Yao & Artusio’s Anesthesiology: Problem-Oriented Patient Management

Cover......Page 1
Contributors......Page 147
Preface......Page 172
Acknowledgments......Page 174
1 Asthma and Chronic Obstructive Pulmonary Disease......Page 175
A.2. What is the prevalence of asthma and chronic obstructive pulmonary disease (COPD)?......Page 179
A.3. What is the etiology of asthma?......Page 180
A.4. Discuss the pathogenesis of asthma. How is asthma distinguished from COPD?......Page 181
A.5. What are the triggers of bronchospasm?......Page 182
A.6. What is the universal finding in ABGs during asthmatic attacks: hypoxemia or CO2 retention?......Page 184
B.1. How would you evaluate the patient preoperatively? What preoperative workup would you order?......Page 185
B.2. How would you distinguish obstructive lung disease from restrictive lung disease by spirometry?......Page 187
B.3. Define normal lung volumes and lung capacities. Give normal values for an average adult male.......Page 188
B.4. What are flow–volume loops? Draw flow–volume loops for a healthy subject and patients with COPD, restrictive lung disease, fixed obstruction of the upper airway, variable extrathoracic obstruction, and variable intrathoracic obstruction.......Page 190
B.5. Define closing volume (CV) and closing capacity (CC). What is the normal value of CV?......Page 193
B.6. Why is the functional residual capacity (FRC) important in oxygenation?......Page 194
B.7. How are FRC and CC affected by age and posture? How are they affected by anesthesia?......Page 195
B.9. Interpret the following ABG: pH, 7.36; PCO2, 60 mmHg; PO2, 70 mmHg; and CO2 content, 36 mEq per L.......Page 196
B.11. How would you prepare this asthmatic patient with COPD for surgery?......Page 197
B.12. The patient comes to your perioperative clinic 2 weeks before surgery. He wants to know if his smoking puts him at increased risk during surgery. What do you tell him? Should he quit now?......Page 198
B.13. You discover that the patient had a recent upper respiratory infection (URI), would you postpone surgery? For how long?......Page 200
B.14. What medications would you expect the patient to have taken in the past or be taking at the present time?......Page 201
B.15. The patient was on 20 mg of prednisone per day for 5 days as part of the treatment of an asthma exacerbation 3 months ago. He is currently not on steroids. Should the patient receive stress-dose steroids?......Page 202
B.16. Should patients with reactive airway disease receive preoperative steroids?......Page 203
C.1 If the patient had a severe asthmatic attack in the operating room before the induction of anesthesia, would you proceed with the anesthetic or postpone the surgery?......Page 204
C.2. The patient did not have an asthmatic attack in the operating room and you proceed with induction. How would you induce anesthesia? Would you use a supraglottic airway instead of an endotracheal tube?......Page 205
C.4. Would you use thiopental, methohexital, etomidate, or ketamine for induction?......Page 207
C.5. Would you administer lidocaine for intubation?......Page 208
C.6. If this is an emergency surgery and rapid sequence induction is indicated, how would you induce anesthesia in this patient?......Page 209
C.7. Could a regional technique be used for this surgery? Discuss the advantages and disadvantages of neuraxial anesthesia in this patient for this surgery.......Page 211
C.8. Would you choose an inhalational or an intravenous technique for maintenance of anesthesia?......Page 212
C.9. What mechanisms produce bronchodilation from volatile anesthetics?......Page 213
C.10. Which muscle relaxants would you use? Why?......Page 214
C.11. How will you ventilate the patient? Will you use positive end-expiratory pressure (PEEP)? How can you detect the presence of auto-PEEP on your ventilator?......Page 215
C.12. What is the differential diagnosis of intraoperative bronchospasm?......Page 217
C.13. In the middle of surgery, peak inspiratory pressures (PIPs) suddenly increase. How do you manage this?......Page 218
C.14. How would you give β2-agonists? What is their mechanism of action on asthma?......Page 220
C.15. If the patient does not respond to the aforementioned treatment and becomes cyanotic, what would you do?......Page 222
C.16. The asthmatic attack was relieved with your treatment, and the surgery was completed. Following emergence, the patient was found to be hypoventilating. What are the common causes of hypoventilation? What will be your approach to treat hypoventilation?......Page 223
C.17. Would you consider a deep extubation in this patient?......Page 225
D.1. In patients with asthma and COPD, are there special considerations for the use of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative pain control?......Page 227
D.2. Would you consider using a regional technique for analgesia?......Page 228
D.4. The patient is hypoventilating in postanesthesia care unit (PACU). Would you initiate noninvasive ventilation (NIV)?......Page 230
2 Bronchoscopy, Mediastinoscopy, and Thoracoscopy......Page 232
A.1. How is the diagnosis of lung cancer made? What is your prediction for the most likely type of malignancy?......Page 234
A.2. What are the less common manifestations of bronchogenic carcinoma?......Page 236
A.3. The patient has a long history of cigarette smoking. What is the significance of this finding?......Page 237
B.1. How would you evaluate the patient prior to surgery?......Page 238
B.2. What are the pulmonary function guidelines that indicate an increased risk for morbidity and mortality?......Page 240
B.3. What are the preoperative concerns of induction immunotherapy?......Page 243
C.1. How would you premedicate, monitor, and anesthetize this patient?......Page 244
C.2. How many types of bronchoscopes are available and what are the intraoperative considerations of each one?......Page 247
C.3. What are the indications for cervical mediastinoscopy? Are there potential complications?......Page 250
C.4. The decision was made to proceed with a robotic right middle lobectomy. How would this alter your management?......Page 251
C.5. What are the indications for single-lung ventilation and how can it be accomplished?......Page 253
C.6. What are the contraindications to the use of double-lumen endotracheal tubes (DLTs)?......Page 256
C.7. Would you use a right- or left-sided DLT?......Page 257
C.8. How do you know that the tube is in the correct position?......Page 258
C.9. How many types of bronchial blockers are available? What are the advantages and disadvantages of bronchial blockers?......Page 261
C.10. How will systemic oxygenation be monitored during single-lung ventilation? What is the mechanism of pulse oximetry?......Page 264
C.11. The patient was placed in the lateral decubitus position. Describe the effects of lateral positioning on pulmonary blood flow and respiration.......Page 266
Respiratory Effects......Page 267
C.12. What is hypoxic pulmonary vasoconstriction (HPV)?......Page 268
C.13. What are the effects of anesthetic agents on HPV and their clinical implications?......Page 269
C.14. Discuss pulmonary blood flow distribution, shunt flow, and partial pressure of oxygen in the arterial blood (PaO2) (fractional inspired O2 concentration [FIO2] = 1.0) during single-lung ventilation in the lateral position.......Page 270
Ventilated Lung......Page 271
Collapsed Lung......Page 272
D. Postoperative Management......Page 273
D.2. Why is it important to control postoperative pain? How would you achieve this goal?......Page 274
Epidural, Paravertebral, and Intrathecal Analgesia......Page 275
Peripheral Nerve Blocks......Page 277
Systemic Opioids and Adjuvants......Page 278
Oral and Transdermal Agents......Page 279
Intrapleural Regional Analgesia......Page 280
Shoulder Pain after Lung Resection......Page 281
3 Aspiration and Postoperative Respiratory Failure......Page 283
A.1. What are the risk factors for perioperative aspiration?......Page 285
A.2. How does large volume aspiration affect the respiratory system?......Page 286
A.3. How should you manage the patient after an aspiration event?......Page 288
A.4. How would you prevent aspiration during emergency surgery?......Page 290
B.1. How can you predict which patients will develop postoperative respiratory failure?......Page 291
B.2. How can intraoperative anesthesia management prevent respiratory failure?......Page 292
B.3. What is the pathogenesis of postoperative respiratory failure?......Page 294
B.4. What is the diagnostic approach to postoperative respiratory failure?......Page 297
C.1. What are the indications for noninvasive positive pressure ventilation (NIPPV)?......Page 300
C.2. What are the indications for emergency endotracheal intubation?......Page 302
D.1. What is the definition and etiology of the acute respiratory distress syndrome (ARDS)?......Page 303
D.2. Explain the pathophysiology of ARDS.......Page 305
D.3. What role does ventilator-induced lung injury (VILI) play in ARDS?......Page 307
E.1. Which mode of mechanical ventilation will you choose? Describe the features of that mode.......Page 309
E.2. How should you set the fraction of inspired oxygen (FIO2)?......Page 314
E.3. How should you set the positive end-expiratory pressure (PEEP)?......Page 315
E.4. What tidal volume and inspiratory pressure target should you set?......Page 318
F.1. What else can promote additional lung recruitment?......Page 320
F.2. What rescue strategies can you use for refractory ARDS?......Page 322
G.1. What is the cause and treatment of the hemodynamic instability associated with mechanical ventilation?......Page 324
G.2. What is the adjunctive medical therapy for ARDS?......Page 327
H.1. Explain the importance of the decision to extubate the patient or continue mechanical ventilation.......Page 332
H.3. How will you recognize when the patient is ready for extubation?......Page 333
4 Lung Transplantation......Page 340
A.1. What are the expected manifestations of severe obstructive pulmonary disease in this patient, and why is she a transplant candidate?......Page 342
A.2. What other end-stage lung diseases can also be treated with transplantation?......Page 344
A.3. How many lung transplantations have been performed?......Page 348
A.4. What are the selection criteria for recipients?......Page 349
A.5. How is the decision made to transplant one or both lungs, and does this influence preoperative management?......Page 350
A.6. How does a single-lung transplantation (SLT) differ technically from a bilateral-lung transplantation (BLT)?......Page 352
B.2. Would you premedicate this patient? If so, how?......Page 355
B.3. What vascular access is appropriate?......Page 356
B.4. Is preoperative epidural catheter placement advantageous?......Page 357
C.2. How would you monitor this patient?......Page 358
C.3. How would you induce anesthesia in this patient?......Page 359
C.4. How would you ventilate this patient? What kind of endotracheal tube would you use?......Page 361
C.5. How does the physiology of single-lung ventilation influence the procedure?......Page 362
C.7. What problems are associated with the lateral position?......Page 364
C.9. At what specific points in the procedure are problems anticipated?......Page 365
C.10. How would you deal with problems related to clamping of the pulmonary artery (PA)?......Page 366
C.11. What hemodynamic alterations would you expect during graft implantation and reperfusion? How would you correct them?......Page 367
C.12. When is cardiopulmonary bypass (CPB) necessary for lung transplantation?......Page 369
C.13. Should fluid administration be restricted, and are blood products commonly required?......Page 370
C.14. Would you extubate the patient upon conclusion of the procedure?......Page 373
D.1. What are the major complications after lung transplantation?......Page 374
D.2. How is postoperative ventilation managed, and for how long is it required?......Page 376
D.3. What special precautions should be taken when a lung transplant recipient requires general anesthesia for subsequent nonpulmonary surgery?......Page 377
D.4. What are the long-term outcomes of lung transplantation?......Page 379
D.5. Are there surgical alternatives to lung transplantation?......Page 381
5 Ischemic Heart Disease and Coronary Artery Bypass Grafting......Page 383
A.1. What is triple-vessel CAD? Name the branches of the coronary arteries.......Page 388
A.2. What are the indications for CABG?......Page 389
A.3. What is percutaneous coronary intervention (PCI)? Discuss its indications, contraindications, and results.......Page 390
A.4. What are the expected results of CABG?......Page 393
B.1. Which preoperative tests would you order?......Page 395
B.2. How would you evaluate the patient’s left ventricular function?......Page 396
B.3. Which factors determine myocardial oxygen supply?......Page 397
B.4. What are the three major determinants of myocardial oxygen consumption? How are they measured clinically?......Page 398
B.5. Would you continue the β-blocker (metoprolol) on the day of surgery? Why/why not? What is its half-life? What is the role of β-adrenergic blockers in treating congestive heart failure (CHF)?......Page 399
B.6. Would you continue the angiotensin-converting enzyme (ACE) inhibitor on the day of surgery? Why/why not?......Page 400
B.7. If the patient who is on lisinopril develops hypotension intraoperatively, how would you manage it?......Page 401
C. Intraoperative Management......Page 402
C.I-1. What is your plan to monitor the patient?......Page 403
C.I-2. What is the Allen test?......Page 404
C.I-3. How would you monitor electrocardiogram (ECG)? Why lead V5? If you do not have precordial leads in your ECG machine, how can you monitor the left ventricle (LV)?......Page 405
C.I-4. Should you monitor temperature from multiple sites?......Page 406
Diagnostic......Page 407
Similar to Central Venous Catheter Insertion......Page 409
C.I-8. What are the hemodynamic consequences of myocardial ischemia? How can you detect myocardial ischemia? Is PAOP a sensitive indicator of myocardial ischemia?......Page 410
C.I-9. Discuss the principles and clinical applications of intraoperative transesophageal two-dimensional echocardiography.......Page 414
C.I-10. How would you induce anesthesia? Is there any advantage/disadvantage to using propofol versus etomidate as the main induction agent? What kind of neuromuscular blocker (NMB) would you use? Why?......Page 420
C.I-11. How would you maintain anesthesia? Volatile anesthetics or total intravenous anesthesia (TIVA)?......Page 422
C.I-12. What are the cardiovascular effects of volatile anesthetics, morphine, and fentanyl?......Page 424
C.I-15. If ST-segment depression is seen during surgery, how would you treat it? What is the relation between perioperative myocardial ischemia and postoperative MI?......Page 425
C.I-16. Discuss autologous transfusion and blood conservation for cardiac surgery.......Page 427
C.I-17. What antifibrinolytic will you use to reduce blood transfusions?......Page 429
C.I-18. How do you know that the tip of the PA catheter is in the right ventricle (RV) or the PA?......Page 431
C.II-1. What anticoagulant would you give before cardiopulmonary bypass (CPB)? How much would you give? What is its mechanism?......Page 432
C.II-2. What is the half-life of heparin? How is it eliminated?......Page 433
C.II-3. How do you monitor heparin dosage? What is the activated coagulation time (ACT) test?......Page 434
C.II-5. What kinds of pumps are used in CPB? Are they pulsatile or not?......Page 435
C.II-6. What is the purpose of venting the LV? How can it be done?......Page 436
Without Gas Interface......Page 437
C.II-8. What kind of priming solution would you use? How much priming solution would you use? When would you prime with blood? Why?......Page 439
Disadvantages of Hemodilution......Page 440
Clinical Monitoring......Page 441
Laboratory Monitoring at Least Once Every Hour......Page 442
C.II-11. What should your target BP be during CPB?......Page 443
C.II-12. How would you treat hypotension during CPB?......Page 445
C.II-14. How do you prepare an IV infusion of sodium nitroprusside, nicardipine, and nitroglycerin? What are the usual doses? Which do you prefer to use?......Page 447
C.II-15. How much pump flow would you maintain during CPB? During hemodilution? During hypothermia?......Page 450
C.II-16. How does blood viscosity change during hemodilution and hypothermia?......Page 452
C.II-18. Would you give muscle relaxants during CPB? How is the action of muscle relaxants affected during CPB?......Page 453
C.II-19. How do you know the patient is well perfused during CPB?......Page 454
C.II-20. How much gas flow would you use for the oxygenator? What kind of gas would you use? Why?......Page 455
C.II-22. How would you preserve the myocardium during CPB?......Page 456
C.II-23. What is cardioplegia? How much would you use?......Page 458
C.II-24. The arterial blood gases and electrolytes during CPB are as follows: pH, 7.36; PaCO2, 42 mmHg; PaO2, 449 mmHg; CO2 content, 24 mEq per L; sodium (Na), 128 mEq per L; potassium (K), 5.8 mEq per L; glucose, 180 mg/dL; and hematocrit, 20%. The patient’s temperature is 27°C (80.6°F). At what temperature are blood gases measured? How would you correct the blood gases according to patient’s body temperature? Would you treat the arterial blood gases at 37°C (98.6°F) or at patient’s body temperature?......Page 459
C.II-25. How does the blood sugar level change during CPB? Why? What is optimal glucose control intraoperatively? Does hyperglycemia increase neurologic complications during CPB?......Page 463
C.II-26. What are the effects of CPB on platelet and coagulation factors?......Page 467
C.II-27. If the blood level of the venous reservoir is low, what would you replace it with? Blood or balanced salt solution?......Page 468
C.II-29. For how long a period can the aorta be cross-clamped?......Page 469
C.II-31. Why does it take longer to rewarm than to cool the patient via the pump oxygenator?......Page 470
C.II-34. If the HR is 40 beats per minute, what should you do?......Page 472
Anesthesia Machine......Page 473
C.II-36. How would you decide the need for inotropic support?......Page 474
C.III-1. How would you reverse heparin? How much protamine would you use? What are the other drugs used to neutralize heparin?......Page 476
C.III-2. What is the action mechanism of protamine?......Page 477
C.III-4. What is a protamine reaction? How can you prevent this condition? How do you treat it?......Page 478
Cardiac Surgery......Page 483
C.III-6. What are the principles of IABP?......Page 484
D.1. Would you reverse the muscle relaxants? Why?......Page 485
D.3. What criteria would you use in deciding when to wean the patient from the ventilator?......Page 486
Pulmonary......Page 487
Hemorrhage......Page 488
6 Mechanical Circulatory Support......Page 489
A.2. How is an IABP placed and positioned?......Page 491
A.3. Describe an IABP inflation and deflation timing.......Page 492
A.4. How does the IABP help improve hemodynamics?......Page 494
A.5. What are the indications for IABP placement?......Page 496
A.6. What are the contraindications and potential complications of IABP placement?......Page 497
A.8. What are the main advantages and disadvantages of IABP support?......Page 498
A.10. What is a ventricular assist device (VAD)?......Page 499
A.11. What are the types of percutaneous/temporary VADs?......Page 500
A.12. What are the types of permanent VADs?......Page 501
A.13. How does VAD work?......Page 502
A.15. What are the physiologic considerations in patients requiring a VAD?......Page 503
A.17. What are common complications from VAD?......Page 504
B.1. What is the focus of the preoperative assessment of an LVAD patient?......Page 506
C.1. Detail the anesthetic management for a patient undergoing LVAD placement.......Page 508
C.2. How is a VAD patient monitored during a general anesthetic?......Page 511
C.3. Prescribe an anesthetic for a VAD patient.......Page 512
C.4. What is ECMO? What are the indications for ECMO? What are the different types of ECMO?......Page 514
C.7. What are the necessary equipment and teams required to place ECMO? What are the pros and cons of different venoatrial ECMO (VA-ECMO) cannula placement?......Page 516
C.8. How are patients monitored and managed while on ECMO?......Page 517
C.10. How frequently is VA-ECMO being used and how effective is it in cardiogenic shock?......Page 518
D.2. How is weaning from ECMO accomplished?......Page 519
7 Valvular Heart Disease......Page 522
A.1. What are the major etiologies of AS, AI, mitral stenosis (MS), and MR?......Page 525
A.2. What are the major changes in the loading conditions of the LV that result from the four different lesions? Why do they occur? What changes result from them?......Page 526
A.3. What are pressure–volume (P–V) loops? What do the different inflection points represent?......Page 529
A.4. What are representative P–V loops for the four valvular lesions?......Page 531
A.5. Draw the pressure/time curves for the LV, left atrium, pulmonary artery, and aorta for a normal patient and for patients with each of the four valvular lesions.......Page 534
Aortic Stenosis......Page 535
Aortic Insufficiency......Page 536
Mitral Stenosis......Page 537
Mitral Regurgitation......Page 538
A.6. What are the basic principles of echocardiography? What are M-mode, B-mode, and Doppler color modalities? How do TTE and transesophageal echocardiography (TEE) differ?......Page 539
A.7. What are the three TEE vantage points for the comprehensive imaging of the LV? How are pressure gradients measured by echocardiography? How do the pressure gradients derived from Doppler echocardiography differ from those obtained in the catheterization laboratory by direct pressure measurement?......Page 543
