- Sections
- Airway Management
- Ambulatory Anesthesia/General Anesthesia/Bariatric Surgery
- Critical Care
- Neuro-Anesthesia
- Non-OR Anesthesia
- OB Anesthesia
- Orthopedic Surgery
- Pain
- Pediatric Anesthesia
- Pharmacology
- Preoperative Evaluation
- Physiology
- Technology
- Thoracic Anesthesia
- Wellness In Training
- Administration and Quality
- Airway Management
- 1
Extubation of the Difficult Airway
- ALISON DALTON, MDAssistant Professor of Anesthesia and Critical Care University of Chicago Division of the Biological Sciences 5841 S Maryland Avenue Chicago, IL
Purchase PDFIt is well known that induction and intubation are periods associated with patient risk. Especially in the case of patients with known or suspected difficult airways, extubation may be associated with similar risk. Therefore, attempts at extubation must be well planned, and preparations for urgent or emergent intubation must be in order prior to removal of an endotracheal tube. Preparations should be made on a case-by-case basis with consideration given to that specific patient’s indications for difficult airway management. Patients at risk for airway obstruction from edema require different techniques and preparations compared with those patients at risk for intracranial hypertension. Advanced preparations should include consideration of the best location for extubation (ie, OR, PACU, ICU), required tools (ie, airway exchange catheter, videolaryngoscope, fiberoptic bronchoscope supraglottic device), and personnel. A thorough plan for emergent reintubation should be considered taking into account the patient’s baseline airway anatomy, previous difficulty of intubation, subsequent airway edema, hemodynamics, and other complicating factors (ie, patient now in a Halo device, jaw wiring).
This review contains 5 figures, 6 tables, and 45 references.
keywords: airway edema, airway exchange catheter, cricothyrotomy, difficult airway, difficult intubation, extubation, fiberoptic bronchoscopy, retrograde intubation
- 2
Functional Airway Anatomy
- GILBERT S TANG, MDNorthwestern University, McGaw Medical Center (Northwestern Memorial Hospital), Anesthesiology, Chicago, IL
Purchase PDFThe anesthesiologist maintains patency of the airway through the use of various airway techniques, from simple maneuvers such as jaw thrust and chin lift, to the insertion of oropharyngeal or nasopharyngeal airways, to the placement of advanced airway devices such as supraglottic airways and endotracheal tubes. Understanding the structure, function and anatomic relationships of the airway provides the foundation to evaluate the patient and determine a safe plan for airway management.The nose and mouth are the beginning point of the airway, which can be divided into the upper airway consisting of nasal cavity, nasopharynx, oral cavity, oropharynx, hypopharynx and larynx, and the lower airway consisting of the trachea, bronchi and subdivisions of the bronchi. The airway is the conduit from which air flows to and from the alveoli, where oxygenation and ventilation occurs. It plays important functions in trapping airborne contaminants, producing mucus and secretions, permitting olfactory and general sensation, warming and humidifying the air, providing immunologic defense from infection through lymphoid tissues, allowing a mechanism for vocalization, creating a functional separation between the swallowing and breathing, and protecting from aspiration of oral and stomach contents.
This review contains 2 tables and 34 references.
Key words: airway, intubation, pharynx, larynx, kiesselbach’s plexus, vocal cord injury, swallow, cough, laryngospasm, bronchospasm, obstruction, aspiration, pediatric airway
- 3
Physiologic and Pathophysiologic Responses to Intubation
- GILBERT S TANG, MDNorthwestern University, McGaw Medical Center (Northwestern Memorial Hospital), Anesthesiology, Chicago, IL
Purchase PDFThe placement of an endotracheal tube provides definitive airway control for the anesthesiologist and protects the patient from aspiration, hypoventilation and hypoxemia. Airway instrumentation and intubation, however, cause physiologic changes that may have negative effects especially in patients with systemic disease. An abundance of sensory receptors and nerve endings exist in the upper airway that respond to noxious stimulation by activation of the autonomic nervous system, which cause brief but profound cardiovascular and neurologic effects. Stimulation of upper airway receptors may elicit reflexes such as sneezing, coughing, gagging, swallowing, vomiting, laryngospasm and bronchospasm. The presence of the endotracheal tube also bypasses the normal conduit for air movement and changes the airway physiology.
This review contains 6 figures, 4 tables, and 47 references.
Keywords: intubation, sympathetic response, coronary artery disease, aortic dissection, aortic aneurysm, intracranial pressure, attenuating response, airway devices
- 4
Medical Imaging of the Airway
- GILBERT S TANG, MDNorthwestern University, McGaw Medical Center (Northwestern Memorial Hospital), Anesthesiology, Chicago, IL
Purchase PDFNon-invasive imaging techniques such as ultrasonography, x-ray, computerized tomography (CT) and magnetic resonance imaging (MRI) provide details about airway anatomy that complement the physical examination. They are of particular value in patients with traumatic injury, malignancy, abscess, foreign body or mass in the airway that displace, distort, disrupt, encroach or compress airway structures in ways that may not be readily apparent otherwise. Many anesthesiologists do not receive formal training in interpreting medical imaging, and a thorough discussion of this subject is beyond the scope of this review. Interpreting the subtleties of normal and abnormal anatomy require years of experience and best left to expert radiologists. The goal here is to introduce the imaging techniques available and examples of clinical applications in airway evaluation of interest to the anesthesiologist.
This review contains 12 figures, 2 tables, and 37 references.
Keywords: piezoelectric effect, photoelectric interaction, Faraday’s law, pneumothorax, cervical spine injury, LeFort fracture, foreign body, airway infection, mediastinal mass
- 5
Airway Physiology
- GILBERT S TANG, MDNorthwestern University, McGaw Medical Center (Northwestern Memorial Hospital), Anesthesiology, Chicago, IL
Purchase PDFAn understanding of airway physiology is important for the anesthesiologist, tasked with supporting the patient's respiratory functions which are altered in the conduct of anesthesia and surgery, or which may be abnormal due to co-existing disease. Airflow and airway resistance, lung compliance, spirometric values, flow-volume measurements, work of breathing, ventilation-perfusion matching, and oxygen-carbon dioxide transport are some of the basic principles. Clinical application of physiology allows the anesthesiologist to anticipate and manage changes that may occur when anesthetizing the patient, altering position or manipulating the airway.
This review contains 5 tables, and 25 references.
Keywords: Ohm’s law, laminar vs turbulent flow, Reynold’s number, Heliox, Bernoulli’s principle, compliance vs elasticity, Law of Laplace, spirometry, dead space, hypoxic pulmonary vasoconstriction
- 6
Preparation for Advanced Airway Management: Pre-oxygenation and Positioning
By Arpan Mehta, BM, FRCA; Adrian Pichurko, MD
Purchase PDFPreparation for Advanced Airway Management: Pre-oxygenation and Positioning
- ARPAN MEHTA, BM, FRCAAssistant Professor of Clinical Anesthesiology, University of Miami Health System
- ADRIAN PICHURKO, MDAssistant Professor, University of Wisconsin School of Medicine and Public Health
Purchase PDFPreoxygenation allows a margin of safety prior to establishing control of a patient’s airway. Effective preoxygenation is influenced by careful technique, respiratory physiology, blood oxygen content, and total body oxygen consumption. Total body oxygen consumption is increased in the pregnant, pediatric, and obese populations, making maintenance of oxygenation more difficult during apnea. In addition to a standard facemask, advanced equipment such as high-flow nasal cannula, THRIVE, and various mask variants may be used. Positioning of a patient for advanced airway management affects preoxygenation, respiratory mechanics, and the conditions for establishing a definitive airway. The “triple airway support” maneuver consists of head extension, neck flexion, and protrusion of the mandibular teeth over the upper teeth; and provides effective mechanics for positive-pressure mask ventilation. Patients with potentially unstable cervical spines present additional challenges and, especially in emergency situations, require careful negotiation of priorities. Common maneuvers such as head tilt, jaw thrust, cricoid pressure, and manual in-line stabilization can cause motion in the unstable cervical spine with uncertain effects.
This review contains 7 figures, 5 tables, and 43 references.
Keywords: preoxygenation, functional residual capacity, blood oxygen content, alveolar fraction of oxygen, total body oxygen consumption, high-flow nasal cannula, apneic oxygenation, sniffing position, triple airway support maneuver, manual in-line stabilization
- 7
Preparation for Advanced Airway Management: Preparation for Awake Intubation
By Arpan Mehta, BM, FRCA; Adrian Pichurko, MD
Purchase PDFPreparation for Advanced Airway Management: Preparation for Awake Intubation
- ARPAN MEHTA, BM, FRCAAssistant Professor of Clinical Anesthesiology, University of Miami Health System
- ADRIAN PICHURKO, MDAssistant Professor, University of Wisconsin School of Medicine and Public Health
Purchase PDFAwake intubation is a key technique in anesthesia, allowing for the safe management of a patient with signs and predictors of a difficult airway/intubation. It is commonly undertaken electively, but can also be used in an emergency. An appropriate history must be taken, along with review of investigations (e.g CT scan, nasendoscopy), followed by a physical examination and development of a safe management plan. A variety of local anesthetic methods exist for topicalization of the airway (2-4% lidocaine), including nerve blocks (glossopharyngeal, recurrent laryngeal, superior laryngeal) to assist this. Sedation and amnesic techniques commonly include the use of benzodiazepines (midazolam), opioids (remifentanil infusion) and alpha agonists (dexmedetomidine). Knowledge of the side effects of these are paramount, including the cardiac and central nervous system with local anesthetic toxicity. 20% lipid emulsions are available in the event of this.
This review contains 4 figures, 5 tables, and 25 references.
Keywords: awake flexible bronchoscopic intubation, awake endoscopic intubation, remifentanil, dexmedetomidine, airway anesthesia, glossopharyngeal nerve block, recurrent laryngeal nerve block, superior laryngeal nerve block, local anesthetic toxicity, lipid emulation.
- 8
Preparation for Advanced Airway Management: Prevention and Prophylaxis Against Pulmonary Aspiration
By Arpan Mehta, BM, FRCA; Adrian Pichurko, MD
Purchase PDFPreparation for Advanced Airway Management: Prevention and Prophylaxis Against Pulmonary Aspiration
- ARPAN MEHTA, BM, FRCAAssistant Professor of Clinical Anesthesiology, University of Miami Health System
- ADRIAN PICHURKO, MDAssistant Professor, University of Wisconsin School of Medicine and Public Health
Purchase PDFPulmonary aspiration refers to the introduction of foreign contents into the lower respiratory tract. Depending on the volume and properties of the aspirate, the sequelae of pulmonary aspiration may vary widely in severity, including death. No method of aspiration prophylaxis is entirely effective, however certain patient, surgical, and anesthetic factors increase the risk. Guidelines for fasting prior to surgery exist for various types of food and liquid, intended to ensure an empty stomach and thus minimize the odds of pulmonary aspiration of gastric contents. Clinical judgment is necessary in addition to these guidelines. There is insufficient evidence to describe the effects of gastric acidity and volume on morbidity and mortality with aspiration of gastric contents. Medications known to decrease gastric acidity and increase gastric emptying are often used anyway. Certain body positions and the application of cricoid pressure might be effective in reducing aspiration in at-risk patients. Awake intubation does not appear to increase the chances of aspiration in patients deemed at high risk of aspiration. Supraglottic airway devices have not shown an increased incidence of pulmonary aspiration. In a retrospective study, patients who aspirated and did not develop new signs or symptoms of respiratory compromise with 2 hours of monitoring were all safely discharged home.
This review contains 5 figures, 5 tables, and 28 references.
Keywords: chemical pneumonitis, acute respiratory distress syndrome (ARDS), gastric emptying, nil per os (NPO), gastric ultrasound, prokinetic agent, Sellick position, cricoid pressure, supraglottic airway device
- 9
Airway Management in a Patient With Ludwig's Angina
- SARA B. ROBERTSON, MDAssistant Professor, University of Mississippi Medical Center, Mississippi, LA
Purchase PDFLudwig’s angina (LA) is a rare but life-threatening deep space neck infection that affects several combined potential spaces in the neck, namely the submental and submandibular spaces. Patients often present with signs and symptoms such as dysphonia, odynophagia, neck and thoracic pain, otalgia, sialorrhea, and cough. In later stages, the patient may present with dysphagia, trismus, cyanosis, dyspnea, and stridor which all may signal an impending airway collapse. This comprehensive review will set out to describe the definition, anatomy, and epidemiology of Ludwig’s angina, how it manifests, and how to diagnose and treat the infection that can be often difficult to recognize. Clinical features of the disease are discussed as well as different strategies for anesthesia and airway management. Two special situations in which Ludwig’s angina can occur—pregnancy and pediatric patients—are also covered.
This review contains 6 tables, and 31 references.
Keywords: Ludwig’s angina, management of the airway in Ludwig’s angina, conservative treatment in Ludwig’s angina, surgical management in Ludwig’s angina, antibiotic treatment for Ludwig’s angina, Ludwig’s angina in pediatrics, Ludwig’s angina in pregnancy, neck anatomy in Ludwig’s angina
- 10
Airway Management in a Patient With Ludwig's Angina
- SARA B. ROBERTSON, MDAssistant Professor, University of Mississippi Medical Center, Mississippi, LA
- 11
Airway Management in an Uncooperative Patient With Acute Spinal Cord Injury
By Sara B. Robertson, M.D.
Purchase PDFAirway Management in an Uncooperative Patient With Acute Spinal Cord Injury
- SARA B. ROBERTSON, M.D.Assistant Professor University of Mississippi Department of Anesthesiology Division of Pediatric Anesthesiology Blair E. Batson Children's Hospital
Purchase PDFManaging the airway of an uncooperative patient with an acute spinal cord injury can be a daunting task for any anesthesia provider. This review introduces the background usually encountered in this situation, epidemiology, cervical spine anatomy and mechanics, injury types most often encountered, and how to most effectively diagnose a cervical spine injury via imaging modalities. Airway considerations including the initial evaluation, manual in-line stabilization, cricoid pressure, and cervical neck collars are covered as well as an algorithm for airway management. Different airway devices are compared as well in this situation. A special circumstance of airway management in the pediatric population with acute spine injury concludes the review.
This review contains 8 tables, 3 figures, and 28 references.
- 12
Physiologic and Pathophysiologic Responses to Intubation
- GILBERT S TANG, MDNorthwestern University, McGaw Medical Center (Northwestern Memorial Hospital), Anesthesiology, Chicago, IL
- 13
Airway Management in an Uncooperative Patient With Acute Spinal Cord Injury
By Sara B. Robertson, M.D.
Purchase PDFAirway Management in an Uncooperative Patient With Acute Spinal Cord Injury
- SARA B. ROBERTSON, M.D.Assistant Professor University of Mississippi Department of Anesthesiology Division of Pediatric Anesthesiology Blair E. Batson Children's Hospital
- 1
- Ambulatory Anesthesia/general Anesthesia/bariatric Surgery
- 1
Anesthetic Management for the Obese Patient -airway, Ventilation, Monitoring, Venous Access
Purchase PDFAnesthetic Management for the Obese Patient -airway, Ventilation, Monitoring, Venous Access
Purchase PDF - 2
Ophthalmologic Anesthesia: Open Eye Injuries
By Stephen R Estime, MD; Safa Rahmani, MD, MS
Purchase PDFOphthalmologic Anesthesia: Open Eye Injuries
- STEPHEN R ESTIME, MDInstructor of Anesthesia, Massachusetts General Department of Anesthesia, Critical Care and Pain Medicine, MA, United States
- SAFA RAHMANI, MD, MSVitreoretinal Fellow, Massachusetts Eye and Ear Department of Ophthalmology, MA, United States
Purchase PDFAnesthetic management for ophthalmic surgery in a patient with an open eye injury requires a pragmatic, evidence-based approach to optimize success. Close communication with the ophthalmologist can make a significant impact on outcome. Additionally, providing appropriate pulmonary aspiration risk reduction using established guidelines; thoughtfully managing the challenging airway; and choosing the best medications during induction, maintenance, and emergence are all critical to minimizing the risks for further eye injury. Anesthetic goals can often be in opposition to one another, but with the appropriate knowledge, experience, and effective communication between patient and surgeon, the anesthesia provider can maintain patient safety while effecting the desired surgical outcome.
This review contains 2 figures, 4 tables and 37 references
Key Words: awake intubation, deep extubation, emergency eye surgery, eye trauma, full stomach, intraocular extrusion, intraocular pressure, open eye injury, succinylcholine and open eye sugammadex
- 3
Anesthesia for Urologic Surgery
- DAN B ELLIS, MDDepartment of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
- ANTON WINTNER, MDDepartment of Urology, Massachusetts General Hospital, Boston, MA
Purchase PDFToday, urologists care for patients who have benign diseases of the ureter, bladder, and urethra such as kidney or bladder stones as well as patients with malignancies such as bladder tumors or prostate cancer. Furthermore, as technology improves, larger, more invasive operations are being replaced by minimally invasive procedures. Patient comorbidities and need for anticoagulant medications have increased in quantity and scope. Therefore, anesthetic techniques, which have historically relied heavily on neuraxial anesthesia, have been forced to evolve to safely care for these progressively ill patients. Thus, a number of historical approaches to urologic procedures are no longer applicable. Therefore, an understanding of the type and scope of the operation being performed as well as an understanding of the patient’s own comorbidities is key to safely caring for the modern urologic patient.
This review contains 5 figures, 9 tables, and 34 references.
Key Words: bladder, cystectomy, hyponatremia, irrigating fluids, lithotripsy, prostate, transurethral resection of prostate, ureter, urethra
- 4
Burns
- EDWARD A. BITTNER, MD, PHD, MSEDDepartment of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
- CONNIE W. CHAUDHARY, MDDepartment of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD
Purchase PDFAnesthetic management of burn-injured patients can be particularly challenging. Burn-injured patients exhibit pathophysiologic changes that can affect nearly all the organs in the body. Challenges the anesthesiologist may encounter when caring for burn patients include difficult airway management, impaired lung function, vascular access issues, hypothermia, pharmacokinetic and pharmacodynamic alterations, and pain management. Other important considerations that could affect the condition of burn patients include blood loss, hypermetabolism, pain control, and temperature management. Anticipating appropriate precautions can change the clinical outcome of these patients. Optimal care requires a full understanding of the unique preoperative, intraoperative, and postoperative issues of the burn-injured patient.
This review contains 2 figures, 3 tables, and 77 references.
Key Words: anesthetic management of acute burns, burn injury, electrical injury, fluid resuscitation, inhalation injury, Parkland formula, pain management
- 5
Sepsis
- MICHAEL R. FILBIN, MDAssistant Professor, Harvard Medical School, Department of emergency Medicine, Massachusetts General Hospital, Boston, MA
Purchase PDFSepsis accounts for approximately one in three hospital deaths, and is associated with very high health care costs due to prolonged lengths of stay in the intensive care unit and hospital. Sepsis is essentially an immunologic response to infection that is propagated systemically, leading to diffuse cellular and microcirculatory dysfunction, vasodilation, vital organ hypoperfusion, and eventual failure. This review covers the pathophysiology, stabilization/assessment, diagnosis, treatment, and disposition and outcomes of sepsis. Figures show the inflammatory and thrombotic response to infection, the action of nitric oxide on vascular smooth muscle cells, accelerated glycolysis and increased lactate production as a result of the catecholamine surge seen in septic shock, sepsis mortality associated with number of organ failures identified in the emergency department (ED), and protocolized therapy for septic shock. Tables list definitions of sepsis syndromes; frequently cited scoring systems for mortality prediction in emergency department patients with sepsis; Sequential Organ Failure Assessment (SOFA) score; current recommendations regarding treatment bundles at 3 and 6 hours of resuscitation; antibiotic recommendations based on suspected source; and vasopressors used in septic shock with recommended dosing, mechanism of action, and indications.
This review contains 5 figures, 7 tables, and 57 references
Keywords: Sepsis; Surviving Sepsis Campaign guidelines, definitions, SEP-1 sepsis quality measure, time-to-antibiotics, volume resuscitation, lactated ringers
- 6
Management of Acute Wounds
- LEE D. FAUCHER, MD, FACSAssociate Professor of Surgery University of Wisconsin School of Medicine & Public Health, Madison WI.
- ANGELA L. GIBSON, MD, PHDAssistant Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
Purchase PDFAcute wounds are the result of local trauma and may be associated with severe life-threatening injuries. All patients with acute wounds should be assessed for comorbidities such as malnutrition, diabetes, peripheral vascular disease, neuropathy, obesity, immune deficiency, autoimmune disorders, connective tissue diseases, coagulopathy, hepatic dysfunction, malignancy, smoking practices, medication use that could interfere with healing, and allergies. The authors address the key considerations in management of the acute wound, including anesthesia, location of wound repair (e.g. operating room or emergency department), hemostasis, irrigation, débridement, closure materials, timing and methods of closure, adjunctive treatment (e.g. tetanus and rabies prophylaxis, antibiotics, and nutritional supplementation), appropriate closure methods for specific wound types, dressings, postoperative wound care, and potential disturbances of wound healing.
This review contains 11 figures, 31 tables, and 92 references.
Keywords: wound, wound infection, burns, suture, staple, wound closure, wound healing, dehiscence, skin grafting
- 7
Principles of Cancer Diagnosis
- SAMANTHA J. BAKER, MDGeneral Surgery Resident, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
- J. BART ROSE, MD, MASAssistant Professor, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
Purchase PDFAs knowledge of cancer pathology deepens, so does the complexity of cancer care. Recommendations from the National Cancer Policy Board Cancer Care System focus on using high-volume centers for patients undergoing high-mortality procedures and clinical trials to develop evidence-based guidelines for cancer prevention, diagnosis, treatment, palliative care, and quality care. Through the implementation of many of these principles, patient-centered care has become increasingly recognized as fundamental model for healthcare.
This review contains 2 figures, 1 table, and 25 references.
Key Words: Cancer, Cancer staging, Core needle biopsy, Fine needle aspiration, Liquid biopsy, Lymph nodes, Sentinel lymph node(s), Surgical biopsy
- 8
Principles of Cancer Treatment
- SAMANTHA J. BAKER, MDGeneral Surgery Resident, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
- J. BART ROSE, MD, MASAssistant Professor, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
Purchase PDFSurgeons often play a pivotal role in the treatment plans for cancer patients, especially when the plan of action includes resection. Locoregional therapies have the advantage of treating the tumor and its local environment while minimizing systemic effects. Other examples of local treatment include radiotherapy and chemotherapy delivered with isolation techniques. In contrast, systemic chemotherapy, systemic radiation, hormone therapy, and immunotherapy are administered throughout the body. Systemic therapy is most useful in treating disease distant to the site of origin but can be limited by systemic side effects. This chapter explores each of these treatment arms in more detail and provides examples of when such options may be deployed.
This review contains 1 figure, 2 tables, and 67 references.
