BIOREACTANCE AND IMPEDANCE TRANSTHORACIC AND TRANSESOPHAGEAL ECHOCARDIOGRAPHY Mixed Venous and Central Venous Saturation FLUID RESPONSIVENESS SUMMARY OF FLUID RESUSCITATION IN SHOCK Care for Patients Receiving Cancer Immunotherapy in the Intensive Care Unit IMMUNE CHECKPOINT INHIBITORS CHIMERIC ANTIGEN RECEPTOR T CELLS Point-of-Care Ultrasound in Critical Care VASCULAR ULTRASOUND PULMONARY ULTRASOUND CARDIAC ULTRASOUND OTHER APPLICATIONS AND THE FUTURE Conclusion Acknowledgment References References 84 84 - Neurocritical Care Intracranial Physiology and Cerebrovascular Autoregulation General Cardiopulmonary Considerations Fluids, Electrolytes, and Nutrition Temperature Control Monitoring CLINICAL EXAMINATION INTRACRANIAL PRESSURE AND CEREBRAL PERFUSION PRESSURE Intracranial Pressure Cerebral Perfusion Pressure CEREBRAL BLOOD FLOW Thermal Diffusion Flowmetry Transcranial Doppler Monitoring CEREBROVASCULAR AUTOREGULATION AND VASOMOTOR REACTIVITY CEREBRAL OXYGENATION Jugular Venous Oxygen Saturation Brain Tissue Oxygen Tension Near-Infrared Spectroscopy BRAIN METABOLISM AND BIOCHEMISTRY—CEREBRAL MICRODIALYSIS NEUROPHYSIOLOGIC MONITORING Electroencephalography Evoked Potentials MULTIMODALITY NEUROMONITORING RADIOGRAPHIC IMAGING Common Diseases in the Neurocritical Care Unit TRAUMATIC BRAIN INJURY Pathophysiology Treatment SPINAL CORD INJURY Cerebrovascular Disease SUBARACHNOID HEMORRHAGE Early Brain Injury Secondary Brain Injury ISCHEMIC STROKE INTRACEREBRAL HEMORRHAGE STATUS EPILEPTICUS Neuromuscular Disease GUILLAIN-BARRÉ SYNDROME MYASTHENIA GRAVIS Central Nervous System Infection MENINGITIS ENCEPHALITIS Postoperative Neurosurgical Care BRAIN DEATH Ethical Considerations Conclusion Acknowledgment References References 85 85 - Extracorporeal Membrane Oxygenation and Cardiac Devices Introduction History of Extracorporeal Cardiorespiratory Support ECMO for Respiratory Failure (VV ECMO) INDICATIONS FOR VV ECMO IN RESPIRATORY FAILURE CONTRAINDICATIONS TO VV ECMO Extracorporeal Membrane Oxygenation for Patients Awaiting and Undergoing Lung Transplantation ECMO for Circulatory Failure (VA ECMO) INDICATIONS FOR VA ECMO CONTRAINDICATIONS TO VA ECMO The Ethics of Extracorporeal Membrane Oxygenation The Mechanics of Extracorporeal Membrane Oxygenation THE PUMP THE OXYGENATOR PULSATILITY WITH VA ECMO FLOW AND GAS EXCHANGE PHYSIOLOGY WITH VV ECMO FLOW AND GAS EXCHANGE PHYSIOLOGY WITH VA ECMO EXTRACORPOREAL MEMBRANE OXYGENATION FOR THE FAILING RIGHT HEART Vascular Access for Extracorporeal Membrane Oxygenation CANNULATION FOR VV ECMO CANNULATION FOR VA ECMO CANNULATION FOR VPA ECMO ALTERNATIVE CANNULATION STRATEGIES Monitoring on Extracorporeal Membrane Oxygenation PUMP PRESSURES AND FLOWS INTRAVASCULAR PRESSURES TISSUE OXIMETRY Anticoagulation Therapeutic Monitoring of Unfractionated Heparin (Table 85.4) ACTIVATED CLOTTING TIME ACTIVATED PARTIAL THROMBOPLASTIN TIME ANTI-FACTOR XA (“HEPARIN LEVEL”) HEPARIN-INDUCED THROMBOCYTOPENIA Weaning from Extracorporeal Membrane Oxygenation WEANING FROM VA ECMO WEANING FROM VV ECMO WEANING THE PATIENT WITH SEPARATE RVAD, LVAD, AND ECMO Complications of Extracorporeal Membrane Oxygenation PERIPHERAL EXTREMITY ISCHEMIA The Anesthesiologist’s Role in Extracorporeal Membrane Oxygenation Acknowledgment References