A.8. What is the role for three-dimensional (3D) echocardiography in the operating room?......Page 547
Aortic Stenosis......Page 548
Aortic Insufficiency......Page 550
Mitral Regurgitation......Page 551
Aortic Stenosis......Page 553
Mitral Regurgitation......Page 554
B.2. What is the New York Heart Association classification of heart failure?......Page 555
B.4. How would you premedicate the patient with severe AS and MR?......Page 556
C.1. Outline the hemodynamic management goals for each of the four valvular lesions. What are the anesthetic goals with respect to heart rate and rhythm, preload, afterload, and contractility?......Page 557
Mitral Stenosis......Page 558
C.2. What are the hemodynamic goals for this patient with the combination of severe AS and MR?......Page 559
C.4. Should the patient have a pulmonary artery catheter placed before induction?......Page 560
C.5. Is a pulmonary artery catheter with pacing capabilities indicated?......Page 561
C.7. What muscle relaxant would you use for this patient?......Page 562
C.8. What are the usual TEE findings in a patient with AS or MR? How do you grade the severity of AS by TEE? How do you quantify the severity of MR? What is the impact of AS on the severity of MR?......Page 563
Aortic Stenosis......Page 565
Mitral Stenosis......Page 566
Mitral Regurgitation......Page 567
C.10. The patient cannot be weaned from CPB following an AV replacement and MV replacement. What are the possible causes?......Page 568
C.11. How would you diagnose right-sided heart failure and pulmonary hypertension? How would you treat it?......Page 569
C.12. How does an intra-aortic balloon pump (IABP) work to benefit the failing heart?......Page 571
C.15. How would you properly time the IABP cycle?......Page 572
C.17. What is the role for ventricular assist devices?......Page 573
D.1. In the intensive care unit (ICU) 4 hours later, the patient became hypotensive with a low cardiac output. How could you distinguish between cardiac tamponade and pump failure? How would the TEE images differ?......Page 574
D.2. Would you extubate this patient early in the ICU? Why?......Page 575
D.3. What are the advantages and disadvantages of early extubation?......Page 576
E.2. How is percutaneous MV repair performed?......Page 577
E.5. What anesthetic techniques and monitors are used?......Page 578
E.6. What is minimally invasive cardiac valve surgery?......Page 579
8 Pacemakers, Implantable Cardioverter-Defibrillators, and Cardiac Resynchronization Therapy Devices......Page 581
A.1. What are the indications for PPMs?......Page 584
A.2. What is sick sinus syndrome? What is chronotropic incompetence?......Page 586
A.3. How would you diagnose first-, second-, and third-degree AV block; bifascicular block (right bundle branch block [RBBB] with left anterior fascicular hemiblock or left posterior fascicular hemiblock); and trifascicular block?......Page 587
A.4. Is it necessary to insert a temporary pacemaker before general anesthesia for an asymptomatic patient with bifascicular or trifascicular block?......Page 590
A.5. What are the three-letter and five-letter identification codes of the North American Society of Pacing and Electrophysiology (NASPE) and British Pacing and Electrophysiology Group (BPEG) generic (NBG) code for pacemaker classification?......Page 591
A.6. How many modes of pacing are available in modern PPMs? How do they work? What is the difference between DDD pacing and DDI pacing?......Page 592
A.7. The patient was mechanically hyperventilated during surgery, and her pacemaker gradually increased her heart rate. What feature of the PPM is accounting for this?......Page 595
A.8. What are the advantages and disadvantages of atrial pacing only? What are the disadvantages of right ventricular pacing only?......Page 596
A.10. How would you know if the patient’s PPM was atrially, ventricularly, or atrioventricularly sequentially pacing?......Page 598
A.11. What is a biventricular PPM or CRT device? What are the indications for such a device?......Page 599
A.13. What is an ICD? How does it work? What is a subcutaneous ICD?......Page 600
A.14. What are the indications for ICDs?......Page 604
A.15. What is the NASPE and BPEG generic defibrillator (NBD) code?......Page 605
B.1. How would you preoperatively evaluate the patient described earlier?......Page 606
B.2. How do you determine whether the patient has a cardiac implantable electronic device (CIED) and define what type of CIED?......Page 607
B.3. How do you determine whether the patient is dependent on the pacing from the CIED?......Page 609
B.4. How do you know if the implanted PPM or ICD is working?......Page 610
B.6. How do you preoperatively prepare the patient for surgery and anesthesia?......Page 611
B.7. Would you recommend reprogramming this device to asynchronously pace before surgery? What would you recommend regarding the ICD functions of the device?......Page 612
B.8. The patient requires an abdominal magnetic resonance imaging (MRI) prior to the surgery. What considerations should you make regarding her CIED?......Page 613
C.2. What drugs and equipment would you like to have on hand in the operating room?......Page 615
C.3. How would you set up the transcutaneous external pacer and defibrillator?......Page 616
C.4. Had this patient’s ICD been implanted the day before surgery, would you consider avoiding certain inhalational gases for anesthesia?......Page 617
C.6. What are the potential responses of pacemakers and ICDs to electrocautery?......Page 618
C.7. How would you prevent the effects of EMI on the pacemaker or ICD from the electrocautery?......Page 619
C.8. What are the effects of a magnet on pacemakers and ICDs?......Page 620
C.9. In the middle of surgery, the patient developed ventricular tachycardia. What would you do?......Page 621
C.10. What precautions should be taken when a patient with a CIED is undergoing extracorporeal shock wave lithotripsy (ESWL)?......Page 622
C.11. Is electroconvulsive therapy (ECT) contraindicated in patients with pacemakers or ICDs?......Page 623
C.12. What precautions should be taken during radiofrequency ablation for a patient with a CIED?......Page 624
C.13. During surgery, the patient developed frequent premature ventricular complexes and some of these resulted in rapid ventricular pacing (see Fig. 8.8). What is accounting for the pacemaker’s behavior?......Page 625
D.2. How would you confirm that the CIED is functioning properly after surgery?......Page 626
9 Thoracic and Thoracoabdominal Aortic Aneurysms......Page 628
A.1. What is a thoracic aortic aneurysm (TAA) and TAAA, and how do they typically present?......Page 630
A.2. How are TAAs and TAAAs classified?......Page 634
A.3. What is the pathogenesis of aortic aneurysms and what genetic conditions predispose to their formation?......Page 635
A.4. What are the risk factors for TAA rupture?......Page 639
A.5. What is the natural history and medical management of thoracic aneurysms?......Page 640
A.6. What is a thoracic aortic dissection, and how does it typically present?......Page 641
DeBakey Classification......Page 644
Penn Classification......Page 645
B.1. What are the indications and timing of surgical intervention for TAAs?......Page 647
B.2. Which patients are candidates for endovascular aortic repair, and what are the advantages to this approach?......Page 650
B.3. What are the preoperative considerations for the anesthesiologist before TAA repair?......Page 651
Cardiovascular......Page 652
Renal......Page 653
Neurologic......Page 654
B.4. What is the preoperative management of a patient presenting with an acute aortic dissection (AAD)?......Page 655
B.5. What is the spinal cord blood supply?......Page 656
Ascending and Arch Aortic Aneurysms......Page 658
Thoracoabdominal Aneurysms......Page 661
Ascending and Arch Aortic Aneurysms......Page 665
Thoracoabdominal Aneurysms......Page 668
C.3. How are endovascular repairs of TAAAs performed?......Page 672
Type A Aortic Dissection......Page 673
Type B Aortic Dissection......Page 677
C.5. What are the specific considerations for anesthetic management of the patient presenting for open TAAA repair?......Page 680
C.6. What are the specific considerations for anesthetic management of the patient presenting for endovascular TAAA repair?......Page 682
C.7. What hemodynamic monitors should be used for the patient undergoing thoracic aneurysm repair?......Page 683
C.8. What strategies are used for spinal cord protection during a TAAA repair?......Page 684
Cerebrospinal Drainage......Page 685
Hypothermia......Page 686
C.9. What strategies are used for mesenteric and renal preservation?......Page 687
Aortic Clamping......Page 689
Aortic Unclamping......Page 691
C.11. Why does a coagulopathy ensue and how is it prevented/treated?......Page 692
Renal Failure......Page 694
Left Upper Extremity Ischemia......Page 695
Spinal Cord Ischemia......Page 696
Endograft Collapse......Page 697
Endoleaks......Page 698
10 Abdominal Aortic Aneurysm Repair......Page 700
A.2. What other diseases are commonly found in patients with aortic aneurysms?......Page 703
A.3. What is the incidence of morbidity and mortality in these patients if they undergo elective open surgical repair? What is the natural history of the disease without surgical repair?......Page 704
A.4. What should be done for smaller aortic aneurysms that are found in patients?......Page 705
A.5. What is the risk of perioperative myocardial infarction (MI) in patients with ischemic heart disease? What can be done to reduce the risk of ischemic events in these patients?......Page 706
A.6. Does the morbidity and mortality of elective repair of an aortic aneurysm differ significantly from that of an emergency repair?......Page 712
B.2. What is the significance of the preoperative ECG? Would you wish to pursue a preoperative cardiac workup? What tests would you request, and what would they tell you?......Page 713
B.3. Is it necessary to evaluate this patient’s pulmonary status?......Page 717
B.4. Preoperative arterial blood gas (ABG) measurement shows pH, 7.35; PaCO2, 47 mmHg; and PaO2, 68 mmHg on room air. What is the significance of this result?......Page 719
B.5. How would you measure creatinine clearance in this patient, and what is its value in this case?......Page 720
B.6. Describe the blood flow to the spinal cord. What is its relevance to surgery involving the abdominal aorta?......Page 721
B.7. How do you detect spinal cord ischemia?......Page 723
B.8. What are the various surgical approaches to repair an AAA?......Page 725
B.9. How does the choice of surgical technique affect the anesthetic management?......Page 728
B.10. How would you premedicate this patient?......Page 729
C.1. Would you use an arterial line? What are the complications of arterial line placement?......Page 730
C.2. What various monitors are available for myocardial ischemia? Is a pulmonary artery catheter (PAC) helpful in determining the occurrence of ischemia?......Page 731
C.3. What additional monitors would you employ?......Page 732
C.5. How would you anesthetize this patient for an open repair of the aorta? What techniques could be used for an endovascular aortic aneurysm repair? Discuss the various anesthetic techniques that can be employed for this surgery.......Page 735
C.6. This patient is to be heparinized intraoperatively, and anticoagulation may be continued postoperatively. Is this a contraindication to the preoperative placement of either an epidural or intraspinal catheter? What if the patient is receiving anticoagulants in the preoperative period?......Page 737
C.7. What are your plans for fluid and blood replacement during surgery?......Page 739
C.8. What are the hemodynamic changes of aortic cross-clamp placement? What efforts can be made to minimize these changes both before and during cross-clamping? If the patient develops ST-segment depressions with a rising pulmonary capillary wedge pressure (PCWP) during cross-clamp, what maneuvers should be taken?......Page 740
C.9. Because this case involves an infrarenal aneurysm, is renal blood flow affected with the placement of the cross-clamp? If an endovascular repair is chosen, what are the risks to the kidneys? Are there any treatment maneuvers that can be taken to minimize these risks in either repair?......Page 742
C.10. What are the hemodynamic consequences of aortic cross-clamp removal? What can be done to minimize the effects of removing the aortic cross-clamp? If the systemic blood pressure remains depressed after removal of the cross-clamp, what is the differential diagnosis? How would you diagnose and correct the problem?......Page 744
D.1. What are the parameters used to extubate this patient?......Page 746
D.2. What are the anticipated changes in postoperative pulmonary function in these patients? How does the surgical technique affect postoperative pulmonary function? Are there any postoperative maneuvers that can improve respiratory parameters?......Page 747
D.3. How would you control postoperative pain? What are the alternatives in the management of this patient’s postoperative pain?......Page 748
11 Hypertension......Page 751
A.1. Define hypertension and categorize its severity.......Page 753
A.2. What is the prevalence of hypertension?......Page 756
A.3. What is the general classification of hypertension? Enumerate the causes of each type of hypertension.......Page 757
A.4. What are the clinical patterns of hypertension encountered?......Page 758
A.5. What is the pathophysiology of essential hypertension?......Page 759
A.6. What is the pathophysiology of isolated systolic hypertension (ISH) and of pulse pressure hypertension (PPH)?......Page 760
Renal Involvement......Page 762
A.8. Are hypertensive patients at an increased risk for perioperative cardiac morbidity?......Page 763
A.9. Perioperative cerebral and renal complications are mostly associated with which subtype of hypertension?......Page 765
A.10. Would you employ a controlled hypotensive technique for hypertensive patients? How much would you safely lower the BP?......Page 766
A.11. What are the BP goals for patients with hypertension and when should antihypertensive drugs be initiated?......Page 769
Antiadrenergic Agents......Page 770
Dopaminergic Agonists......Page 771
Calcium Channel Blockers......Page 772
Angiotensin II Receptor Blockers......Page 773
Other Vasodilators......Page 774
A.14. Does chronic angiotensin-converting enzyme (ACE) inhibition influence anesthetic induction?......Page 775
B.1. How would you evaluate this patient preoperatively?......Page 777
B.2. Would you postpone the surgery? Why? What BP would you like the patient to achieve before surgery?......Page 779
B.3. Should all or any of the chronic medications be discontinued before the operation?......Page 780
B.4. Should hypokalemia be treated before anesthesia? Why?......Page 781
B.6. Does an asymptomatic carotid bruit increase the risk in these patients?......Page 782
B.8. If the patient is an untreated hypertensive patient with BP 170/70 mmHg, would you treat the patient preoperatively with an antihypertensive agent?......Page 783
C.1. How would you monitor this patient?......Page 784
C.2. What are the anesthetic goals for hypertensive patients?......Page 785
C.4. How does tracheal intubation produce hypertension?......Page 787
C.6. What other measures can prevent hypertension and tachycardia at the time of intubation?......Page 788
C.7. After induction and intubation, the BP decreased to 70/40 mmHg. What would you do?......Page 789
C.8. What is your choice of agents for maintenance of anesthesia? Why?......Page 790
C.9. How would you manage fluid therapy for hypertensive patients?......Page 791
C.10. During the surgery, BP increased to 220/120 mmHg. How would you treat the hypertension?......Page 792
C.11. What could you do to prevent hypertension during extubation and emergence?......Page 793
D.1. The patient developed hypertension, BP 210/110 mmHg, in the postanesthesia care unit. What would you do?......Page 794
12 Cardiac Tamponade......Page 796
A.1. What is the differential diagnosis of low CO following cardiac surgery?......Page 798
A.2. Describe the pathophysiology of cardiac tamponade.......Page 800
A.3. What are the common etiologies of cardiac tamponade?......Page 801
A.4. What is the difference between acute and delayed cardiac tamponade?......Page 803
A.5. What is regional cardiac tamponade?......Page 804
A.6. Describe the ventricular interaction in cardiac tamponade.......Page 806
A.8. What is the Beck triad? Describe the typical signs and symptoms of cardiac tamponade.......Page 809
A.9. Define pulsus paradoxus and describe its pathophysiology.......Page 811
A.10. What is Kussmaul sign? Is this finding consistent with tamponade physiology?......Page 813
A.11. Which medical conditions mimic cardiac tamponade?......Page 815
B.1. Interpret and explain the pathophysiologic basis for this patient’s hemodynamic findings.......Page 816
B.2. How would you optimize this patient’s cardiovascular status prior to definitive diagnosis and treatment?......Page 818
B.3. What are the radiographic findings in tamponade?......Page 821
B.4. A limited bedside transthoracic echocardiogram is performed, demonstrating a layer of clotted blood anterior to the right atrium (RA) and ventricle. What echocardiographic findings support the diagnosis of tamponade?......Page 822
B.5. What additional information should be obtained from a limited echocardiographic study?......Page 825
B.6. Describe the procedures for treating cardiac tamponade. What are the clinical indications for each approach?......Page 826
B.7. Having made the diagnosis of tamponade, what additional investigations are required prior to surgery?......Page 828
B.8. Explain the technical and physiologic principles behind rotational thromboelastometry.......Page 829
B.9. A rotational thromboelastometry was performed, and a 10-minute analysis reveals the following results (see Fig. 12.9 and Table 12.8). How do you interpret this information?......Page 830
B.10. Given the ROTEM® findings and high clinical suspicion for occult postsurgical bleeding, what hemostatic products would you arrange to have in the operating room?......Page 832
B.11. How would you organize and conduct the transport of this patient to the operating room?......Page 833
Propofol......Page 834
Ketamine......Page 835
Midazolam......Page 836
C.2. What is the effect of supine positioning and positive pressure ventilation on the hemodynamics of a patient with tamponade?......Page 837
C.3. Describe the induction process for cardiac tamponade.......Page 838
C.4. Following induction and intubation, the systemic blood pressure decreases to 55/30 mmHg. Describe your management.......Page 839
C.5. What hemodynamic changes are frequently associated with opening the pericardial space?......Page 840
C.6. Following the removal of approximately 500 mL of dark blood and clots from the mediastinum, the patient’s CO remains low. What are your differential diagnoses?......Page 842
C.7. What is pericardial decompression syndrome (PDS)?......Page 843
D.1. A pericardial drain is placed following mediastinal decompression. How should this drainage tube be managed?......Page 844
D.2. How would you manage hypertension in the intensive care unit?......Page 845
13 Heart Transplantation and Subsequent Noncardiac Surgery......Page 848
A.1. What are the common diagnoses requiring adult heart transplantation?......Page 851
A.2. What are the indications and relative contraindications for recipient selection?......Page 852
A.3. What are the criteria for donor heart selection?......Page 853
A.4. What is the role of donation after cardiac death (DCD) for heart transplantation?......Page 855
A.5. What are the principles of perioperative donor management?......Page 856
A.6. What are the risk factors associated with posttransplant mortality?......Page 857
A.8. When is a combined heart/lung transplant indicated? What are the important differences?......Page 859
A.9. What are the medical and surgical alternatives to cardiac transplantation?......Page 860
A.10. What is the role of ventricular assist devices (VADs) in this type of patient?......Page 861
A.11. What are the considerations in anesthetizing patients for LVAD insertion?......Page 862
B.1. How would you assess this patient preoperatively?......Page 863
C.1. What anesthetic equipment and monitors would you set up? Why?......Page 865
C.2. What is the role of transesophageal echocardiography (TEE)?......Page 866
C.3. Describe the induction and maintenance of anesthesia.......Page 867
C.4. How would you manage this patient during cardiopulmonary bypass (CPB)?......Page 868
D.3. How would you treat RV failure following heart transplantation?......Page 869
D.5. What is the pathophysiology of the denervated heart?......Page 871
D.6. What are the common cardiac dysrhythmias following heart transplant?......Page 872
D.8. How would you treat posttransplant bleeding?......Page 873
D.9. What are the causes of early graft failure?......Page 874
D.10. How would you manage this patient in the intensive care unit?......Page 875
E.1. How would you monitor this patient?......Page 876
E.4. Do you need to use a muscarinic antagonist with cholinesterase inhibitors to reverse the muscle relaxant in heart-transplanted patients?......Page 877
E.5. What are the anesthetic implications for heart-transplanted patients?......Page 878
E.6. What is the significant implication of the denervated heart?......Page 879
E.8. What is the significance of infection in these patients?......Page 880
E.10. What is cardiac allograft vasculopathy (CAV)? Why is this important?......Page 881