Key Words: Biopsy, Cancer, Chemotherapy, Directed therapy, Hormone therapy, Immunotherapy, Lymph nodes, Proton therapy, Radiation therapy, Staging
- 9
Postoperative and Adjunctive Wound Care
- LEE FAUCHER, MD, FACSAssociate Professor of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
- REBECCA A. BUSCH, MDGeneral Surgery Resident, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
Purchase PDFWounds are a major source of complications in surgery, but many can be avoided by using a sound, evidence-based approach to wound care. Preoperative considerations are discussed and include smoking cessation, glycemic control, weight loss, and adequate nutritional intake. Intraoperative considerations are presented and include proper classification of surgical wounds, hyperoxia and warming, and fascia closure techniques. Postoperative considerations that are presented include recognizing both early and late fascia complications, understanding skin closure techniques, and using adjuncts to postoperative wound management.
This review contains 7 figures, 24 tables, and 67 references.
Keywords: Surgical site infection, infection, closure, suture, negative pressure wound therapy, open abdomen, mesh, surgery, granulation tissue
- 10
Minimally Invasive Surgery: Equipment and Troubleshooting
By Jacob A. Greenberg, MD, EDM; Laura E. Fischer, MD, MS
Purchase PDFMinimally Invasive Surgery: Equipment and Troubleshooting
- JACOB A. GREENBERG, MD, EDMAssistant Professor, Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI
- LAURA E. FISCHER, MD, MSResident Physician, Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI
Purchase PDFThe field of minimally invasive surgery has evolved rapidly since the first laparoscopic appendectomies and cholecystectomies were performed nearly 30 years ago.1 Minimally invasive approaches are now widely used for gastrointestinal resection, hernia repair, antireflux surgery, bariatric surgery, and solid-organ surgery, such as hepatic, pancreatic, adrenal, and renal resections. Although the techniques and equipment needed to access, expose, and dissect vary according to the type of operation and surgeon’s preference, a basic set of equipment is essential for any laparoscopic or robotic procedure: endoscope, camera, light source, signal processing unit, video monitor, insufflator and gas supply, trocars, and surgical instruments. Understanding how to use and troubleshoot this equipment is critical for any surgeon who performs minimally invasive surgery. We review the essentials of basic laparoscopic equipment, including the mechanics of normally functioning equipment and the various types of laparoscopic trocars and instruments. We also discuss robotic equipment and the fundamental differences from laparoscopy. Minilaparoscopy and single-site equipment are briefly explained. Additionally, we discuss potential technical difficulties that surgeons may encounter while performing minimally invasive procedures and provide suggestions for troubleshooting these problems.
This review 13 figure, 2 tables, and 64 references.
Key Words: Laparoscopy, Robotic Surgery, Minimally Invasive Surgery, Laparoscopic Surgery, Trocars, Surgical Energy Devices, Insufflator, Laparoscopic Instrumentation, Ergonomics, Single Site Surgery - 11
Basic Concepts of Anesthesia
- GEORGE P. YANG, MD, PHDAssociate Professor, Department of Surgery, Stanford University School of Medicine, Stanford, CA and Palo Alto VA Health Care System, Palo Alto, CA
- POOJA PANDYA, MDClinical Instructor, Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, and Palo Alto VA Health Care System, Palo Alto, CA
Purchase PDFIt is expected that surgeons have detailed and nuanced knowledge of the procedures they perform. It is equally necessary that surgeons have a working knowledge of anesthesia because it is important in patient selection for surgery, and for intraoperative factors including patient positioning and invasive monitoring. Proper care of the operative patient requires excellent communication and coordination between the surgical and anesthetic team. Providing optimal perioperative care for the patient requires the surgeon to understand the risks and benefits of each anesthetic approach and to relay potential portions of the procedure that may have a profound impact on the patient’s physiology so the anesthesiologist can properly prepare for it. With the increasing complexity of patients and the operations being performed, this ensures the best possible outcome.
This review contains 6 figures, 13 tables, and 142 references.
Key words: Local anesthetic, regional anesthesia, general anesthesia, sedation, cardiovascular risks, preoperative evaluation, difficult airway, perioperative medications, surgical risk calculators
- 12
Robotic Surgery
- ALFREDO M. CARBONELL, DO, FACS, FACOSPrfessor of Surgery and Chief, Division of Minimal Access and Bariatric Surgery, Department of Surgery, University of South Carolina School of Medicine-Greenville, Greenville Health System, Greenville, SC
- JEREMY A WARREN, MDAssistant Professor of Surgery, Division of Minimal Access and Bariatric Surgery, Department of Surgery, University of South Carolina School of Medicine-Greenville, Greenville Health System, Greenville, SC
Purchase PDFRobots have revolutionized industrial production, from automobiles to pharmaceutical manufacturing, and offer an exciting, novel approach to surgical diseases. Robots employed in surgical use initially raised some concern related to malfunction and independent action. However, the surgeon’s decision-making capability is still crucial for each surgical procedure because of the anatomic or physiologic variables of each clinical situation. Currently, surgical robots consist of instruments that are remotely manipulated by a surgeon using an electromechanical interface and represent extensions of the surgeon’s mind and hands. This review provides an overview of robotic surgery, and covers the application of robotic surgery in general surgery. Figures show the AESOP 3000 robotic arm, the da Vinci robotic surgical system, the ZEUS Surgical System, the ZEUS robotic arms, the da Vinci Si, the da Vinci wristed endoscopic stapler, the da Vinci Xi patient side cart and robotic arms, the da Vinci Single-Site robotic instruments, and the da Vinci Single-Site port with instruments positioned and robotic arms docked. The video shows a robotic Rives-Stoppa retromuscular incisional hernia repair with bilateral transversus abdominis release.
This review contains 9 highly rendered figures, 1 video, and 85 references
Key words: Robotic, surgery, hernia, inguinal, ventral, incisional, fundoplication, paraesophageal hernia, myotomy, gastrectomy, cholecystectomy, pancreatectomy, splenectomy, bariatric, adrenalectomy, colon, colectomy, colorectal
- 13
Clinical Trial Design and Statistics
By Julie Ann Sosa, MA, MD, FACS; Samantha M. Thomas, MS; April K.S. Salama, MD
Purchase PDFClinical Trial Design and Statistics
- JULIE ANN SOSA, MA, MD, FACSAssociate Professor of Surgery, Divisions of Endocrine Surgery and Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, CT
- SAMANTHA M. THOMAS, MSBiostatistician, Department of Biostatistics & Bioinformatics, Duke Cancer Institute, Durham, NC
- APRIL K.S. SALAMA, MDAssistant Professor of Medicine, Division of Medical Oncology, Duke University School of Medicine, Durham, NC
Purchase PDFA clinical trial is a planned experiment designed to prospectively measure the efficacy or effectiveness of an intervention by comparing outcomes in a group of subjects treated with the test intervention with those observed in one or more comparable group(s) of subjects receiving another intervention. Historically, the gold standard for a clinical trial has been a prospective, randomized, double-blind study, but it is sometimes impractical or unethical to conduct such in clinical medicine and surgery. Conventional outcomes have traditionally been clinical end points; with the rise of new technologies, however, they are increasingly being supplemented and/or replaced by surrogate end points, such as serum biomarkers. Because patients are involved, safety considerations and ethical principles must be incorporated into all phases of clinical trial design, conduct, data analysis, and presentation. This review covers the history of clinical trials, clinical trial phases, ethical issues, implementing the study, basic biostatistics for data analysis, and other resources. Figures show drug development and clinical trial process, and type I and II error. Tables list Food and Drug Administration new drug application types, and types of missing data in clinical trials.
This review contains 2 figures, 3 tables, and 38 references
Keywords: Clinical trial, study design, type I error, type II error, double-blind study, ethics
- 14
Anesthesia for Urologic Surgery
- DAN B ELLIS, MDDepartment of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
- ANTON WINTNER, MDDepartment of Urology, Massachusetts General Hospital, Boston, MA
- 15
Postoperative Management for the Obese Patient
By Shiliang Alice Cao, M.D., ScM; Maurice Frankie Joyce, M.D., EdM
Purchase PDFPostoperative Management for the Obese Patient
- SHILIANG ALICE CAO, M.D., SCMMassachusetts General Hospital, Department of Anesthesia, Critical Care & Pain Medicine
- MAURICE FRANKIE JOYCE, M.D., EDMTufts Medical Center, Department of Anesthesiology and Perioperative Medicine
Purchase PDFObesity results in physiologic changes that effect nearly every organ system, including respiratory, cardiovascular, gastrointestinal, endocrine, genitourinary, and neuropsychiatric. These changes are associated with complications in the postoperative period that the anesthesia provider must take into account when planning the anesthetic of the obese patient. Obesity is associated with obstructive sleep apnea, obesity hypoventilation syndrome, and restrictive-type changes in lung volumes that decrease the obese patient’s ability to compensate for the changes that take place with anesthesia. The anesthetic provider should conduct a thorough preoperative evaluation, ensure complete reversal of neuromuscular blockade prior to extubation to prevent obstruction, ensure adequate pain control without compromising respiratory function, and consider use of Continuous positive airway pressure (CPAP) machines for patients on home CPAP. Obesity is also associated with an increased risk of perioperative arrhythmias, thrombotic events, impaired wound healing, decreased kidney function, and postoperative cognitive decline. Anesthetic providers should make every effort to take steps in order to prevent these complications and be knowledgeable about their management should they occur.
This review contains 3 figures, 2 tables, 37 references
- 16
Anesthesia for Laparoscopic Surgery: Anesthetic Management and Complications
By Edward A. Bittner, MD, PhD, MSEd; Shiliang Alice Cao, M.D., ScM
Purchase PDFAnesthesia for Laparoscopic Surgery: Anesthetic Management and Complications
- EDWARD A. BITTNER, MD, PHD, MSEDDepartment of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
- SHILIANG ALICE CAO, M.D., SCMMassachusetts General Hospital, Department of Anesthesia, Critical Care & Pain Medicine
Purchase PDFLaparoscopic surgery results in physiologic changes that encompass multiple organ systems, with respiratory, cardiovascular and neurologic and splanchnic effects. Insufflation of the peritoneum results in reduced lung volumes, atelectasis, and endobronchial migration of the endotracheal tube. Pneumoperitoneum can result in changes to venous return, cardiac output and blood pressure. Hypercapnia due to carbon dioxide gas used in insufflation can reduce cerebral perfusion pressure. Complications during laparoscopic surgery often occur during port placement and creation of the pneumoperitoneum. Problems include injury to blood vessels during trocar entry, vascular injury in the pneumoperitoneum with limited surgical access, severe bradycardia and arrhythmias due to vagal stimulation from peritoneal stretching, subcutaneous emphysema, pneumothorax, gas embolism, and complications associated with steep Trendelenburg positioning. A thorough understanding of the physiologic changes associated with laparoscopic procedures and recognition of potential complications will facilitate in optimal patient care.
This review contains 4 figures, 1 table and 52 references
Keywords: Laparoscopy; laparoscopic surgery; carbon dioxide; pneumoperitoneum; capnothorax; general anesthesia; subcutaneous emphysema; insufflation
- 17
Clinical Trial Design and Statistics
By Julie Ann Sosa, MA, MD, FACS; Samantha M. Thomas, MS; April K.S. Salama, MD
Purchase PDFClinical Trial Design and Statistics
- JULIE ANN SOSA, MA, MD, FACSAssociate Professor of Surgery, Divisions of Endocrine Surgery and Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, CT
- SAMANTHA M. THOMAS, MSBiostatistician, Department of Biostatistics & Bioinformatics, Duke Cancer Institute, Durham, NC
- APRIL K.S. SALAMA, MDAssistant Professor of Medicine, Division of Medical Oncology, Duke University School of Medicine, Durham, NC
- 1
- Critical Care
- 1
Neurosurgical Critical Care
- JOSE MANUEL SARMIENTO, MD, MPHNeurosurgery Resident, Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States,
- SHOURI LAHIRI, MDAssistant Professor of Neurology, Departments of Neurology, Neurosurgery, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United
Purchase PDFThe overarching goal of neurosurgical critical care is to prevent potential deleterious effects of secondary brain injury. The initial management of patients with traumatic brain injury prioritizes the assessment of injury severity and prevention of hypotension and hypoxemia. The assessment of severity in patients with traumatic brain injury is important for determining the need for intubation and need for placement of intracranial monitoring. The stepwise management of increased intracranial pressure following traumatic brain injury is emphasized to prevent cerebral herniation syndromes and cerebral infarcts. Treatment with glucocorticoids following acute spinal cord injury is not recommended. Operative indications for intracranial monitor placement, hemicraniectomy, and spinal decompression are reviewed.
This review contains 1 figure, 3 tables and 32 references
Key Words: glucocorticoids in spinal cord injury, hemicraniectomy, intracranial hypertension, multimodal monitoring, secondary brain injury, spinal cord injury, spinal decompression, traumatic brain injury
- 2
Neurovascular Critical Care
- JOSE MANUEL SARMIENTO, MD, MPHNeurosurgery Resident, Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States,
- SHOURI LAHIRI, MDAssistant Professor of Neurology, Departments of Neurology, Neurosurgery, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United
Purchase PDFIschemic stroke and intracranial hemorrhage are among the most devastating and debilitating injuries in medicine. Initial management principles for acute ischemic stroke rely on prompt revascularization before the brain parenchymal is infarcted. Large hemispheric infarctions and malignant cerebral edema occur uncommonly in a subset of patients with acute ischemic stroke and are associated with high morbidity and mortality rates. The indications for decompressive hemicraniectomy for malignant cerebral edema are reviewed. Medical management of intraparenchymal hematomas and aneurysmal subarachnoid hemorrhage in the intensive care setting is emphasized. Important clinical sequelae of subarachnoid hemorrhage such as rebleeding, cerebral vasospasm, and cerebral salt wasting are reviewed.
This review contains 5 figures, 4 tables and 52 references
Key Words: acute ischemic stroke, cerebral aneurysm, cerebral vasospasm, decompressive hemicraniectomy, intracerebral hemorrhage, large hemispheric infarctions, subarachnoid hemorrhage, malignant cerebral edema
- 3
The Post-anesthesia Care Unit
- EVAN R BOHNENBLUST, MDFellow, Critical Care Medicine, Department of Anesthesiology, Cedars-Sinai Medical Center, LA, United States
Purchase PDFThis general overview of the postanesthesia care unit (PACU) summarizes the most current standards and guidelines for patient care and monitoring. It also details the causes and treatment of the most common complications observed in PACU, such as postoperative nausea and vomiting, hemodynamic compromise, and respiratory insufficiency. Other relevant topics such as residual neuromuscular blockade and emergence delirium are also addressed. Finally, this chapter concludes with a discussion of the development of commonly used discharge scoring systems, including a discussion of the differences between the ambulatory and inpatient surgery populations. Each of these sections discusses current trends in management as supported by the latest literature and guidelines.
This review contains 1 figure, 8 tables, and 53 references.
Key Words: Aldrete scoring, delayed awakening, emergence delirium, postanesthesia care unit, postanesthesia care unit discharge criteria, postoperative nausea and vomiting, postoperative respiratory failure, residual neuromuscular blockade, sugammadex
- 4
Endocrine Disorders and Considerations
Purchase PDFEndocrine Disorders and Considerations
Purchase PDF - 5
Venous Thromboembolism and Transfusion Medicine
By Maulik Rajyaguru, DO; Jill Yaung, MD
Purchase PDFVenous Thromboembolism and Transfusion Medicine
- MAULIK RAJYAGURU, DOClinical Anesthesiologist and Critical Care Fellow, Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
- JILL YAUNG, MDClinical Anesthesiologist and Critical Care Intensivist, Cedars-Sinai Heart Institute, Department of Surgery, Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
Purchase PDFVenous thromboembolism (VTE) and transfusion medicine are frequently encountered issues in the intensive care unit. VTE can significantly worsen the risk of morbidity and mortality in any hospitalized patient, but proper preventive measures can reduce its incidence. Blood product transfusions can be lifesaving in appropriate situations but can also be both medically and economically detrimental if used without proper clinical judgment. In this review, we present an overview of VTE diagnosis, pharmacologic and mechanical prophylaxis, and treatment. Additionally, we review current indications for blood product use in various clinical situations, basics of massive transfusions, and adverse medical reactions to transfusions.
This review contains 2 figures, 8 tables, and 54 references.
Key Words: anticoagulation, blood component separation, venous thrombosis, immunohematology, massive transfusion, superficial venous thrombosis, transfusion threshold, venous thromboembolism
- 6
Pancreatic and Adrenal Disorders
- JILL YAUNG, MDClinical Anesthesiologist and Critical Care Intensivist, Cedars-Sinai Heart Institute, Department of Surgery, Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
Purchase PDFCritically ill patients who lack preexisting endocrine diagnoses may still develop endocrine dysfunction, as exhibited by critical illness-related corticosteroid insufficiency and glycemic abnormalities. Glycemic control remains an important issue in critically ill patients, as hyperglycemia, hypoglycemia, and glucose variability are all independently associated with increased mortality. Hyperglycemia is a common manifestation of critical illness that may result from an acute response to stress and injury or may reflect preexisting diabetes mellitus. Hypoglycemia most commonly occurs as a result of treatment of hyperglycemia but may also be due to other causes such as sepsis and decreased nutritional intake. Hypoglycemia and other glycemic emergencies such as diabetic ketoacidosis and a hyperosmolar hyperglycemic state must be quickly recognized and treated. This review provides a general overview of diabetes mellitus, glycemic targets in the critically ill, glycemic emergencies, adrenal gland disorders, pheochromocytoma, and carcinoid syndrome.
This review contains 1 figures, 4 tables, and 43 references.
Keywords: adrenal crisis, carcinoid syndrome, critical illness-related corticosteroid insufficiency, Cushing syndrome, diabetes mellitus, diabetic ketoacidosis, glycemic goals, hyperosmolar hyperglycemic state, hypoglycemia, pheochromocytoma
- 7
Pituitary, Thyroid, and Parathyroid Disorders
- JILL YAUNG, MDClinical Anesthesiologist and Critical Care Intensivist, Cedars-Sinai Heart Institute, Department of Surgery, Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
Purchase PDFCritically ill patients may have preexisting endocrine disorders that need to be recognized and addressed. Disruption of normal endocrine gland function leads to inappropriate hormone secretion, resulting in hormone excess or deficiency. Both extremes may have detrimental systemic consequences and may pose significant challenges to the intensivist. Proper recognition of endocrine emergencies such as severe hyponatremia secondary to the syndrome of inappropriate antidiuretic hormone secretion, thyroid storm, and myxedema coma is vital, as delay in treatment may result in significant morbidity or death. This review provides an overview of common pituitary, thyroid, and parathyroid disorders and emergencies, including definitions, manifestations, diagnosis, and management.
This review contains 2 figures, 7 tables, and 30 references.
Key Words: acromegaly, diabetes insipidus, hyperparathyroidism, hypoparathyroidism, myxedema coma, nonthyroidal illness syndrome, syndrome of inappropriate antidiuretic hormone secretion, thyrotoxicosis, thyroid storm
- 8
Cardiovascular System: Heart Diseases
By Ben O’Brien, MD, PhD, FRCA, FFICM, MHBA, SFFMLM; Simon J Finney, MRCP, FRCA, FFICM, EDIC, MSc, PhD; Alastair G Proudfoot, MRCP, PhD, FFICM
Purchase PDFCardiovascular System: Heart Diseases
- BEN O’BRIEN, MD, PHD, FRCA, FFICM, MHBA, SFFMLMProfessor of Perioperative Medicine, Consultant in Intensive Care Medicine and Cardiac Anaesthesia, Barts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London, UK
- SIMON J FINNEY, MRCP, FRCA, FFICM, EDIC, MSC, PHDConsultant in Intensive Care and Anaesthesia, Barts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London, UK
- ALASTAIR G PROUDFOOT, MRCP, PHD, FFICMConsultant in Critical Care, Barts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London, UK
Purchase PDFEvery year, about one in every four people die of heart disease in the United States. The most common condition is coronary artery disease and its sequelae of myocardial infarction, cardiac arrest and heart failure. As the population ages, structural heart disease, particularly of the aortic and mitral valves, becomes ever more prevalent. Indeed, heart disease is part of the every day practice of all anesthesiologists who care for adult patients. These mini-reviews outline some of the key considerations with respect to coronary artery disease, structural heart disease and cardiac dysrhythmia along with some of the emerging technologies that are used to care for these patients.
This review contains 3 table and 14 references.
Keywords: aortic valve disease, cardiac ablation procedures, cardiac pacing, cardiac resynchronisation, ischaemic heart disease, infective endocarditis, mitral valve disease, coronary artery physiology
- 9
The Respiratory System
- ZERLINA WONG, MDClinical Assistant Professor of Anesthesiology, Keck Medicine of USC, Los Angeles, CA
- MICHAEL NUROK, MBCHB, PHDAssociate Professor of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
Purchase PDFThe pulmonary system is crucial for survival. Managing respiratory mechanics and airway requires a sophisticated understanding of pulmonary physiology. This chapter discusses the ways in which oxygen is brought into the body and carbon dioxide is expelled and reviews the principles of respiratory mechanics, including lung compliance, airway resistance, chemoreceptor and mechanoreceptor control of ventilation, hypoxic pulmonary vasoconstriction, distribution of perfusion, and other properties that affect oxygen and carbon dioxide transport. The respiratory system exists in a state of equilibrium, where the inward elastic recoil of the lungs is balanced with the outward elastic recoil of the chest wall. Airway resistance and compliance are important factors that affect ventilation and air movement. This chapter reviews the role that chemoreceptors and mechanoreceptors have on controlling ventilation, as well as the effects that hypercarbia and hypoxemia have on pulmonary and cerebral circulation, and the Bohr and Haldane effects that elucidate understanding of the hemoglobin dissociation curve. These principles all inform the care of patients who require mechanical ventilation, as we endeavor to support them through their surgery or intensive care stay.
This review contains 7 figures and 38 references.
Key Words: apneic oxygenation, Bohr effect, chemoreceptors, compliance, Haldane effect, hypoxic pulmonary vasoconstriction, resistance, respiratory mechanics, ventilation-perfusion
- 10
Neurophysiologic Monitoring
By Scott Vaughan, DO; Chadron Vassar, DO ; Nitin Kumar, MD; Kerolos Yousef, DO, MBA
Purchase PDFNeurophysiologic Monitoring
- SCOTT VAUGHAN, DOAssociate Chair Department of Anesthesia and Director of Neuroanesthesia Geisinger Medical Center, Danville PA
- CHADRON VASSAR, DO CA3 Resident Geisinger Medical Center, Danville PA
- NITIN KUMAR, MDCA3 Resident Geisinger Medical Center Danville, PA
- KEROLOS YOUSEF, DO, MBACA3 Resident Geisinger Medical Center Danville, PA
Purchase PDFNeurophysiologic monitoring is a diverse group of instruments that are used to monitor the central and peripheral nervous system during surgical procedures. Some are used to monitor anesthetic depth, whereas others are used by neurologists to monitor the integrity of the nervous system during surgical procedure. The goal of neurophysiologic monitoring is to have reliable, reproducible, and predictive monitors that can identify impending compromise to the neurologic system (or anesthetic) with minimal false predictive value and high positive predictive value. This allows for the identification of neurologic tissues by location and type that are at risk of compromise by vascular and/or mechanical injury.