References 86 86 - Cardiopulmonary Resuscitation and Advanced Cardiac Life Support Sudden Cardiac Arrest and Cardiopulmonary Resuscitation BRIEF HISTORY AND PHYSIOLOGIC CONSIDERATIONS BASIC LIFE SUPPORT Recognition of Sudden Cardiac Arrest Bystander Cardiopulmonary Resuscitation Shock First or Chest Compressions? Automated External Defibrillators and Manual Defibrillation Single versus Stacked Defibrillation Determination of Efficiency of Cardiopulmonary Resuscitation Update to Airway Management and Ventilation in Cardiac Arrest ADVANCED CARDIAC LIFE SUPPORT: MANAGEMENT OF CARDIAC ARREST Asystole Pulseless Electrical Activity Pulseless Ventricular Tachycardia or Ventricular Fibrillation Resuscitation Medications During Cardiac Arrest . Epinephrine produces beneficial effects in patients during cardiac arrest, primarily due to its α-adrenergic effects increasin... . Vasopressin is a nonadrenergic peripheral vasoconstrictor that also causes coronary and renal vasoconstriction. Studies compar... . The role of antiarrhythmic medications during shock-refractory VF/pulseless VT is to facilitate the restoration and maintenanc... . The use of steroids in cardiac arrest has been assessed in both IHCA and OHCA settings. In IHCA, patients administered steroid... Cardiopulmonary Resuscitation in Patients With Mechanical Circulatory Support Cardiopulmonary Resuscitation Using a Mechanical Cardiopulmonary Resuscitation Device Echocardiography in Cardiac Arrest Cardiac or Respiratory Arrest Associated With Opioid Overdose Recognition and Emergency Response for Suspected Stroke Recognition and Management of Specific Arrythmias BRADYARRHYTHMIAS TACHYARRHYTHMIA Postresuscitation Interventions EMERGENCY PERCUTANEOUS CORONARY INTERVENTION TARGETED TEMPERATURE MANAGEMENT POSTRESUSCITATION OXYGEN AND VENTILATION THERAPY GLYCEMIC CONTROL IN THE POST–CARDIAC ARREST PATIENT DETERMINE THE CAUSE AND EXTENT OF INJURY AFTER CARDIAC ARREST Laboratory Testing Chest Radiographs Computed Tomography Imaging Magnetic Resonance Imaging of the Brain Echocardiography and Critical Care Ultrasonography TERMINATION OF RESUSCITATION EFFORTS—INDICATORS OF POOR OUTCOME POST-RETURN OF SPONTANEOUS CIRCULATION Pediatric Resuscitation PEDIATRIC BASIC LIFE SUPPORT PEDIATRIC ADVANCED LIFE SUPPORT HIGHLIGHTING THE SIMILARITIES OR DIFFERENCES VERSUS ADULT RESUSCITATION FOREIGN BODY AIRWAY OBSTRUCTION DROWNING SUDDEN UNEXPLAINED DEATHS TERMINATION OF PEDIATRIC RESUSCITATION ATTEMPTS Future of Resuscitation Science and Care INDIVIDUALIZED CARDIOPULMONARY RESUSCITATION Extracorporeal Membrane Oxygenation COORDINATED POSTRESUSCITATION CARE Acknowledgment References References 87 87 - Acute and Anesthetic Care of the Burn-Injured Patient Introduction Pathophysiology Burn Shock Negative Imbibition Pressure Permeability Effects Of The Burn Fluid Loss in Burns: The Temporal Aspect Mediators Important in Fluid Loss Hemodynamic Alterations Inhalation Injury Pathophysiology Diagnosis of Inhalation Injury Treatment Acute Management Patient Evaluation Estimation of Size and Depth of Burn Injury Fluid Resuscitation Endpoints for the Fluid Treatment Fluid Creep/Resuscitation Failure Electrical Injury Chemical Burns Cold Injury Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Special Considerations