E.11. What is the significant implication of posttransplant hypertension?......Page 882
E.12. What is the significant implication of renal dysfunction?......Page 883
E.14. Is ambulatory surgery appropriate for heart transplant recipients?......Page 884
14 Ischemic Heart Disease and Noncardiac Surgery......Page 886
A.1. What are the preoperative predictors for major adverse cardiac events (MACE) perioperatively?......Page 888
A.2. What are the determinants of myocardial oxygen demand? How are they measured clinically?......Page 891
A.4. What is the mechanism of perioperative myocardial ischemia and MI?......Page 892
A.5. What is the incidence of perioperative reinfarction for noncardiac surgery?......Page 894
β-Adrenergic Antagonists (Esmolol, Atenolol, Metoprolol, Bisoprolol)......Page 895
Nitrovasodilators (Nitroglycerin, Isosorbide Dinitrate)......Page 897
Calcium Channel Blockers (Verapamil, Diltiazem, Nifedipine, Nicardipine)......Page 898
Aspirin......Page 899
Statins......Page 900
A.7. Based on his MI, would you recommend that the surgery be postponed for a certain period of time? If so, why?......Page 901
A.8. Would you recommend that this elective colectomy be postponed if the patient underwent placement of a right coronary artery, second-generation DES, and is taking aspirin and clopidogrel (Plavix)?......Page 902
B.1. How would you evaluate the patient’s cardiac condition? What laboratory tests would you like to order?......Page 907
B.2. Would you recommend further cardiac testing or coronary revascularization before surgery?......Page 908
B.3. How would you classify the cardiac risk according to the type of surgery?......Page 910
B.4. What is the role of exercise or pharmacologic stress test for this patient?......Page 911
B.5. Would you discontinue any medication before surgery?......Page 913
B.7. Is there a role for α2-agonist in premedication?......Page 914
Intraoperative Predictors......Page 915
C.2. How would you monitor the patient in the operating room?......Page 916
C.3. What electrocardiogram (ECG) leads would you monitor? Why lead V5?......Page 917
C.4. Would you use a pulmonary artery catheter (PAC)?......Page 918
C.5. Would you use transesophageal echocardiography (TEE) as a monitor?......Page 919
C.6. Is regional anesthesia better than general anesthesia for patients with cardiac disease?......Page 920
C.7. How will you induce general anesthesia?......Page 921
C.9. What is the best choice of anesthetic agents for maintenance of anesthesia? Why?......Page 923
C.10. You notice a new 3-mm ST-segment depression in lead V5. How would you treat it?......Page 925
C.11. Would you give prophylactic intravenous NTG to prevent myocardial ischemia?......Page 926
C.12. What is the significance of tight control of the heart rate intraoperatively?......Page 927
D. Postoperative Management......Page 928
D.1. What are the postoperative predictors of perioperative MACE?......Page 929
D.2. How would you control postoperative pain?......Page 930
D.3. Is postoperative anemia associated with adverse cardiac outcome?......Page 931
D.4. Is postoperative hypothermia associated with postoperative myocardial ischemia?......Page 932
D.5. How would you make a diagnosis of perioperative MI (PMI)?......Page 933
D.6. How would you manage the patient with a suspected PMI?......Page 935
15 Intestinal Obstruction and Enhanced Recovery after Surgery......Page 938
A.1. What is the differential diagnosis of the acute abdomen?......Page 940
A.3. Differentiate between simple and strangulated bowel obstruction.......Page 943
A.4. Is it important to differentiate whether the bowel obstruction is located in the small bowel or large bowel? Why? How might the distinction be made?......Page 944
A.5. What are the causes and effects of bowel distention?......Page 946
A.6. Describe the fluid shifts during small bowel intestinal obstruction.......Page 948
A.7. Discuss the systemic derangements that occur with intestinal obstruction.......Page 951
A.8. What is an ileus? Discuss its causes and pathophysiology.......Page 952
B.1. What is Enhanced Recovery after Surgery (ERAS)? What are the core tenants of these programs?......Page 953
B.3. What components of ERAS are applied in the preoperative phase of the care of colorectal surgery (CRS) patients?......Page 954
B.4. Is it important to decompress the abdomen before induction of anesthesia? Why?......Page 956
B.6. What are the implications of the tense abdominal wall?......Page 957
B.7. Outline the methods of abdominal decompression.......Page 958
B.8. Discuss the goals of fluid management.......Page 959
B.9. What would you use as a guide to fluid volume replacement?......Page 960
C.1. What dangers are present during induction? How are they planned for?......Page 963
C.3. In what position would you intubate this patient?......Page 965
C.5. Would you remove or leave the nasogastric tube (NGT) in place before inducing anesthesia?......Page 966
C.7. Are there any benefits to using a high concentration of inspired oxygen (FIO2)?......Page 967
C.8. What components of ERAS are applied in the intraoperative phase of the care of CRS patients?......Page 969
Weakness......Page 978
Challenges......Page 979
D.1. What are the principles of postoperative care in this patient?......Page 980
D.2. Are there any postoperative respiratory problems associated with factors other than aspiration?......Page 981
D.3. If the patient did aspirate gastric contents, what are the possible sequelae of this event? What is the treatment?......Page 982
D.4. What is gram-negative sepsis? Describe the clinical picture and treatment.......Page 983
D.5. What components of ERAS are applied in the postoperative phase of the care of CRS patients?......Page 986
16 Liver Transplantation......Page 993
A.1. What are the potential graft options for liver transplantation?......Page 996
A.2. What are the indications and contraindications for liver transplantation?......Page 997
A.3. What is acute liver failure (ALF)?......Page 998
A.4. What is the MELD score, and how is it used in liver transplantation evaluation?......Page 999
A.5. What is portal hypertension? What are the sequelae of portal hypertension?......Page 1001
A.6. Describe the cardiovascular system of patients with end-stage liver disease (ESLD).......Page 1002
A.7. What causes acute kidney injury (AKI) in patients with cirrhosis?......Page 1003
A.9. Discuss the neurologic manifestations of acute and chronic liver disease.......Page 1005
A.10. Why do patients with ESLD have abnormalities of hemostasis?......Page 1007
A.11. What is the differential diagnosis for hypoxemia in patients with cirrhosis?......Page 1009
A.12. What are the risk factors and treatment guidelines for spontaneous bacterial peritonitis (SBP)?......Page 1010
B.1. What preoperative workup is desirable?......Page 1011
B.2. How is ascites managed preoperatively?......Page 1013
B.3. How is hyponatremia managed preoperatively?......Page 1014
B.4. What is a transjugular intrahepatic portosystemic shunt (TIPS) procedure? What is the role of TIPS in the management of patients with ESLD?......Page 1015
B.5. How are hepatic encephalopathy and elevated intracranial pressure (ICP) treated?......Page 1016
B.6. Should this patient be transfused with fresh frozen plasma prior to surgery?......Page 1018
C.1. What monitors would you use? Why?......Page 1019
C.3. How does liver disease affect intraoperative medication management?......Page 1020
C.4. What happens during the first stage (preanhepatic phase) of the liver transplant operation?......Page 1022
C.5. What happens during the second stage (anhepatic phase) of the liver transplant operation?......Page 1023
C.7. What is venovenous bypass? What are the potential advantages and disadvantages of this procedure?......Page 1024
C.8. What surgical techniques anastomose the donor and recipient inferior vena cava (IVC)?......Page 1026
C.9. What are the potential advantages of the “piggyback” (vena cava preservation) technique?......Page 1027
C.10. What hemodynamic changes are expected after removal of vascular clamps? What is postreperfusion syndrome (PRS)?......Page 1028
C.13. What happens during the third stage of the liver transplant operation?......Page 1029
C.14. What causes intraoperative bleeding during each phase of liver transplantation? How is coagulopathy monitored and treated? What are thromboelastography (TEG) and rotational thromboelastography (ROTEM)?......Page 1030
C.16. How are the complications of massive transfusion prevented?......Page 1032
C.17. How is hyperfibrinolysis managed?......Page 1033
D.1. What are the goals of immediate postoperative care of the liver transplant patient?......Page 1034
D.3. What coagulation disturbances should be anticipated in the postoperative period?......Page 1035
D.5. What vascular and biliary complications occur after liver transplantation?......Page 1036
D.6. What immunosuppressive agents will be given after liver transplantation? What are the major side effects?......Page 1037
Acknowledgment......Page 1039
17 Brain Tumor and Craniotomy......Page 1040
A.1. What is the pathology of intracranial tumors?......Page 1043
A.2. What is intracranial pressure (ICP), and what are its determinants?......Page 1045
A.3. How does the presence of a mass alter the ICP in this patient, and what are the clinical manifestations of these alterations?......Page 1047
A.4. What is cerebral blood flow (CBF), and what are its determinants?......Page 1049
A.5. What are the cerebral steal syndromes?......Page 1053
A.6. Are there any issues specific to posterior cranial fossa pathology?......Page 1054
A.7. What is the role of preoperative embolization therapy?......Page 1056
B.1. What are the special considerations in preoperative evaluation of the patient scheduled for posterior fossa craniotomy?......Page 1058
B.2. In a patient who presents with intracranial hypertension, what management might have already been initiated preoperatively, and what are the implications for anesthetic management?......Page 1059
B.3. What are the types of intraoperative neurophysiologic monitoring (IOM) that would likely be used for this procedure, and how will they affect the anesthetic management plan?......Page 1061
B.4. What are the options for patient positioning during posterior fossa surgery?......Page 1065
B.5. What are the principal disadvantages associated with the common posterior fossa craniotomy positions?......Page 1066
B.6. How does the sitting position affect your preoperative assessment and planning?......Page 1068
B.7. How should the patient position ultimately be determined?......Page 1071
B.8. Should this patient receive premedication?......Page 1072
C.1. What are the anesthetic goals for craniotomy?......Page 1073
C.2. What monitors should be used during craniotomy?......Page 1075
C.3. Would you monitor for venous air embolism (VAE)? What are the monitoring options?......Page 1076
C.4. What specific risks are associated with induction of anesthesia?......Page 1079
C.5. How would you induce anesthesia?......Page 1080
Volatile Anesthetics......Page 1083
Nitrous Oxide......Page 1084
Intravenous Anesthetics......Page 1085
Opioids......Page 1086
C.7. How would you manage ventilation and maintain arterial carbon dioxide (CO2)?......Page 1088
C.8. How would you approach diuretic therapy?......Page 1089
C.9. How would you manage serum glucose?......Page 1091
C.10. How would you approach fluid management?......Page 1093
C.11. Once the bone plate is removed and the dura retracted, the surgeon reports that the brain is still “tight.” What would be your response?......Page 1094
C.12. If deliberate hypotension is indicated, how will you achieve it?......Page 1095
C.13. While the surgeon is resecting tumor from near the brainstem, the patient’s heart rate suddenly drops to 20 beats per minute. What is your assessment and management?......Page 1096
C.14. Are there any measures you can take to prevent VAE?......Page 1097
C.15. During the procedure, the precordial Doppler becomes loud and turbulent. The end-tidal CO2 (EtCO2) drops from 31 to 13 mmHg, and the systemic pressure from 121/63 to 64/32 mmHg. What is your assessment and management plan?......Page 1098
C.16. What is your approach to emergence? What if the patient does not regain consciousness?......Page 1100
D.1. What postoperative complications are of greatest concern? What level of monitoring is required?......Page 1102
D.2. What is your approach to postoperative pain control?......Page 1103
D.3. In the ICU, the patient’s neurologic status deteriorates and ICP monitoring is instituted. What are the different methods of monitoring ICP, and what are their limitations?......Page 1105
18 Carotid Artery Disease......Page 1108
A.1. What are the presenting symptoms of carotid stenosis?......Page 1111
A.2. What is the prevalence of carotid artery disease?......Page 1112
A.3. What is the natural course of carotid artery disease as it relates to stroke?......Page 1113
A.5. Do we screen patients for asymptomatic carotid stenosis?......Page 1114
A.7. What are the current medical options that the patient has for treating carotid atherosclerosis?......Page 1115
A.8. What are the indications for CEA and carotid artery stenting (CAS) in asymptomatic carotid atherosclerotic disease?......Page 1116
A.9. What are the indications for performing a CEA in symptomatic carotid stenosis?......Page 1118
A.10. Is there any role for CAS in symptomatic patients?......Page 1120
A.11. Discuss the anatomy of the cerebral vasculature, including the carotid artery and the circle of Willis.......Page 1121
A.12. Discuss cerebral blood flow (CBF) in the presence of carotid artery disease.......Page 1122
A.13. Discuss the different surgical approaches to carotid revascularization.......Page 1124
A.14. Discuss the endovascular approaches to carotid stenting.......Page 1126
A.16. What is critically low CBF as measured by the electroencephalogram (EEG)?......Page 1129
A.17. What is cerebral autoregulation?......Page 1130
A.18. How does PaCO2 affect CBF?......Page 1131
A.21. What is meant by the term intracerebral steal?......Page 1132
B.1. What will you look for in your preoperative evaluation of this patient?......Page 1133
B.2. Is this patient’s blood pressure too high for elective surgery?......Page 1134
B.3. What laboratory data are required preoperatively?......Page 1136
B.5. Will you premedicate this patient?......Page 1137
C.2. How will you know that the patient’s cerebral perfusion is adequate during surgery?......Page 1138
C.3. Discuss the differences and relative advantages and disadvantages of unprocessed EEG and processed EEG monitoring.......Page 1139
C.4. How will you measure CBF intraoperatively? What are the relative advantages and disadvantages of each technique?......Page 1142
C.5. Describe the use of stump pressure and its limitations.......Page 1143
C.7. Describe the use of jugular venous oxygen saturation (SjvO2) and its limitations.......Page 1144
C.9. Discuss somatosensory evoked potentials (SSEPs) as a monitor of CBF during CEA.......Page 1145
C.10. What type of anesthesia will you choose for this patient if she chose to have an endarterectomy?......Page 1146
C.11. What type of anesthesia will you choose for this patient if she chose to have a carotid stent?......Page 1148
C.12. How will you induce and maintain general anesthesia in this patient for CEA?......Page 1149
C.13. How would you proceed if the patient were to receive regional anesthesia?......Page 1151
C.15. Discuss the protective effects of anesthetic agents on cerebral function.......Page 1152
C.16. How will you manage this patient’s ventilation under general anesthesia?......Page 1156
C.17. How will you manage this patient’s blood pressure intraoperatively?......Page 1157
C.18. Discuss reperfusion injury following CEA and CAS.......Page 1159
C.19. What intravenous fluids will you give this patient intraoperatively?......Page 1160
D.2. Postoperatively, the patient’s blood pressure is 170/96 mmHg. Will you treat this?......Page 1161
D.3. What immediate postoperative complications might you expect after a CEA?......Page 1162
D.4. What postoperative complications might you expect after a CAS?......Page 1165
D.5. Discuss postoperative neurocognitive dysfunction following uncomplicated carotid intervention.......Page 1166
19 Awake Craniotomy for Mapping and Surgery in the Eloquent Cortex......Page 1168
A. Medical Disease and Differential Diagnosis......Page 1170
A.2. What is the underlying pathology?......Page 1171
A.3. What determines intracranial pressure (ICP)?......Page 1175
A.4. How does a space-occupying mass alter ICP?......Page 1176
A.5. What is autoregulation, and why is it important?......Page 1178
A.6. How is cerebral blood flow (CBF) regulated?......Page 1180
A.7. What drug therapies may be associated with this pathology?......Page 1182
B.1. Why is the craniotomy performed awake?......Page 1183
B.2. What neurologic symptoms of the patient are important?......Page 1185
B.3. What is the status of their other comorbid conditions?......Page 1186
B.5. What laboratory data are required?......Page 1188
B.6. What radiology data should be reviewed?......Page 1190
B.7. How do you prepare the patient for an awake craniotomy?......Page 1191
B.9. What precautions should be made for airway management?......Page 1192
C. Intraoperative Management......Page 1193
C.2. Does this patient require invasive monitoring?......Page 1194
C.4. Why use hypertonic fluids during a craniotomy?......Page 1195
C.5. What intravenous fluids (IVFs) are recommended?......Page 1197
C.7. Venous air embolism (VAE): Is it a concern in this case?......Page 1199
C.8. How is the eloquent cortex mapped?......Page 1201
C.9. How are intraoperative seizures treated?......Page 1202
C.10. How will you conduct this anesthetic?......Page 1203
D.1. What are the major concerns following craniotomy?......Page 1208
Acknowledgments......Page 1212
20 Head Injury......Page 1214
A.1. What types of intracranial injuries are most likely to have occurred in this patient?......Page 1219
A.2. What is the difference between primary and secondary injury? What factors contribute to secondary injury?......Page 1222
Benefits......Page 1223
A.4. What is the effect of hyperglycemia on neurologic outcome following head trauma?......Page 1224
A.5. What alterations in sodium and potassium balance can occur in patients with head injury?......Page 1225
A.6. In addition to sodium and potassium, what other electrolyte abnormalities can be present after head trauma?......Page 1226
A.7. What are the neuroprotective effects of administering magnesium (Mg)?......Page 1227
A.8. What role do gender and female sex hormones have in the pathophysiology of traumatic brain injury (TBI)?......Page 1228
A.9. What is the role of decompressive craniectomy (DC) as a treatment option for ICP control after head injury?......Page 1230
A.10. Do genetic factors play a role in the outcome after head injury?......Page 1231
B.1. What is the GCS? What is the significance of a GCS of 7T in this patient?......Page 1233
B.2. In addition to the GCS, what other assessments can be done to evaluate neurologic function?......Page 1234
B.3. What is the role of CT scanning in the initial evaluation of the patient with head injury? What are the management options in patients whose neurologic condition is deteriorating before obtaining a CT scan?......Page 1235
B.4. What is the role of ICP monitoring in the management of head injury?......Page 1236
B.5. How can you clear this patient’s cervical spine?......Page 1237
B.7. What is your plan for airway management in this patient? How would it change if the patient were combative? How would it change if the patient had facial fractures with significant swelling of the head and neck?......Page 1239
B.8. What are the effects of succinylcholine on ICP? What is the significance of the effect, if any?......Page 1241
B.9. What coagulation abnormalities are present after TBI? What modalities can be used to provide hemostasis and reduce intracranial hematoma expansion?......Page 1242
C.1. What is appropriate hemodynamic monitoring during CT scanning and during craniotomy for evacuation of a subdural hematoma?......Page 1244
C.2. Should hyperventilation be used in this patient?......Page 1246
C.3. What are the implications of arterial hypertension in patients with head injury? How should BP be managed?......Page 1247
C.4. What should be done about intravenous (IV) fluid replacement? Should corticosteroids be given empirically?......Page 1249
C.5. Should hypertonic saline (HTS) be administered to this patient? How is HTS administered?......Page 1250
C.6. The patient underwent a craniectomy for evacuation of a frontal intracerebral hematoma. Should some anesthetic agents be avoided in this situation? Which ones? What agents might be preferred in this situation?......Page 1251
C.7. Should hypothermia be employed in this patient?......Page 1252
D.1. What are the postoperative ventilation concerns in this patient?......Page 1253
D.2. What specific measure should be used to control the patient’s ICP? What type of monitoring devices can be used to measure ICP?......Page 1254
D.3. What is neurogenic pulmonary edema? Would you avoid positive end-expiratory pressure (PEEP) in a patient with increased ICP?......Page 1256
D.4. What is the role of antiseizure prophylaxis in the perioperative management of head trauma?......Page 1257
D.5. How can cerebral oxygenation monitoring be used in the clinical management of TBI?......Page 1258
D.6. What methods can be used in the neurointensive care unit to prevent hyperthermia?......Page 1260
21 Cerebral Aneurysm......Page 1262