This review contains 3 figures, 8 tables, and 34 references.
Key Words: auditory evoked potentials, bispectral index monitor, electrocorticography, electroencephalography, electromyographic monitoring, M-ENTROPY, motor evoked potentials, narcotrend index, sensory evoked potentials, spectral analysis
- 11
Encephalopathy and Delirium
- ALLIYA S. QAZI, MDSurgical Critical Care Fellow, Department of Surgery, Stanford University School of Medicine, Stanford, CA
- JULIANA BARR, MD, FCCMAssociate Professor, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, and Staff Intensivist and Anesthesiologist, Anesthesiology, Perioperative, and Pain Medicine Service, VA Palo Alto Health Care System, Palo Alto, CA.
Purchase PDFDelirium occurs commonly in critically ill patients. ICU delirium is associated with increased short-term and long-term mortality, increased ICU length of stay, and long-term cognitive deficits in these patients. There are significant health-care costs associated with ICU delirium. Delirium is often overlooked in patients when assessed by clinicians based on clinical judgment alone. The use of a validated delirium assessment tool increases delirium detection rates in patients. ICU delirium is a multifactorial process. Nonmodifiable risk factors include age, dementia, prior coma, emergency surgery or trauma, and a high severity of illness. Modifiable risk factors include benzodiazepine use and blood transfusions. There is no evidence to support the use of any pharmacologic agent for either the prevention or treatment of ICU delirium. Antipsychotics should only be used for symptom management in ICU patients with delirium, and then discontinued when no longer needed. The mainstay of delirium management should be a multi-component, non-pharmacologic strategy aimed at minimizing risk factors. One such multimodal strategy, the ABCDEF Bundle, can significantly decrease the incidence of ICU delirium. Additional research is needed to better understand the pathophysiology and management of ICU delirium.
This review contains 5 figures, 7 tables, and 51 references
Keywords: Delirium, Encephalopathy, Intensive Care, Outcomes, ABCDEF Bundle, ICU Liberation.
- 12
Cardiovascular System: Heart Failure, Cardiogenic Shock, Cardiomyopathy
By Ben O’Brien, MD; Simon J Finney, MD, PhD; Alastair G Proudfoot, MD, PhD
Purchase PDFCardiovascular System: Heart Failure, Cardiogenic Shock, Cardiomyopathy
- BEN O’BRIEN, MDBarts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London, United Kingdom
- SIMON J FINNEY, MD, PHDBarts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London, United Kingdom
- ALASTAIR G PROUDFOOT, MD, PHDBarts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London, United Kingdom
Purchase PDFAround 2% of adults have heart failure, and the prevalence increases with advancing ages. This may manifest chronically but also acutely. Cardiogenic shock is the most extreme manifestation of acute heart failure, manifesting as the rapid development of life-threatening tissue hypoperfusion and organ dysfunction. The causes and management of these heart failure syndromes are considered in this set of mini reviews with a focus on management of the precipitating etiology, specifically coronary artery disease. The importance of risk stratification and risk-based management strategies in pulmonary embolism as a cause of acute right ventricular failure is discussed. Mechanical support of the failing heart is possible with intra-aortic balloon pumps and ventricular assist devices. These can be used in acutely or chronically and their indications are reviewed herein. Finally, advances in cardiopulmonary resuscitation are considered.
This review contains 3 figures, 3 tables, and 57 references.
Key Words: cardiovascular system, cardiac tamponade, cardiogenic shock, cardiomyopathy, cardiopulmonary resuscitation, circulatory support, heart failure, mechanical pulmonary embolism
- 13
Acute Kidney Injury and Renal Replacement Therapy
By Karen L. Krechmery, RN, MSN, FNP-C, ACNP-BC; Diego Casali, MD
Purchase PDFAcute Kidney Injury and Renal Replacement Therapy
- KAREN L. KRECHMERY, RN, MSN, FNP-C, ACNP-BCNurse Practitioner, Cedars Sinai Medical Center
- DIEGO CASALI, MDCardiothoracic Intensivist, Cedars Sinai Medical Center
Purchase PDFAcute kidney injury (AKI) is a common syndrome encountered in critical illness and is associated with significant morbidity and increased mortality. Despite attempts to prevent the development of AKI, its incidence continues to rise, probably due to increased recognition in the setting of clearer definitions of the stages of AKI. Despite advances in the field of Nephrology, the treatment of AKI and its complications remains difficult in clinical practice. Critical care clinicians must have an understanding of the current definitions, pathophysiology, and treatment modalities. Renal replacement therapy (RRT) is a mainstay of treatment, but a lack of consensus regarding the optimal timing for initiation remains. There is a need for further research regarding both the timing of initiation of RRT and biomarkers that might allow earlier detection, differentiation of etiologies and monitoring of interventions.
This review contains 3 figures, 7 tables, and 33 references
Key Words: acute kidney injury (AKI), KDIGO, renal replacement therapy (RRT), risk, injury, failure, loss of kidney function, end stage renal disease (RIFLE), nephrology
- 14
The Post-anesthesia Care Unit
- EVAN R BOHNENBLUST, MDFellow, Critical Care Medicine, Department of Anesthesiology, Cedars-Sinai Medical Center, LA, United States
- 15
Venous Thromboembolism and Transfusion Medicine
By Maulik Rajyaguru, DO; Jill Yaung, MD
Purchase PDFVenous Thromboembolism and Transfusion Medicine
- MAULIK RAJYAGURU, DOClinical Anesthesiologist and Critical Care Fellow, Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
- JILL YAUNG, MDClinical Anesthesiologist and Critical Care Intensivist, Cedars-Sinai Heart Institute, Department of Surgery, Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
- 16
Cardiovascular System: Heart Diseases
By Ben O’Brien, MD, PhD, FRCA, FFICM, MHBA, SFFMLM; Simon J Finney, MRCP, FRCA, FFICM, EDIC, MSc, PhD; Alastair G Proudfoot, MRCP, PhD, FFICM
Purchase PDFCardiovascular System: Heart Diseases
- BEN O’BRIEN, MD, PHD, FRCA, FFICM, MHBA, SFFMLMProfessor of Perioperative Medicine, Consultant in Intensive Care Medicine and Cardiac Anaesthesia, Barts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London, UK
- SIMON J FINNEY, MRCP, FRCA, FFICM, EDIC, MSC, PHDConsultant in Intensive Care and Anaesthesia, Barts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London, UK
- ALASTAIR G PROUDFOOT, MRCP, PHD, FFICMConsultant in Critical Care, Barts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London, UK
- 17
Acute Kidney Injury and Renal Replacement Therapy
By Karen L. Krechmery, RN, MSN, FNP-C, ACNP-BC; Diego Casali, MD
Purchase PDFAcute Kidney Injury and Renal Replacement Therapy
- KAREN L. KRECHMERY, RN, MSN, FNP-C, ACNP-BCNurse Practitioner, Cedars Sinai Medical Center
- DIEGO CASALI, MDCardiothoracic Intensivist, Cedars Sinai Medical Center
- 18
Encephalopathy and Delirium
- ALLIYA S. QAZI, MDSurgical Critical Care Fellow, Department of Surgery, Stanford University School of Medicine, Stanford, CA
- JULIANA BARR, MD, FCCMAssociate Professor, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, and Staff Intensivist and Anesthesiologist, Anesthesiology, Perioperative, and Pain Medicine Service, VA Palo Alto Health Care System, Palo Alto, CA.
- 1
- Neuro-anesthesia
- 1
Endoscopic Pituitary Surgery
Purchase PDFEndoscopic Pituitary Surgery
Purchase PDF - 2
Anesthetic Management of Intracranial Aneurysms
By Matthew J Hammer, MD; Laura B Hemmer, MD, FASA
Purchase PDFAnesthetic Management of Intracranial Aneurysms
- MATTHEW J HAMMER, MDClinical Instructor, Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL
- LAURA B HEMMER, MD, FASAAssociate Professor, Department of Anesthesiology, Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University Chicago, IL
Purchase PDFDespite efforts in the past decades to improve outcomes, intracranial aneurysm surgery still carries a considerable mortality risk, and its complications can cause a marked disability. To optimize and safely anesthetize a patient for these high-risk surgeries, the anesthesiologist must have a detailed understanding of the natural history, systemic physiologic perturbations, and intraoperative and postoperative complications of intracranial aneurysms. Various grading scales are used to predict adverse events, such as vasospasm or mortality, and are outlined in this chapter. Endovascular coiling and open surgical clip ligation (clipping) are the two most commonly employed interventions for treatment of aneurysms. The anesthetic goals for these complex patients are summarized.
This review contains 2 tables and 59 references.
Key Words: adenosine, burst suppression, emergence hypertension, endovascular coiling, indocyanine green, intracranial aneurysm clipping, intraoperative hypothermia, motor evoked potentials
- 3
Carotid Endarterectomy
- AMANDA WIDING, MD,1 PGY-3 RESIDENTDepartment of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA
- LOUISA PALMER, MDInstructor of Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital,
Purchase PDFCarotid artery stenosis is associated with an elevated incidence of stroke, and carotid endarterectomy is performed to prevent future strokes in cases of severe carotid artery stenosis. Patients presenting for carotid endarterectomy often have a number of comorbidities that make them challenging to anesthetize. Both regional and general anesthetic techniques may be successfully used, but with either, careful management of hemodynamics throughout the perioperative course is critical. During carotid cross-clamping, it is important to monitor the patient’s neurologic status to ensure adequate perfusion to the ipsilateral hemisphere, and for this, a number of neuromonitoring modalities are available, with EEG monitoring being the most common. Several potential complications require close monitoring of the patient in the immediate postoperative period.
This review contains 6 figures, 2 videos, 9 tables, and 51 references.
Key Words: carotid artery stenosis, carotid endarterectomy, carotid artery stenting, cerebral hyperperfusion syndrome, cervical plexus block, electroencephalography, neck hematoma, neuromonitoring, preoperative optimization, stroke, transcranial Doppler
- 4
Epilepsy and Anesthesia
- JENNIFER NELLI, MD, FRCPCStaff Anesthesiologist, Hamilton Health Sciences, McMaster University, Hamilton, Canada
Purchase PDFEpilepsy is one of the most common neurological conditions with the worldwide prevalence as high as 1%.1,2,3 Epilepsy can be classified into three categories: (1) generalized epilepsies, (2) focal epilepsies, and (3) a new group of combined generalized and focal epilepsies.8 Treatment of epilepsy begins with the initiation of an antiepileptic drug (AED). Patients who continue to seizure despite adequate therapy with two AEDs may require surgical interventions.1 There are many different surgical procedures that may be used in the management of epilepsy, including temporal lobectomy, extratemporal resections, hemispherectomy, vagal nerve stimulation (VNS), and deep brain stimulation (DBS). Epilepsy surgery often requires intraoperative localization of the epileptic focus. This can be achieved with intraoperative electrocorticography (ECoG). Many of our anesthetic drugs interfere with the intraoperative EEG recording, and a knowledge of their properties is required to provide a safe anesthetic. Anesthesia for epilepsy surgery can be done in one of three ways: (1) awake with local anesthesia, (2) general anesthesia, and (3) the asleep-awake-asleep technique. Complications including hemorrhage, venous air embolism, and status epilepticus may occur and require prompt treatment by the anesthesiologist. A thorough knowledge of neuroanesthesia is required to provide appropriate care to the epileptic patient.
This review contains 3 figures, 8 tables, and 55 references.
Keywords: Awake craniotomy, electrocorticography, epilepsy, neuroanesthesia, perioperative care, status epilepticus, treatment, temporal lobe surgery, intraoperative electrocorticography
- 5
Ethical Considerations of the Neurosurgical Patient
- BENJAMIN TOLCHIN, MD, MSComprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT. Epilepsy Center of Excellence, Neurology Service, VA Connecticut Healthcare System, West Haven, CT.
Purchase PDFNeurosurgeons, anesthesiologists, and other clinicians treating patients with neurological disorders can encounter a set of unusually difficult ethical issues, including especially questions about whether to initiate or continue neurosurgical or life-sustaining interventions for neurologically impaired patients. These questions are especially challenging because neurologically injured patients are often unable to make treatment decisions for themselves and because the prognosis for recovery is often uncertain. This article includes ethical frameworks for addressing these difficult questions.
This review contains 5 tables, and 31 references.
Keywords: Bioethics, Autonomy, Beneficence, Justice, Informed consent, Surrogate decision making, Vegetative state, Minimally conscious state, Brain death, Organ donation
- 6
Posterior Fossa
- TALIA S. VOGEL, MDAssistant in Anaesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, [email protected]
- PENNY P. LIU, MDAssistant Professor Anesthesiology, Vice Chair of Clinical Affairs, Director of Neuroanesthesiology, Tufts University School of Medicine, Tufts Medical Center.
Purchase PDFThe posterior fossa houses essential brainstem nuclei, cranial nerves, cerebral vasculature, and mechanisms for cerebrospinal fluid drainage. Anesthetic considerations for posterior fossa surgery include thorough preoperative evaluation, intraoperative monitoring, and anesthetic planning to allow neurophysiological monitoring. Careful positioning is imperative to optimize surgical conditions and to risk stratify patients for complications, including venous air embolus. Venous air embolus is a common complication of posterior fossa surgery given the plentitude of venous channels in the posterior fossa, and rapid recognition is key to managing this complication. Posterior fossa surgery also has a number of other known complications including postoperative apnea, prolonged ventilation, and possible brainstem stroke.
This review contains 4 tables, 1 video, and 31 references.
Keywords: Posterior fossa surgery, Brainstem surgery, Neuroanesthesiology, Venous air embolism/embolus, Sitting craniotomy, Prone craniotomy, Transesophageal echocardiogram, Neurophysiologic monitoring
- 7
Carotid Endarterectomy
- AMANDA WIDING, MD,1 PGY-3 RESIDENTDepartment of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA
- LOUISA PALMER, MDInstructor of Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital,
- 8
Awake Craniotomy
- DENNIS J. MCNICHOLL, MDInstructor in Anaesthesia Brigham and Women's Hospital Brigham and Womens Hospital CWN L1, Anesthesia 75 Francis St Boston MA 02115
Purchase PDFPrior to the advent of anesthesia, performing surgical procedures on patients in the awake state was the order of the day. In modern times, especially with the continued advancement and safety of anesthesia, such a practice of performing surgery on a patient in the awake state might appear unnecessary, and perhaps even medieval. However, this practice still does intentionally occur for a subset of neurosurgery patients. This unique dimension of the procedure places special demands on the anesthesiologist’s knowledge base, skill and training in order to produce a successful patient outcome. This chapter delves into salient aspects of patient selection, operating room setup, monitoring and communication considerations, pharmacologic regimens, regional anesthetic options and a thorough list of complications for which to be prepared.
This review contains 5 figures, 5 tables, and 69 references.
Keywords: awake craniotomy, functional neurosurgery, eloquent cortex, awake-asleep-awake, electrocorticography, epilepsy, deep brain stimulator, dexmedetomidine, intraoperative seizure
- 9
Epilepsy and Anesthesia
- JENNIFER NELLI, MD, FRCPCStaff Anesthesiologist, Hamilton Health Sciences, McMaster University, Hamilton, Canada
- 1
- Non-or Anesthesia
- 1
Antepartum Complications of Pregnancy
- GAEA MOORE, MDStaff Physician, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Kaiser-Permanente Oakland Medical Center, Oakland, CA
Purchase PDFPregnancy presents unique considerations and challenges to the critical care provider, including the physiologic adaptations to the pregnant state, recruitment and collaboration with a multidisciplinary care team, determination of fetal status, preparing for and managing cardiac arrest in pregnancy, and evaluation and management of diseases unique to pregnancy (including preeclampsia and acute fatty liver of pregnancy).
This review contains 48 references, and 4 tables
Keywords: acute fatty liver of pregnancy, maternal cardiac arrest, perimortem cesarean section, preeclampsia, pregnancy
- 2
Monitoring Standards Outside the OR
Purchase PDFMonitoring Standards Outside the OR
Purchase PDF - 3
Candidiasis
- BRETT A MELNIKOFF, MDSurgical Resident, Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL
- RENÉ P MYERS, MDAssistant Professor of Surgery, Division of Plastic Surgery, Assistant Professor of Neurosurgery, University of Alabama at Birmingham School of Medicine, Children’s of Alabama, Birmingham, AL
Purchase PDFFungal infections remain an important cause of morbidity and mortality in surgical settings, with critically ill patients, transplant recipients, and sick neonates all especially vulnerable. Over the past few decades, technological and scientific advancements have improved physicians’ ability to sustain life in critically ill patients; developments in chemotherapeutics and immune-based therapies have yielded increased survival for many cancer patients; organ transplantation has evolved dramatically; and the use of invasive therapies (eg, ventricular assist devices) has increased markedly. With these changes has come an increase in the incidence of serious Candida infections. This review covers the definition and classification, epidemiology and risk factors, and clinical evaluation of candidiasis, as well as management of candidemia, acute disseminated candidiasis, nonhematogenous candidiasis, and peritonitis and intra-abdominal abscess. Figures show Candida endophthalmitis in patients with persistent fungemia and superficial candidiasis in the gastrointestinal tract. Tables list clinical presentation and diagnostic methods for common fungal infections, antimicrobial agents of choice for candidal infections, and the latest guidelines for candidiasis.
This review contains 2 figures, 9 tables and 131 references.
Key words: acute disseminated candidiasis, candidemia, candidiasis, candiduria, nonhematogenous candidiasis
- 4
Noncandidal Fungal Infections
- BRETT A MELNIKOFF, MDSurgical Resident, Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL
- RENÉ P MYERS, MDAssistant Professor of Surgery, Division of Plastic Surgery, Assistant Professor of Neurosurgery, University of Alabama at Birmingham School of Medicine, Children’s of Alabama, Birmingham, AL
Purchase PDFFungal infections remain an important cause of morbidity and mortality in surgical settings, with critically ill patients, transplant recipients, and sick neonates all especially vulnerable. Over the past few decades, technological and scientific advancements have improved physicians’ ability to sustain life in critically ill patients; developments in chemotherapeutics and immune-based therapies have yielded increased survival for many cancer patients; organ transplantation has evolved dramatically; and the use of invasive therapies (eg, ventricular assist devices) has increased markedly. With these changes has come an increase in the incidence of serious fungal infections, including the less common but potentially fatal noncandidal infections caused by Aspergillus and the Zygomycetes Mucor and Rhizopus. This review outlines an approach to the workup and management of the nonneutropenic surgical patient with a suspected noncandidal infection (aspergillosis and zygomycosis). Figures show biopsy samples from an elderly man with chronic progressive disseminated histoplasmosis and thick-walled, broad-based budding yeasts typical for Blastomyces dermatitidis on biopsy material.
This review contains 2 figures, 9 tables and 47 references.
Key words: aspergillosis, aspergillosis prophylaxis, blastomycosis, Cryptococcus, histoplasmosis, noncandidal fungal infections
- 5
Candidiasis
- BRETT A MELNIKOFF, MDSurgical Resident, Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL
- RENÉ P MYERS, MDAssistant Professor of Surgery, Division of Plastic Surgery, Assistant Professor of Neurosurgery, University of Alabama at Birmingham School of Medicine, Children’s of Alabama, Birmingham, AL
- 6
Noncandidal Fungal Infections
- BRETT A MELNIKOFF, MDSurgical Resident, Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL
- RENÉ P MYERS, MDAssistant Professor of Surgery, Division of Plastic Surgery, Assistant Professor of Neurosurgery, University of Alabama at Birmingham School of Medicine, Children’s of Alabama, Birmingham, AL
- 1
- OB Anesthesia
- 1
Antepartum and Postpartum Hemorrhage
- LAURIANE GUICHARD, MDResident, University of Michigan Department of Anesthesiology, Ann Arbor, MI, United States
- CARLO PANCARO, MDAssociate Professor, University of Michigan Department of Anesthesiology, Ann Arbor, MI, United States
Purchase PDFObstetric hemorrhage is among the leading causes and the most preventable cause, of maternal mortality. Hemorrhage can be divided into early (stage 1) to late stages (stage 3), depending on the amount of blood lost and vital sign changes. Etiologies include antepartum hemorrhage such as abnormal placentation and postpartum hemorrhage such as uterine atony and retained products of conception. Early recognition of ongoing hemorrhage based on risk factors, vital sign changes, and quantification of blood loss is essential to adequately resuscitate the patient. Obstetric hemorrhage emergency flowcharts and the use of point-of-care testing such as rotational thromboelastometry have been developed to guide clinicians in their resuscitative efforts and blood product use as hemorrhage progresses.
This review contains 5 figures, 6 tables and 29 references
Key Words: abnormal placentation, antepartum hemorrhage, blood products, massive hemorrhage, maternal early warning signs of hemorrhage, postpartum hemorrhage, rotational thromboelastometry, uterine atony
- 2
Hematologic Disease
Purchase PDFHematologic Disease
Purchase PDF - 3
Nonobstetric Surgery During Pregnancy: an Overview for Anesthesia Providers
By Rebecca L Hamilton, MD; Elizabeth Young Han, BA; Dan M Drzymalski, MD
Purchase PDFNonobstetric Surgery During Pregnancy: an Overview for Anesthesia Providers
- REBECCA L HAMILTON, MDResident Physician, Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston MA, Department of Cell and Molecular Biology, Karolinska Institute, Stockholm, Sweden
- ELIZABETH YOUNG HAN, BAMedical Student, Tufts University School of Medicine, Boston MA,
- DAN M DRZYMALSKI, MDObstetric Anesthesiologist, Assistant Professor, Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston MA
Purchase PDFA pregnant patient’s surgery can be challenging for the anesthesia provider—the needs of the parturient and fetus must be addressed while balancing the physiologic and pharmacologic changes that occur during pregnancy. Improved outcomes have led to an increase in the frequency of surgeries in parturients, with approximately 50,000 procedures performed annually in the US. Due to a lack of randomized controlled studies, determining the optimal anesthetic technique for nonobstetric surgery during pregnancy is predicated on understanding the physiologic changes of pregnancy. The anesthesia provider must become familiar with specific changes and challenges in each parturient to formulate a safe anesthetic plan. Here, we review physiologic and pharmacologic conditions observed in common surgical cases that may occur during pregnancy. Our goal is to inform safe clinical practices determined by the latest scientific methods for nonobstetric surgery during pregnancy.