Pediatrics Elderly Obese Patients Infection Control Metabolic Considerations Nutrition Anesthetic Management Preoperative Evaluation Intraoperative Management Airway Management Vascular Access Ventilator Management Monitoring Pharmacologic Considerations Anesthetic Drugs Opioids NSAIDS α2 Agonists Anxiolytics Gabapentin Ketamine Regional Anesthesia Muscle Relaxants Fluid Management and Blood Loss During Excision Temperature Management Surgical Considerations Postoperative Care Pain Management Conclusion References References 88 88 - OCCUPATIONAL SAFETY, INFECTION CONTROL, AND SUBSTANCE ABUSE Physical Exposures INHALATIONAL ANESTHETICS Provider Health Effects Fetal Health Effects Mitigating Health effects RADIATION Ionizing Radiation: X-rays Mitigating Health Effects Nonionizing Radiation: Lasers SURGICAL SMOKE Infectious Exposures INFECTION PRECAUTIONS Standard Precautions Environmental Controls Needlestick and Sharps Safety Vaccine Preventable Illness TRANSMISSION OF INFECTIOUS AGENTS Contact Transmission Droplet Transmission Airborne Transmission Complex Transmission Bloodborne Organisms Emerging Diseases Substance Use Disorders EPIDEMIOLOGY ETIOLOGY IMPACT PREVENTION AND DETECTION INTERVENTION, TREATMENT, PROGNOSIS, AND REENTRY Fatigue INCIDENCE AND IMPACT GUIDELINES REQUIREMENTS AND RECOMMENDATIONS Acknowledgment References References 89 89 - Clinical Research Introduction Key Principles RANDOM ERROR SYSTEMATIC ERROR Confounding Selection Bias Information Bias DESIGN ERROR STATISTICAL INFERENCE Study Design OBSERVATIONAL STUDIES Descriptive Studies Analytic Studies Surveys Health Services Research EXPERIMENTAL STUDIES Unrandomized Studies Randomized Studies ANALYSES OF PUBLISHED RESEARCH Systematic Reviews Metaanalyses Individual Patient Metaanalysis Study Protocol HYPOTHESES POPULATION INTERVENTIONS AND COMPARATORS OUTCOMES SAMPLE SIZE DATA ANALYSIS PLAN SUPPORTING STUDIES Feasibility and Pilot Studies Sub-Studies Sub-Analyses Ethical and Regulatory Considerations ETHICS APPROVAL REGISTRATION REGULATORY APPROVAL DATA SHARING Study Management FINANCIAL MANAGEMENT DATA MANAGEMENT HUMAN RESOURCE MANAGEMENT ADVERSE EVENT REPORTING MONITORING AND AUDIT Study Reporting MANUSCRIPT AUTHORSHIP PUBLISHING RESEARCH INTEGRITY Reflection, Feedback, and Forward Planning References References 90 90 - Interpreting the Medical Literature Introduction INTENT OF THE CHAPTER The Publication Process TYPES OF JOURNALS TYPES OF JOURNAL ARTICLES THE PEER REVIEW PROCESS Accessing the Medical Literature PRIMARY LITERATURE SECONDARY LITERATURE TRADITIONAL AND SOCIAL MEDIA Assessing the Methodology of a Study THE “EVIDENCE PYRAMID” AND ITS EVOLUTION BASIC RESEARCH DESIGNS BIG DATA AND PRAGMATIC CLINICAL TRIALS Tools to Ensure Study Quality RECOGNITION OF THE NEED FOR STANDARDS IN STUDY REPORTING SUMMARY OF REPORTING GUIDELINES REGISTRATION OF CLINICAL TRIALS AND STUDY PROTOCOLS Interpreting the Analysis of a Study THE CONCERN OVER P < .05 REDUCING BIAS IN STUDY DESIGN CORRELATION VERSUS CAUSATION DATA-DRIVEN ANALYTIC METHODS The Dark Side of the Medical Literature INCENTIVES TO PUBLISH POOR-QUALITY RESEARCH For Researchers For Medical Journals MISCONDUCT IN THE PUBLICATION PROCESS EVOLVING MECHANISMS TO DETECT RESEARCH MISCONDUCT Conclusions References References