A.1. What are the incidence, prevalence, and causes of subarachnoid hemorrhage (SAH), and what are the risk factors associated with rupture of intracranial aneurysms?......Page 1265
A.2. What are common sizes and locations of intracranial aneurysms?......Page 1267
A.5. How does one assess the severity of SAH?......Page 1268
A.6. What are the cardiovascular effects of SAH?......Page 1269
A.7. How is the diagnosis of SAH made?......Page 1271
B.2. What type of anesthesia is required for coiling of an aneurysm?......Page 1272
B.4. What types of emergencies can occur during coiling of an aneurysm, and how should they be managed?......Page 1273
B.5. What other modalities of endovascular therapy are available?......Page 1274
B.6. A craniotomy is planned for the following day to clip the middle cerebral artery aneurysm. Should surgery be postponed because of the patient’s elevated troponin and CPK-MB fractions?......Page 1275
B.7. Would you premedicate this patient before craniotomy?......Page 1276
C.1. What are the goals of the induction and maintenance of anesthesia for this patient?......Page 1277
C.3. How would you assess fluid status in this patient?......Page 1278
C.4. Would monitoring central venous pressure (CVP) be useful for craniotomy and aneurysm clipping in this patient?......Page 1279
C.5. What other forms of monitoring would you consider?......Page 1280
C.7. How would you accomplish a smooth and safe induction and intubation in this patient?......Page 1282
C.8. Would you perform a rapid sequence induction and tracheal intubation for this patient?......Page 1283
C.10. What is optimal fluid management for aneurysm clipping? Would you use a dextrose-containing solution?......Page 1285
C.11. After the bone plate was removed and as the dura was being opened, the surgeon complained that the brain was “tight.” What could you do to achieve better brain relaxation and facilitate surgical exposure?......Page 1287
C.12. How might transmural pressure be decreased to allow for aneurysm clip placement?......Page 1288
C.13. What is the purpose of controlled hypotension, and how is it achieved?......Page 1290
C.15. What methods of cerebral protection might you use during this operation?......Page 1291
C.16. Would you induce mild hypothermia as a means of cerebral protection?......Page 1293
C.18. What steps should be taken in the case of intraoperative rupture of an intracranial aneurysm?......Page 1294
C.19. How would you plan the emergence from an anesthetic for aneurysm clipping?......Page 1295
D.2. What would be the differential diagnosis if the patient did not return to her preoperative neurologic condition?......Page 1296
D.3. On postoperative day 2, the patient became disoriented and developed hemiplegia. A CT scan was obtained, which shows no new intracranial bleeding. What other diagnostic studies should be performed?......Page 1297
D.4. What is cerebral vasospasm, and what causes it?......Page 1298
D.6. How is the diagnosis of cerebral vasospasm made?......Page 1299
D.7. What steps can be taken to prevent cerebral vasospasm?......Page 1300
D.8. What treatments can be undertaken once a diagnosis of cerebral vasospasm is made?......Page 1302
D.9. What are other neurologic complications following SAH and aneurysm clipping?......Page 1303
D.10. What other organ systems may manifest problems postoperatively in aneurysm clipping patients?......Page 1304
22 Pheochromocytoma......Page 1306
A. Medical Disease and Differential Diagnosis......Page 1307
A.2. What is a pheochromocytoma?......Page 1308
A.3. Describe the anatomy of the adrenal gland.......Page 1309
A.5. What are the mechanisms of action of epinephrine and norepinephrine?......Page 1310
A.6. What is the pathway for synthesis and breakdown of catecholamines?......Page 1311
A.7. What does the adrenal cortex secrete?......Page 1312
A.8. What are the metabolic actions of the glucocorticoids and the mineralocorticoids?......Page 1313
A.10. What is the prevalence of pheochromocytomas and paragangliomas?......Page 1314
B.1. How can you diagnose and localize the tumor preoperatively?......Page 1315
B.2. How do you pharmacologically prepare the patient with a pheochromocytoma for surgery?......Page 1317
B.3. What other aspects of preoperative management are important?......Page 1319
C.1. What drugs should be avoided during the operation?......Page 1320
C.3. Describe the anesthetic management of the patient with pheochromocytoma.......Page 1321
C.4. What drugs are used to control the effects of catecholamine stimulation during surgery?......Page 1322
C.5. What are some management concerns after the tumor is removed?......Page 1323
C.6. What are some of the concerns with laparoscopic adrenalectomy?......Page 1324
D.2. What other problems can arise in the postoperative period?......Page 1325
23 Diabetes Mellitus......Page 1327
A. Medical Disease and Differential Diagnosis......Page 1328
A.2. What are the factors in the etiology of the disease?......Page 1329
A.3. How is DM classified?......Page 1330
A.4. What are the complications of DM?......Page 1331
A.5. How are the different forms of this illness treated?......Page 1332
A.6. How is control of the disease adequately monitored?......Page 1337
A.7. What are some of the factors that alter insulin requirements?......Page 1338
A.8. What are the principles of management of diabetic ketoacidosis (DKA)?......Page 1339
B.1. How should this patient be evaluated?......Page 1340
B.2. How would the stiff joint syndrome affect her airway management?......Page 1343
B.4. How should this patient be prepared for anesthesia and surgery?......Page 1344
B.5. For elective surgery, how are insulin and glucose requirements managed on the day of surgery?......Page 1345
C.1. What are the effects of anesthesia and surgery on insulin and glucose metabolism?......Page 1347
C.3. How should this patient be monitored?......Page 1348
C.4. How is hyperglycemia treated intraoperatively?......Page 1349
D.1. How is diabetes controlled in this patient postoperatively?......Page 1350
D.2. Does diabetes increase perioperative risk?......Page 1351
D.4. Is it necessary to achieve tight perioperative control of glucose?......Page 1352
24 Transurethral Resection of the Prostate and Geriatric Anesthesia......Page 1354
A.2. What are the normal physiologic consequences of aging for the various organ systems?......Page 1358
A.3. How should drug dosages be adjusted for elderly patients? Should any particular medications be avoided?......Page 1359
A.5. In patients with a history of recent MI, would you recommend that the surgery be postponed for a certain period?......Page 1361
B.1. How would you evaluate the patient’s cardiac condition? Does he need additional testing?......Page 1362
B.3. For a patient with a cardiac implantable electronic device (CIED), what information should you know? What precautions should be taken?......Page 1363
B.4. What types of coronary stents are available? What is their perioperative relevance?......Page 1364
B.5. What is the conventional recommendation for dual antiplatelet therapy (DAPT) in a patient with previous percutaneous coronary intervention (PCI) undergoing elective noncardiac surgery?......Page 1365
B.6. What risk is associated with continuing perioperative antiplatelet therapy? What risk is there with stopping it?......Page 1366
C. Intraoperative Management......Page 1367
C.2. Is there a preferred anesthetic technique for patients undergoing TURP, and why?......Page 1368
C.4. What intravenous fluid would you use during TURP?......Page 1369
C.5. Forty minutes after a sensory level of T10 was established with intrathecal anesthesia, and monopolar TURP (M-TURP) resection was initiated with the use of glycine as the bladder irrigating solution, the patient becomes agitated and complains of nausea. Further sedation along with an antiemetic is administered. However, shortly thereafter, the patient becomes very restless, blood pressure rises, and heart rate decreases. The patient becomes cyanotic and obtunded, blood pressure precipitously falls, and pupils are dilated and unresponsive to light. What is the most likely cause of these signs and symptoms, and would these occur during bipolar (B-TURP) or laser TURP (L-TURP) resection?......Page 1370
C.6. What are the important characteristics of irrigation solutions used during TURP?......Page 1371
C.7. What is the effect on body temperature of continuous bladder irrigation during TURP?......Page 1372
Hematologic and Renal......Page 1373
Central Nervous System......Page 1374
C.9. How does the patient absorb irrigation solution during TURP?......Page 1375
C.11. What is the effect on cardiopulmonary, renal, and central nervous system (CNS) functions of excessive absorption of irrigation solution during TURP?......Page 1376
C.12. What causes CNS dysfunction in patients who have undergone M-TURP?......Page 1378
C.14. What prophylactic measures may reduce the incidence of TURP syndrome?......Page 1379
C.15. What therapeutic measures are recommended for patients with TURP syndrome?......Page 1380
C.16. Is hypertonic saline administration necessary to correct hyponatremia? Explain. What are the risks of rapidly correcting hyponatremia?......Page 1381
C.17. What are the toxic effects of glycine? Is there an antidote to glycine toxicity? What are the metabolic by-products of glycine?......Page 1382
C.18. What are the symptoms and clinical course of TURP-induced hyperammonemia?......Page 1383
C.19. What are the clinical characteristics, causes, and prognosis of TURP-related blindness?......Page 1384
C.20. What are the causes of excessive bleeding during TURP?......Page 1385
C.22. What are the causes of hypotension during TURP?......Page 1386
D.2. What are the signs of post-TURP septicemia? What preventive measures are generally recommended?......Page 1387
D.4. What is postoperative cognitive dysfunction (POCD)? How does this differ from delirium, and what is the time course to resolution?......Page 1388
D.5. What are the mechanisms and risk factors for POCD? How would you mitigate the risk of POCD? Does anesthesia type influence development of POCD?......Page 1389
E.1. What differentiates M-TURP from B-TURP?......Page 1391
E.2. Are decreased morbidity and mortality associated more closely with M-TURP or with B-TURP?......Page 1392
E.3. What differentiates the technologies for L-TURP?......Page 1393
25 Kidney Transplant......Page 1394
A.1. What are the causes of chronic renal disease that can progress to renal failure?......Page 1396
A.2. How is chronic kidney disease (CKD) diagnosed?......Page 1397
A.4. What are the common clinical manifestations of ESRD?......Page 1398
A.5. What electrolyte imbalances occur in patients with impaired renal function, and how are they treated?......Page 1399
A.6. How is metabolic acidosis managed in chronic renal failure?......Page 1402
A.7. Are patients with renal disease at increased risk of cardiovascular disease?......Page 1403
A.8. When is the best time to receive a kidney transplant?......Page 1404
A.9. How are immunosuppressive drugs managed in kidney transplant recipients?......Page 1405
A.10. How are kidneys allocated to recipients on the waiting list in the United States?......Page 1406
A.11. What is donation after cardiac death (DCD)?......Page 1407
A.12. What is a living donor transplant program?......Page 1408
A.13. What is a paired donor exchange transplant program?......Page 1409
A.14. What are some barriers to receiving a kidney transplant?......Page 1410
A.15. What surgical techniques are available for donor nephrectomy (DN)?......Page 1411
A.16. How is a donor kidney preserved?......Page 1412
A.17. Describe the operative procedure of kidney transplantation.......Page 1413
B.1. What preoperative workup would you order for a recipient?......Page 1415
B.3. How are routine medications and immunosuppressive medications managed in the perioperative period?......Page 1417
C.1. Are a central venous pressure (CVP) monitoring line, an arterial line, and a pulmonary artery catheter required for the transplant procedure?......Page 1419
C.2. What type of intravenous fluid should be used during surgery?......Page 1421
C.3. How would you conduct the anesthesia induction?......Page 1422
C.5. How are the nondepolarizing muscle relaxants affected by renal failure?......Page 1424
C.6. How would you maintain anesthesia during the case?......Page 1426
C.7. What are the effects of inhalation anesthetics on renal blood flow (RBF), glomerular filtration (GFR), and urine output?......Page 1427
C.8. What are the potential nephrotoxic effects of inhalation anesthetics? What are the nephrotoxic metabolites of inhalation anesthetics?......Page 1428
C.9. How does renal failure affect the pharmacology of opioids?......Page 1430
D.2. What are immunosuppressive agents, and how do they affect anesthetic care?......Page 1431
26 Robotic-Assisted Laparoscopic Surgery......Page 1433
A. Medical Disease and Differential Diagnosis......Page 1436
A.2. How is prostate cancer diagnosed?......Page 1437
A.4. Define laparoscopy.......Page 1438
A.5. Describe the development of robotic-assisted laparoscopy.......Page 1439
A.6. What are the advantages and disadvantages of minimally invasive surgery over open surgery?......Page 1440
A.7. What are the contraindications to laparoscopic or robotic-assisted laparoscopic surgery? Is pregnancy a contraindication to robotic surgery?......Page 1441
A.8. What other specialties commonly perform robotic surgery?......Page 1442
A.9. Why is carbon dioxide (CO2) the gas of choice for robotic laparoscopy? What are its disadvantages?......Page 1443
A.10. How much endogenous CO2 is produced at basal level and at maximal exercise?......Page 1444
A.11. How much CO2 is stored in the body? Where is it stored? Of what significance is this to laparoscopy?......Page 1445
A.12. Describe the diffusion and solubility properties of CO2 and their significance in laparoscopy.......Page 1446
A.13. Is CO2 soluble in water or plasma? Is it soluble in blood? Why?......Page 1447
B.1. What do you want to know about this patient’s history and physical condition that may affect whether or not you clear him for robotic surgery?......Page 1448
B.2. What factors increase this patient’s risk of pulmonary complications?......Page 1449
B.3. What laboratory tests should be performed preoperatively?......Page 1450
B.5. What additional procedures should be done before surgery?......Page 1451
B.6. What are the three major forces that uniquely alter the patient’s physiology during robotic laparoscopy?......Page 1452
C.1. What is the anesthetic technique of choice for robotic-assisted laparoscopy? Why?......Page 1453
C.3. What anesthetic agents or adjuvant drugs are recommended for laparoscopy? Are any anesthetic agents contraindicated?......Page 1454
C.4. Should nitrous oxide (N2O) be used during laparoscopy? What are the pros and cons? Does N2O cause bowel distention during laparoscopy? Does N2O cause nausea and vomiting after laparoscopy?......Page 1455
C.5. Can laparoscopy be performed under local or regional anesthesia?......Page 1458
C.6. What monitors and devices would you apply to the patient? Why?......Page 1459
C.7. How is the patient to be positioned? What special precautions are required for robotic laparoscopy?......Page 1461
Circulatory......Page 1463
C.9. What techniques are available for initial access to the peritoneal cavity? What anesthetic problems can arise during insufflation?......Page 1464
C.10. What intravenous (IV) solution and how much fluid volume do you plan to infuse?......Page 1465
C.12. What is the arterial to end-tidal CO2 gradient (PaCO2–EtCO2) in the normal awake patient? What is the cause of the gradient? Does the gradient change during laparoscopy? Why?......Page 1467
C.13. Is an arterial line necessary? Why? Does end-tidal CO2 tension accurately reflect arterial CO2 tension? Under what circumstances may the EtCO2 exceed the PaCO2? Why?......Page 1468
C.15. What factors play a role in the unusually rapid and marked elevation of CO2 that is sometimes seen in laparoscopy?......Page 1470
C.16. How rapidly does the PaCO2 rise in the apneic patient (endogenous CO2)? How rapidly does the PaCO2 rise if 5% CO2 gas is inhaled (exogenous)? How rapidly can the CO2 rise during laparoscopy? What factors explain the differences?......Page 1471
C.17. What is the net effect of pneumoperitoneum, hypercarbia, and steep Trendelenburg on the cardiovascular system?......Page 1472
C.18. What is the net effect of pneumoperitoneum, hypercarbia, and steep Trendelenburg on the respiratory system?......Page 1475
C.19. What is the net effect of pneumoperitoneum, hypercarbia, and steep Trendelenburg on the central nervous system?......Page 1476
C.20. What are the neuroendocrine changes that occur during laparoscopy?......Page 1478
C.21. What is the net effect of pneumoperitoneum, hypercarbia, and steep Trendelenburg on the renal system?......Page 1479
C.22. What is the net effect of pneumoperitoneum, hypercarbia, and steep Trendelenburg on the bowel and gastrointestinal system?......Page 1480
C.23. How would you recognize a CO2 embolism during laparoscopy? How does this differ from an air embolism? Why should N2O be discontinued during suspected embolization? Will N2O increase the size of CO2 emboli?......Page 1481
C.25. How is a gas embolism (CO2 or air) treated?......Page 1484
C.26. What are the causes of pneumothorax or pneumomediastinum during laparoscopy? How would you diagnose it? How would you treat it?......Page 1485
C.27. How would you decide when to extubate?......Page 1487
Complications of Pneumoperitoneum......Page 1488
Late Complications......Page 1489
D.2. In the postanesthesia care unit (PACU), our patient complains of numbness and weakness of the lower extremities after 6 hours of anesthesia for robotic prostatectomy. What tests will you order? When would you remove the Foley catheter and arterial line? Under what circumstances would you order a chest x-ray film?......Page 1490
D.3. What is the incidence of postoperative nausea and vomiting?......Page 1492
27 Placenta Previa/Placenta Accreta Spectrum......Page 1493
A.1. What are the leading causes of maternal mortality, and what role does anesthesia play in this mortality?......Page 1496
A.2. What is the differential diagnosis for an antepartum hemorrhage?......Page 1499
A.3. How would you diagnose the etiology of antepartum bleeding after midpregnancy?......Page 1501
A.4. What is the incidence of placenta previa, and what are the associated conditions?......Page 1502
A.6. What is the usual obstetric management for placenta previa?......Page 1503
A.7. What is vasa previa? How is it diagnosed and managed?......Page 1506
A.9. How is placental abruption diagnosed and managed?......Page 1508
A.10. What complications are associated with placental abruption?......Page 1509
A.11. Who is at risk for uterine rupture, and how is uterine rupture diagnosed?......Page 1510
A.14. What is the placenta accreta spectrum (PAS)?......Page 1512
A.15. How is the PAS diagnosed?......Page 1514
A.16. How is the PAS managed obstetrically?......Page 1515
A.17. What tests and/or interventions can improve neonatal outcome of a preterm birth?......Page 1518
B.1. How does pregnancy change respiratory function, and what impact does this have on anesthetic care?......Page 1522
B.2. What are the maternal cardiovascular changes of pregnancy?......Page 1524
B.4. What hematologic changes occur during pregnancy?......Page 1527
B.5. What laboratory data do you need before taking this patient to the operating room?......Page 1528
B.6. What preoperative medications would you administer to this patient?......Page 1529
C.1. What monitors would you use for this patient?......Page 1530
C.2. What anesthetic could be used in this patient?......Page 1531
C.3. What are the absolute and relative contraindications for neuraxial anesthesia?......Page 1532
C.4. How is postpartum hemorrhage (PPH) defined, and what are the etiologies of this bleeding?......Page 1533
C.5. After delivery of the fetus, the placenta is removed with some difficulty in one small area and generalized oozing from the placental implantation site is noted. What is the most likely cause of this patient’s bleeding?......Page 1534
C.6. After delivery of the placenta in a cesarean section, what maneuvers and drugs can enhance myometrial contractility and therefore decrease blood loss?......Page 1535
C.7. When should this patient receive tranexamic acid (TXA)?......Page 1539
C.8. If this patient had ongoing bleeding intraoperatively, what guidelines help determine when red blood cell (RBC) transfusions should be given?......Page 1540
C.9. What laboratory tests should be ordered during the resuscitation of this patient?......Page 1542
C.10. If this patient had a massive blood loss, what blood replacement therapy would be indicated?......Page 1543
C.11. What is the role of recombinant activated factor VII (rFVIIa) in the hemorrhaging obstetric patient?......Page 1548
C.12. What is the role of type O Rh-negative (universal donor) uncrossmatched blood in emergency transfusions, and how does this change your future management?......Page 1549
C.13. What complications can occur from the transfusion of blood products?......Page 1550
C.14. What is the role of autologous transfusion in obstetric patients?......Page 1553
C.16. What is disseminated intravascular coagulation (DIC)?......Page 1555
C.17. Define amniotic fluid embolism (AFE) syndrome and discuss treatment.......Page 1556
D.1. If the patient received epidural anesthesia and subsequently developed DIC, when should the epidural catheter be removed?......Page 1558
D.2. You have successfully treated the patient’s massive hemorrhage. Her laboratory values have returned to normal. The patient, however, is still hypotensive despite appropriate intravascular volume replacement and support with vasopressors. What is your concern in this case?......Page 1559