This review contains 5 figures, 4 tables and 46 references
Keywords: anesthesia, nonobstetric surgery, obstetric anesthesia, pregnancy, surgery, physiology, pharmacology, gynecology
- 4
Antepartum and Intrapartum Fetal Assessment and Management
By Jourdan E Triebwasser, MD, MA; Lori J Day, MD; Deborah R Berman, MD
Purchase PDFAntepartum and Intrapartum Fetal Assessment and Management
- JOURDAN E TRIEBWASSER, MD, MAAssistant Professor, Division of Maternal-Fetal Medicine, Perelman School of Medicine,University of Pennsylvania, Philadelphia, PA
- LORI J DAY, MDAssistant Professor of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
- DEBORAH R BERMAN, MDAssociate Professor of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
Purchase PDFAntenatal surveillance and intrapartum fetal monitoring are routine components of obstetric care, particularly in the high-risk patient. The goal of antenatal testing is to reduce stillbirths in pregnancies with heightened risk. The goal of intrapartum monitoring is to reduce fetal acidemia, which can lead to asphyxia and long-term neurologic sequelae. Both antepartum and intrapartum monitoring of the fetal heart rate and its variability are sensitive to acidemia. Standard nomenclature exists for describing the features of fetal heart rate tracing. Ultrasonography is a useful adjunct to fetal heart rate monitoring, particularly for antenatal testing. The decision to initiate antenatal testing or intrapartum monitoring depends on many factors, particularly gestational age and maternal status. All forms of surveillance have high false-positive rates and poor positive predictive value. If the results of abnormal testing will not affect clinical management, testing should not be performed.
This review contains 9 figures, 7 tables, and 50 references.
Keywords: acidemia, antenatal testing, assessment, biophysical profile, electronic fetal monitoring, labor and delivery, nonstress test, stillbirth
- 5
Endocrine Disease
- ERIC MORELL, MDSubsection Chief of Obstetrical Anesthesiology, Kaweah Delta Medical Center, Visalia, CA
- FEYCE PERALTA, MDAssistant Professor of Anesthesiology, McGaw Medical Center of Northwestern University, Chicago, IL
Purchase PDFEndocrine disease has become increasingly prevalent in parturients, primarily due to the increase in prevalence of diabetes mellitus. Both preexisting diabetes mellitus and gestational diabetes mellitus are associated with significant maternal and fetal complications. The Hyperglycemia and Adverse Pregnancy Outcome study demonstrated that not only was the presence of diabetes mellitus associated with complications during pregnancy but the degree of glycemic control also had an effect on the development of adverse events. Other than diabetes mellitus, the next most common endocrine disease encountered during pregnancy is thyroid disease, with hypothyroidism being more common than hyperthyroidism. Overt hypothyroidism has been shown to be associated with premature birth, low birth weight, pregnancy loss, reduction in offspring IQ, and the development of pregnancy-induced hypertension and, therefore, requires levothyroxine therapy throughout pregnancy. Hyperthyroidism is similarly associated with premature birth, low birth weight, pregnancy loss, hypertensive disorders during pregnancy, gestational diabetes mellitus, maternal heart failure, transient fetal hypothyroidism, neonatal Graves disease, and neonatal mortality. Additional endocrine diseases encountered in pregnancy include pheochromocytomas, prolactinomas, and primary hyperparathyroidism. Due to the rarity of these diseases, diagnosis is often delayed and can result in poor maternal and fetal outcomes.
This review contains 6 figures, 5 tables, and 38 references.
Key Words: diabetes, gestational, hyperglycemia, hyperparathyroidism, hyperthyroidism, hypothyroidism, pheochromocytoma, prolactinoma
- 6
Renal Disease
- ERIC MORELL, MDSubsection Chief of Obstetrical Anesthesiology, Kaweah Delta Medical Center, Visalia, CA
- FEYCE PERALTA, MDAssistant Professor of Anesthesiology, McGaw Medical Center of Northwestern University, Chicago, IL
Purchase PDFRenal disease can lead to significant complications during pregnancy, both for mother and child, and must be managed appropriately and efficiently. Recommended intervention depends on the severity and the underlying cause, as well as the acute versus chronic nature of the disease, and should involve optimization both prior to and during pregnancy. With suboptimal treatment, chronic kidney disease can progress to end-stage renal disease necessitating dialysis. Furthermore, renal disease has a negative effect on the fetus including an increase in the risk of intrauterine growth restriction, preterm delivery, and fetal loss. Urolithiasis and pyelonephritis are not uncommon in pregnancy and require special attention. The diagnosis of urolithiasis is complicated, as ultrasonography is the safest modality for the developing fetus but is also associated with a substantial false-negative rate. Although the majority of stones will pass without intervention, some may require the placement of ureteral stents or manual extraction. It is unclear whether urolithiasis itself has a negative impact on pregnancy, as the data are conflicting; however, pyelonephritis has been shown to cause an increase in delivering a fetus with low birth weight and spontaneous preterm birth. Therefore, all urinary tract infections are treated aggressively during pregnancy.
This review contains 5 figures, 6 tables, and 43 references.
Key Words: acute kidney injury, chronic kidney disease, dialysis, end-stage renal disease, lupus nephritis, pyelonephritis, renal transplant, urolithiasis
- 7
Physiologic and Anatomic Changes During Pregnancy
By Abdulaziz Alfadhel, MBBS; Elizabeth Young Han, BA; Dan Drzymalski, MD
Purchase PDFPhysiologic and Anatomic Changes During Pregnancy
- ABDULAZIZ ALFADHEL, MBBSResident in Anesthesia, Tufts Medical Center, Boston, MA
- ELIZABETH YOUNG HAN, BAMedical Student, Tufts University School of Medicine, Boston, MA
- DAN DRZYMALSKI, MDAssistant Professor, Tufts University School of Medicine, Attending Anesthesiologist, Tufts Medical Center, Boston, MA
Purchase PDFPregnancy results in physiologic and anatomic changes that allow the mother to adapt to the greater metabolic requirements of pregnancy. These changes include the enlarging uterus, which results in compression of surrounding structures, and increased hormonal production, which exerts its effects on maternal physiology. Cardiac output increases to maintain higher uterine blood flow, and minute ventilation increases, which results in a chronic respiratory alkalosis. Plasma volume increases, which results in physiologic anemia of pregnancy and may contribute to gestational thrombocytopenia. An understanding of these and other changes that occur in pregnancy is important for the anesthesiologist because they have important implications for management of the parturient undergoing an anesthetic procedure. The goal of this chapter is to highlight some of the most salient features of physiologic changes that occur during pregnancy and to begin to offer some basic anesthetic management strategies.
This review contains 6 tables, 5 figures and 36 references.
Key Words: airway changes during labor, cardiovascular changes during pregnancy, gastroesophageal reflux disease, gestational thrombocytopenia, hydronephrosis during pregnancy, left uterine displacement, physiologic anemia, ventilatory mechanics
- 8
Obstetric Anesthetic Complications
- YING EVA LU, MD
- LINDEN LEE, MD
Purchase PDFAnesthesia-associated maternal mortality and complications continue to decline due to improvements in practice and ongoing research in the field of obstetric anesthesiology. This chapter covers key topics in obstetric anesthetic complications, including accidental dural puncture, post-dural puncture headache, general anesthesia-related complications, inadequate labor analgesia, high neural blockade, post-partum back pain, CNS infections, as well as neurological injury.
This review contains 54 references.
Keywords: accidental dural puncture, post-dural puncture headache, general anesthesia-related complications, inadequate labor analgesia, high neural blockade, postpartum back pain, CNS infections, neurological injury.
- 9
Anesthesia for Cesarean Delivery
By Emily E. Naoum, MD; Rebecca D. Minehart, MD, MSHPEd
Purchase PDFAnesthesia for Cesarean Delivery
- EMILY E. NAOUM, MDObstetric Anesthesia Fellow University of Michigan Medicine, Ann Arbor, MI
- REBECCA D. MINEHART, MD, MSHPEDAssistant Professor, Harvard Medical School Program Director, MGH Obstetric Anesthesia Fellowship Associate Director for Anesthesia Programs at the Center for Medical Simulation Massachusetts General Hospital, Boston, MA
Purchase PDFCesarean delivery is a cornerstone of obstetric anesthesia and it is imperative for providers to have a deep understanding of the indications, preparation, techniques, and potential complications of both the procedure and the anesthesia. It is necessary to obtain a focused but thorough history and physical and to develop an appropriate individual by considering a multitude of factors including co-morbid maternal and fetal conditions, timing of delivery, technical needs of the surgeon, potential adverse events, and systems based decision making. Anesthesia providers need to determine the safest method to provide anesthesia for the mother with an aim to minimize risk to the fetus. Once the decision of which anesthetic technique will be utilized is made, the provider must have the knowledge of how to best execute the plan and remain vigilant by maintaining a back-up plan in the case of complications. Obstetric anesthesia for cesarean delivery carries a set of unique challenges and potential risks in addition to the standard risks associated with general and neuraxial anesthesia.
This review contains 5 figures, 7 tables, and 87 references.
Keywords: Maternal Physiology, Maternal-Fetal Considerations, Systemic Medications, Cesarean Delivery, Difficult Airway, Aspiration Prophylaxis, Supine Hypotensive Syndrome, Aspiration of Gastric Contents, Vaginal Birth After Cesarean Section (VBAC)
- 10
Anesthesia for Cesarean Delivery
By Emily E. Naoum, MD; Rebecca D. Minehart, MD, MSHPEd
Purchase PDFAnesthesia for Cesarean Delivery
- EMILY E. NAOUM, MDObstetric Anesthesia Fellow University of Michigan Medicine, Ann Arbor, MI
- REBECCA D. MINEHART, MD, MSHPEDAssistant Professor, Harvard Medical School Program Director, MGH Obstetric Anesthesia Fellowship Associate Director for Anesthesia Programs at the Center for Medical Simulation Massachusetts General Hospital, Boston, MA
- 11
Nonobstetric Surgery During Pregnancy: an Overview for Anesthesia Providers
By Rebecca L Hamilton, MD; Elizabeth Young Han, BA; Dan M Drzymalski, MD
Purchase PDFNonobstetric Surgery During Pregnancy: an Overview for Anesthesia Providers
- REBECCA L HAMILTON, MDResident Physician, Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston MA, Department of Cell and Molecular Biology, Karolinska Institute, Stockholm, Sweden
- ELIZABETH YOUNG HAN, BAMedical Student, Tufts University School of Medicine, Boston MA,
- DAN M DRZYMALSKI, MDObstetric Anesthesiologist, Assistant Professor, Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston MA
- 1
- Orthopedic Surgery
- 1
Commonly Associated Medical Syndromes
- ELAINE I. YANG, MDAssistant Attending Anesthesiologist, Hospital for Special Surgery, New York, NY, Assistant Professor of Anesthesiology, Weill Cornell Medical College, New York, NY
- GENEWOO HONG, MD, JDAssistant Attending Anesthesiologist, Hospital for Special Surgery, New York, NY, Assistant Professor of Anesthesiology, Weill Cornell Medical College, New York, NY
Purchase PDFRheumatologic diseases such as RA, ankylosing spondylitis, psoriatic arthritis, SLR, and osteogenesis imperfecta make up a large percentage of pathologies in patients undergoing orthopedic surgery. These arthropathies are progressive, difficult to treat, and often lead to lifelong debilitating pain and disability. In addition to their effects on bones and joints, they are all characterized as medical syndromes, which affect many other organs and tissues throughout the body. Subsequently, these patients often have many comorbidities that make rendering a safe anesthetic challenging. Disease-modifying therapy combines aggressive immunomodulatory agents and immunosuppression. Severe joint destruction is treated surgically, but these surgeries are often at increased risk due to the effects of these syndromes on other organ systems. In this review, we address the approach to and evaluation of these five commonly associated medical syndromes and their medical and/or surgical treatment as well as any anesthetic considerations.
This review 5 figures, 4 tables, and 50 references.
Key Words: anesthetic considerations, ankylosing spondylitis, inflammatory arthropathies, psoriatic arthritis, orthopedics, osteogenesis imperfecta, rheumatoid arthritis, rheumatologic syndromes, systemic lupus erythematosus
- 1
- Pain
- 1
Chronic Pain in Children
Purchase PDFChronic Pain in Children
Purchase PDF - 2
Patient-controlled Analgesia
- DEVIN PECK, MDAssociate Partner, Austin Pain Associates, Austin, TX
Purchase PDFPatient-controlled analgesia (PCA) is a method for controlling pain in which a patient is able to self-administer pain medications via activation of a mechanical distribution system. The key element of PCA is that the patient is in control of the analgesia. Respiratory depression is preceded by sedation, and a sedated patient is unable or unlikely to push the PCA button. The pump can also be programmed to have a continuous infusion rate, which is administered to the patient regardless of whether the patient activates a dose. Basal rates bypass the safety mechanism of patient control and can place the patient at higher risk for respiratory depression and sedation. Initiation of a PCA is often most appropriate in patients requiring frequent as-needed dosing of medications or when such dosing is anticipated. Patients’ acceptance of the technique is high, related in part to a sense of control over their own pain relief, a reduction in the delay for the receipt of pain medications, not receiving injections, and not having to interrupt or to bother nurses.
This review contains 2 tables and 20 references.
Key words: analgesic delivery systems, morphine metabolism, multimodal pain management, opioid pharmacology, opioid side effects, patient-controlled analgesia, patient safety, respiratory depression
- 3
Patient-controlled Epidural Analgesia/continuous Epidural Catheters
- DEVIN PECK, MDAssociate Partner, Austin Pain Associates, Austin, TX
Purchase PDFAlthough useful for management of many types of pain, the most common indication for epidural catheter placement is for management of labor pain. High lumbar and thoracic epidural catheter placement has gained increasing popularity in recent years for the management of postoperative pain. The technique is most commonly employed for procedures in which a thoracic or an extensive abdominal incision is anticipated. Absolute contraindications for epidural catheter placement include patient refusal, uncorrected hypovolemia, increased intracranial pressure, local infection at the planned site of insertion, and patient allergy to amide/ester local anesthetics. Relative contraindications include coagulopathy, an uncooperative patient, severe anatomic abnormalities of the spine, sepsis, and hypertension. The advantages include attenuation of the sympathetic response to surgical stimulation and pain; effects on the cardiovascular, respiratory, and gastrointestinal systems; thromboprotective effects; and possibly limitation of tumor spread. The risks of epidural catheter placement include epidural hematoma, infection, nerve or spinal cord injury, dural puncture, or respiratory or cardiovascular depression from a high block. Epidural opioids provide analgesia without causing motor or sympathetic blockade. Epidurally administered local anesthetics may result in decreased postoperative ileus, nausea, vomiting, and sedation, which can be associated with opioids. Local anesthetics and opioids act additively or synergistically and, when used together, can lead to a reduction in the dose of each drug.
This review contains 2 figures, 4 tables and 30 references.
- 4
Iatrogenic Withdrawal Syndromes in Children: A Review of Sedative and Analgesic Weaning
By R. Blake Windsor, MD, FAAP; Jean Solodiuk, RN, PhD
Purchase PDFIatrogenic Withdrawal Syndromes in Children: A Review of Sedative and Analgesic Weaning
- R. BLAKE WINDSOR, MD, FAAPAssistant in Pain Medicine, Department of Anesthesia, Peri-Operative, and Pain Medicine, Adjunct in Emergency Medicine, Department of Medicine, Boston Children’s Hospital, Instructor in Anaesthesia, Harvard Medical School, Boston, MA
- JEAN SOLODIUK, RN, PHDResearch Associate, Department of Anesthesia, Peri-Operative, and Pain Medicine, Harvard Medical School, Boston, MA
Purchase PDFIatrogenic withdrawal syndromes develop in children exposed to prolonged sedative and analgesic medications. Signs of withdrawal include central nervous system irritability, gastrointestinal dysfunction, and autonomic dysfunction. The most important steps to the safe management of sedative and analgesic weaning in children are the early identification of the risk of withdrawal, use of a validated withdrawal assessment scale, use of nonpharmacologic interventions, and administration of medication for weaning, if indicated. This article reviews the physiologic mechanisms of opioid tolerance and withdrawal, validated pediatric withdrawal scales, and safe management of iatrogenic withdrawal syndromes. Figures illustrate cellular responses to acute and chronic exposure to opioids. A suggested algorithm for the safe and rapid weaning of sedative and analgesic medications, using the best available evidence, is discussed.
Key words: analgesic weaning, opioid tolerance, pediatric withdrawal, sedation weaning, weaning algorithm for children
- 5
Opioid-sparing Analgesics in Chronic Pain Management
By Maricela Schnur , MD, MBA; Michael Fitzsimons, MD; Fangfang Xing, MD
Purchase PDFOpioid-sparing Analgesics in Chronic Pain Management
- MARICELA SCHNUR , MD, MBAResident Physician, Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
- MICHAEL FITZSIMONS, MDAssistant Professor, Harvard Medical School, Director, Division of Cardiac Anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
- FANGFANG XING, MDResident Physician, Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
Purchase PDFChronic pain impacts the lives of millions of people in significant medical and psychosocial ways. Pharmacologic treatments are steering away from chronic opioid therapy due to serious side effects, an epidemic of prescription opioid abuse, and a lack of clear long-term benefit. Therefore, nonopioid medications such as nonsteroidal antiinflammatory drugs, acetaminophen, tricyclic antidepressants, lidocaine patch, and anticonvulsants are important opioid-sparing or primary treatment options. Agents such as capsaicin, cannabis, botulinum toxin, and ketamine are less frequently prescribed adjuncts that are under active investigation to determine their roles in chronic pain therapy. Understanding the research can help the clinician determine the risks and benefits of these medications for their patients. In the future, dose and delivery optimization, combination therapy, elucidating the biology of pain, and developing novel agents will improve pharmacologic approaches to treatment.
- 6
Labor Pain Pathophysiology and Analgesic Options
By Ben Homra, MBBS Candidate; Alan D. Kaye, MD, PhD; Elyse Cornett, PhD; Justin Creel; Matthew B. Novitch, BS; Brendon M Hart, DO; Alexander D Allian, MS; Eric M Helander, MBBS
Purchase PDFLabor Pain Pathophysiology and Analgesic Options
- BEN HOMRA, MBBS CANDIDATEUniversity of Queensland SOM-Ochsner Clinical School, New Orleans, LA
- ALAN D. KAYE, MD, PHDProfessor, Program Director, and Chairman, Department of Anesthesiology, Professor, Department of Pharmacology, Louisiana State University Health Sciences Center New Orleans, New Orleans, LAV
- ELYSE CORNETT, PHDClinical Research Coordinator, Department of Anesthesiology, LSU Health Sciences Center Shreveport, Shreveport, LA
- JUSTIN CREEL
- MATTHEW B. NOVITCH, BS
- BRENDON M HART, DO
- ALEXANDER D ALLIAN, MS
- ERIC M HELANDER, MBBS
Purchase PDFRegional neuraxial blocks, such as spinal and epidural anesthetics, are used for most women in the United States for labor pain. They are the most effective methods for preserving consciousness and the ability to participate in the second stage of labor. Regional neuraxial blocks may be augmented by combining spinal and epidural techniques, postlabor nonopioids and opioids, distraction therapy, and patient-controlled analgesia. In addition, several alternative analgesic methods have been recently recommended for labor pain without consensus on their respective efficacies, including yoga, exercise during pregnancy, acupuncture, hypnotism, hydrotherapy, and therapeutic massage. This review focuses on current updates and recent trends in labor pain management, the pathophysiology of labor pain, and the basic mechanisms supporting the efficacies of systemic, inhalation, neuraxial, and local analgesia during labor.
Key words: epidural, fentanyl, labor pain, local anesthetic, spinal analgesia
- 7
Spinal Cord Stimulation
- JASON D. ROSS, MDDepartment of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine
- EDGAR L. ROSS, MDDepartment of Anesthesia Perioperative and Pain Medicine, Brigham Health System, Harvard Medical School
Purchase PDFChronic pain remains the number one public health problem in the developed world. One third of Americans suffers from chronic pain, costing more than heart disease, diabetes, and cancer combined. Concurrent is the growing realization that the enormous increase in opioid prescribing has been ineffective simultaneously leading to widespread misuse and diversion. Yet implantable stimulation therapies is often considered salvage therapy because of the cost, outdated efficacy studies, and inherent bias of use in end-stage patients only. This would prove an impossible challenge for almost any therapy, yet stimulation has been shown to be effective under these circumstances. Using patient satisfaction ratings and objective measures in recent randomized trials allow comparison to conservative therapies such as medication management. The growing sophistication of implantable stimulators make these therapies viable options for more patients than ever before and should challenge the conventional wisdom that stimulation of the nervous system is only a salvage therapy. Many of the procedures discussed are off-label, yet the growing body of literature and practical experience suggest that these have significant clinical potential. In the setting of a comprehensive treatment plan, implantable stimulators are capable of changing lives for even the most refractory conditions.
This review contains 6 figures, 4 tables, and 60 references.
Key words: Spinal Cord Stimulation (SCS), peripheral nerve stimulation, electrodes, IPG, PNS, implantable pulse generator, complications, epidural electrodes, paddle electrodes, percutaneous electrodes, restorative stimulation
- 8
Postoperative Pain Management
- ABHISHEK PARMAR, MD, MSAssistant Professor, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
Purchase PDFThe aim of this review is to provide practical clinical information on modern pain management options to guide the clinician on evidence-based practices, optimizing the treatment of pain and avoiding practices that may lead to potential abuse. Postoperative pain management is an essential component of any surgeon’s practice and has clear implications for surgical outcomes, patient satisfaction, and population health. Understanding options within a multimodal approach to pain management in the acute setting is a key determinant to improving outcomes for our patients. This review discusses multimodal analgesic options, including a variety of pain medications (opiates, antiinflammatory medications, and patient-controlled analgesia) and techniques (epidural catheter placement, regional nerve blocks) to be used in tandem. Lastly, best possible practices to avoid opiate abuse are discussed.
This review contains 4 figures, 5 tables, 1 video and 96 references.
Key words: antiinflammatories, epidural, narcotics, patient-controlled analgesia, postoperative pain, regional nerve block
- 9
Sympathetic Blocks
By Christopher J. Gilligan, MD; Christina Chhoeum, BS; Shafik Boyaji, MD
Purchase PDFSympathetic Blocks
- CHRISTOPHER J. GILLIGAN, MDChief, Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine; Assistant Professor of Anaesthesia, Harvard Medical School
- CHRISTINA CHHOEUM, BSBrigham & Women’s Hospital
- SHAFIK BOYAJI, MDInternal Medicine Specialist, Brigham Women's Hospital
Purchase PDFThe autonomic nervous system (ANS) is the part of the nervous system that regulates involuntary functions. It is composed of the sympathetic and the parasympathetic nervous systems (SNS and PNS, respectively). The sympathetic nervous system, in addition to its vital role as part of the autonomic nervous system and the emergency response, is thought to be involved in numerous pathologic, painful conditions. These conditions are referred to as Sympathetically Mediated Pain (SMP). SMP is often considered a result of a vicious circle of events, which include changes in peripheral and central somatosensory processes. This assumption is based upon the observations that the pain is spatially correlated with signs of autonomic dysfunction, blocking the efferent sympathetic supply to the affected area would relieve the pain. Sympathetic blocks emerged as a way to help diagnose and treat several painful conditions, including complex regional pain syndrome (CRPS), phantom pain, neuralgias, herpes zoster, and even fibromyalgia. Additionally, sympathetic blockades have been used to improve perfusion, treat angina and malignant arrhythmias, and posttraumatic stress disorder (PTSD) symptoms.
This review contains 1 table and 68 references.
Key words: Sympathetic nervous system, sympathetically mediated pain, sympathetic blocks, neuropathic pain, chronic pain, stellate ganglion block, celiac plexus block, lumbar sympathetic block, superior hypogastric plexus block
- 1
- Pediatric Anesthesia
- 1
Neonatal Physiology
- BRIAN FRUGONI, MDHealth Sciences Assistant Clinical Professor, University of California, San Diego Medical Center, San Diego, CA, United States
- LAURA DOWNEY, MDAssistant Professor, Emory University, School of Medicine, Staff Anesthesiologist at Children’s Healthcare of Atlanta, Atlanta, GA, United States
Purchase PDFThe neonate has many unique physiologic characteristics that set it apart from older children and adults. Many of these differences arise from the requirements for fetal growth and development and the abrupt transition from fetal to extrauterine life. All organ systems are impacted, with critical implications for medical management. Understanding the unique features of the neonate is essential for the safe anesthetic care of these patients. This chapter reviews fetal development of the different organ systems, along with their function during the neonatal period. Placental physiology as it pertains to anesthetic management will be reviewed. Special attention will be paid to transitional cardiac and respiratory physiology as well as neonatal respiratory mechanics. Renal acid–base maintenance, fluid and electrolyte management, hematologic and neurologic systems will be discussed. Emphasis is on the term neonate, although preterm neonatal physiology is also briefly reviewed. Common neonatal disease states are also covered. The goal is for the anesthesia practitioner to gain a greater understanding of the unique aspects of the neonate so that they may better care for this vulnerable subset of patients.
This review contains 8 figures, 13 tables, and 52 references.
Key Words: apnea of prematurity, chronic lung disease, infant lung mechanics, intraventricular hemorrhage, neonate, patent ductus arteriosus, patent foramen ovale, persistent fetal circulation, transitional circulation, retinopathy of prematurity
- 2
Anesthesia for Common Cardiac Lesions
- DOUGLAS ATKINSON, MDInstructor in Anaesthesia, Harvard Medical School, Assistant in the Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, United States
- VIVIANE G NASR , MDAssociate Professor in Anaesthesia, Harvard Medical School, Associate in the Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, United States
Purchase PDFCongenital heart disease is the most common congenital malformation with an incidence of 4 to 10 per 1,000 live births. Anesthesiologists are required to manage these patients when they present for surgical or percutaneous interventions, including definitive and/or palliative procedures. The preoperative evaluation of the cardiac patient includes a thorough physical examination, laboratory testing, and diagnostic imaging such as echocardiography and magnetic resonance imaging. The perioperative management of children with cardiac disease requires a thorough understanding of the underlying pathophysiology, invasive monitoring such as arterial pressure and central venous pressure, and different surgical procedures and interventions in the catheterization laboratory. In addition, understanding cardiopulmonary bypass including perfusion, temperature, and acid-base is a must. This chapter presents a systematic approach for the preoperative assessment of children with cardiac disease and management on cardiopulmonary bypass and discusses the different surgical procedures and catheterization laboratory interventions, indications, and potential complications.
This review contains 1 figure, 9 tables, and 23 references.
Key Words: associated anomalies, cardiac surgical procedures, cardiopulmonary bypass, congenital heart disease, intraoperative monitoring, inotropes, interventional catheterization, preoperative evaluation, vasodilators
- 3
Pharmacologic Differences in Children
- RAYMOND PARK, MDAssociate in Perioperative Anesthesia, Boston Children’s Hospital, Instructor in Anesthesia, Harvard Medical School, Boston, MA
- LAUREN KELLY UGARTE, MA, MDAssociate in Perioperative Anesthesia, Boston Children’s Hospital, Instructor in Anesthesia, Harvard Medical School, Boston, MA
Purchase PDFChildren are physiologically different from adults. Their anesthetic care requires ample consideration of the pharmacologic effects of medications on their minds and bodies to provide an overall pleasant and safe experience. There are many available pharmacologic agents that can be used in the course of a child’s anesthetic. It is essential to be aware of the potential uses and risks of each. Pediatric anesthesia providers must consider physiologic differences in children versus adults that affect pharmacodynamics. They should also consider various medication routes that are available to initiate sedation or anesthesia, dosing changes that need to be made due to metabolism immaturity and increased risk of medication toxicity, concern for possible neurotoxic effects of medications on the developing brain, and adverse effects of medication due to congenital issues or undiagnosed pathology. Medications we use in pediatric anesthesia have always been off label due to limited studies in this population of patients and ongoing studies will help enhance our practice.
This review contains 7 figures, 10 tables, and 67 references.
Key Words: anesthetic neurotoxicity, anesthesia uptake, apnea risk, benzodiazepine effects, neonates, midazolam bioavailability, opioids, opioid-sparing medications, premedication routes, propofol infusion syndrome, succinylcholine complications, sugammadex, uptake and distribution in infants.
- 4
Preoperative Evaluation of Pediatric Patients With Muscle Disorders
By Julianne Bacsik, MD
Purchase PDFPreoperative Evaluation of Pediatric Patients With Muscle Disorders
- JULIANNE BACSIK, MDSenior Associate, Assistant Professor of Anaesthesia,Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
Purchase PDFThe preoperative assessment of pediatric patients with myopathy begins with a description of which muscle groups are impacted and the degree of disability present. Particular focus on respiratory status is necessary, as weak muscles of respiration can cause ventilatory insufficiency. This is exacerbated by swallowing difficulty, poor clearance of secretions, inadequate cough, and spinal and rib cage deformity. Restrictive lung disease may be severe. Cardiac dysfunction often accompanies skeletal muscle disease. Cardiomyopathy and conduction defects are prevalent in patients with muscle disorders and require preoperative evaluation. There is wide phenotypic variability among patients with muscle disease. By grouping myopathies according to pathophysiology, we can understand both the presentation and the most significant comorbidities associated with specific types of muscle disease. Finally, we can consider the specific anesthesia considerations that are pertinent to each, highlighting the risks of malignant hyperthermia and anesthesia-induced rhabdomyolysis.
This review contains 3 tables and 38 references.
Keywords: anesthesia considerations, congenital myopathy, malignant hyperthermia, mitochondrial disorders, muscular dystrophy, myotonia, succinylcholine, anesthesia-induced rhabdomyolysis
- 5
Common Pediatric PACU Problems
- DUSICA BAJIC, MD, PHDAssistant Professor of Anaesthesia, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA, Department of Anaesthesia, Harvard Medical School, Boston, MA
Purchase PDFPerioperative care of neonates, infants, and children significantly differs from that in adults. It was estimated that about 1.5 million to 2 million children under 3 years of age undergo anesthesia annually in the United States. Although the exact incidence of pediatric postoperative problems and complications are not quantified, it is known that both minor and major morbidity most commonly occurs in infants and children under 3 years of age, especially those with severe comorbidities. In the ever-growing field of pediatric same-day surgery, safe and efficient flow through the perioperative and postoperative periods necessitates in-depth knowledge of managing potential PACU complications. In this chapter, we provide an overview of specific and most common pediatric complications such as airway complications, postoperative nausea and vomiting, and emergence agitation. Although not novel, availability of an immediate response team (designated postoperative anesthesia staff) and availability of PACU standing orders avoids delays in physician evaluation, treatment, and length of pediatric patients’ distress. We also lay out criteria for discharge, as well as implementation of Postanesthesia Recovery Score system evaluations.
This review contains 3 figures, 11 tables, and 52 references.
Keywords aspiration, bronchospasm, discharge criteria, emergence agitation, emergence delirium, laryngospasm, negative pressure pulmonary edema, PONV, postintubation croup, vomiting
- 6
Anesthesia for Premature Infants and Micropremies
- ELAINE NG, MD FRCPC MSHPEStaff Anesthesiologist, Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Associate Professor, Department of Anesthesia, University of Toronto, Toronto
Purchase PDFAdvances in medicine has led to the increased survival of micropremies and premature infants. The anesthetic management for these patients has unique considerations and should only be provided by experts at specialized pediatric centers. Technical procedures and monitoring can be challenging due to their small size. Related to the physiology and immaturity of the airway, respiratory, cardiac and neurologic systems, there is an increased perioperative risk that may be related to hypoxemia and apnea and rapid desaturation, reversal of intracardiac shunts, and intraventricular hemorrhage. Immature renal and hepatic systems are related to decreased drug metabolism and demand careful and accurate administration of medications. The patients are prone to hypothermia and hypoglycemia. In addition, there may be congenital anomalies, syndromes, or other metabolic issues that may not have been fully worked up at the time of presentation for anesthesia. Emerging information related to potential neurotoxicity related to exposure to anesthetic agents has led to continual research and understanding of these mechanisms in order to provide the safest care. A meticulous approach, careful planning, and collaborative approach with the multidisciplinary neonatal team are essential to ensure the best possible outcome for this unique patient population.
This review contains 3 figures, 4 tables, and 36 references.
Keywords: inguinal hernia repair, micropremies, prematurity, neonatal anesthesia, neurotoxicity, neonatal intensive care, necrotizing enterocolitis, preterm infants
- 7
Neonatal Emergencies II: Necrotizing Enterocolitis and Abdominal Wall Defects
By Iva Vassileva Vesselinova, MD
Purchase PDFNeonatal Emergencies II: Necrotizing Enterocolitis and Abdominal Wall Defects
- IVA VASSILEVA VESSELINOVA, MDAttending Anesthesiologist, Pediatric Anesthesia Team, Odense University Hospital, Odense, Denmark
Purchase PDFRecent advances in perinatal care have dramatically improved the survival of the youngest and smallest infants, including critically ill neonates and those born with congenital malformations. This has increased the neonatal population at risk for intraabdominal diseases due to prematurity that require surgical intervention. Thus, the pediatric anesthesiologist is increasingly confronted with the challenging task of providing anesthetic care for these vulnerable patients. Despite our better understanding of the immature transitional physiology and developmental pharmacology, pathology of the diseases of prematurity and impact of surgery and anesthesia on their fragile homeostasis, the risk for adverse perioperative events is still the highest in neonatal patients. Therefore, thoughtful preparation, anticipation of potential complications, and efficient collaboration within the multidisciplinary team are essential to ensure safety and quality of the delivered anesthetic care. This review focuses on the perioperative management of necrotizing enterocolitis and abdominal wall defects, with emphasis on preoperative stabilization and tailoring of anesthetic intraoperative plan to the unique neonatal physiology and disease process.
This review contains 4 tables, and 50 references.
Key Words: anesthesia, necrotizing enterocolitis, gastroschisis, omphalocele, neonatal, prematurity, resuscitation, morbidity, mortality.
- 8
Airway Management in Children
- JAMES PEYTON, MBCHB MRCP FRCAAssociate in Perioperative Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, Assistant Professor of Anesthesia, Harvard Medical School, Boston, MA
- RAYMOND PARK, MDAssociate in Perioperative Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, Assistant Professor of Anesthesia, Harvard Medical School, Boston, MA
Purchase PDFAirway management in children is usually very straightforward. Unfortunately, when it is not straightforward complications associated with problems encountered while managing the airway can be life-threatening. Airway management can be considered to consist of several different techniques for oxygenating and ventilating an anesthetized patient, namely mask ventilation, supraglottic airway device ventilation, and tracheal intubation. This chapter discusses these techniques and the factors associated with difficulty in performing them. There are anatomic features associated with difficulty in all of these techniques that are caused by syndromes or abnormal airway anatomy in children, although around 20% of difficult intubations are unanticipated. The majority of complications occur when attempting a difficult tracheal intubation. Morbidity and mortality relating to tracheal intubation correlate to the number of attempts at tracheal intubation. Severe hypoxia is estimated to occur in around 9% of children who are difficult to intubate and hypoxic cardiac arrest in nearly 2%, so the key to successful airway management is to focus on maintaining oxygenation and choosing a technique with the best chance of a successful outcome during the first attempt at airway management.
This review contains 6 figures, 7 tables, and 41 references.
Keywords: cricothyrotomy, difficult airway, direct laryngoscopy, fiberoptic bronchoscopy, front of neck access, intubation, pediatric, videolaryngoscopy
- 9
Neonatal Emergencies II: Infantile Hypertrophic Pyloric Stenosis & Intestinal Obstruction
By Iva Vassileva Vesselinova, MD
Purchase PDFNeonatal Emergencies II: Infantile Hypertrophic Pyloric Stenosis & Intestinal Obstruction
- IVA VASSILEVA VESSELINOVA, MDAttending Anesthesiologist, Pediatric Anesthesia Team, Odense University Hospital, Odense, Denmark
Purchase PDFThis review focuses on the clinical presentation, diagnosis, preoperative stabilization and intraoperative management of infantile hypertrophic pyloric stenosis (IHPS) and neonatal gastrointestinal obstructions. IHPS poses medical emergency, which demands adequate preoperative optimization of the intravascular status and metabolic derangements before proceeding with surgery. In contrast, malrotation and volvulus require immediate surgical exploration under ongoing aggressive resuscitation in order to minimize further deterioration and preserve bowel length. Congenital anomalies, associated with disorders such as duodenal atresia, malrotation, volvulus, and anorectal malformations, warrant focused examinations to characterize the defect and severity of functional impairment, but they should not delay interventions for which time is a critical factor.
This review contains 2 tables, and 41 references.
Key words: neonatal, infantile pyloric stenosis, gastrointestinal, vomiting, metabolic, resuscitation, obstruction, malformation, apnea, rapid sequence.
- 10
Neonatal Emergencies II: Myelomeningocele
- IVA VASSILEVA VESSELINOVA, MDAttending Anesthesiologist, Pediatric Anesthesia Team, Odense University Hospital, Odense, Denmark
Purchase PDFMyelomeningocele is the most common and severe congenital malformation of the central nervous system, associated with substantial neurological morbidity, devastating lifelong medical disability and increased mortality. This review focuses on the perioperative anesthesia considerations of postnatal correction of myelomeningocele.
This contains 3 tables, and 34 references.
Key words: myelomeningocele, Arnold Chiari malformation, tethered spinal cord syndrome, hydrocephalus, cerebrospinal fluid, ventriculo-peritoneal shunt, latex hypersensitivity, morbidity, mortality.
- 11
Pharmacologic Differences in Children
- RAYMOND PARK, MDAssociate in Perioperative Anesthesia, Boston Children’s Hospital, Instructor in Anesthesia, Harvard Medical School, Boston, MA
- LAUREN KELLY UGARTE, MA, MDAssociate in Perioperative Anesthesia, Boston Children’s Hospital, Instructor in Anesthesia, Harvard Medical School, Boston, MA
- 12
Cardiac Patients for Non-cardiac Surgeries
By Zhe Amy Fang, MD, FRCPC; Annette Y. Schure, MD, DEAA
Purchase PDFCardiac Patients for Non-cardiac Surgeries
- ZHE AMY FANG, MD, FRCPCFellow in Pediatric Cardiac Anesthesia Boston Children’s Hospital Harvard Medical School 25 Shattuck St Boston, MA 02115 United States
- ANNETTE Y. SCHURE, MD, DEAASenior Associate in Anesthesia Boston Children’s Hospital Instructor in Anesthesia Harvard Medical School 25 Shattuck St, Boston, MA 02115, United States
Purchase PDFCongenital heart disease (CHD) is the most common congenital malformation; and recent advances in pediatric cardiology, surgery and critical care have significantly improved the survival rates of even the most complex defects. Many children will not only require multiple cardiac surgeries, but also various imaging studies and corrective procedures for extra-cardiac anomalies. Cardiac patients undergoing non-cardiac surgery are at increased risk, especially those with complex lesions, young age (<2 years), pulmonary hypertension, congestive heart failure or significantly decreased ventricular function. Given the current survival rates for CHD, all anesthesiologists, with or without additional pediatric or cardiac training, will encounter more patients in their daily practice who have either repaired or unrepaired CHD. The perioperative management of children with cardiac disease requires a thorough understanding of the underlying pathophysiology, the implications of various repairs and long term problems. The preoperative evaluation can be extensive and has to be customized to the individual patient and the procedure. Careful planning and consideration of disease specific challenges are important.
This review contains 14 figures, 7 tables and 47 references
Keywords: Congenital heart disease, pediatric cardiac disease, non-cardiac surgery, preoperative evaluation, anesthetic management, cardiac patients, extra-cardiac anomalies, congenital malformations
- 13
Cardiac Patients for Non-cardiac Surgeries
By Zhe Amy Fang, MD, FRCPC; Annette Y. Schure, MD, DEAA
Purchase PDFCardiac Patients for Non-cardiac Surgeries
- ZHE AMY FANG, MD, FRCPCFellow in Pediatric Cardiac Anesthesia Boston Children’s Hospital Harvard Medical School 25 Shattuck St Boston, MA 02115 United States
- ANNETTE Y. SCHURE, MD, DEAASenior Associate in Anesthesia Boston Children’s Hospital Instructor in Anesthesia Harvard Medical School 25 Shattuck St, Boston, MA 02115, United States
- 1
- Pharmacology
- 1
Basic Pharmacologic Concepts
By Bryan Cook, PharmD, BCPS; Lindsay Urben, PharmD, BCPS, BCCCP
Purchase PDFBasic Pharmacologic Concepts
- BRYAN COOK, PHARMD, BCPSClinical Pharmacy Specialist, Brigham & Women’s Hospital, Boston, MA
- LINDSAY URBEN, PHARMD, BCPS, BCCCPClinical Pharmacist, Brigham & Women’s Hospital, Boston, MA
Purchase PDFPharmacokinetic and pharmacodynamic principles specifically describe the different ways a drug and the body interact with each other. Pharmacokinetics focuses mainly on the absorption of medications into the body, the distribution into various tissues, how the body metabolizes and breaks down medications, and the elimination of any remaining medication or metabolites. Moreover, patient-specific characteristics, such as comorbidities and organ dysfunction, must be considered as they may also influence a drug’s absorption, distribution, metabolism, and elimination. Pharmacodynamics involves the different ways a medication affects the body, particularly when interacting with different receptors and the subsequent biochemical actions that elicit physiologic responses. Different drug-specific properties, such as affinity, efficacy, and agonism, also play a role in a patient’s response to the medication. When the concepts of pharmacokinetics and pharmacodynamics are joined together, computer models and simulations can be utilized to help predict the expected physiologic effects of a drug based on varying dosing parameters while taking tissue distribution and metabolism into consideration.
This review contains 6 figures, 5 tables and 21 references.
Keywords: biophase, compartment distribution, context-sensitive half-time, dose-response relationship, pharmacodynamics, pharmacokinetics, pharmacogenomics, receptor sensitization
- 2
Management of Drug Interactions Between Anti-infectives and Common Anesthetics
By Kevin McLaughlin, PharmD, BCPS; James Schurr, PharmD, BCPS, MD; Craig A Stevens, PharmD, BCPS
Purchase PDFManagement of Drug Interactions Between Anti-infectives and Common Anesthetics
- KEVIN MCLAUGHLIN, PHARMD, BCPSSenior Pharmacist Department of Pharmacy Brigham and Women’s Hospital, Boston, MA
- JAMES SCHURR, PHARMD, BCPS, MDCandidate, School of Medicine, Stony Brook University, Stony Brook, NY
- CRAIG A STEVENS, PHARMD, BCPS
Purchase PDFInteractions between various medications can lead to changes in the expected response of one or more of those medications. Drug interactions can be pharmacokinetic (altered absorption, distribution, metabolism or excretion of the medication) or pharmacodynamic (alterations based on similarities or differences in the mechanisms of medications with respect to their effect on the body). Although drug interactions exist in many specialties in medicine, this chapter focuses on those that affect the responses of common anesthetic agents or drugs given with those agents. While anesthesiologists monitor objective measures and titrate many medications to the desired effect, understanding and anticipating drug interactions can help reduce unexpected effects of medications.
This review contains 2 figures, 4 tables and 36 references
Key words: anesthetic agents, antiinfective agents, drug interactions, mechanism, pharmacodynamics, pharmacokinetics
- 3
Anticoagulation and Reversal Agents
By Sarah Culbreth, PharmD, BCPS; Dirk Varelmann, MD; Jessica Rimsans, PharmD, BCPS
Purchase PDFAnticoagulation and Reversal Agents
- SARAH CULBRETH, PHARMD, BCPSClinical Pharmacy Specialist, Department of Pharmacy, Brigham and Women’s Hospital
- DIRK VARELMANN, MDAttending Anesthesiologist, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital
- JESSICA RIMSANS, PHARMD, BCPSClinical Pharmacy Specialist, Department of Pharmacy, Brigham and Women’s Hospital
Purchase PDFManaging the balance between bleeding risk and the need to treat thromboembolic disease continues to challenge anesthesiologists and interventionalists, particularly as new direct oral anticoagulants (DOAC) are approved for use. While in the hospital, patients are often placed on parenteral anticoagulants that require monitoring to ensure the dynamic changes that occur in acute illness do not lead to excessive or insufficient anticoagulation. Until recently, vitamin K antagonists (VKA) have been the mainstay of therapy in patients with atrial fibrillation and venous thromboembolism. To facilitate procedures and or minimize bleeding, VKAs were either held or its effects reversed by vitamin K, fresh frozen plasma, or four-factor prothrombin complex concentrate to facilitate procedures and minimize bleeding. Those patients on DOACs continue to challenge the interventionist as there is no commercially available targeted reversal agent for all DOACs. When anticoagulation reversal is warranted, timing or urgency of reversal, the mechanism of action of the anticoagulant, half-life of the anticoagulant, risk of bleeding associated with the procedure, end-organ function, and the patient’s risk factors for thrombosis and bleeding should be considered. This chapter briefly reviews anticoagulants and reversal strategies.
This review contains 1 figure, 13 tables, and 56 references.
Key Word: activated prothrombin complex concentrate, anticoagulation, antithrombotic, life-threatening bleeding, reversal, periprocedural, prothrombin complex concentrate, surgery
- 4
Cardiovascular Drugs
- ALLISON DALTON, MD
Purchase PDFGiven the dynamic nature of the operating room environment, anesthesiologists must be prepared to handle cardiovascular comorbidities and complications. From perioperative hypertension to cardiovascular shock to cardiac arrhythmias, one must be able to diagnose and treat a wide range of cardiovascular conditions. We will evaluate recent literature to determine the best treatment modalities for the treatment of acute heart failure, cardiogenic shock, vasoplegia after cardiopulmonary bypass, pulmonary hypertension, septic shock, perioperative hypertension, and cardiac arrhythmias. Selection of appropriate inotropic medications and vasopressors may improve mortality in shock. Treatment of pulmonary hypertension, perioperative hypertension, and arrhythmias requires knowledge of a variety of classes of medications with specific applications and adverse effects.