28 Hypertensive Disorders of Pregnancy......Page 1561
A.1. What is the classification of hypertension disorders in pregnancy as defined by the American College of Obstetricians and Gynecologists?......Page 1563
A.2. What is preeclampsia?......Page 1564
A.4. What is eclampsia?......Page 1565
A.6. What are the risk factors for developing preeclampsia?......Page 1566
Immunologic Factors......Page 1568
Endothelial Factors......Page 1569
Platelet Factors......Page 1571
Calcium......Page 1572
A.9. Discuss the pathologic alterations of preeclampsia.......Page 1573
Hematologic Changes......Page 1574
Endocrine Changes......Page 1575
Uteroplacental Perfusion......Page 1576
B.1. What initial laboratory studies are recommended for patients with preeclampsia?......Page 1577
B.2. Discuss bleeding time and platelet count evaluation during preoperative assessment of a patient with preeclampsia requesting epidural analgesia/anesthesia for labor and delivery.......Page 1578
B.3. What types of monitoring are important for patients with preeclampsia? When is a central venous pressure (CVP) monitor indicated?......Page 1579
B.4. Discuss the obstetric management of preeclampsia with severe features.......Page 1580
B.5. What are the antihypertensive agents of choice for preeclampsia?......Page 1581
B.6. What drug therapy is the treatment of choice for seizure prophylaxis?......Page 1583
B.7. Discuss the mechanism of action of magnesium sulfate.......Page 1584
B.9. Discuss the treatment of magnesium sulfate toxicity.......Page 1585
B.11. Discuss the management of eclampsia.......Page 1586
C.1. What is your choice of labor analgesia for patients with preeclampsia?......Page 1587
C.3. What sensory level of analgesia is required for labor and delivery?......Page 1588
C.5. Is the addition of epinephrine to local anesthetics advisable in preeclamptic patients?......Page 1589
C.7. What would you do after an accidental dural puncture? How do you treat postdural puncture headache?......Page 1590
C.8. How would you manage total spinal anesthesia?......Page 1591
C.10. When and how would you give spinal anesthesia?......Page 1592
C.11. Discuss a general anesthesia technique for the patient with preeclampsia presenting for cesarean delivery.......Page 1593
D.1. Discuss the postpartum management of preeclamptic patients.......Page 1594
D.2. Can nonsteroidal anti-inflammatory drugs (NSAIDs) be used to treat postpartum pain in preeclamptic patients?......Page 1595
29 Breech Presentation, Fetal Distress, and Mitral Stenosis......Page 1597
A.1. How are fetal lie, presentation, and position defined and determined?......Page 1600
A.3. What are the different types of breech presentation, and what is their incidence?......Page 1601
A.5. What are the delivery problems associated with breech presentation?......Page 1602
A.6. What is the usual obstetrical management for patients with breech presentation?......Page 1603
A.7. What is the incidence of heart disease in pregnancy and the mortality rate associated with maternal cardiac disease?......Page 1604
A.8. How is peripartum cardiomyopathy defined?......Page 1605
A.9. What classifications help predict an individual pregnant woman’s cardiac risk?......Page 1606
A.10. What are the cardiovascular changes of pregnancy?......Page 1608
A.12. What are the normal electrocardiographic and echocardiographic changes seen during pregnancy?......Page 1609
A.13. What causes rheumatic heart disease?......Page 1610
A.14. What are the physiologic consequences of mitral stenosis?......Page 1612
A.17. What are the echocardiographic findings associated with mitral stenosis?......Page 1613
A.19. If mitral stenosis is first recognized during pregnancy and symptoms develop, how would you treat the patient?......Page 1615
A.21. What are the determinants of uterine blood flow?......Page 1617
B.3. What is the normal FHR with beat-to-beat variability?......Page 1618
B.4. What are FHR decelerations?......Page 1619
B.5. How accurate is FHR monitoring in predicting fetal well-being?......Page 1620
B.7. What is the significance of meconium-stained amniotic fluid?......Page 1622
B.9. What are the usual noninvasive tests used to evaluate the pregnant cardiac patient?......Page 1623
B.10. What preoperative medications, if any, would you give this patient?......Page 1624
C.1. What monitors would you use in this functional New York Heart Association (NYHA) class II patient during her cesarean section?......Page 1626
C.3. What are the hemodynamic goals of intraoperative management of the pregnant patient with mitral stenosis?......Page 1627
C.5. How would you manage local anesthetic systemic toxicity (LAST) in this patient?......Page 1628
C.7. What technique could you use for general anesthesia in this patient?......Page 1632
C.8. If you are unexpectedly unable to intubate this patient, how would you manage the airway?......Page 1636
C.9. Would this patient benefit from the use of β-blockers?......Page 1639
C.12. What is the significance of Apgar scores?......Page 1640
C.13. At birth, what should be done to minimize an infant’s risk of meconium aspiration syndrome?......Page 1641
C.14. If the Apgar score of the newborn is 3 at 1 minute, how would you treat the newborn?......Page 1642
C.15. Blood gases are sent immediately after delivery. What are the normal values for umbilical vein and artery blood gases?......Page 1643
D.1. Immediately after the baby is delivered, the mother’s oxygen saturation decreases. What is the differential diagnosis?......Page 1644
D.2. Additional bleeding occurs in the postanesthesia care unit, and the obstetrician diagnoses retained placenta. What, if any, antibiotics are indicated to prevent endometritis after manual extraction of retained placenta?......Page 1645
30 Appendectomy for a Pregnant Patient 648......Page 1646
Medical Conditions......Page 1648
Surgical Conditions......Page 1649
A.2. How would you make the clinical diagnosis of acute appendicitis?......Page 1650
A.4. What is the incidence of gangrenous appendix/peritonitis during pregnancy, and is this incidence higher in pregnant than in nonpregnant women?......Page 1651
A.5. What are the main concerns associated with nonobstetric surgery in the pregnant patient?......Page 1653
A.6. What are the factors influencing teratogenicity from anesthetic agents in humans?......Page 1654
A.8. What factors influence fetal oxygenation, and how would you prevent intrauterine fetal asphyxia?......Page 1656
A.9. What is the incidence of trauma during pregnancy, and what are the risks to the mother and the fetus secondary to trauma?......Page 1657
A.10. What are other common surgeries performed during pregnancy?......Page 1658
B.1. Preoperatively, what would you discuss with this patient? Are any additional medical consultations warranted?......Page 1659
B.2. Is there a difference in the goal of anesthesia for delivery and for nonobstetric surgery in a pregnant patient?......Page 1660
Cardiovascular System......Page 1661
Respiratory System......Page 1662
Gastrointestinal System......Page 1663
C.2. If you choose epidural anesthesia, describe your technique and dosage.......Page 1664
C.4. What vasopressor would you choose to improve uteroplacental perfusion?......Page 1665
C.5. When this patient arrived in the operating room, she desired a general anesthetic. Describe your technique.......Page 1666
C.6. Does any controversy exist surrounding the use of nitrous oxide?......Page 1667
C.8. What is the impact of nonobstetric surgery on maternal mortality, birth defects, and fetal loss? What factors influence it?......Page 1668
C.10. How would your anesthetic management differ if the patient were having upper extremity surgery?......Page 1669
C.11. The surgeon schedules the procedure to be performed laparoscopically. Does this pose any additional problems?......Page 1670
D.2. Postoperatively, what monitors would you use?......Page 1671
D.3. What other postoperative precautions would you take? What is the incidence of preterm delivery following nonobstetric surgery during pregnancy?......Page 1672
D.4. The next day, the patient went into premature labor and now needs a cesarean section for prematurity and breech presentation. She requires another general anesthetic. In what way would your technique differ from your previous anesthetic technique?......Page 1673
31 Hemophilia and Disorders of Coagulation......Page 1674
A.1. Describe the various laboratory tests that evaluate the coagulation cascade and the specific components measured by each.......Page 1677
A.2. What is the difference between platelet adhesion, activation, and aggregation at sites of vascular injury?......Page 1683
A.3. Describe the physiologic events that occur following endothelial interruption in the blood vessel.......Page 1685
A.4. What factors prevent the extension of a clot beyond the site of injury?......Page 1686
A.5. Describe the factors involved in the extrinsic, intrinsic, and common coagulation cascade.......Page 1687
A.6. Describe the typical presentation history and pathophysiology associated with von Willebrand disease (vWD).......Page 1690
A.7. Explain the pathophysiology, frequency, and treatment of significant rare disorders of coagulation (factor VII [FVII], factor XII [FXII], and fibrinogen).......Page 1695
A.8. Differentiate between hemophilia A, B, and C.......Page 1697
A.9. What are the differences in factor replacement therapy between patients with hemophilia A and hemophilia B?......Page 1699
A.10. What is acquired hemophilia?......Page 1700
A.12. How are patients with severe hemophilia managed in the outpatient setting?......Page 1701
A.13. Describe the levels of FVIII necessary to maintain hemostasis in patients with spontaneous or surgical bleeding.......Page 1705
B.1. What steps would you take to normalize this patient’s coagulation status before surgery?......Page 1707
Approach 1......Page 1708
B.3. Would you administer FVIII using a bolus or infusion technique?......Page 1709
B.4. Can hemophiliac patients fail to mount an appropriate coagulation response following FVIII infusion?......Page 1710
B.6. How much FVIII activity is present in plasma? What are the risks associated with plasma administration?......Page 1711
B.7. What are the indications for the administration of plasma?......Page 1714
B.8. What is cryoprecipitate, and how is it prepared? How much FVIII activity is present in cryoprecipitate? When is cryoprecipitate indicated?......Page 1715
B.10. What is the role of desmopressin (D-amino D-arginine vasopressin [DDAVP]) for hemostatic management in this patient?......Page 1717
B.12. What are the options for operative treatment of patients with acquired hemophilia? Describe the mechanism of action and dosing considerations for each of these therapies.......Page 1719
C.1. Is it safe to administer an intramuscular injection to this patient before surgery?......Page 1722
C.3. If general anesthesia is used, would it be safe to intubate the patient’s trachea?......Page 1723
C.5. What special considerations should be taken in choosing anesthetic drugs for this patient?......Page 1724
C.6. During an operative procedure, if the surgeon indicates that significant blood loss is occurring, would you transfuse this patient with packed red blood cells (RBCs) or whole blood?......Page 1725
C.7. During the transfusion of the first unit of whole blood, the patient’s temperature rose from 36.8°C to 37.9°C (98.2°F to 100.2°F). What immediate steps should be taken by the anesthesiologist at this time?......Page 1726
C.9. Can FVIII be safely administered to patients who have developed circulating inhibitors?......Page 1727
C.10. The surgeon has requested the use of a tourniquet to minimize surgical bleeding. What are the physiologic and hemodynamic responses to tourniquet use?......Page 1729
D.1. What special consideration should be given to postoperative pain management for this patient?......Page 1730
D.3. Can this patient be treated with FVIII supplements using home infusion?......Page 1731
Acknowledgment......Page 1732
32 Sickle Cell Disease......Page 1733
A.2. What is sickle cell disease (SCD)?......Page 1735
A.4. What are some of the other common hemoglobinopathies and what are their clinical features?......Page 1737
A.5. What are the clinical features of SCD?......Page 1738
A.6. Describe the different types of sickle cell crises.......Page 1740
A.7. Discuss the pathophysiologic effects of SCD.......Page 1741
A.8. What is acute chest syndrome?......Page 1744
B.1. What preoperative evaluation and testing would you perform on this patient prior to anesthesia? Would you ask for a hematology consult, and what question(s) would you ask?......Page 1745
B.2. What preoperative instructions would you give this patient prior to being admitted to the hospital? How would you prepare this patient for general anesthesia and regional anesthesia?......Page 1747
B.3. Discuss the indications for perioperative exchange transfusion in this patient.......Page 1748
Acute conditions......Page 1749
C.1. Discuss the anesthetic management for this patient. Discuss both regional and general anesthesia considerations.......Page 1750
C.3. What precautions should one take to prevent sickling in this patient?......Page 1752
C.4. Discuss what issues or concerns should be brought up by the team during the debrief at the conclusion of the case. What would you sign-out to the postanesthesia care unit (PACU) staff?......Page 1753
D.1. Discuss the postoperative management of this patient. What opioid sparing techniques can you use and discuss a multimodal analgesic plan?......Page 1754
D.2. What complications might occur in this patient in the immediate postoperative period?......Page 1756
D.4. What is the role of hyperbaric oxygen therapy in treatment of sickle cell crisis?......Page 1757
33 Airway Trauma......Page 1759
A.1. What variables mitigate injury from motorcycle collisions?......Page 1761
A.3. How is the initial assessment of a trauma patient organized?......Page 1762
A.4. How would you evaluate airway and breathing?......Page 1763
A.6. How would you evaluate mental status and neurologic condition?......Page 1764
A.7. What diagnostic tests are indicated for this patient based on the mechanism of injury?......Page 1765
A.8. What are the zones of the neck, and what is their clinical significance?......Page 1766
B.1. What laboratory tests would you want?......Page 1767
B.2. What x-ray studies are most important to the anesthesiologist?......Page 1768
B.4. Should this patient be intubated before going for computed tomography (CT) scanning?......Page 1769
B.6. Are any prophylactic medications indicated?......Page 1770
C.1. What monitors would you use? Is invasive monitoring necessary before definitive airway control?......Page 1771
C.3. Is the patient likely to require tube thoracostomy? Should this be placed before managing the airway?......Page 1772
C.5. What are the risks of rapid sequence induction in this patient?......Page 1773
C.7. How can you minimize the risk of exacerbating cervical spine trauma?......Page 1774
C.8. How can you minimize the risks of aspiration?......Page 1775
C.9. How would you anesthetize the airway for an awake intubation?......Page 1776
C.10. What are the risks of awake fiberoptic intubation?......Page 1778
C.11. If the patient cannot be ventilated, what options are available?......Page 1779
C.13. What surgical airway options are available in this case?......Page 1780
C.14. What maintenance anesthetics are indicated or contraindicated in this patient?......Page 1781
C.15. What complications will the surgical plan introduce?......Page 1782
D.1. What are the criteria for extubation?......Page 1783
D.3. How does alcohol abuse affect postoperative management?......Page 1784
D.4. What pain medication should be used?......Page 1785
34 Open-Eye Injury and Cataract Surgery......Page 1786
A.2. What are the determinants of intraocular pressure (IOP) under normal circumstances? What is the normal range? What was the expected IOP in this patient’s injured eye?......Page 1789
A.3. How is aqueous humor formed and eliminated?......Page 1790
A.4. How is IOP affected by arterial PCO2, systemic blood pressure, coughing and vomiting, deep inspiration, and hypoxemia?......Page 1791
A.6. What is glaucoma?......Page 1792
A.8. How do carbonic anhydrase inhibitors work to decrease IOP? By what mechanism may osmotic agents decrease IOP?......Page 1793
A.10. Are topically applied ophthalmic medications absorbed systemically? How can this absorption be reduced? Which eyedrops may have effects that are of concern to the anesthesiologist?......Page 1794
Phenylephrine Hydrochloride (Neo-Synephrine)......Page 1795
Echothiophate Iodide (Phospholine Iodide)......Page 1796
B.1. Is an open-globe injury always a surgical emergency?......Page 1797
B.3. The patient ate shortly before the accident. Would you attempt to pass a nasogastric tube or to administer emetics to empty the stomach?......Page 1798
B.5. How would you premedicate this patient?......Page 1799
C.1. What are some factors that may increase the risk of vitreous herniation during induction and maintenance of anesthesia?......Page 1800
C.3. Would you consider an awake intubation?......Page 1801
C.4. Is succinylcholine contraindicated in open-globe injuries? How does succinylcholine affect IOP?......Page 1802
C.7. How will you perform a rapid sequence induction and intubation without using succinylcholine?......Page 1803
C.9. Would you consider the use of etomidate as an induction agent? What about propofol?......Page 1806
C.11. During the procedure, the patient’s pulse suddenly dropped to 40 beats per minute. What do you think was happening? What is the oculocardiac reflex (OCR)?......Page 1807
C.14. How do you diagnose and treat the OCR?......Page 1808
C.16. Can a retrobulbar block prevent the OCR? Is it appropriate in this patient?......Page 1809
D.4. When would you extubate this patient?......Page 1810
D.6. Will taping the eyes shut or applying ointment prevent corneal abrasions? Are there any contributing factors?......Page 1811
D.7. A month after the surgical repair, the patient complained of impaired vision in the operative eye. He was examined and found to have a detached retina. As part of the surgical treatment, the ophthalmologist injected a gas bubble into the patient’s posterior chamber. Why is this important to an anesthesiologist?......Page 1812
E.3. How would you conduct the preoperative medical evaluation for a patient having cataract surgery?......Page 1813
E.4. What is the cardiac risk for this patient? If this patient is on anticoagulation and/or antiplatelet medications, should he stop or continue these medications?......Page 1814
E.6. What is the postoperative course after cataract surgery?......Page 1815
35 Laser Treatment for Laryngeal Lesions......Page 1816
A.1. What is the cause of RRP?......Page 1817
A.3. How do you diagnose RRP?......Page 1818
A.4. What are the available treatment options for RRP?......Page 1819
A.5. What are common adverse effects of α-interferon therapy?......Page 1820
A.6. What is the differential diagnosis of hoarseness in this child?......Page 1821
B.1. What are the key points of the preanesthetic history and physical examination in this patient?......Page 1822
B.2. What preoperative laboratory tests are necessary?......Page 1823
B.4. What are the special anesthetic considerations prior to inducing anesthesia in this patient?......Page 1824
C.1. What is a laser, and how does it work?......Page 1825
C.2. What are the characteristics of laser radiation?......Page 1826
C.3. Discuss some advantages associated with the use of lasers for laryngeal surgery.......Page 1827
C.4. What are some disadvantages of lasers compared with microdebriders?......Page 1828
C.5. How would you protect the external surface of a conventional endotracheal tube (ETT) for use during laser microlaryngoscopy?......Page 1830
C.6. What special ETTs are available for laser surgery?......Page 1831
C.7. How would you manage an airway fire?......Page 1832
C.8. What is the Venturi effect?......Page 1833
C.10. How would you institute and maintain manual jet ventilation?......Page 1834
C.11. How is anesthesia maintained during jet ventilation?......Page 1835
C.13. Are there contraindications for the use of jet ventilation?......Page 1836
C.14. Discuss airway management options during laryngeal papilloma resection.......Page 1837
C.15. How would you plan to monitor this patient?......Page 1838
D. Postoperative Management......Page 1839
D.1. What are the common postoperative complications?......Page 1840
36 Tracheoesophageal Fistula......Page 1841
A.1. What is the diagnosis? What are the clinical features of this disease?......Page 1842
A.2. What is the pathophysiology of this disease?......Page 1843
A.4. How are tracheoesophageal fistula (TEF) and esophageal atresia (EA) inherited?......Page 1844
A.5. How are the different types of TEF/EA classified?......Page 1845
A.6. What other problems may this child have, and when should these be investigated?......Page 1846
B.1. What laboratory workup should be obtained before surgery?......Page 1847
B.3. How is severe lung disease managed before repair?......Page 1849
C. Intraoperative Management......Page 1850
C.2. Discuss fluid and temperature management for this baby.......Page 1851
C.3. What are the options regarding induction and intubation?......Page 1852
C.4. What is the role of rigid and fiberoptic bronchoscopy in this patient prior to incision?......Page 1854
C.5. Describe the steps of an open repair of EA/TEF.......Page 1855
C.6. What are common intraoperative problems, and how can they be managed?......Page 1856
C.7. If the surgeon decides to proceed thoracoscopically, how will you perform your anesthetic? Is one-lung ventilation required? What are some complications unique to thoracoscopy in the newborn?......Page 1857
D.1. When should the baby be extubated?......Page 1858
D.2. What options are available for postoperative analgesia?......Page 1859
D.3. What are early and late complications of TEF repair?......Page 1860
37 Congenital Diaphragmatic Hernia......Page 1861
A.1. What differential diagnoses are compatible with these signs and symptoms?......Page 1863
A.2. Describe the incidence and classification of congenital diaphragmatic hernia (CDH).......Page 1865
A.3. What are the causes of hypoxemia in patients with CDH?......Page 1866
A.4. How do you assess the severity of pulmonary hypoplasia?......Page 1867
A.6. What other congenital anomalies are usually associated with CDH?......Page 1868
B.1. How would you interpret the following arterial blood gas analyses: pH, 7.20; PaCO2, 55 mmHg; PaO2, 35 mmHg; and CO2 content, 19 mEq per L? How would you correct them?......Page 1869
B.3. Should CDH be repaired urgently once the diagnosis is made and confirmed?......Page 1870
B.5. What is the current role of extracorporeal membrane oxygenation (ECMO) in the management of CDH?......Page 1871
Cardiovascular......Page 1872
C.3. Would you use nitrous oxide for anesthesia? Why?......Page 1873
C.5. Is the infant with CDH more at risk from hypothermia?......Page 1874
C.6. The surgeon returned the intrathoracic stomach and intestine to the peritoneal cavity and the ipsilateral lung was found to be hypoplastic and collapsed. The resident anesthesiologist tried to expand the collapsed lung manually with positive airway pressure. Five minutes after the abdomen was closed, the blood pressure suddenly dropped from 70/40 to 30/20 mmHg, the heart rate from 150 to 80 beats per minute, and the pulse oximeter from 95% down to 60% saturation. What would you immediately do?......Page 1875
C.7. Discuss fluid therapy in this patient.......Page 1876
D.1. What is the mortality rate in patients with CDH? What postoperative problems would you expect in this patient?......Page 1877
38 Tetralogy of Fallot......Page 1879
A.1. What is TOF?......Page 1881
Tetralogy of Fallot with Pulmonary Stenosis......Page 1882
Tetralogy of Fallot with Pulmonary Atresia......Page 1883
Tetralogy of Fallot with Absent Pulmonary Valve......Page 1885
A.2. What is the pathophysiology of TOF/PS?......Page 1886
A.3. What is shunting, and how is QP:QS calculated?......Page 1887
A.4. What is the pathophysiology of TOF with pulmonary atresia?......Page 1889
A.5. How is SaO2 determined in single ventricle physiology?......Page 1890
A.6. What is a “pink Tet”?......Page 1891
A.7. What are hypercyanotic spells? How are they treated?......Page 1892
A.8. What palliative surgical procedures are available for treating patients with TOF/PS?......Page 1894
A.9. What palliative catheter-based procedures are available for patients with TOF?......Page 1896
A.10. What definitive surgical procedures are available for treating patients with TOF/PS?......Page 1897
A.11. What palliative and definitive surgical procedures are available for patients with TOF with pulmonary atresia?......Page 1898
B.1. What preoperative history and physical examination information do you want?......Page 1900
B.2. Which other abnormalities need to be considered in this patient?......Page 1901
B.3. What premedication will you give to a child with congenital heart disease?......Page 1902
C.2. Why would end-tidal carbon dioxide (EtCO2) monitoring be of particular use in a patient with TOF/PS?......Page 1903
C.3. What is near-infrared spectroscopy (NIRS) and what does it measure?......Page 1904
C.4. What are the important management issues during creation of a palliative shunt?......Page 1905
C.5. What is the effect of inhalation anesthetics on airway reflexes, myocardial contractility, systemic vascular resistance (SVR), and pulmonary vascular resistance (PVR) in children?......Page 1906
C.7. What interventions will reliably reduce PVR?......Page 1907
C.8. How does heparin administration and activated coagulation time (ACT) monitoring for CPB differ in children as compared with adults?......Page 1909
C.9. How is heparin reversed?......Page 1910
C.11. What is the role of transesophageal echocardiography (TEE) in this patient?......Page 1911
C.12. What effect would a residual ventricular septal defect (VSD) have in this patient following separation from CPB?......Page 1912
D.1. How should postoperative ventilation be managed in this patient following placement of a transannular patch for TOF/PS?......Page 1913
D.2. Following complete repair of TOF/PS in an infant, what SaO2 is acceptable?......Page 1914
D.3. Following placement of a modified Blalock-Taussig shunt (MBTS) for TOF/PS in an infant, what SaO2 is acceptable?......Page 1915
D.4. What is junctional ectopic tachycardia (JET)?......Page 1916
39 Transposition of the Great Arteries......Page 1919
A.1. What defines the cardiac situs?......Page 1921
A.3. What additional cardiac lesions are associated with D-TGA?......Page 1922
A.4. What is the natural history of D-TGA?......Page 1923
A.5. What is the pathophysiology of D-TGA?......Page 1924
A.6. What determines the oxygen saturation in patients with D-TGA?......Page 1925
A.7. Why did this infant have reverse differential cyanosis?......Page 1927
A.8. What are the preoperative issues pertaining to the coronary arteries in D-TGA?......Page 1928
A.9. What are the clinical subsets of D-TGA?......Page 1930
A.10. What is the differential diagnosis of D-TGA and how is the diagnosis made?......Page 1931
Intact Ventricular Septum......Page 1934
Ventricular Septal Defect......Page 1935
Pulmonary Artery Hypertension......Page 1936
Arterial Anatomic Repair: Arterial Switch (Jatene) Operation......Page 1937
Rastelli, LeCompte, and Nikaidoh Procedures......Page 1940
B.1. What information is important to prepare for this case?......Page 1941
B.2. What are the anesthetic goals before cardiopulmonary bypass (CPB)?......Page 1942
B.3. What is the plan for glucose management in this patient?......Page 1943
C.2. What would be the best method of induction for this patient?......Page 1944
C.3. Is CPB in infants and children different from adults?......Page 1945
C.4. What is modified ultrafiltration (MUF)?......Page 1948
Arterial Anatomic Repair: Arterial Switch (Jatene) Operation......Page 1950
Rastelli Procedure......Page 1951
C.6. What is hypothermia, and how is it classified? What is low-flow cardiopulmonary bypass (LFCPB)? What is deep hypothermic circulatory arrest (DHCA)?......Page 1952
C.7. Why is hypothermia beneficial to the brain during LFCPB and DHCA?......Page 1953
C.8. Explain the difference between α-stat and pH-stat blood gas management.......Page 1955
C.9. What are the immediate post-CPB issues following ASO?......Page 1957
D.1. How is myocardial ischemia addressed in the intensive care unit (ICU) following the ASO?......Page 1958
D.2. What immediate postoperative problems would be anticipated following the Rastelli procedure?......Page 1959
D.3. What intermediate and long-term surgical problems are seen after ASO?......Page 1960
D.4. What are the long-term outcomes after ASO?......Page 1961
D.5. What are the long-term outcomes after Rastelli repair for patients with D-TGA with left ventricular outflow tract (LVOT) obstruction?......Page 1962
D.6. What is long-term neurologic outcome like after ASO?......Page 1963
40 Pyloric Stenosis......Page 1965
A.1. What is the diagnosis in this patient?......Page 1966
A.2. What is the differential diagnosis of pyloric stenosis?......Page 1967
A.3. What are the metabolic problems in this newborn secondary to his disease?......Page 1968
Fluids......Page 1969
Diagnostic Tests......Page 1970
Maintenance Fluids......Page 1971
Correction of Deficits......Page 1972
A.7. How would you correct the metabolic alkalosis in this patient?......Page 1973
Physical Examination......Page 1974
B.2. How would you evaluate a heart murmur?......Page 1975
B.4. What are the types of VSD? What type of shunt do they cause?......Page 1976
B.5. What are the risks of surgery and anesthesia in a patient with VSD?......Page 1977
C.1. What induction–intubation sequence would you use?......Page 1978
C.2. What are the anatomic characteristics of the airway in the newborn and how do they differ from those in the adult?......Page 1979
C.3. How do you determine the size of an endotracheal tube in a pediatric patient?......Page 1980
C.5. What are the advantages and the disadvantages of commonly employed nonrebreathing systems?......Page 1981
C.7. How does the pulse oximeter function?......Page 1982
D.1. What are the complications that can occur in the postanesthesia recovery period?......Page 1983
D.2. How would you treat postextubation “croup” in this infant?......Page 1984
41 Inflammatory Airway Disease in Childhood: Laryngotracheobronchitis......Page 1986
A.3. How does stridor correlate with anatomic location?......Page 1988
A.4. Define croup. What is the clinical presentation of laryngotracheitis?......Page 1989
A.6. What is bacterial tracheitis?......Page 1990
A.8. How is the severity of croup assessed?......Page 1991
A.9. What is the medical management of croup? Does this have implications for the anesthesiologist?......Page 1992
A.10. What is epiglottitis? What are its common causes? What is the incidence?......Page 1993
A.12. How is the diagnosis of epiglottitis made?......Page 1995
A.13. What is postextubation croup? How is it managed?......Page 1997
A.14. What are the nonacute causes of partial airway obstruction in children?......Page 1998
Intrinsic Pathologies......Page 1999
B.2. Why is general anesthesia administered to a child with epiglottitis?......Page 2000
B.3. How would you prepare the patient for anesthesia?......Page 2001
C.2. How would you induce anesthesia?......Page 2002
C.3. Should a child with epiglottitis undergo a rapid sequence induction?......Page 2003
C.4. Is awake intubation a practical alternative to secure the patient’s airway?......Page 2004
C.5. What would you do if the airway cannot be secured with intubation?......Page 2005
C.6. Should this patient have a nasotracheal or orotracheal tube placed?......Page 2006
D.1. How long should this patient remain intubated? What criteria determine extubation time?......Page 2007
D.2. How would you make this patient comfortable during the course of intubation?......Page 2008
D.3. What outcome can one expect for the child with acute epiglottitis?......Page 2009
42 Cleft Palate......Page 2010
A. Medical Disease and Differential Diagnosis......Page 2011
A.1. Describe the anatomic concept of a cleft palate and a cleft lip.......Page 2012
A.2. What is the cause of a cleft lip or a cleft palate?......Page 2013
A.4. Discuss the pathophysiology of a cleft lip and palate in the neonate and the older child (e.g., age >5 years).......Page 2014
A.5. What other conditions are associated with a cleft lip and a cleft palate?......Page 2015
A.7. What is Treacher Collins syndrome?......Page 2016
A.9. Discuss indications and timing of closure of cleft lip and palate.......Page 2017
A.10. What is velopharyngeal incompetence, and how can it be diagnosed?......Page 2018
A.11. What is the relation of tonsillectomy and adenoidectomy to velopharyngeal incompetence?......Page 2019
B.1. What information do you need before closure of a cleft lip and palate?......Page 2020
B.2. What preoperative orders are needed?......Page 2021
C.2. Discuss the induction and the anesthetic management for cleft lip and palate.......Page 2022
C.5. Briefly describe the surgical techniques used to repair cleft defects.......Page 2024
C.6. How does a pharyngeal flap affect anesthetic management or any subsequent anesthetic administered to this patient?......Page 2025
C.8. What is the crucial problem of anesthesia for cleft palate? What are the unique considerations of this surgical repair?......Page 2026
C.9. What is laryngospasm? How would you make a diagnosis of laryngospasm?......Page 2027
D.1. What complications of cleft lip and cleft palate surgery may be seen in the recovery room?......Page 2028
D.2. How do you protect the airway postoperatively?......Page 2029
D.3. How would you control postoperative pain in patients following a cleft lip and cleft palate repair?......Page 2030
43 Congenital Heart Disease with a Cervical Mass in Infancy......Page 2032
A.1. What is 22q11 deletion syndrome?......Page 2034
A.2. What are the associated cardiovascular defects in 22q11 deletion syndrome?......Page 2035
A.3. What are the metabolic and endocrine abnormalities in patients with 22q11 deletion syndrome and the attendant manifestations?......Page 2036
A.5. What is the differential diagnosis of cervical masses in infancy?......Page 2037
A.6. What is a cystic hygroma? What are the complications? What is the treatment?......Page 2039
A.8. What is the pathophysiology of the IAA syndrome?......Page 2040
A.9. How is ductal patency maintained?......Page 2041
A.10. What are the side effects of prostaglandin infusion?......Page 2042
B.1. What preoperative studies should be obtained to evaluate the neck mass?......Page 2043
B.3. What features of the difficult airway can be noted on physical examination?......Page 2044
B.5. What laboratory studies are necessary before surgery?......Page 2046
B.6. What are the causes of heart failure (HF) in the infant? How would you assess this infant in your preoperative evaluation for signs of HF?......Page 2047
B.7. How would you optimize the preoperative treatment of HF?......Page 2050
B.9. When is premedication useful in infants and children?......Page 2051
B.10. Before the planned surgery, the infant is scheduled for a magnetic resonance imaging (MRI) scan. You are asked to ensure that the baby remains immobile for 20 minutes to perform the scan adequately. How would you accomplish this?......Page 2052
C.1. What anesthesia equipment, circuit, and monitors would you use?......Page 2053
C.2. Describe techniques other than direct laryngoscopy that would be useful for securing the airway in this baby.......Page 2054
Retrograde Cricothyroid Wire......Page 2055
Nasal Intubation with Laryngoscope and Magill Forceps......Page 2056
Fiberoptic Intubation......Page 2057
C.3. How would you monitor blood loss in this patient?......Page 2058
C.4. What anesthetic technique should be used in a patient who may experience severe loss of blood intraoperatively?......Page 2059
C.5. How would you induce and maintain anesthesia in this neonate?......Page 2060
D.1. How would you manage this patient postoperatively?......Page 2061
44 Patent Ductus Arteriosus and Prematurity......Page 2063
A.1. How would you classify prematurity? What are the common problems associated with prematurity?......Page 2066
A.2. What are the survival rates of preterm infants?......Page 2067
A.3. What are the incidence and survival rates of respiratory distress syndrome (RDS)? Discuss its pathophysiology.......Page 2068
A.4. What is bronchopulmonary dysplasia (BPD)? How would you treat it?......Page 2069
A.5. What are apnea spells? What are the possible causes of apneic spells?......Page 2070
A.7. How would you make a diagnosis of PDA? Describe its treatment.......Page 2072
A.8. Would you give digitalis to treat congestive heart failure in preterm infants? Why?......Page 2073
A.9. How does indomethacin close the ductus? What are the adverse effects of indomethacin?......Page 2074
A.11. What is retinopathy of prematurity (ROP) (retrolental fibroplasia [RLF])? Discuss its etiology, pathophysiology, prognosis, prevention, and treatment.......Page 2075
A.12. Define neutral and critical temperatures. What are these values in the preterm neonate, in the term neonate, and in the adult? Discuss temperature regulation in the neonate.......Page 2078
B.2. What are the normal values of arterial blood gases and pH in neonates and infants?......Page 2079
B.4. What are the normal values of arterial blood pressure, heart rate, and respiratory rate for preterm infants?......Page 2080
B.5. What are the normal values of WBC, red blood cells (RBCs), hemoglobin, glucose, electrolytes, calcium, blood urea nitrogen, and creatinine for preterm infants?......Page 2081
B.6. Would you transfuse blood to this patient preoperatively?......Page 2082
B.8. Would you correct a serum calcium level of 6.0 mg per dL? What other information would you like to have? Which contains more calcium, 10 mL of 10% calcium chloride or 10 mL of 10% calcium gluconate? Could you hyperventilate this child safely?......Page 2083
C.1. Where should the procedure take place? In the neonatal intensive care unit (NICU) or the operating room?......Page 2084
C.2. What monitors would you use for this child during surgery?......Page 2085
C.3. How does the oxygen analyzer work?......Page 2086
C.4. What is the Doppler effect? How does the Doppler transducer measure blood pressure?......Page 2087
C.6. How would you maintain the patient’s body temperature?......Page 2088
C.7. How do the anesthetic requirements of the preterm infant differ from those of the adult?......Page 2089
C.8. What size endotracheal tube would you have used if the patient had not been intubated?......Page 2090
C.10. How would you maintain anesthesia?......Page 2091
C.11. How would you ventilate the patient? What tidal volume, respiratory rates, and FIO2 would you set for the infant?......Page 2092
C.12. Discuss blood and fluid therapy in this preterm infant.......Page 2093
C.13. During dissection of the ductus arteriosus, the arterial oxygen saturation dropped from 92% to 80% and the heart rate decreased from 140 beats per minute to 80 beats per minute. What were the causes? How would you correct this situation?......Page 2094
D.2. How can one minimize the risk of transporting the patient to the NICU after surgery?......Page 2095
D.3. The patient’s condition deteriorated postoperatively in the intensive care unit (ICU). Physical examination revealed persistent cardiac murmur. What was the possible diagnosis?......Page 2096
45 Post-tonsillectomy Hemorrhage......Page 2098
A.1. Approximately how many pediatric tonsillectomies are performed in the United States each year? What are the indications for tonsillectomy?......Page 2100
A.2. What is the differential diagnosis for this patient?......Page 2101
A.3. What is the treatment for a patient with von Willebrand disease?......Page 2102
A.4. Describe the vascular anatomy of the tonsils. What is the incidence of post-tonsillectomy hemorrhage?......Page 2103
A.5. What are the risk factors for post-tonsillectomy hemorrhage? Does age matter?......Page 2105
B.1. What is your approach to assessing this patient?......Page 2106
B.3. Should you plan to use vasopressors?......Page 2107
B.6. What are your expectations of the surgeon, specifically as it relates to induction of anesthesia?......Page 2108
C.2. What is your plan for management of blood in the oropharynx?......Page 2109
C.4. Laryngoscopy and intubation prove challenging due to blood in the airway. What options do you have now?......Page 2110
D.1. Is postoperative management in the pediatric intensive care unit (PICU) indicated?......Page 2111
D.3. Discuss potential postoperative complications for this patient.......Page 2113
D.4. What discharge instructions should be given post-tonsillectomy?......Page 2114
46 Brachial Plexus Block......Page 2115
A.3. What implications does the use of atenolol have on the patient’s coexisting medical condition?......Page 2118
B.1. What testing would be helpful to elucidate the cause of this patient’s fainting spells?......Page 2119
C.1. What anesthetic technique would you use?......Page 2121
C.2. Describe the relevant anatomy of the brachial plexus.......Page 2122
C.3. What relevant anatomic structures in the neck and below the neck can be injured or injected accidentally during brachial plexus block?......Page 2124
C.4. What regional technique would you choose to block the brachial plexus in this patient?......Page 2125
Interscalene Block......Page 2126
Infraclavicular Block......Page 2127
Axillary Block......Page 2128
C.6. Describe the landmarks and procedures for nerve stimulator and ultrasound-guided interscalene block.......Page 2129
C.7. Describe the landmarks and procedures for supraclavicular block.......Page 2132
C.8. Describe the landmarks and procedures for infraclavicular block.......Page 2134
C.9. Describe the landmarks and procedures for axillary block.......Page 2136
C.10. The patient requests to have the brachial plexus block performed after you administer general anesthesia. Would you agree to this request?......Page 2138
C.12. What is the incidence of hemidiaphragmatic paresis following interscalene brachial plexus block? Can this complication be avoided by decreasing the volume or concentration of local anesthetic injected or by using ultrasound-guided supraclavicular block?......Page 2140
C.14. What would you do if the patient complained of dyspnea after you performed an interscalene or supraclavicular block?......Page 2142
C.15. The surgeon prefers to perform the surgical procedure in the sitting position. What are the advantages and disadvantages of this position compared to the lateral position in this patient?......Page 2143
C.16. Which nerves are most commonly missed with axillary brachial plexus block? With interscalene block? With all brachial plexus blocks?......Page 2144
C.18. What is the maximum safe dose of local anesthetic for brachial plexus block?......Page 2145
D.2. In the postanesthesia care unit, the patient complains of dyspnea. How would you evaluate and manage this?......Page 2146