This review contains 3 figures, 9 tables and 54 references
Keywords: amiodarone, antiarrhythmic, beta blocker, calcium channel blocker, catecholamine, inotrope, nitrate, vasoconstrictor, vasodilator
- 5
Local Anesthetics for Neuraxial and Regional Techniques
By Michael J Schontz, PharmD, BCPS, BCCCP; Krystina Geiger, PharmD, BCPS, BCCCP
Purchase PDFLocal Anesthetics for Neuraxial and Regional Techniques
- MICHAEL J SCHONTZ, PHARMD, BCPS, BCCCPClinical Pharmacist, Brigham and Women’s Hospital, Boston, MA
- KRYSTINA GEIGER, PHARMD, BCPS, BCCCPClinical Pharmacist, Brigham and Women’s Hospital, Boston, MA
Purchase PDFLocal anesthetics are used with neuraxial and regional techniques to provide pain relief, most commonly postoperatively. Each agent is a sodium-channel blocker, although each agent differs in onset of action, potency, duration of action, and safety profile. Chemical structure and lipophilicity are the main determinants of these characteristics. The agents may be used alone or in combination with an additive which alters the local anesthetic’s properties . Clinically, local anesthetics provide pain relief in a multimodal approach. This reduces opiate consumption, opiate-related adverse effects, and length of stay. Additional benefits when using neuraxial techniques include decreases in mortality, venous thromboembolism, myocardial infarction, pneumonia, respiratory depression, and duration of ileus. Although there are many adverse effects, the most serious include neurologic and cardiovascular. Seizures and cardiac arrest may result from local anesthetic systemic toxicity when systemic levels are elevated or the patient is predisposed. Dose adjustment, removal, or reversal of the agent may be clinically indicated. Lipid emulsion therapy is a reversal agent which acts as a sequestering vehicle for the local anesthetic. Liposomal bupivacaine, the newest formulation of local anesthetic, may provide an increased duration of action compared with standard formulations, although more evidence is needed.
This review contains 5 figures, 5 tables, and 59 references.
Keywords: amide, ester, epidural, local anesthetic, local anesthetic systemic toxicity, lipid emulsion therapy, liposomal bupivacaine, peripheral nerve block
- 6
Neuromuscular Blockers and Reversal Agents
By Kristen Flight, MD; Jennifer J Yang, PharmD, BCPS, BCCCP; Lindsay M Urben, PharmD, BCPS, BCCCP; Michael J Schontz, PharmD, BCPS
Purchase PDFNeuromuscular Blockers and Reversal Agents
- KRISTEN FLIGHT, MDInstructor, Harvard Medical School, Boston, MA, Pediatric Anesthesiologist, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- JENNIFER J YANG, PHARMD, BCPS, BCCCPCritical Care Pharmacy Clinical Coordinator, Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY
- LINDSAY M URBEN, PHARMD, BCPS, BCCCPClinical Pharmacist, Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA, Clinical Pharmacist Specialist-Neuro ICU, Department of Pharmacy, University of Louisville Hospital, Louisville, KY
- MICHAEL J SCHONTZ, PHARMD, BCPSClinical Pharmacist, Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA
Purchase PDFNeuromuscular blocking drugs, which include depolarizing and nondepolarizing drugs, are used to facilitate intubation and provide skeletal muscle relaxation during surgery and in the intensive care unit. The agents differ in their mechanism, duration of action, side-effect profile, and metabolism. Succinylcholine is the only depolarizing agent in clinic use and is typically used for emergent control of the airway, rapid sequence intubations, and short surgical procedures. The risk of hyperkalemia in certain clinical conditions and risk of malignant hyperthermia in susceptible individuals limit the use of succinylcholine in specific patient populations. Nondepolarizing agents vary in their duration of action, but all provide muscle relaxation for a longer duration than succinylcholine. Clinical effects of neuromuscular blocking drugs can be assessed with neuromuscular monitoring, although there is significant variability among providers in the regular use of neuromuscular monitoring. Reversal agents are used to restore neuromuscular transmission, as residual neuromuscular blockade after extubation has been associated with multiple adverse events, including hypoxemia, atelectasis, and aspiration. Sugammadex is an encapsulating agent capable of immediately reversing the effects of rocuronium-induced neuromuscular blockade that will likely impact the way many providers administer rocuronium and may decrease the future use of succinylcholine.
This review contains 4 figures, 6 tables, and 41 references.
Keywords: hyperkalemia, neuromuscular monitoring, neuromuscular transmission, nondepolarizing neuromuscular blocking agents, residual neuromuscular blockade, reversal agents, succinylcholine sugammadex, sugammadex
- 7
Opioids for Anesthesia and Postoperative Pain Control
By Bryan Cook, PharmD, BCPS; Krystina Geiger, PharmD, BCPS, BCCCP; Megan Barra, PharmD, BCPS, BCCCP
Purchase PDFOpioids for Anesthesia and Postoperative Pain Control
- BRYAN COOK, PHARMD, BCPSClinical Pharmacy Specialist, Brigham & Women’s Hospital, Boston, MA
- KRYSTINA GEIGER, PHARMD, BCPS, BCCCPClinical Pharmacist, Brigham and Women’s Hospital, Boston, MA
- MEGAN BARRA, PHARMD, BCPS, BCCCPClinical Pharmacist, Massachusetts General Hospital, Boston, MA
Purchase PDFOpioid agonists are frequently used to provide anesthesia in combination with sedatives and hypnotic agents and manage postoperative acute pain. There are many different opioid agents available that differ in their potency, onset and duration of action, metabolism, drug interactions, and side-effect profile. All opioids have distinct effects upon various organ systems, including central nervous system depression, respiratory depression, and decreased gastrointestinal motility. Fentanyl and fentanyl-derived agents (alfentanil, sufentanil, remifentanil) are most frequently used in the intraoperative period due to their quick onset and duration of action, allowing them to be easily titrated and discontinued at the completion of a procedure. Oral opioids with moderate durations of action, such as oxycodone, hydrocodone, and morphine, are commonly used for acute pain management in the postoperative setting. When oral analgesics cannot be used, intravenous patient-controlled analgesia is another option for pain management.
This review contains 5 figures, 11 tables, and 59 references.
Key Words: analgesia, anesthesia, central nervous system depression, fentanyl, morphine, opioid agonist, pain management, patient-controlled analgesia, perioperative, respiratory depression
- 8
Sedation in the Intensive Care Setting
By William John Wallisch IV, MD; Ata Murat Kaynar, MD, MPH
Purchase PDFSedation in the Intensive Care Setting
- WILLIAM JOHN WALLISCH IV, MDAssistant Professor, Department of Anesthesiology, The University of Kansas, School of Medicine, Kansas City, KS
- ATA MURAT KAYNAR, MD, MPHProfessor, Departments of Critical Care Medicine and Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
Purchase PDFThe recent clinical trials on sedation and delirium in the ICU shifted the scales dramatically in the past 10 to 20 years and less sedation is now the accepted norm with titration goals. Now the art of sedation is in the hands of the clinicians to achieve a balance between alleviation of pain and anxiety while keeping patients calm, cooperative, and part of daily activities in the ICU. In this chapter we summarize the various assessment tools for optimal sedation in the ICU as well as the medications used to achieve sedation. However, the clinicians should not forget the nonpharmacologic approaches such as prevention of sleep interruption as part of a successful comprehensive sedation program in the ICU.
This review contains 3 tables, and 22 references.
Key Words: confusion assessment method, delirium, dexmedetomidine, etomidate, fentanyl, GABA, ketamine, propofol, Richmond agitation-sedation scale (RASS), sedation-agitation scale (SAS)
- 9
Pharmacologic Considerations for the Obese Patient
By Joy L. Chen, MD; Taylor J. Pak, BS; Tiffany S. Moon, MD, FASA
Purchase PDFPharmacologic Considerations for the Obese Patient
- JOY L. CHEN, MDAssistant Professor, University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, Dallas, TX
- TAYLOR J. PAK, BSResearch Coordinator, University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, Dallas, TX
- TIFFANY S. MOON, MD, FASAAssociate Professor, University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, Dallas, TX
Purchase PDFObese patients gain lean and mass in different proportions to total body mass. This results in different volumes of distribution (Vd) for medications according to their lipid solubility compared to that of normal weight patients. High body mass index (BMI) patients are at increased risk of medical comorbidities that may affect drug metabolism and clearance. Anesthesiologists should factor in these differences in order to prevent erroneous medication dosing.
This review contains 1 figure, 5 tables, and 65 references.
Keywords: obesity, induction agents, analgesics, inhaled anesthetics, neuromuscular blocking agents, reversal agents, local anesthetics, pharmacology, pharmacokinetics, pharmacodynamics
- 10
Clinical Pharmacology
By Molly Droege, PharmD, BCPS; Eric W. Mueller, PharmD, FCCM, FCCP
Purchase PDFClinical Pharmacology
- MOLLY DROEGE, PHARMD, BCPSClinical Pharmacy Specialist, Trauma, Surgery, and Orthopedics PGY1 Assistant Residency Program Director University of Cincinnati Medical Center
- ERIC W. MUELLER, PHARMD, FCCM, FCCPAssistant Director, Clinical Services/Research University of Cincinnati Medical Center
Purchase PDFCritically ill patients often require surgical procedures and therapeutic interventions that produce significant pathophysiologic changes. Drug pharmacology can be greatly altered in this population wherein comorbid diseases, varied organ function, and polypharmacy can produce adverse drug reactions (ADRs). This review aims to describe basic pharmacokinetic principles (absorption, distribution, metabolism, elimination) and changes in these processes due to altered organ function in critically ill surgical patients. This knowledge is a key factor in reducing ADRs.
This review contains 10 figures, 2 tables, 101 references
Keywords: adverse drug reactions, drug interactions, obesity, pharmacodynamics, pharmacokinetics, plasma protein binding, therapeutic drug monitoring
- 11
Systemic Antifungal Agents
- BRETT A MELNIKOFF, MDSurgical Resident, Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL
- RENÉ P MYERS, MDAssistant Professor of Surgery, Division of Plastic Surgery, Assistant Professor of Neurosurgery, University of Alabama at Birmingham School of Medicine, Children’s of Alabama, Birmingham, AL
Purchase PDFFungal infections remain an important cause of morbidity and mortality in surgical settings, with critically ill patients, transplant recipients, and sick neonates all especially vulnerable. Fungal infections remain an important cause of morbidity and mortality in surgical settings, with critically ill patients, transplant recipients, and sick neonates all especially vulnerable. Despite the development of a number of new and useful antifungal agents in the past decade and the noteworthy improvements in therapeutic approaches to fungal infections, physicians’ ability to diagnose these infections in a timely fashion remains limited, and patient outcomes remain poor. Antifungal prophylaxis has emerged as a potential means of reducing the occurrence of serious fungal infections. In patient populations estimated to be at high risk for acquiring a fungal infection, antifungal prophylaxis has reduced infection rates by about 50%; however, it has not been shown to significantly improve mortality. This review discusses both established and newly approved systemic antifungal agents. Tables list characteristics of currently available antifungals and antifungal chemotherapy.
This review contains 4 tables and 34 references.
Key words: antifungal chemotherapy, antifungal prophylaxis, antifungals, Candida prophylaxis, systemic antifungal medications
- 12
Anticoagulation and Reversal Agents
By Sarah Culbreth, PharmD, BCPS; Dirk Varelmann, MD; Jessica Rimsans, PharmD, BCPS
Purchase PDFAnticoagulation and Reversal Agents
- SARAH CULBRETH, PHARMD, BCPSClinical Pharmacy Specialist, Department of Pharmacy, Brigham and Women’s Hospital
- DIRK VARELMANN, MDAttending Anesthesiologist, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital
- JESSICA RIMSANS, PHARMD, BCPSClinical Pharmacy Specialist, Department of Pharmacy, Brigham and Women’s Hospital
- 13
Anesthesia for Airway Endoscopy and Micro-laryngeal Surgery
By Vicki E. Modest, MD; Paul H. Alfille, MD
Purchase PDFAnesthesia for Airway Endoscopy and Micro-laryngeal Surgery
- VICKI E. MODEST, MDAssistant Professor of Anesthesia Harvard Medical School Department of Anesthesia, Critical Care and Pain Medicine Massachusetts General Hospital 55 Fruit Street, Boston. MA 02114
- PAUL H. ALFILLE, MDAssistant Professor of Anesthesia Harvard Medical School Department of Anesthesia, Critical Care and Pain Medicine Massachusetts General Hospital 55 Fruit Street, Boston. MA 02114
Purchase PDFPre- and intra-operative anesthetic management considerations for airway endoscopy and micro-laryngeal surgery are covered in this chapter. Often presenting with critically obstructed or otherwise compromised airways, a carefully devised induction and airway control plan is essential. Unique to this type of surgery is the shared surgical field, requiring the utmost level of communication and cooperation between the surgical and anesthesia teams. Included is a discussion of ventilation options, routine and otherwise, and associated airway instrumentation such as jet ventilation catheters. Challenges of patient management during suspension laryngoscopy, are presented. Also addressed are laser basics, specific anesthetic considerations including risks and potential harms in the setting of these high-risk for fire procedures.
This review contains 5 figures, 2 tables, and 40 references.
Keywords: airway endoscopy, micro-laryngeal surgery, anesthetic considerations, obstructed airway, preoperative evaluation, airway intubation, laryngeal microsurgery, fire, OR
- 14
Central and Peripheral Nervous System
By Esther Benedetti, M.D., FIPP; James Burnett, M.D.; Meredith Degnan, M.D.; Danielle Horne, M.D.; Andres Missair, M.D., EDRA; Joshua Oppenheimer, M.D.; Evan Peskin, M.D.; Adi Pulikal, M.D.
Purchase PDFCentral and Peripheral Nervous System
- ESTHER BENEDETTI, M.D., FIPP
- JAMES BURNETT, M.D.
- MEREDITH DEGNAN, M.D.
- DANIELLE HORNE, M.D.
- ANDRES MISSAIR, M.D., EDRA
- JOSHUA OPPENHEIMER, M.D.
- EVAN PESKIN, M.D.
- ADI PULIKAL, M.D.
Purchase PDFThe neuronal, chemical, and electrical transmission of pain is a complex and intricate subject that continues to be studied and expounded. This review discusses the relevant physiology and influential factors contributing to the experience and subjective variation in a variety of acute and chronic pain presentations.
This review contains 4 figures, 4 tables, and 30 references
Keywords: acute pain, chronic pain, somatic pain, neuropathic pain, visceral pain, nociception, pain perception, gender-related pain, cancer pain, spine pain
- 15
Pharmacologic Considerations for the Obese Patient
By Joy L. Chen, MD; Taylor J. Pak, BS; Tiffany S. Moon, MD, FASA
Purchase PDFPharmacologic Considerations for the Obese Patient
- JOY L. CHEN, MDAssistant Professor, University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, Dallas, TX
- TAYLOR J. PAK, BSResearch Coordinator, University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, Dallas, TX
- TIFFANY S. MOON, MD, FASAAssociate Professor, University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, Dallas, TX
- 16
Systemic Antifungal Agents
- BRETT A MELNIKOFF, MDSurgical Resident, Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL
- RENÉ P MYERS, MDAssistant Professor of Surgery, Division of Plastic Surgery, Assistant Professor of Neurosurgery, University of Alabama at Birmingham School of Medicine, Children’s of Alabama, Birmingham, AL
- 1
- Preoperative Evaluation
- 1
The Patient With Advanced Renal Disease
Purchase PDFThe Patient With Advanced Renal Disease
Purchase PDF - 2
Morbid Obesity
By Breck Finzer, MD; Megan Adams, DO, MBA; John P Lawrence, MD, MEd, MBA
Purchase PDFMorbid Obesity
- BRECK FINZER, MDAssistant Professor of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, OH, United States
- MEGAN ADAMS, DO, MBAChief Resident, Anesthesiology, University of Cincinnati Medical Center, Cincinnati, OH, United States
- JOHN P LAWRENCE, MD, MED, MBAAHN System Chair for Anesthesiology, Allegheny Health Network, Pittsburgh, PA, United States
Purchase PDFRecent statistics indicate that the obesity rate exceeds 35% in 5 states and 30% in 25 states in the United States. As the prevalence of obesity continues to increase, the number of bariatric and nonbariatric surgeries in this patient population also continues to grow. As such, anesthesia providers must be cognizant of some special considerations pertaining to surgery and anesthesia for the obese patient. Overall, surgery on obese patients is considered higher risk than in nonobese patients, and targeted perioperative assessment and planning are crucial for reducing morbidity and mortality. Obesity results in alterations in physiology, and these effects are seen within all major organ systems. Extra consideration should be dedicated not only to the preoperative airway evaluation but also to logistic issues that may arise. To this end, it is crucial that the operating room be equipped with size-appropriate equipment as well as allowing for adequate time to move, position, and induce obese patients. Intraoperative concerns due to obesity include appropriate drug dosing, choice of anesthetic, and the cardiopulmonary impact of the anesthetic. Postoperative concerns include pain control, pulmonary hygiene maneuvers, as well as continued management of comorbid conditions. These alterations and their impact on the perioperative care of an obese patient at various points of perioperative care are herein reviewed.
This review contains 2 figures, 5 tables and 36 references
Key Words: airway evaluation, body mass index, drug dosing, morbid obesity, obesity hypoventilation syndrome, preoperative evaluation, rapid desaturation, sleep apnea evaluation, surgical risk evaluation
- 3
Pulmonary Diseases: Preoperative Assessment
- SUZANNE BENNETT, MDAssociate Professor, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
- QUINN M NGUYEN, MDClinical Instructor, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio,
Purchase PDFPostoperative pulmonary complications contribute to significant morbidity, mortality, and healthcare costs. The surgical patient with underlying pulmonary disease experiences a higher risk for postoperative pulmonary complications. Evaluation of the patient with pulmonary disease prior to surgery allows for the early identification of risk factors and opportunity for optimization resulting in improved perioperative outcomes for all surgical procedures. Complete understanding of the anesthetic options and their effect on pulmonary physiology and postoperative pulmonary complications assists in the evaluation and management of the patient with pulmonary disease. The patient-related risk factors, procedure-related risk factors, and risk factor stratification must be evaluated and performed while taking into consideration the risk and type of surgery. A thorough preoperative evaluation of the patient with pulmonary disease allows for the rational development of a multidisciplinary perioperative plan with the goal of reducing postoperative pulmonary complications.
This review contains 6 figures, 11 tables, and 49 references.
Keywords: assessment of perioperative risk, asthma, bronchitis, cessation of smoking, COPD, emphysema, obstructive sleep apnea, perioperative smoking, Pulmonary Function Tests (PFTs), nitrogen washout
- 4
The Geriatric Patient
- MAGGIE MECHLIN, MDAssistant Professor, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH
- PETER ARRABAL, DOClinical Instructor, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH
Purchase PDFAn aging population combined with the increasing availability of invasive medical procedures has created a growing number of elderly patients that anesthesiologists care for every day. Geriatric patients present unique challenges that must be taken into consideration when crafting an anesthetic plan. To start with, one must first decide what it means to be elderly. Is it an age cutoff? If so, at what age does a patient become elderly? Is it a physiologic definition? If so, what amount of physiologic derangement must be present and in how many organ systems for someone to be classified as elderly? Although there is no clear consensus, a reasonable definition would combine age with the patient’s physical tolerance towards the stresses of surgery. This chapter attempts to address the myriad challenges faced by the perioperative physician who is planning to anesthetize an elderly patient. There are unique points to be noted in the preoperative physical examination, cognitive evaluation, creation of the anesthetic plan, and risk stratification. There are additional concerns related to a patient’s wishes regarding code status and potential end-of-life care. By addressing all these issues, anesthesiologists can provide safe, successful, and compassionate care to a complex and diverse elderly population.
This review contains 5 figures, 3 tables, and 52 references.
Key Words: anesthetizing the elderly, code status discussion, delirium, pharmacokinetic changes of aging, postoperative cognitive decline, physiologic changes of aging, regional anesthesia for orthopedic surgery, risk stratification
- 5
Advanced Hepatic Disease
- COURTNEY JONES, MDAssistant Professor University of Cincinnati Department of Anesthesiology
- CORY FRANCE, MDResident University of Cincinnati Department of Anesthesiology
Purchase PDFAdvanced liver disease poses many challenges to the anesthesiologist. In this focused review, we will identify the varying etiologies and demographics of the disease before detailing the wide-ranging impact on various organ systems. The effects of liver disease are often profound and require a thorough understanding of the underlying pathophysiology. Particular attention will be paid to those areas in which a thorough evaluation and optimization can enhance perioperative outcomes of those with advanced liver disease. Given the liver’s extensive involvement in drug metabolism, we will also review drug dosing and how it is altered in advanced disease. Procedures commonly performed on patients with advanced hepatic dysfunction will be discussed as their role is increasing in the management of the disease. While liver disease is familiar to the medical community, there have been recent advances that provide the anesthesiologist with new evidence-based management strategies. Though there is still much work to be done to understand the complex interactions of severe hepatic dysfunction, these recent advances will be highlighted to improve current management of these ill patients.
This review contains 5 tables, and 51 references.
Key Words: Thromboelastogram (TEG), MELD-Na, Prothrombin complex concentrates, Hepatopulmonary Syndrome, Portopulmonary Hypertension, Hepatic hydrothorax, Large volume paracentesis, Non-Alcoholic Fatty Liver Disease (NAFLD)
- 6
Preoperative Assessment of Patients With Other Endocrine Disorders
By Gretchen A. Lemmink, MD; Sean A. Josephs, MD
Purchase PDFPreoperative Assessment of Patients With Other Endocrine Disorders
- GRETCHEN A. LEMMINK, MDAssistant Professor of Anesthesiology, University of Cincinnati Medical Center
- SEAN A. JOSEPHS, MDAssociate Professor, Department of Anesthesiology, University of Cincinnati College of Medicine
Purchase PDFThe rate of rise of endocrine disease in the general population is staggering. Roughly 1 in 10 Americans have been diagnosed with an endocrine disorder, the vast majority of which is diabetes mellitus. This is closely followed by thyroid disorders and also includes patients with disease of the adrenal glands, parathyroid glands and pituitary. These individuals present for surgery with a multitude of metabolic and electrolyte derangements. Their disease may be complicated by obesity and severe, poorly controlled hypertension. Frequently, end-organ damage resulting from long-standing endocrinopathy is also present, including renal and cardiovascular abnormalities. These patients often present for surgery with undiagnosed disease due to the subtle physiologic alterations characteristic of many endocrine disorders. Identification and optimization of these individuals is paramount prior to surgery to avoid intraoperative and postoperative complications. This article reviews the wide-ranging challenges unique to endocrine disorders in the perioperative period and specifically addresses preoperative concerns and patient optimization.
This review contains 4 figures, 5 tables, and 42 references.
Keywords: hypothyroidism, hyperthyroidism, thyroid storm, myxedema coma, hyperparathyroidism, hypoparathyroidism, hypercortisolism (Cushing’s Syndrome), hyperaldosteronism, adrenal insufficiency (Addison’s Disease), pheochromocytoma
- 7
Preoperative Assessment of the Patient With Diabetes Mellitus
By Sean A. Josephs, MD; Gretchen A. Lemmink, MD
Purchase PDFPreoperative Assessment of the Patient With Diabetes Mellitus
- SEAN A. JOSEPHS, MDAssociate Professor of Anesthesiology, University of Cincinnati College of Medicine
- GRETCHEN A. LEMMINK, MDAssistant Professor of Anesthesiology, University of Cincinnati Medical Center
Purchase PDFDiabetes mellitus is a major cause of morbidity and mortality. Nearly 30 million Americans have diabetes, more than 25% of which are undiagnosed. Patients with diabetes have multiple problems that should be addressed prior to surgery. They often have uncontrolled glucose levels that should be treated preoperatively. Current studies suggest that outcomes may be improved if perioperative glycemic control is optimized. Patients with diabetes develop end-organ dysfunction that can complicate perioperative management. Preoperative assessment of cardiac, neurologic, vascular, and renal function is necessary for all patients with diabetes that undergo major surgery. Optimization of cardiac disease in particular can reduce major adverse cardiac events for patients with risk factors such as diabetes. Diabetic patients can occasionally present for major surgery with hyperglycemic emergencies such as diabetic ketoacidosis and hyperglycemic hyperosmolar state. These conditions require urgent treatment to prevent mortality regardless of the need for surgery. This article reviews the preoperative assessment and management of these issues.
This review contains 1 figure, 4 tables, and 37 references.
Key Words: diabetes mellitus (DM), end-organ damage, hyperglycemia, polyuria, polydipsia, polyphagia, perioperative glycemic management, diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), perioperative cardiac risk factors
- 8
Special Perioperative Considerations in Anesthesiology
By William E. Hurford, MD; William Pitman, MD
Purchase PDFSpecial Perioperative Considerations in Anesthesiology
- WILLIAM E. HURFORD, MDProfessor of Anesthesia, Department of Anesthesiology, University of Cincinnati, Cincinnati, OH
- WILLIAM PITMAN, MDClinical Instructor of Anesthesia, Department of Anesthesiology, University of Cincinnati, Cincinnati, OH
Purchase PDFAnesthesia providers are faced with increasing work stressors and challenges that affect both patient care and the health of providers. Most physicians cope with stressors by relying on situational and personal characteristics. Addiction remains a relatively common maladaptive response. Anesthesiologists tend to abuse more potent medications than the general population and have a higher mortality rate than other practitioners with substance use disorder. Distractions from personal stressors, combined with a myriad of distractions in the operating room, can jeopardize vigilant practice. How can we better provide for the safety of our patients and satisfaction within our own lives? 1) Mindful practice can lead to an internal state of personal wellness. 2) Intentional design of clinical processes can simplify our workflows and increase resilience to errors. 3) Adoption of performance improvement techniques and error reduction strategies can focus on identifying deviations from practice. 4) Checklists and standardized workflows, along with structured communication and team training can improve shared understanding and the reliability of our work. Adoption of such interventions can reduce the burden of our work and improve outcomes for both the practitioner and the patient.
This review contains 2 figures, 6 tables, and 55 references.
Keywords: burnout, disclosure of mistakes, distractions, malpractice, mindfulness, performance improvement, physician impairment, safety, substance use disorder
- 9
Coronaviruses: Hcov, Sars-cov, Mers-cov, and COVID-19
- MICHAEL G. ISON, MD, MSCAssociate Professor, Divisions of Infectious Diseases & Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL
Purchase PDFCoronaviruses (CoVs) are a group of viral pathogens that infect mammals and birds. The presentation in humans is typically that of a mild upper respiratory tract infection, similar to the common cold. However, in recent years, dramatic attention has arisen for more lethal members of this viral family (e.g., severe acute respiratory syndrome [SARS-CoV], Middle East respiratory syndrome [MERS-CoV], and coronavirus disease 2019 [COVID-19]). The epidemiology, clinical presentation, diagnosis, and management of these viruses are discussed in this review. Importantly, new guideline tables from the Centers for Disease Control and Prevention, as well as the World Health Organization are provided at the conclusion of the review.
This review contains 12 tables, 3 figure and 48 references.
Keywords: Coronavirus, severe acute respiratory distress syndrome (SARS), Middle East respiratory syndrome (MERS), COVID-19, respiratory infection, antiviral, real-time polymerase chain reaction
- 10
Preoperative Evaluation of the Obese Patient
By Joy L. Chen, MD; Taylor J. Pak, BS; Tiffany S. Moon, MD, FASA
Purchase PDFPreoperative Evaluation of the Obese Patient
- JOY L. CHEN, MDAssistant Professor, University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, Dallas, TX
- TAYLOR J. PAK, BSResearch Coordinator, University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, Dallas, TX
- TIFFANY S. MOON, MD, FASAAssociate Professor, University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, Dallas, TX
Purchase PDFBenjamin Franklin once said, “an ounce of prevention is worth a pound of cure.” The same can be said about anesthetic interventions for patients undergoing endovascular, endoscopic, and surgical procedures. In order to provide safe anesthetics and the best possible outcomes, it is important to obtain the patient’s health history, perform a physical examination, adjust medications as necessary, and order appropriate laboratory and imaging studies prior to surgery. A preoperative evaluation allows the clinician an opportunity to optimize the patient’s health prior to the operating room. In particular, those with an increased risk for anesthetic and surgical complications should be paid additional attention. Since obese patients tend to suffer from comorbidities as well as increased anesthetic and surgical complications, preoperative evaluations can help mitigate their risks.
This review contains 2 figures, 5 tables and 35 references.
Keywords: obesity, anesthetic complications, cardiovascular system, pulmonary system, gastrointestinal system, endocrine system, airway examination, preoperative evaluation
- 11
Perioperative Antithrombotic Therapy Management and Venous Thromboembolism Prophylaxis
By Herbert Chen, MD, FACS; Irene Lou, MD
Purchase PDFPerioperative Antithrombotic Therapy Management and Venous Thromboembolism Prophylaxis
- HERBERT CHEN, MD, FACSChairman, Division of General Surgery, Layton F. Rikkers M.D. Chair in Surgical Leadership, Vice-Chair for Research, Department of Surgery, University of Wisconsin, Madison, WI
- IRENE LOU, MDPostdoctoral Trainee, Department of Surgery, University of Wisconsin, Madison, WI
Purchase PDFThe management of perioperative anticoagulation, antiplatelet therapy, and perioperative venous thromboembolism (VTE) prophylaxis is essentially a balancing act between patient risk factors for thrombosis and surgical risk factors for bleeding. The purpose of this review is to assist surgeons with the identification of patients at increased risk for thromboembolism when antithrombotic therapy is interrupted, patients for whom bridging anticoagulation should be considered, patients who require perioperative VTE prophylaxis, and patients at increased risk for bleeding complications and to briefly review the literature and major guidelines regarding perioperative antithrombotic therapy management and perioperative VTE prophylaxis. Figures show approaches to the management of perioperative anticoagulation, antiplatelet therapy, and VTE prophylaxis.
This review contains 2 figures, 7 tables, and 61 references.
Keywords: Venous thromboembolism, pulmonary embolism, anticoagulation, surgery, perioperative period, prophylaxis
- 12
Evaluation of Surgical Risk
- RYAN SCHMOCKER, MDResident, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI
- SURESH AGARWAL, MD, FACS, FCCMChief, Division of Trauma and Critical Care Surgery, Professor, Department of Surgery, Duke University, Durham, NC
Purchase PDFIn assessing surgical risk, appropriate preoperative evaluation should systematically address a patient's pre-existing medical conditions and identifies unrecognized comorbidities, ideally leading to the anticipation and treatment of potential complications both pre- and postoperation. Thus, a thorough evaluation of the patient history and physical examination is essential. Various risk assessments discussed in this review are those for cardiac, pulmonary, renal, hepatic, and hematologic concerns. Cardiac risk assessment focuses on patient-related risk factors, including coronary artery disease, congestive heart failure, valvular heart disease, arrhythmias and conduction defects, implanted pacemakers and implantable cardiac defibrillators, cardiomyopathy, and hypertension. The pulmonary patient-related risk factors are explored and include age and general health status, smoking, chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, obesity, pulmonary hypertension, and heart failure. Preoperative medication management is also explored.
This review contains 3 figures, 31 tables, and 75 references.
Key words: surgical risk calculators, cardiac complications, coronary artery disease, hypertension, perioperative, cardiac risk assessment, preoperative evaluation
- 13
Preoperative Evaluation of the Obese Patient
By Joy L. Chen, MD; Taylor J. Pak, BS; Tiffany S. Moon, MD, FASA
Purchase PDFPreoperative Evaluation of the Obese Patient
- JOY L. CHEN, MDAssistant Professor, University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, Dallas, TX
- TAYLOR J. PAK, BSResearch Coordinator, University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, Dallas, TX
- TIFFANY S. MOON, MD, FASAAssociate Professor, University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, Dallas, TX
- 14
Pulmonary Diseases: Preoperative Assessment
- SUZANNE BENNETT, MDAssociate Professor, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
- QUINN M NGUYEN, MDClinical Instructor, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio,
- 1
- Physiology
- 1
Cardiovascular System: Part I
- VANETTA LEVESQUE, MDUniversity of Mississippi Medical Center
Purchase PDFThis chapter reviews the cardiovascular system in its entirety. It begins with the details of the cardiac cycle, a highly coordinated sequence of electrical and mechanical events that allows blood flow from the atria to the ventricles, which then pump blood out to pulmonary, and systemic circulations. There is an overview of basic ventricular physiology, assessment of ventricular contractility, and systolic and diastolic function. Cardiac output, its determinants, regulation, and its measurement according to the Fick principle and other methods are also extensively reviewed. The chapter moves on to describe the importance of blood pressure and its determinants. It follows with a description of how arterial blood pressure and other intracardiac pressures are measured. Finally, in the event of cardiac arrest, the chapter describes high quality CPR, and several algorithms used in managing patients in cardiac arrest.
This review contains 5 figures, and 51 references.
Keywords: electrocardiogram (ECG), Frank-Starling law, myocardial contractility, Fick principle, cardiac output, blood pressure, intracardiac pressures, advanced cardiac life support
- 2
Physiology of Geriatrics
- CHRISTINA M. MATADIAL, MDAssociate Professor of Clinical Anesthesia Department of Anesthesiology, University of Miami Miller School of Medicine Bruce W. Carter VA Medical Center, Miami, FL
Purchase PDFThe aging population is growing and life expectancy is prolonged. The elderly population is able to enjoy prolonged life with good management of their chronic conditions. Many elderly do not have medical conditions but we still see a decline in their organ function and physiologic reserve that weighs in on their daily living. As well these changes in anatomy, physiology and chemistry puts them at risk of developing medical conditions and experience adverse outcomes during surgery and anesthesia. The central nervous, cardiovascular, respiratory, hepatic and renal systems all work together and are affected as a whole with aging causing physiologic changes but also compensatory mechanisms. In this review we will study the aging physiology of the body and touch on its implications in anesthesia.
This review contains 5 figures, 3 tables, and 55 references.
Keywords: Healthy aging, age-related changes, Postoperative cognitive dysfunction, diastolic dysfunction, vascular stiffening, ventricular arterial coupling, Chronic obstructive pulmonary disease, Spirometry, Glomerular Filtration Rate, hallmarks of aging
- 3
Cardiovascular System: Part II
- VANETTA LEVESQUE, MDAssistant Professor, University of Mississippi Medical Center, Jackson, MS
Purchase PDFThis chapter gives an overview of blood circulation, then focuses on regional blood flow to a number of organs, and ends with a description of the microcirculation. It begins with venous return and blood volume. Most blood volume is contained within the venous system, and the chapter describes several mechanisms that allow for this volume of blood to be returned to the right heart. Next it describes the various means by which the blood circulation and volume are controlled. The chapter devotes considerable time describing the central, peripheral, and hormonal regulation of circulation and blood volume. Next, regional blood flow is described. Blood flow in different regions of the body is usually autoregulated, and variably controlled by the autonomic nervous system, and various humoral agents. The final section describes the mechanism by which blood flow in the microcirculation delivers nutrients, and removes wastes from the tissue by diffusion. Also described are the regulation of the microcirculation by pre and post capillary sphincters, and the effect of viscosity.
This review contains 5 figures, and 40 references.
Keywords: venous return, vascular compliance, venous capacitance, vasomotor center, hypothalamic-pituitary-adrenal axis (HPA), microcirculation, regional blood flow, mixed venous oxygen saturation
- 4
Hepatic Physiology and Enhanced Recovery After Surgery
By Jeremy T. Rainey, DO; Caroline A. Walker, MD
Purchase PDFHepatic Physiology and Enhanced Recovery After Surgery
- JEREMY T. RAINEY, DOAssistant Professor, Anesthesiology and Critical Care Medicine, Department of Anesthesiology University of Mississippi Medical Center
- CAROLINE A. WALKER, MDAssistant Professor Anesthesiology, Cardiovascular and Thoracic Anesthesiology Department of Anesthesiology University of Mississippi Medical Center
Purchase PDFThe liver is responsible for maintaining many of the body’s physiologic functions including: maintaining glucose and blood volume homeostasis; creating, recycling and excreting bile acids to aid in digestion and absorption; metabolizing and excreting both intrinsic and extrinsic toxins; creating the major factors required for coagulation and almost all plasma proteins; and metabolizing many of the medications commonly used in anesthetic management. It is crucial for the developing anesthesiologist to have a firm understanding of the organs’ function and how this alters the perioperative planning for patients undergoing anesthesia. This review aims to breakdown hepatic physiology and critical functions, review metabolism and the important cytochrome P450 system, and introduce the resident to the important concepts of enhanced recovery after surgery.
This review 5 figures, 4 tables, and 29 references.
Keywords: hepatic physiology, hepatic blood supply, intrinsic regulation, extrinsic regulation, urea cycle, hepatic metabolism, CYP450, phase reactions, hepatic clearance, ERAS
- 5
Endocrine and Metabolic Systems
- SUWARNA ANAND, MDAssistant Professor, Department of Anesthesiology, University of Mississippi Medical Center, Jackson MS
Purchase PDFThe endocrine system and the nervous system work in synchrony to maintain homeostasis in the body. Growth, development, reproduction, blood pressure, concentrations of ions and other substances in blood, and even behavior are all regulated by the endocrine system. Endocrine physiology involves the secretion of hormones and their subsequent actions on target tissues. The present overview focuses on the endocrine physiology and the pathophysiologic states that influence the growth and development of an individual.
This review contains 11 tables, and 27 references.
Keywords: diabetes mellitus, thyroid, parathyroid hormone, hypoparathyroid, hypothalamus, pituitary, adrenal gland, carbohydrate metabolism, protein, lipids
- 6
Renal and Urinary Systems/electrolyte Balance
- HENRIQUE VALE, MD
Purchase PDFRenal physiology involves the regulation of fluid balance and blood pressure, absorption of glucose, amino acids, and other small molecules, maintenance of acid-base balance; regulation of sodium, potassium, and other electrolytes; clearance of toxins; production of various hormones, such as erythropoietin, which is responsible for production of red blood cells in the bone marrow, and renin which helps to regulate the extracellular fluid and osmolality.1,2 The physiology of the kidneys is studied at the level of smallest functional unit of the kidney, the nephron. The filtration process begins by the nephron filtering the blood entering the kidneys (glomerular filtration). This filtrate flows along the nephron to promote reabsorption of water and small molecules and the secretion of wastes from the blood into the urine (tubular reabsorption and tubular secretion). At the end the remaining filtrate goes to the collecting duct to enter the renal pelvis. From the renal pelvis, the urine passes to the bladder and is excreted to the exterior.1-3 In order to work properly the kidney must receive adequate blood flow, any reduction of blood flow to the kidneys, can result in damage of the kidney structure that can be reversible or not. Multiple studies can provide a qualitative assessment of the renal function and also look for structural abnormalities.1
This review has 6 figures, 5 tables, and 36 references.
Keywords: renal blood flow, glomerular filtration, Glomerular Filtration Rate (GFR), vasopressin, antidiuretic hormone, aldosterone, juxtaglomerular cells, chronic kidney disease, pathophysiology, diabetes mellitus
- 7
Hypernatremia
- GAMAL MOSTAFA, MDProfessor of Surgery, Wayne State University, Detroit, Michigan
Purchase PDFHypernatremia is an electrolyte disorder most prevalent in the elderly and the critically ill, with over 60% of cases developing over the course of an inpatient stay. Characterized by elevated serum sodium concentrations, this disorder is manifested either by pure-water loss without replacement, or excessive sodium intake without appropriate water balance. Left untreated it may lead to seizures and coma. General treatment in the case of severe hypernatremia is infusion of isotonic saline followed by pure-water after the patient is stabilized. Further treatment of the underlying cause may involve diuretics, thiazides, and a variety of other medications in conjunction with dietary and lifestyle modifications.
This review contains 2 references.
Key words: Hypernatremia, Edematous States ,Volume Depletion, Osmolality, Diuretics
- 8
Clinical Immunology and Innate Immunity
- LUNG-YI LEE, MDDepartment of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
- DAVID P FOLEY, MDDepartment of Surgery, University of Wisconsin School of Medicine and Public Health, and Veterans Administration Surgical Services, William S. Middleton Veterans Hospital, Madison, WI
Purchase PDFOur body encounters a multitude of microorganisms in our daily lives. Due to surveillance of our robust immune system, these microbial encounters remain largely benign and only become pathologic at times. The majority of these pathogens are cleared rapidly by our innate immune system. The innate immune system is our body’s first line of defense that mounts a nonspecific response against pathogens. In this review, a contemporary summary of this complex system and its relevance to disease processes that are commonly seen in the surgical setting are presented, including components and activation of innate immunity, and relevant clinical scenarios.
This review contains 10 figures, 11 tables, and 32 references.
Keywords: Innate immunity, humoral immunity, phagocytosis, neutrophils, macrophages, pathogen-associated molecular pattern, damage-associated molecular pattern, wound healing, sepsis, SIRS, deep vein thrombosis, solid-organ rejection
- 9
Principles and Techniques of Abdominal Access and Physiology of Pneumoperitoneum
By Jon C. Gould, MD, FACS; Kathleen Simon, MD
Purchase PDFPrinciples and Techniques of Abdominal Access and Physiology of Pneumoperitoneum
- JON C. GOULD, MD, FACSAssociate Professor of Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health.
- KATHLEEN SIMON, MDSurgery Resident, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
Purchase PDFLaparoscopic surgery has gained popularity in recent time. An essential aspect of this technique is production of a pneumoperitoneum with insufflation for adequate visualization and manipulation of abdominal contents. Various techniques have been developed over the years for optimal access with minimization of complications. Some of these complications include vascular injury, visceral injury, and incisional hernia. Furthermore, considerations with regards to the patient’s physical morphology, and the cardiovascular/respiratory effects of increased abdominal pressure and anesthesia must be accounted for. The guidelines to optimize patient care in these regards are discussed in this review.
This review contains 2 videos, 5 figures, 2 tables, and 79 references.
Keywords: trocar insertion, port site hernia, Veress needle, optical trocar, trocar related injuries, Hassan cannula, pneumoperitoneum, air embolism, pneumoperitoneum physiology
- 1
- Technology
- 1
Mathematics and Statistics in Anesthesiology
- DANIEL MORTLOCK, PHDSenior Lecturer, Imperial College London, London, Guest Professor at Stockholm University, Stockholm, Sweden
Purchase PDFMathematics is the language of quantitative science, and probability and statistics are the extension of classical logic to real world data analysis and experimental design. The basics of mathematical functions and probability theory are summarized here, providing the tools for statistical modeling and assessment of experimental results. There is a focus on the Bayesian approach to such problems (ie, Bayesian data analysis); therefore, the basic laws of probability are stated, along with several standard probability distributions (eg, binomial, Poisson, Gaussian). A number of standard classical tests (eg, p values, the t-test) are also defined and, to the degree possible, linked to the underlying principles of probability theory.
This review contains 5 figures, 1 table, and 15 references.
Keywords: Bayesian data analysis, mathematical models, power analysis, probability, p values, statistical tests, statistics, survey design
- 2
The Physics of Ultrasound
By Gerry van Rensburg, MB ChB, FCA(SA), MMed(Anaest.); Andrew Smith, MB BS, FRCA, FFICM; Ben O’Brien, MD, PhD(habil), FRCA, FFICM, SFFMLM, MHBA
Purchase PDFThe Physics of Ultrasound
- GERRY VAN RENSBURG, MB CHB, FCA(SA), MMED(ANAEST.)Clinical Fellow, Department of Perioperative Medicine, Barts Heart Centre, London
- ANDREW SMITH, MB BS, FRCA, FFICMConsultant, Department of Perioperative Medicine, Barts Heart Centre, London
- BEN O’BRIEN, MD, PHD(HABIL), FRCA, FFICM, SFFMLM, MHBAClinical Director, Department of Perioperative Medicine, Barts Heart Centre, London
Purchase PDFClinical ultrasound has attained significant importance for the practising anesthesiologist. Its applications reach far and wide in anatomic and physiologic diagnosis, and it is a powerful adjunct for guiding interventional procedures. This article describes the physical principles that allow for the generation of ultrasound, its transmission and reflection from within the body, and generation of the ultrasound images used in daily practice. We not only review definitions of important technical terms but also provide synonyms in plain language, as jargon often presents a barrier to grasping basic and fundamental principles. Furthermore, we review the mathematical and physical principles that facilitate the generation of Doppler modes, such as pulsed wave, continuous wave, color flow. Clinically safe practice requires that all data be interpreted in the light of the technology’s shortcomings; we additionally review the common pitfalls and artifacts encountered in the use of this imaging modality.
This review contains 16 figures, 1 table, and 5 references.
Keywords: attenuation, continuous wave Doppler, Doppler, frequency, imaging artefacts, physics, pulsed-wave Doppler, ultrasound
- 3
Modes of Ventilation
- MICHAEL J HARRISON, MBBS, MD, FRCA, FANZCAHonorary Clinical Associate Professor, University of Auckland, New Zealand
Purchase PDFLung ventilation is required to maintain oxygenation and eliminate carbon dioxide. The basic parameters of ventilation—tidal volume, respiratory rate, airway resistance, and lung and thoracic compliance—all combine to affect the airway pressure. These parameters, in turn, can affect cardiac output and hemodynamic stability through their effect on intrathoracic pressure and on venous return to the heart. Since the 1950s, many machines have been designed to allow the physician to optimize ventilation. These designs have revolved around three physical variables: volume, pressure, and time. Volume is required to overcome the anatomic respiratory dead space and allows gas exchange in the alveoli. Pressure is required to inflate the elastic system comprising the lungs and thorax, but must also be limited to prevent tissue damage. Time not only determines the respiratory rate but also the rate of flow of gas in and out of the lungs.
Many permutations of these basic parameters in anesthesia machines are available today. Knowledge of the common forms of ventilation and their advantages and disadvantages will guide the anesthesiologist in choosing from among these various complex systems.
This review contains 5 figures, 3 tables, and 27 references.