D.3. On the third postoperative day after removal of the brachial plexus catheter, the patient complains of persistent numbness and paresthesia in the ulnar nerve distribution. What would you tell the patient? How would you manage neurologic dysfunction after brachial plexus block that persists for 1 week?......Page 2147
47 Nerve Blocks of the Lower Extremity......Page 2149
A.2. Should surgery be allowed to proceed in this patient who has a subdural bleed?......Page 2152
A.3. Does the patient’s atrial fibrillation need to be addressed prior to surgery, and if so, how?......Page 2153
B.1. What is dabigatran (Pradaxa)? How is its effect measured? How far in advance of elective surgery should it be stopped? Can its effect be reversed?......Page 2154
B.2. What concerns do you have regarding neuraxial anesthesia in this patient who has a subdural hematoma?......Page 2156
B.4. The surgeon is willing to wait a few days prior to surgery while the swelling around the injury decreases. When would you feel comfortable proceeding with surgery in this patient?......Page 2157
C. Intraoperative Management......Page 2158
C.1. What two nerve plexuses need to be blocked in this case? What nerve roots contribute to each plexus? Name the major nerves that come from each plexus.......Page 2159
C.2. What is the innervation to the medial and lateral aspects of the ankle? What nerves need to be blocked for his surgery?......Page 2161
C.3. What nerves are blocked with an ankle block? Would you do an ankle block in this case?......Page 2162
C.4. Explain the posterior landmark technique to blocking the lumbar plexus. What motor response would be elicited with a nerve stimulator? At what stimulation level would you feel safe injecting the patient? Why not at a lower level of stimulation? Can ultrasound guidance be utilized for this injection?......Page 2165
C.5. What is a fascia iliaca block (three-in-one block)?......Page 2166
C.6. Describe the different ultrasound approaches to blocking the saphenous nerve above the knee.......Page 2171
C.7. What benefits might a saphenous nerve block above the knee provide compared to a femoral nerve block?......Page 2174
C.8. How would pain from a midthigh tourniquet dictate which peripheral nerve blocks to use in this patient? Describe the landmark technique of sciatic nerve block in the gluteal region. What is seen while performing an ultrasound technique to block the sciatic nerve?......Page 2176
C.9. Why does a popliteal nerve block have a high failure rate if performed too proximate to the popliteal fossa when using a landmark/nerve stimulator technique? Describe how this can be avoided when using ultrasound-based popliteal block.......Page 2178
C.10. What is the IPACK block? In what situations would this block be useful?......Page 2180
D.1. Describe compartment syndrome and how that risk would influence your postoperative plan for peripheral regional analgesia.......Page 2183
D.2. How would the addition of dexamethasone to your local anesthetic influence the duration of the blocks placed in the OR?......Page 2184
D.3. What is liposomal bupivacaine?......Page 2185
D.4. What benefit would a peripheral nerve catheter provide over a long-acting local anesthetic? Are there any downsides?......Page 2186
D.5. You were able to perform a continuous spinal epidural (CSE) at L3–L4 and used 0.125% bupivacaine via epidural route for postoperative pain control. The patient reports that he is comfortable regarding both his back pain and his ankle pain. What benefit would continuing the patient’s methadone confer in this case?......Page 2187
D.6. How can regional analgesia aid in fast-track postoperative care?......Page 2188
48 Complex Regional Pain Syndromes......Page 2190
A.1. What is the differential diagnosis of pain in this patient?......Page 2192
A.3. What are the two types of CRPS?......Page 2193
A.4. What are the diagnostic criteria for CRPS? What is the incidence of this disease?......Page 2194
Stage I......Page 2195
A.7. What are the possible etiologies of CRPS?......Page 2196
A.8. Explain the pathophysiology of the development of CRPS.......Page 2197
A.11. What is central pain? How will you differentiate central pain from CRPS?......Page 2198
A.12. Is the social history of this patient relevant to the development of chronic pain syndrome?......Page 2199
B.1. How will you work up CRPS types I and II?......Page 2200
B.3. Where is the stellate ganglion located?......Page 2201
B.5. What are the clinical signs of stellate ganglion block?......Page 2202
B.9. What is a differential block?......Page 2203
B.11. What factors determine the onset, potency, and duration of a local anesthetic block?......Page 2204
B.13. How will you treat this patient?......Page 2206
B.15. What is the role of intravenous regional block (Bier method) in diagnosis and treatment of CRPS?......Page 2207
B.16. Compare and contrast the mechanism of actions of ketamine and methadone.......Page 2208
B.17. What roles does ketamine infusion play in the treatment of CRPS? Is there a guideline for ketamine infusion in treating CRPS?......Page 2209
B.18. What is neuromodulation? What is the role of spinal cord stimulation (SCS) in treating CRPS?......Page 2210
B.20. What role does intrathecal (IT) therapy play in managing CRPS?......Page 2211
B.21. If opioids are prescribed as treatment for CRPS patients, what is the Centers for Disease Control and Prevention (CDC) guideline of chronic opioid therapy?......Page 2212
Central Nervous System Effects......Page 2213
Cardiovascular Effects......Page 2214
C.4 What are the possible complications of SCS?......Page 2215
C.5. What are the possible complications of IT therapy?......Page 2216
49 Cancer Pain......Page 2217
A.1. What is the definition of pain?......Page 2219
A.2. How significant is the problem of pain in patients with cancer?......Page 2220
A.3. What are the components of cancer pain?......Page 2221
A.5. How do psychological factors affect pain in patients with cancer?......Page 2222
A.6. What are the causes of pain in patients with cancer?......Page 2223
A.7. How do you classify pin in patients with cancer?......Page 2224
A.8. What are the characteristics of pancreatic cancer pain?......Page 2225
A.10. What is the differential diagnosis of abdominal pain?......Page 2226
B.1. What is the World Health Organization stepladder approach for cancer pain management?......Page 2227
B.4. How does mixed opioid agonist/antagonist differ from opioid agonist?......Page 2229
B.5. Describe the role of methadone in the management of cancer pain.......Page 2230
B.7. What is the mechanism of action of opioids?......Page 2231
B.8. What are the side effects of opioid therapy?......Page 2232
B.10. How would you treat the side effects of opioid therapy?......Page 2233
B.11. What is tramadol? Is it an opioid?......Page 2234
B.12. When would you consider adjuvant analgesics as part of the treatment plan?......Page 2235
B.13. The patient and his family are worried about addiction. How would you approach this problem?......Page 2236
B.14. Describe different routes of opioid administration.......Page 2237
B.15. Describe advantages and complications of patient-controlled analgesia (PCA). What is minimum effective analgesic concentration (MEAC)?......Page 2239
B.16. What is meperidine? How is it different from other opioids?......Page 2240
B.17. What is rotation of opioids? When would you consider rotation of opioids?......Page 2241
C.1. Describe the role of peripheral nerve blocks in cancer pain management.......Page 2242
C.2. Describe the role of celiac plexus block in cancer pain management.......Page 2244
C.3. What are the complications of celiac plexus block?......Page 2245
C.4. Would you consider neuraxial opioid infusion in this patient? Discuss complications of this procedure.......Page 2246
C.5. Which medications can be used intrathecally? What is ziconotide?......Page 2247
C.7. Would you consider neuraxial neurolysis in this patient to manage his pain? Discuss advantages and disadvantages of these blocks.......Page 2248
C.8. Which neuroablative procedures can be considered in the terminal stage of pancreatic cancer?......Page 2249
D.1. What are the various nonpharmacologic techniques of cancer pain management?......Page 2250
D.2. What physical modalities have been successfully tried in cancer pain management?......Page 2251
D.3. Describe the role of neuromodulation in cancer pain management.......Page 2252
D.4. What psychological techniques have been promoted for comfort care and pain relief?......Page 2253
D.5. What are distraction and reframing techniques? What is the role of hypnosis in cancer pain?......Page 2254
50 Low Back Pain and Sciatica......Page 2256
A.1. How great an issue is low back pain in the general population?......Page 2257
A.2. What is the prevalence of low back pain?......Page 2258
A.3. What is the societal cost of low back pain?......Page 2259
A.4. What causes low back pain?......Page 2260
A.5. What are the risk factors for low back pain?......Page 2261
A.6. What are the potential sources of pain in the spine?......Page 2263
A.7. What is the anatomy of the intervertebral discs? What is the mechanism of pain from herniated discs?......Page 2266
A.8. What is the anatomy of the spinal facets? How do the facet joints cause pain?......Page 2268
A.9. What are the important findings through history and physical examination?......Page 2269
A.10. What are the appropriate diagnostic studies for low back pain?......Page 2271
A.11. What is the differential diagnosis of low back pain?......Page 2272
A.12. What are the causes of persistent back pain after multiple spine surgeries?......Page 2274
B.1. What are the noninterventional treatments available?......Page 2275
B.2. What traditional interventional treatments are available and how should they be used?......Page 2277
B.3. What are some of the recent safety improvements recommended for lumbar epidural steroid injection?......Page 2280
B.4. What are some of other approaches in minimally invasive interventions?......Page 2283
B.5. What are the concerns about magnetic resonance imaging (MRI) safety in patients with a spinal cord stimulator (SCS)?......Page 2289
B.6. When should surgery be considered?......Page 2291
B.7. What surgical options are available for the treatment of disc disease?......Page 2292
51 Perioperative Pain Management......Page 2301
A.1. What would be your advice to the patient about the planned thoracotomy and postoperative pain relief?......Page 2304
A.2. How will you decide about the choice of anesthetic technique?......Page 2305
A.4. What would be your perioperative analgesic strategy?......Page 2307
A.5. Does the choice of analgesic technique influence postoperative outcome?......Page 2309
A.6. Does it matter if the epidural catheter is at the thoracic or lumbar level?......Page 2310
A.7. Does the choice of drugs influence the efficacy or safety of thoracic epidural analgesia (TEA)?......Page 2311
A.8. What are the usual doses and concentrations of the anesthetic combinations commonly employed in epidural analgesia?......Page 2312
A.10. What are the alternatives to TEA?......Page 2314
A.11. What is the usual clinical regimen for intravenous patient-controlled analgesia (IV-PCA) and is special patient monitoring required during its use?......Page 2317
A.12. What are the side effects and complications of epidural technique?......Page 2319
Therapeutic Intravenous Unfractionated Heparin......Page 2321
Postoperative Low Molecular Weight Heparin......Page 2322
Oral Anticoagulants......Page 2323
Newer Agents......Page 2324
B.1. How does chronic opioid therapy influence postoperative pain management?......Page 2325
B.3. What are the main differences between a chronic opioid-consuming patient and a patient who abuses or is addicted to opioids?......Page 2327
B.4. What issues need to be considered in the opioid-tolerant patient who is scheduled for surgery?......Page 2328
B.5. What would be your strategy regarding preoperative information and choice of anesthesia technique?......Page 2329
B.6. What are the choices for perioperative pain management in opioid-tolerant patients?......Page 2330
B.7. What issues need to be considered before discharging an opioid-tolerant patient?......Page 2332
C.1. What would be your preoperative considerations and advice to the patient?......Page 2333
C.2. What are the consequences of inadequate pain management after ambulatory surgery?......Page 2335
C.3. What is the role of premedication or preoperative analgesic?......Page 2336
C.4. Does the choice of anesthetic technique influence postoperative pain?......Page 2337
C.5. Are nonsteroidal anti-inflammatory drugs (NSAIDs) effective? If so, does the choice of drug matter?......Page 2338
C.6. What is the role of surgical technique in influencing postoperative pain after a laparoscopic cholecystectomy?......Page 2339
C.7. What would be your strategy for pain control after discharge home?......Page 2340
D.1. What is the extent of the problem, and which patients are at greatest risk of undertreatment?......Page 2342
D.3. What is the role of an APS in improving postoperative pain management?......Page 2343
D.4. Does an APS improve postoperative outcome?......Page 2344
52 Acupuncture......Page 2346
A.1. What is acupuncture?......Page 2347
A.2. How is acupuncture practiced? (Video 52.1)......Page 2348
A.3. What are the mechanisms of acupuncture analgesia?......Page 2350
A.4. What were the conclusions of the National Institutes of Health Consensus Conference about acupuncture?......Page 2351
B. Acupuncture for the Treatment of Chronic Conditions......Page 2352
B.1. What are the rationales in integrating acupuncture for the treatment of postoperative nausea and vomiting?......Page 2353
B.2. Can acupuncture be used for the treatment of chemotherapy-induced nausea and vomiting?......Page 2354
B.3. How effective is acupuncture for the management of chronic headache?......Page 2355
B.4. Can acupuncture be used for the treatment of chronic neck and back pain?......Page 2356
B.5. Can acupuncture be used for the treatment of osteoarthritis?......Page 2357
B.7. Can acupuncture/acupressure be used to decrease anxiety?......Page 2358
B.8. What is ear acupuncture/acupressure? Can it be useful for alleviating anxiety and pain? (Video 52.2)......Page 2359
C.1. What are the possible complications of acupuncture treatment?......Page 2360
53 Myasthenia Gravis......Page 2362
A.1. What is MG?......Page 2363
A.2. What is the etiology and pathophysiology of MG?......Page 2364
A.3. Describe the clinical classification of MG.......Page 2366
A.4. How is the diagnosis of MG made?......Page 2367
A.5. What should be considered in the differential diagnosis?......Page 2368
A.6. How does myasthenic syndrome (Lambert-Eaton syndrome) differ from MG?......Page 2369
Medical Therapy......Page 2370
Surgical Therapy......Page 2372
B.2. What preoperative laboratory data are required?......Page 2373
B.3. How should the patient’s medications be managed preoperatively?......Page 2374
C.2. How should this patient be monitored intraoperatively?......Page 2375
C.3. What anesthetic regimen would you choose for this patient?......Page 2376
C.4. Can neuromuscular blocking drugs be used safely in a patient with MG?......Page 2377
C.5. Should the MG patient who is in remission (i.e., symptom free without treatment) be managed differently?......Page 2379
D.1. What factors will help you predict this patient’s need for continued intubation or other postoperative ventilatory support?......Page 2380
D.2. How will you determine if this patient’s trachea can be safely extubated?......Page 2381
D.3. How will you manage postoperative analgesia?......Page 2382
D.4. How will you define and manage postextubation ventilatory failure in this patient?......Page 2383
54 Malignant Hyperthermia......Page 2385
A.2. What is malignant hyperthermia (MH)?......Page 2387
A.3. What are the clinical features of a susceptible patient?......Page 2388
A.4. Does the history of previous uneventful sevoflurane anesthesia reasonably exclude the patient’s susceptibility to MH?......Page 2389
A.5. What are the clinical features of the syndrome?......Page 2390
A.6. What are the laboratory findings during an acute crisis of MH?......Page 2391
A.7. What is the incidence of this syndrome?......Page 2392
A.8. What is the mode of inheritance of the disease? Does MH “skip” generations?......Page 2394
A.9. What genetic disorder results in MH susceptibility?......Page 2395
A.10. What is the pathophysiology of the syndrome?......Page 2397
A.11. What laboratory tests can further substantiate the susceptibility of the patient to MH?......Page 2398
Molecular Genetic Testing for MH Susceptibility......Page 2399
A.12. What is neuroleptic malignant syndrome (NMS)?......Page 2401
B.1. How would you prepare this patient for anesthesia and surgery?......Page 2403
B.4. Is outpatient surgery appropriate for this patient?......Page 2404
B.5. In anticipation of general anesthesia, what preparations would you make?......Page 2405
C.1. What anesthetic techniques and agents would you employ?......Page 2407
C.3. What anesthetic agents are contraindicated?......Page 2408
C.5. What is the significance of masseter muscle spasm occurring after succinylcholine administration?......Page 2409
C.6. Twenty minutes into the procedure with sevoflurane anesthesia, the patient developed increasing tachycardia with ventricular premature beats and mottled skin. What emergency measures would you take?......Page 2410
C.8. What steps should be taken to avoid major morbidity from MH?......Page 2412
C.9. How does the new formulation of dantrolene (Ryanodex) compare with the existing formulation of dantrolene (Dantrium or Revonto)?......Page 2413
D.1. What complications may follow this syndrome?......Page 2414
D.3. What would you advise the patient and the family?......Page 2415
D.4. What precautions should an MH-susceptible patient take outside of the operating room (OR)?......Page 2416
55 Postoperative Residual Neuromuscular Weakness and Prolonged Apnea......Page 2418
A.2. How is residual neuromuscular blockade (NMB) diagnosed?......Page 2420
A.3. What is the order of recovery of voluntary muscle groups from nondepolarizing muscle relaxants?......Page 2421
A.4. What is the mechanism of action of succinylcholine, and how is it metabolized? What are the side effects of succinylcholine?......Page 2422
A.5. If succinylcholine were the only muscle relaxant used during the case and the patient did not exhibit a response to train-of-four (TOF) stimulation, what is the likely diagnosis? How would you confirm it?......Page 2425
A.6. What are acetylcholinesterase and serum cholinesterase? What is the clinical significance of heterozygosity for atypical pseudocholinesterase (PChE)?......Page 2426
A.8. What are some factors that can lower PChE levels?......Page 2429
B.1. How is the choice among muscle relaxants made?......Page 2430
B.2. What factors can alter sensitivity to nondepolarizing neuromuscular blockers?......Page 2431
B.3. What are the characteristics of nondepolarizing block?......Page 2432
B.5. Why is the TOF ratio of clinical importance?......Page 2433
B.6. How do we define adequate recovery of neuromuscular function?......Page 2434
B.7. Are there useful and/or trustworthy clinical tests of neuromuscular recovery?......Page 2435
B.8. How accurate are subjective estimates of the TOF ratio, and what purpose do peripheral nerve stimulator (PNS) monitors serve?......Page 2436
B.11. How can the TOF ratio be measured quantitatively?......Page 2437
B.12. What are the limitations of acetylcholinesterase antagonists?......Page 2439
B.14. Is reversal of blockade always necessary?......Page 2440
B.15. Is there any way to rapidly antagonize a profound nondepolarizing block?......Page 2441
C.1. What is the incidence of residual NMB in the PACU?......Page 2444
C.2. Does undetected postoperative residual neuromuscular block (PORB) have clinical consequences?......Page 2446
56 Burns......Page 2448
A.2. How do you express the extent of the burn injury?......Page 2451
A.3. Should the “rule of nines” be used in children?......Page 2452
A.4. What functions does the skin perform?......Page 2453
A.5. What pathophysiologic changes accompany major thermal injury?......Page 2454
A.8. Does this patient have a smoke inhalation burn? How do you make the diagnosis?......Page 2455
A.9. What is carbon monoxide poisoning? How do you diagnose and treat carbon monoxide poisoning?......Page 2456
A.11. What fluid formula would you use?......Page 2457
A.12. What cardiovascular changes typify the burn injury?......Page 2458
A.14. What are Curling ulcers? How can they be prevented?......Page 2459
B.1. What preoperative preparations would you order? What are particular concerns in this patient?......Page 2460
B.3. What are the advantages and disadvantages of early tangential excision split-thickness skin grafting (TE/STSG)?......Page 2461
B.5. Are you concerned about this patient’s blood pressure? What treatment would you institute?......Page 2462
B.7. How do you calculate oxygen content and oxygen delivery? What factors govern the oxygen delivery to the tissues?......Page 2463
C.2. What information can be obtained from an arterial line and a pulmonary artery catheter? How are these calculations performed?......Page 2464
C.5. What anesthetic agents would you use? Discuss inhalation versus intravenous agents.......Page 2466
C.7. How is temperature best maintained?......Page 2467
C.10. Why is succinylcholine contraindicated in burned patients? For how long should it be avoided?......Page 2468
C.11. What other adverse effects are associated with succinylcholine?......Page 2469
C.12. How are the doses of nondepolarizing muscle relaxants affected by burn injury?......Page 2470
D.1. How would you monitor this patient during transport?......Page 2471