Key words: CPAP, HFOV, IMV, IPPV, jet ventilation, PEEP, pressure cycled, pulmonary ventilation, SIMV, spontaneous, volume cycled
- 4
Electrical and Fire Safety in the OR
- FERENC E GYULAI, MDVice Chair, Department of Anesthesiology and Perioperative Medicine, Professor of Clinical Anesthesiology, School of Medicine, University of Missouri, University Hospital, Columbia, MO
Purchase PDFIn the OR, electrical shocks and fire represent two very important risks and they occur more commonly than most people recognize. Electrical and fire safety in the OR is every team member’s responsibility. Prevention is the first step, but when incidents occur, optimal outcomes depend on concerted efforts. Thisapproach, along with a comprehensive electrical and fire safety program, is a continued effort to create a safer healthcare environment for every worker and patient. Understanding the basic principles of electricity and fire safety is the first step towards this goal. Unfortunately, many institutions do not involve the key players (surgery and anesthesia department members) in the education and preparation process. By involving all team members, optimal outcomes for patients at this vulnerable time may be achieved. Our patients expect us to know the risks and management of these potentially life-threatening occurrences. This chapter endeavours to facilitate these goals.
This review contains 9 figures, 3 tables, and 51 references
Keywords: electrosurgical unit, fire extinguisher, ground fault circuit interrupter, grounding, ignition source, line isolation monitor, macroshock, microshock, Ohm law
- 5
The Anesthesia Machine: Managing Exhaled and Waste Gases
- CHRISTINE JETTE, MD, DABAClinical Assistant Professor, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
Purchase PDFEffective and safe CO2 absorption is critical to the anesthesia circle system to prevent rebreathing and hypercapnia. Advances in the original soda lime–based absorbents and their container systems continue to improve patient safety, reducing the risk of compound A and carbon monoxide production, with seemingly little compromise to the efficiency of CO2 absorption capabilities. Scavenging systems and the removal of waste anesthesia gases remain a critical component to anesthesia care, and vigilance to maintain approved systems is a key to operating room staff safety. Advances in anesthesia machine design have resulted in more complicated internal breathing circuits that are increasingly difficult to rid of trace anesthetic gases. This inadvertently led to a necessary change in guidelines on anesthesia machine preparation for patients susceptible to malignant hyperthermia (MH).
This review contains 5 figures, 6 tables, and 59 references.
Keywords: carbon dioxide absorption, carbon monoxide, CO2 absorption, compound A, malignant hyperthermia machine preparation, operating room safety, scavenging systems, waste anesthesia gases
- 6
Temperature Measurement and Thermal Management
By Yvon F Bryan, MD; Kathleen N. Johnson, BS
Purchase PDFTemperature Measurement and Thermal Management
- YVON F BRYAN, MDDepartment of Anesthesiology, Wake Forest School of Medicine, Medical Center, Boulevard, NC
- KATHLEEN N. JOHNSON, BSDepartment of Anesthesiology, Wake Forest School of Medicine, Medical Center, Boulevard, NC
Purchase PDFTemperature measurement and thermal management in surgical patients are both challenging issues that depend on regulating the patient’s immediate thermal environment in the face of the nonphysiologic perturbations that routinely occur in the operation room. Recognizing the different mechanisms involved in the physics of heat transfer, such as radiation, convection, conduction, and evaporation is paramount. In addition, the patient’s comorbidities and prescribed medications combine with the agents used during general anesthesia to further alter thermoregulation. Correctly measuring and monitoring temperature is critical and is an expected part of the American Society of Anesthesiologists (ASA) basic standards for monitoring for all but the shortest or lightest anesthetics. Understanding the advantages and disadvantages of the different anatomic sites available to measure temperature is imperative to prevent erroneous temperature recordings. Correctly preventing inadvertent hypothermia and iatrogenic hyperthermia are critical prior to deciding to institute thermal management. Different mechanisms exist to treat heat loss, using both passive and active warming. Other unique environments within the hospital impose stress on thermoregulation systems such as cardiopulmonary bypass and MRI. This review is a summary of the scientific and medical literature necessary to understand the fundamentals of temperature measurement and thermal management.
This review contains 3 figures, 3 tables, and 43 references.
Key Words: forced air convection, general anesthetics, hyperthermia, temperature measurement, thermal management, thermoregulation, threshold
- 7
External and Implantable Pacemakers and Defibrillators
- ROYA SAFFARY, MDClinical Assistant Professor, Department of Anesthesiology, Stanford Hospital, Stanford, CA
Purchase PDFApproximately 250,000 pacemakers are implanted every year in the United States.26 As the population continues to age, the number is likely to increase; therefore, it is imperative for all physicians, especially anesthesiologists, to become familiar with implantable cardiac devices and the appropriate management of patients with these devices. Anesthesiologists must be comfortable evaluating and managing patients with pacemakers and/or defibrillators during the perioperative period, as more of this patient population present for noncardiac, elective surgery. This requires a strong understanding of the types of devices, indications, settings, and functionality. In addition, it is important to understand and anticipate possible interactions during surgery with surgical instruments, such as bi- and monopolar electrocautery. This review provides a brief overview of the history of implantable devices, presents the guidelines regarding indications for placement, discusses important management considerations, and concludes with recent advances and future directions.
This review contains 1 figures, 5 tables, and 30 references.
Key Words: cardiac, defibrillator, electrophysiology, external, implantable, pacemaker, pacing, transcutaneous, transvenous
- 8
Respiratory Monitoring and Instrumentation
By Oana Predescu, MD, MSc, PhD, FRCPC; Angelina Guzzo, MD, PhD, FRCPC
Purchase PDFRespiratory Monitoring and Instrumentation
- OANA PREDESCU, MD, MSC, PHD, FRCPCAssistant Professor, Anesthesia, Montreal General Hospital Acute Pain Clinical Director, McGill University, Montreal, QC
- ANGELINA GUZZO, MD, PHD, FRCPCAssistant Professor, Anesthesia, Montreal General Hospital Residency Coordinator, McGill University, Montreal, QC
Purchase PDFThe American Society of Anesthesia Standards for Basic Anesthetic Monitoring and the Practice Guidelines for Postanesthetic Care stress the importance and necessity of respiratory monitoring during anesthesia to ensure adequate oxygenation and adequate ventilation. Respiratory monitoring represents a continuous real-time evaluation of the patient’s physiology and is essential in assisting clinical decision-making and ensuring patient safety. This chapter discusses spirometry as well as different monitoring instruments for assessing ventilation and oxygenation. A brief history of each monitoring instrument is outlined.
This review contains 8 figures, 2 tables, and 8 references.
Key Words: capnography, co-oximetry, expired gas concentration, flow-volume loops, infrared absorption spectroscopy, inspiratory pressure, mass spectroscopy, pulse oximetry, Raman scattering, spirometry
- 1
- Thoracic Anesthesia
- 1
Airway Procedures
- JU-MEI NG, MDAssistant Professor of Anesthesia, Harvard Medical School, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Boston
Purchase PDFThere has been a marked increase in the number and complexity of airway procedures performed both in the operating room and procedural areas. The anesthesiologist is challenged with establishing a patent shared airway and maintaining adequate gas exchange in patients with compromised airways and/or respiratory function. This review presents a general approach to the patient presenting for an airway procedure and highlights the commonly occurring complications. Airway fire, bleeding, and airway disruption or obstruction may occur. Some of the newer interventional bronchoscopic procedures are introduced, with emphasis on anesthetic implications. A more detailed discussion surrounds the anesthetic management of central airway obstruction and airway stenting.
This review contains 8 figures, 5 tables, 30 references.
Key Words: anesthesia for flexible bronchoscopy, anesthesia for rigid bronchoscopy, airway stenting, bronchoscopy, central airway obstruction, interventional pulmonology, total intravenous anesthesia, ventilation
- 2
Nonpulmonary Thoracic Procedures
- JAIDA C FITZGERALD, MDInstructor in Anesthesia, Boston Children’s Hospital, Brigham and Women’s Hospital, Department of Anesthesia, Perioperative and Pain Medicine, Boston, MA
Purchase PDFThere has been a shift toward minimally invasive thoracic procedures employing thoracoscopy as opposed to open thoracotomy, which has been associated with less morbidity and decreased hospital length of stay. The anesthesiologist has a vital role in perioperative management of patients undergoing thoracic procedures, as implementation of lung protective strategies, goal-directed fluid management, and thoracic epidural analgesia have all been shown to improve patient outcome. It is important for the anesthesiologist to recognize patients with particularly dangerous pathology who can become acutely unstable with the induction of anesthesia, including those with anterior mediastinal masses and hemodynamically significant pericardial effusions. Given the vital structures located within the chest, every thoracic procedure has the potential for life threatening harm from injury to surrounding structures.
This review contains 3 figures, 9 tables, and 19 references.
Key Words: cardiac tamponade, goal-directed fluid therapy, innominate artery compression, mediastinal mass, mediastinoscopy, pectus excavatum, single lung ventilation, SVC syndrome, thoracic epidural analgesia
- 3
Lung Isolation
- BRYAN HIERLMEIER, MDAssistant Professor, University of Mississippi Medical Center, Jackson, MS
- VANETTA LEVESQUE, MDAssistant Professor, University of Mississippi Medical Center, Jackson, MS
- HENRIQUE VALE, MDAssistant Professor, University of Mississippi Medical Center, Jackson, MS
Purchase PDFLung isolation is being used more frequently in adult patients due to increasing incidence of thoracoscopy and video-assisted thoracoscopic surgery. There are several indications for lung isolation and one-lung ventilation (OLV) during surgery. Isolation is usually achieved by double-lumen endotracheal tubes or use of some type of bronchial blocker system. The initiation of OLV frequently leads to hypoxemia, the management of which should be stepwise. Additionally, clinical outcomes are significantly improved with the use of lung protective strategies during OLV. This review covers the use of few of the most common lung isolation devices, management of OLV using lung protective ventilation strategies, and management of oxygenation and hypoxemia during OLV.
This review contains 12 figures, 9 tables, and 39 references.
Key Words: bronchial blockers, double-lumen tube, uninvent, hypoxemia, hypoxic pulmonary vasoconstriction, one lung ventilation, positive end expiratory pressure, tracheal anatomy, lung isolation
- 4
Pain Management Strategies for Thoracic Surgery
By Brett Weiner, MD; Harman Boparai, MD; Grant H. Chen, MD
Purchase PDFPain Management Strategies for Thoracic Surgery
- BRETT WEINER, MDNew York Presbyterian Hospital, Cornell University School of Medicine, Attending Physician
- HARMAN BOPARAI, MDNew York Presbyterian Hospital, Cornell University School of Medicine, Resident
- GRANT H. CHEN, MDMemorial Sloan Kettering Cancer Center, Attending Physician
Purchase PDFImproper management of postoperative pain following thoracic surgery can be quite debilitating and lead to a number of complications due to the multitude of comorbid conditions manifested by the population of patients undergoing these types of procedures. These can include advanced lung disease, advanced age, heart disease, renal insufficiency and obesity.¹ The source of this acute postsurgical pain is multifactorial and can include skin incisions, deep tissue injuries, thoracostomy tubes, costovertebral joint separation and rib or sternal fractures.² Benefits of effective analgesia include decreased risk of perioperative morbidity, decreased hospital stay, decreased cost and increased patient satisfaction.³ There have been numerous studies conducted to determine the best pain management regimen for control of postthoracotomy pain, however, no single technique has thus far proven to be superior. Instead, most clinicians would advocate for a multimodal approach combining regional techniques, such as thoracic epidural analgesia or paravertebral blocks, with systemic analgesic medications including a combination of cyclooxygenase (COX)-2 inhibitors, nonsteroidal anti-inflammatory drugs, opioids and other analgesic adjuncts. This chapter will examine the different analgesic options currently available and being utilized for various types of thoracic surgical procedures. This will include a review of the systemic analgesic and non-analgesic optiondis as well as regional anesthetic techniques. The chapter will conclude with a discussion of chronic post-thoracotomy pain syndrome and currently available treatments.
This review contains 4 tables, and 87 references.
Keywords: systemic analgesic therapy, opioid analgesic medications, regional anesthetic techniques, thoracic epidural analgesia, paravertebral analgesia, chronic post-thoracotomy pain management, Enhanced Recovery After Surgery (ERAS), intrathecal opioid analgesia, intercostal analgesia, intrapleural analgesia
- 5
Nonpulmonary Thoracic Procedures
- JAIDA C FITZGERALD, MDInstructor in Anesthesia, Boston Children’s Hospital, Brigham and Women’s Hospital, Department of Anesthesia, Perioperative and Pain Medicine, Boston, MA
- 6
Lung Isolation
- BRYAN HIERLMEIER, MDAssistant Professor, University of Mississippi Medical Center, Jackson, MS
- HENRIQUE VALE, MD
- VANETTA LEVESQUE, MDAssistant Professor, University of Mississippi Medical Center, Jackson, MS
- 1
- Wellness in Training
- 1
A Wellness Roadmap for Medical Trainees: What a Program Director Should Know
By Richard Joseph, MD MBA; Lori Berkowitz, MD
Purchase PDFA Wellness Roadmap for Medical Trainees: What a Program Director Should Know
- RICHARD JOSEPH, MD MBABrigham and Women’s Hospital, Division of General Internal Medicine and Primary Care, Boston, MA
- LORI BERKOWITZ, MDObstetrics & Gynecology, Massachusetts General Hospital, Boston, MA
Purchase PDFThis review contains 2 figures, and 25 references.
- 2
Self-compassion During GME Training
- REBECCA M. REIMERS, MD, MPHDepartment of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
Purchase PDFSelf-compassion is a positive psychology concept that is related to resilience, improved coping, and reduced stress. The three key components are self-kindness, mindfulness, and understanding that we are all part of a common humanity. Self-compassion is in opposition of harsh self-judgment or self-criticism, which have been linked to stress, emotional dysregularion, and avoidance of negative feedback. Self-compassion can be useful during individual times of crisis and on a daily basis for improved resilience and coping. Exercises for acute events, suggestions for daily living, and a review of self-compassion research in healthcare settings are reviewed and explained in the following article.
This review contains 1 table and 16 references.
Keywords: mindfulness; resilience; self-compassion; well-being; residency; burnout; graduate medical education
- 3
Sleep Well to Be Well: Importance of Healthy Sleep During Medical Training
By Ilia Kritikou, MD; Ilene Rosen, MD, MSCE
Purchase PDFSleep Well to Be Well: Importance of Healthy Sleep During Medical Training
- ILIA KRITIKOU, MDDivision of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- ILENE ROSEN, MD, MSCEDivision of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
Purchase PDFSleep is vital for our survival and wellness; lack of sleep is associated with significant cognitive, behavioral and physical health consequences, including increased mortality. In resident physicians and other health care providers, scheduled in-house calls, frequent pager/phone calls, and work required during nights are the norm. These phenomena along with the normal pull for work/life balance lead to acute and chronic partial sleep restriction, sleep disruption and circadian misalignment. As is true for the general population, residents are not immune to sleepiness and performance deficits associated with curtailed sleep. Residents are also at risk for metabolic dysregulation, including increased risk of obesity, cardiovascular disease, and mood disturbances that accompany disrupted sleep and circadian misalignment. Initial data suggesting worse patient outcomes when residents work >80 hours weekly, pushed Accreditation Council for Graduate Medical Education (ACGME) to limit resident duty-hours to 80 weekly, 30 per shift; newer data fail to show improved patient outcomes under the new limited work schedule. Nevertheless, recent studies suggest extended work schedules and circadian misalignment negatively affect well-being of resident physicians, increase risk of motor vehicle accidents. Long-term effects are yet to be determined.Implementing educational programs that foster programmatic, individual responsibility for fatigue management, GME programs and their leadership may mitigate negative consequences on safety and wellness.
This review contains 2 figures, 3 tables, and 36 references.
Keywords: sleep, sleep deprivation, sleepiness, circadian rhythms, residency, health care, patient outcomes, ACGME, wellness
- 4
Creating a Culture of Wellness - No Jerks Allowed
- HOPE A RICCIOTTI, MDChair, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Purchase PDFThe culture of a health care system influences physician wellness; in turn, physician wellness is an indicator of the health care system quality. A career as a physician was traditionally viewed as a calling where patients came first, even to the personal detriment of the physician. Organizational cultures that support work-life integration allow flexibility and cooperative scheduling for the activities of work, home, family, community and self. Today’s health care challenges require collaboration, teamwork and the collective intelligence to get to the solutions that our complex environment requires. Open workspace is one method that can transform culture; academic medicine is following the model of the business world with spaces that flatten hierarchy, enhance communication among faculty and trainees, and foster a culture of civility and greater attachment to the organization. Top-down hierarchical leadership is outdated and counterproductive. Organizations with a flat structure are nimble, innovative and tend to outperform those with more traditional hierarchies. Adopting the humble attitude of a servant leader is essential to building positive department and organizational culture. Effective leaders have self-awareness, self-regulation, motivation, empathy and social skills, qualities collectively known as emotional intelligence. We need to move away from a physician centric culture and replace it with a new brand of department or health care organization that is just and collaborative, that promotes innovation and teamwork, iterates quickly and nurtures individuals at all levels to voice ideas and demonstrate leadership. These same ingredients promote joy in work and align with safe care models.
This review contains 27 references.
Keywords: Culture change, emotional intelligence, flattened hierarchy, innovation, leadership, servant leader, work-life integration
- 5
Mindfulness
- ALICE D. DOMAR, PH.DExecutive Director, Domar Centers for Mind/Body Health, Director of Integrative Care, Boston IVF, Senior Staff Psychologist, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Associate Professor of Obstetrics, Gynecology and Reproductive Biology, part-time, Harvard Medical School
Purchase PDFMost if not all physicians in training report feelings of exhaustion, burnout and inadequacy. Although many of these are normal reactions to an intense and rigorous period in their lives, it is possible to learn behaviors which can counter some of the physical and psychological impact. Mindfulness has been shown to be an effective antidote, and it is possible to incorporate mindfulness into one’s daily routine in a practical and efficient manner. Practicing mindfulness can ease the consequences of stress while simultaneously improving patient care. The key is the amount of practice one engages in; the more times one can practice mindfulness on a daily basis, the more benefits one receives. Physicians are encouraged to learn basic mindfulness skills and incorporate them into their personal and professional lives.
This review contains 11 references.
Keywords: mindfulness, meditation, residents, medical training, stress, depression, anxiety, symptom reduction
- 6
Embracing Uncertainty
- ARABELLA L. SIMPKIN, MD, MMSCMassachusetts General Hospital Department of Medicine 100 Cambridge Street, 16th Floor, Boston, MA 02114
Purchase PDFWe are constantly faced with uncertainty, which can instill a sense of vulnerability and fear. Prior studies link intolerance of uncertainty to burnout, ineffective communication strategies, cognitive biases and inappropriate resource use. Paradoxically, uncertainty is the driver of curiosity and progress, and is an important part of the practice of medicine. Indeed, the only certainty is in uncertainty. Unfortunately, we Western culture too often equates uncertainty with ignorance or failure, viewing it as a threat rather than a surmountable challenge, thus encouraging denial of this fundamental state for both physicians and patients. The time is ripe for a renewed perspective. Changing our culture to acknowledge, celebrate and embrace uncertainty could have positive downstream ramifications: decreasing physician burnout by reducing stress from uncertainty and altering our perspective on this state; and lightening physician’s burdens by absolving responsibility for implicitly having promised more than a physician or even medicine can deliver. Indeed, understanding and embracing uncertainty could be the most significant contribution of 21st century science to the human intellect.
This review contains 29 references.
- 7
Perfectionism
- ALICE D. DOMAR, PHDExecutive Director, Domar Centers for Mind/Body Health, Director of Integrative Care, Boston IVF, Senior Staff Psychologist, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Associate Professor of Obstetrics, Gynecology and Reproductive Biology, part-time, Harvard Medical School
Purchase PDFPerfectionism is common and even encouraged in medicine. Acceptance to medical school is predicated on academic excellence; those who commence being schooled in medicine and their perfectionistic tendencies may be rewarded. Residency and fellowship years are a time where teamwork, appropriate social behavior and flexibility may be as important as academic knowledge. This can be threatening to the physician who has succeeded through perfectionistic academic self-induced pressure. Committing a mistake, although expected by all in this field, can feel overwhelming and unacceptable to a perfectionist: it can lead to symptoms of stress, depression and even suicide. Solutions to maladaptive perfectionism include cognitive-behavior therapy and coaching.
This review contains 14 references.
Key words: perfectionism, adaptive, maladaptive, physician burnout, suicide, CBT, coaching
- 8
Substance Use Disorders
- ERIK A. LEVINSOHN, MDBeth Israel Deaconess Medical Center
- KEVIN P. HILL, MD, MHSDirector of Addiction Psychiatry, Beth Israel Deaconess Medical Center, Assistant Professor of Psychiatry, Harvard Medical School
Purchase PDFGiven the incredible scope of substance use disorders, this chapter will primarily focus on alcohol and opioid use disorders, while also discussing substance use broadly. Furthermore, this chapter does not provide detailed guidelines for managing patients with a substance use disorder. Instead, this review aims to provide the reader with conceptual background of the biology of addiction as well as a general framework for its diagnosis and management. While this chapter primarily focuses on physicians in the role of caregiver, it is important to note that physicians also struggle with SUDs, at a rate near that of the general population.25
This review contains 3 tables and 25 references.
- 1
- Administration and Quality
- 1
Coding and Billing
- SAMUEL A TISHERMAN, MD, FACS, FCCM
- DANIEL HERR, MD, FCCM
Purchase PDFAppropriate documentation and coding are critical for billing in the intensive care unit (ICU). Diagnoses are based on the International Statistical Classification of Diseases and Related Health Problems (e.g., ICD-9 or ICD-10). Procedures are coded based on the Current Procedural Terminology (CPT) system. Evaluation and management (E/M) services make up the vast majority of non–procedure-based care provided by physicians in the ICU environment. Critical care services (codes 99291 and 99292) represent a specific subset of the CPT codes for E/M with different requirements. Three criteria must be met to justify a critical care code. First, the physician must document that the patient is critically ill (i.e., the patient has impairment in one or more vital organ systems with a high probability of imminent or life-threatening deterioration). Second, critical care requires high-complexity medical decision making to support vital organ function and/or prevent further deterioration. Third, critical care codes are time based. The physician must document the time spent in “full attention” to the patient. Critical care can also be provided via telemedicine technologies. Reimbursement for these services requires appropriate credentialing and contracts with the hospital, as well as appropriate documentation. Hospital reimbursement is based on Medical Severity-Diagnosis Related Groups (MS-DRGs), as documented in the medical record. Based on performance, a portion of hospital reimbursement may be withheld if the rates for certain hospital-acquired conditions are too high. Accurate documentation serves to (1) provide good communication between providers, (2) justify billing, and (3) legally document what was done for the patient and why.
This review contains 4 tables, and 13 references.
Key words: critical care codes, evaluation and management codes, global surgical package, pay for performance
- 1
- 1905-522-8526
- 1-855-647-6511
- For Individuals: [email protected]
For Residency: [email protected]
Copyright © 2025 Decker Medicine LLC. All rights reserved.
Trusted since 1980