D.3. Why do patients often shiver in the recovery room on emergence from anesthesia?......Page 2472
D.4. Discuss the causes of oliguria in the recovery room.......Page 2473
57 Trauma......Page 2475
A.2. What are the injuries associated with thoracic trauma?......Page 2478
A.4. What is the pathophysiology of acute pericardial tamponade?......Page 2479
A.5. What are the anesthetic implications for treating cardiac tamponade?......Page 2480
A.7. What constitutes a primary survey, and what is its objective?......Page 2481
A.8. What constitutes a secondary survey, and what is its objective?......Page 2482
A.10. What are the indications for a thoracotomy to treat a hemothorax?......Page 2483
A.11. How are pneumothoraces categorized?......Page 2484
A.12. What is an occult pneumothorax?......Page 2485
A.13. If the patient has a widened mediastinum on chest radiograph, what are your concerns?......Page 2486
A.15. What is a focused abdominal sonography for trauma (FAST) examination?......Page 2487
A.16. What is diagnostic peritoneal lavage (DPL)?......Page 2488
A.18. Define shock.......Page 2489
A.21. What is the pathophysiology of hypovolemic shock?......Page 2490
Acid–Base Disturbance......Page 2491
A.23. What is the initial treatment of hemorrhagic shock?......Page 2492
A.24. Would you choose crystalloid, colloid, or blood products to treat hemorrhagic shock?......Page 2493
A.25. Is there a place for dextran or hetastarch (Hespan) in treating hypovolemic shock?......Page 2494
B.2. What preoperative testing would you order?......Page 2495
C.2. How would you induce anesthesia?......Page 2496
C.3. What technique could you use if single-lung ventilation was indicated?......Page 2497
C.6. What can be done to decrease the incidence of intraoperative awareness?......Page 2498
C.7. Five minutes after intubation, the peak airway pressure increased from 20 to 40 cm H2O. What are the possible causes?......Page 2499
C.10. The patient’s blood loss was continuing, and the hematocrit was 18%. What type of blood would you give if the type and crossmatch are not completed?......Page 2500
C.11. What precautions should be taken if more than 2 units of low titer type O uncrossmatched whole blood are given?......Page 2501
Transfusion Reactions......Page 2502
Microembolization......Page 2504
What is considered a massive transfusion (MT)? What is the Assessment of Blood Consumption (ABC) score?......Page 2505
C.14. What are the complications associated with an MT?......Page 2506
C.16. How is hypothermia defined?......Page 2508
C.18. What is the treatment of hypothermia?......Page 2509
Red Blood Cell Transfusion Criteria......Page 2510
Cryoprecipitate Transfusion Criteria......Page 2511
What are the guidelines for the ratio of plasma/platelet transfusion to packed red blood cells in an MT?......Page 2512
C.22. If a patient were a member of the Jehovah’s Witness religious sect, would you give a blood transfusion?......Page 2513
Recombinant Activated Factor VII (rFVIIa, NovoSeven)......Page 2514
Fibrinogen Concentrates......Page 2515
What is thromboelastography (TEG) and thromboelastometry? How can they guide transfusion?......Page 2516
Rotation Thromboelastometry......Page 2517
Thromboelastography......Page 2521
D.1. What is acute respiratory distress syndrome (ARDS)? What is acute lung injury?......Page 2524
D.2. How is ARDS treated?......Page 2526
Renal......Page 2527
D.4. If this patient had a crush injury and low urine output, what other concerns might you have? What if the patient has dark or “tea-colored” urine?......Page 2528
58 Scoliosis......Page 2530
A. Medical Disease and Differential Diagnosis......Page 2532
A.1. What is scoliosis?......Page 2533
A.2. What is the most common type of scoliosis?......Page 2535
A.3. What are the other types of scoliosis?......Page 2536
Trauma......Page 2537
A.4. How is the severity of scoliosis assessed, and why is the severity important?......Page 2538
A.5. What are the nonoperative treatment options of scoliosis?......Page 2540
A.6. What abnormalities in pulmonary function tests (PFTs) are most commonly seen in scoliosis? What is the cause of these abnormalities?......Page 2542
A.7. What is the most common arterial blood gas abnormality seen in scoliosis? What are possible causes for this abnormality?......Page 2544
A.8. What abnormalities of ventilatory drive may be associated with scoliosis?......Page 2545
A.9. How may the cardiovascular system be affected in patients with scoliosis?......Page 2546
A.10. What is the relationship between scoliosis and malignant hyperthermia?......Page 2547
B.1. What should the anesthesiologist know about the nature of the spinal curve?......Page 2548
B.3. What aspects of the physical examination are most important?......Page 2549
B.5. What tests would you order preoperatively?......Page 2550
B.6. What is an enhanced recovery after surgery (ERAS) pathway? How has it been applied to the recovery for pediatric patients undergoing posterior spinal instrumentation and fusion?......Page 2551
B.7. How will the surgical procedure influence the anesthetic management?......Page 2553
C.1. What monitoring would you use?......Page 2555
C.2. What is the incidence of neurologic complications in scoliosis surgery, and which patients are at highest risk?......Page 2556
C.4. What are somatosensory evoked potentials (SSEPs), and how are they used?......Page 2557
C.5. How reliable are SSEPs for predicting spinal injury?......Page 2559
C.6. What are motor evoked potentials (MEPs), and how are they used?......Page 2560
C.7. How is spinal cord monitoring affected by anesthetic agents? What other factors affect spinal cord monitoring?......Page 2561
C.8. What is the optimal anesthetic technique for scoliosis surgery?......Page 2562
C.9. What should be done if the SSEPs or MEPs become abnormal during surgery?......Page 2564
C.10. How is the “wake-up” test performed? What complications can occur during this test?......Page 2565
C.11. Four hours into the surgical procedure, the surgeon reports some bubbling in the thoracic portion of the wound. Shortly thereafter, end-tidal carbon dioxide decreases abruptly from 35 to 18 mmHg, heart rate increases from 80 to 120 beats per minute, blood pressure begins to fall, and arterial saturation decreases to 90%. On auscultation through esophageal stethoscope, you hear a loud gurgling murmur. What is your diagnosis?......Page 2566
C.13. What should be done if an air embolus is suspected?......Page 2567
C.14. What complications occur related to positioning the patient?......Page 2568
C.15. What is transfusion-related acute lung injury (TRALI)? How do you distinguish it from transfusion-associated circulatory overload (TACO)?......Page 2571
C.16. What techniques can be used to minimize transfusion requirements?......Page 2572
D.1. When would you extubate the patient?......Page 2575
D.2. What should be done to optimize pulmonary status?......Page 2576
D.4. What fluid therapy would you use postoperatively?......Page 2577
D.5. What complications may occur following scoliosis surgery?......Page 2578
D.6. Upon arrival to the recovery room, you notice that the urine appears to be tea colored. What is your diagnosis, and how should this be managed?......Page 2579
D.7. How would you manage this patient’s pain, nausea, and vomiting postoperatively?......Page 2581
59 Hypoxia and Equipment Failure......Page 2583
A.1. What is hypoxia, and what is hypoxemia?......Page 2585
A.3. Was this patient hypoxemic?......Page 2586
A.4. What is a pulse oximeter, and what is a hemoximeter?......Page 2587
A.5. How does a pulse oximeter work?......Page 2588
A.6. How is a two-wavelength pulse oximeter calibrated by the manufacturer?......Page 2589
A.7. What may affect the accuracy of a two-wavelength pulse oximeter?......Page 2590
A.8. How do the dyshemoglobins, methemoglobin (metHb), and carboxyhemoglobin (HbCO) affect SpO2 readings?......Page 2591
A.9. What is a capnometer, and what is capnography? Of what value are they in patient monitoring?......Page 2592
A.10. What is meant by the term end-tidal carbon dioxide (EtCO2)?......Page 2593
A.11. What is the appearance of a normal capnogram, and what is its significance?......Page 2594
A.12. What are mainstream and sidestream capnometers?......Page 2595
A.13. Show some common capnograms and provide a differential diagnosis of each event.......Page 2596
A.14. What is the arterial–alveolar difference in carbon dioxide (CO2)?......Page 2598
Features Intended to Prevent Human Error......Page 2600
Features to Correct for Use Error......Page 2601
Alarm Systems......Page 2602
A.17. How is the anesthesia machine checked for leaks?......Page 2605
B.1. What should be included in the equipment checkout in preparation for anesthesia?......Page 2607
Low-pressure systems......Page 2608
Breathing system......Page 2609
Manual and automatic ventilation systems......Page 2610
Final position......Page 2611
B.2. What emergency equipment should be easily available to the anesthesiologist?......Page 2612
C.1. How should this patient be monitored?......Page 2613
Ventilation......Page 2614
Circulation......Page 2615
C.2. Following uncomplicated induction of anesthesia and endotracheal intubation, the procedure begins. Upon insufflation of the abdomen with CO2, the SpO2 decreases to 78%. What acute diagnostic and therapeutic interventions would you perform?......Page 2616
C.3. The endotracheal tube was withdrawn 2 cm. Squeezing the reservoir bag in the circle breathing system failed to generate positive pressure in the circuit. What are the common sites for gas leaks in the circle breathing system?......Page 2617
D. Postoperative Management......Page 2619
D.1. What criteria would you use for tracheal extubation?......Page 2620
D.2. What are the causes of postoperative hypoxemia?......Page 2621
D.3. What is the difference between shunt, ventilation/perfusion mismatch, and dead space?......Page 2622
D.4. Postoperatively, the patient developed hypoxia and pulmonary edema. What is the differential diagnosis of pulmonary edema? What is the most likely cause of pulmonary edema in this patient?......Page 2623
D.5. How should the ventilator be set if mechanical ventilation is required postoperatively?......Page 2625
D.6. If this patient had acute respiratory distress syndrome (ARDS) secondary to aspiration, besides low-tidal volume ventilation, what other changes in routine therapy should be considered?......Page 2626
D.8. What methods of oxygen administration may be used postoperatively?......Page 2627
60 Electroconvulsive Therapy......Page 2629
A.1. What are the indications for ECT?......Page 2630
A.3. What is the mechanism of action of ECT?......Page 2632
B.2. How should his anticoagulation be managed during ECT?......Page 2634
B.3. What implications do his history of sleep apnea have on management of ECT?......Page 2635
B.4. How does his history of TIA and carotid endarterectomy impact your preoperative evaluation?......Page 2636
B.6. Are there any psychiatric medications he is taking that would impact your anesthetic care?......Page 2637
C.1. Describe the hemodynamic and cardiac response to ECT in a typical patient.......Page 2639
C.2. Is an arterial line warranted in this patient?......Page 2640
C.3. By what means would you attempt to maximize hemodynamic stability?......Page 2641
C.4. Describe the cerebral hemodynamic effects of ECT.......Page 2642
C.5. How would you proceed with an anesthetic induction for this procedure?......Page 2643
C.6. How do you intend to manage his airway during each treatment?......Page 2644
D.1. The patient is extremely agitated upon emergence. Discuss the risk factors for postictal agitation (PIA) as well as the therapeutic options.......Page 2645
D.2. After three consecutive uneventful inpatient treatments, the psychiatrist asks if the patient may undergo ECT as an outpatient. Would you agree to this plan?......Page 2646
61 Ambulatory Surgery......Page 2648
A.1. Is this patient morbidly obese?......Page 2650
A.3. Is there a link to a decline in memory and thinking with anesthesia and surgery?......Page 2651
B.1. What advantages does outpatient surgery offer?......Page 2653
B.2. What are the goals of the preoperative evaluation of the surgical outpatient?......Page 2654
B.4. What preoperative laboratory testing is necessary for surgical outpatients?......Page 2655
B.5. Which outpatients should receive a preoperative chest roentgenogram?......Page 2656
B.6. In which patients is an electrocardiogram (ECG) necessary before outpatient anesthesia and surgery?......Page 2657
B.7. Would age or physical status influence the decision to perform outpatient surgery?......Page 2659
B.8. What patients are considered inappropriate for ambulatory surgery?......Page 2660
B.9. What questions are critically important to ask this patient when obtaining her history?......Page 2662
B.10. What instructions should the patient be given with regard to continuing or discontinuing lisinopril in the perioperative period?......Page 2663
B.11. What is an enhanced recovery after surgery (ERAS) protocol, and how would you apply it in the outpatient setting?......Page 2664
B.12. How would you premedicate this patient?......Page 2665
B.13. Should every outpatient receive prophylaxis against aspiration pneumonitis?......Page 2666
B.14. Is an overnight fast justified for all outpatients?......Page 2667
C.1. What are the important considerations in choosing an anesthetic technique for outpatient surgery?......Page 2668
C.3. What is the bispectral index (BIS) monitor, and what information does it convey?......Page 2669
C.4. What benefits might be derived from using a BIS monitor?......Page 2670
C.5. Is BIS monitoring applicable to children?......Page 2672
C.6. What are the major limitations of BIS monitoring?......Page 2673
C.8. What anesthetic agents would you use to induce and maintain general anesthesia in this patient?......Page 2675
D.1. What are the common causes of nausea and vomiting in outpatients?......Page 2677
D.2. How would you pharmacologically prevent PONV in the susceptible ambulatory patient?......Page 2679
D.3. How is postoperative pain treated?......Page 2681
D.4. What criteria would you use to establish that a patient can be safely discharged after ambulatory surgery?......Page 2683
D.5. How would you decide when to discharge a patient after regional anesthesia?......Page 2684
D.6. What instructions should be given to an ambulatory surgical patients upon discharge?......Page 2685
62 Magnetic Resonance Imaging......Page 2686
A.1. What is MRI, and how does it work?......Page 2688
A.2. What are some advantages of MRI?......Page 2689
A.3. What are some disadvantages associated with MRI? What are some safety concerns?......Page 2691
A.4. How do you manage patients with implanted devices?......Page 2694
A.5. What are the biologic effects of clinical MRI?......Page 2697
A.6. What are the anesthetic considerations for this procedure?......Page 2699
A.7. What is intraoperative MRI (iMRI)? What is real-time MRI, and in what setting can this be used?......Page 2701
B.1. What type of patients may require sedation or general anesthesia for MRI?......Page 2703
B.2. Do all children require sedation for MRI?......Page 2704
B.4. How would you premedicate this patient? What are some options that can be used to premedicate other patients for MRI?......Page 2705
C.1. What are some of the anesthetic options for this patient?......Page 2707
C.2. How is an MRI conducted?......Page 2709
C.3. How would you monitor this patient?......Page 2710
C.4. What special considerations apply to monitoring equipment used during MRI?......Page 2711
C.5. How would you induce and maintain general anesthesia in this patient?......Page 2712
C.6. What are ways to maintain the airway during an MRI scan?......Page 2713
C.8. What is the risk to the patient of gadolinium administration in the presence of acute renal insufficiency?......Page 2715
D.1. How will you recover the patient from anesthesia?......Page 2716
63 Morbid Obesity, Obstructive Sleep Apnea, and Bariatric Anesthesia......Page 2717
A.1. What problems exist with this patient? The patient asks you if he is high risk. What is the evidence? Is surgical therapy a safe and viable alternative for this patient?......Page 2722
A.2. Define the terms overweight, obesity, MO, super obesity (SO), super-SO (SSO), normal weight, ideal body weight (IBW), and lean body weight (LBW). What is the impact of obesity on society?......Page 2724
A.3. What is OSA? What are the risk factors for OSA?......Page 2727
A.4. How is OSA diagnosed? What is a sleep study, or PSG? How are results obtained from a PSG used to grade the severity of OSA? What are the subtypes of OSA? Are there genetic disorders with a predisposition to OSA? What is the role of OSA screening tests in the preoperative setting?......Page 2728
A.5. How does OSA differ in the pediatric population in clinical presentation and pathogenesis?......Page 2731
A.6. What is the Pickwickian syndrome (PS)? What is obesity hypoventilation syndrome (OHS)? Describe the pathogenesis of severe OSA.......Page 2732
A.7. What is the association between obesity and OSA? What is the etiology of OSA in severe obesity?......Page 2734
A.8. What are the anesthetic implications of OSA?......Page 2736
A.9. What type of metabolic problems would you expect to find in morbidly obese patients? What are the roles of leptin and ghrelin in obesity?......Page 2739
A.10. Describe the changes that occur in the following respiratory parameters in morbidly obese patients:......Page 2741
A.11. What changes occur in PaO2 and PaCO2 in morbidly obese patients?......Page 2743
A.12. What changes occur in intrapulmonary shunt (QS/QT) and dead space (VD/VT) in MO? Describe the Shunt equation and the physiologic dead space, or Bohr equation.......Page 2745
A.13. What changes occur in the cardiovascular system of the obese patient? Discuss cardiac output, blood volume, blood pressure, and pulmonary arterial pressure.......Page 2746
A.15. What anatomic changes that affect the airway are associated with MO and OSA?......Page 2749
A.16. What derangements of the gastrointestinal system are associated with MO?......Page 2752
B.1. How would this patient be optimized for surgery preoperatively? Would you use preoperative screening questionnaires to diagnose OSA? Summarize the workup for this patient.......Page 2753
B.2. One of the recent developments in bariatric surgery is that many patients are receiving prebariatric screening procedures performed in the endoscopy suite. Describe the anesthetic considerations.......Page 2757
B.3. Summarize the evidence-based workup, risk, chance of various adverse outcome, and expected length of stay for this patient.......Page 2759
B.4. What is the role of enhanced recovery after surgery (ERAS) in bariatric surgery? How does the public find a quality bariatric surgery team and surgical facility? What is the role of robotics in bariatric surgery?......Page 2760
B.5. Would you premedicate the patient?......Page 2762
B.6. Describe the mechanism of action of each premedication in the ENERGY protocol.......Page 2764
B.7. How would you adjust doses of anesthetics in the morbidly obese?......Page 2765
C.1. How would you monitor this patient?......Page 2767
C.2. The American Society of Anesthesiologists’ (ASA) Difficult Airway Algorithm (DAA) provides a guideline for management of the difficult airway. How do the comorbidities of MO and OSA modify implementation of the algorithm?......Page 2768
C.3. Why is it important to preoxygenate the obese patient? How would you do it? Compare the effectiveness of the four-maximum-breath and 3-minute techniques. What is the importance of continuous positive airway pressure (CPAP) during the induction of general anesthesia? Describe use of the nasal CPAP mask in the induction of general anesthesia.......Page 2771
C.4. There are many new airway devices on the marketplace. Which of these devices have been particularly successful on the morbidly obese or OSA patient?......Page 2773
C.5. How would you induce anesthesia? Describe the intubation technique.......Page 2777
C.6. How would you maintain general anesthesia? What agents would you choose? How would you prepare for emergence?......Page 2779
C.7. Which muscle relaxants would you use?......Page 2782
C.8. Is postoperative pain severe after bariatric surgery? What are the pain generators? What is the role of regional anesthesia to decrease opioid requirements for bariatric surgery? What are the advantages and disadvantages of regional anesthesia? What are some of the newer techniques available?......Page 2783
C.9. What is the pathophysiology of pneumoperitoneum (PNP)? What is the effect on the cardiopulmonary system? How does it change perioperative care? What are the optimal ventilator strategies for morbidly obese patients undergoing bariatric surgery?......Page 2786
C.10. What are the devices that anesthesiologists place in the upper gastrointestinal canal during laparoscopic bariatric surgery? Are there risks associated with placement and management of these devices?......Page 2788
C.11. When will you extubate this patient? Describe weight-based extubation criteria.......Page 2790
C.12. What is apneic oxygenation?......Page 2792
C.13. What is diffusion hypoxia (DH)? How do you prevent it?......Page 2793
D.1. What are the early postoperative complications of bariatric surgical procedures?......Page 2795
D.2. What are the late complications of bariatric surgical procedures?......Page 2797
D.3. What is the effect of position on respiratory function in the obese patient?......Page 2798
D.4. How would you prevent postoperative atelectasis?......Page 2799
D.6. How would you control postoperative pain?......Page 2800
Index......Page 2805