Anesthesia Student Survival Guide (eBook)

Foreword 6
Contents 8
Contributors 12
CASE STUDIES 16
Chapter 1 Case Study 16
Chapter 2 Case Study 16
Chapter 3 Case Study 17
Chapter 4 Case Study 17
Chapter 5 Case Study 18
Chapter 6 Case Study 18
Chapter 7 Case Study 19
Chapter 8 Case Study 19
Chapter 9 Case Study 20
Chapter 10 Case Study 20
Chapter 11 Case Study 21
Chapter 12 Case Study 22
Chapter 13 Case Study 22
Chapter 14 Case Study 23
Chapter 15 Case Study 23
Chapter 16 Case Study 24
Chapter 17 Case Study 24
Chapter 18 Case Study 25
Chapter 19 Case Study 25
Chapter 20 Case Study 26
Chapter 21 Case Study 27
Chapter 22 Case Study 27
Chapter 23 Case Study 28
Chapter 24 Case Study 28
Chapter 25 Case Study 29
Chapter 26 Case Study 29
Chapter 27 Case Study 30
Chapter 28 Case Study 30
Chapter 29 Case Study 31
Chapter 30 Case Study 32
Chapter 31 Case Study 33
Chapter 32 Case Study 33
Chapter 1 36
How to Be a “Star” Student, Career Options, and the Match 36
Introduction 36
How to Be a “Star” Student 36
Career Options 37
The Match 38
A Typical General Anesthesia Case 39
Preoperative Evaluation 39
Sedation 40
Monitoring 40
Induction and Intubation 41
Maintenance 41
Emergence 42
PACU Management 42
Summary 43
Case Study 43
Suggested Further Reading 47
Chapter 2 48
History of Anesthesia and Introduction to the Specialty 48
Introduction 48
The Story of Ether 49
Chloroform and the Queen 51
Monitors 52
Airway Management 53
CPR 55
Autonomy 55
A Slumber of Anesthesiologists 56
Growing Prestige 56
Life Outside Anesthesia 57
Conclusion 57
Case Study 57
Suggested Further Reading 59
Chapter 3 61
Pharmacology Principles 61
Basic Pharmacologic Principles 61
Pharmacokinetics 62
Absorption 62
Distribution 62
Metabolism and Excretion 63
Pharmacodynamics 66
Case Study 67
Suggested Further Readings 70
Chapter 4 71
Pharmacology of Intravenous Anesthetic Agents 71
Benzodiazepines 72
Opioids 73
Induction Agents 76
Neuromuscular Blocking Agents 79
Depolarizing NMBs 80
Nondepolarizing NMBs 81
Acetylcholinesterase Inhibitors 82
Anticholinergics 83
Case Study 83
Suggested Further Reading 86
Chapter 5 87
Pharmacology of Inhalational Anesthetics 87
Pharmacokinetics of Uptake, Distribution and Elimination 87
Theories of Inhalational Anesthetic Action 90
Depth of Anesthesia and MAC 90
Nitrous Oxide 91
Concentration Effect 93
Second Gas Effect 93
Volatile Anesthetics (Isoflurane, Sevoflurane, and Desflurane) 94
Isoflurane 95
Sevoflurane 95
Desflurane 95
Case Study 95
Suggested Further Reading 98
Chapter 6 99
Pharmacology of Local Anesthetics 99
History of Local Anesthetics 99
Local Anesthetic Mechanism of Action 99
Factors Affecting Local Anesthetic Action 100
Local Anesthetic Metabolism 101
Uses of Local Anesthetics in Anesthesia Practice 103
Local Anesthetic Side Effects and Toxicity 103
Treatment of Local Anesthetic Toxicity 104
Case Study 104
Suggested Further Reading 106
Chapter 7 107
Pharmacology of Adjunct Agents 107
Sympathomimetics 107
Antiemetics 108
Antihypertensives 110
Dexmedetomidine 111
NSAIDS (Nonsteroidal Anti-Inflammatory Drugs) 111
Case Study 112
Suggested Further Readings 114
Chapter 8 116
The Preoperative Patient Evaluation 116
Introduction 116
The Interview 117
History and Physical 117
History 117
Airway 117
Cardiovascular 118
Pulmonary 120
Hepatic and Gastrointestinal Disease 121
Bleeding Disorders 122
Endocrine 122
Renal 122
Neurologic 123
Musculoskeletal 123
Physical Exam 123
Medications/Allergies 123
Medical Records/Family History 124
Laboratory Data 124
Anesthetic Plan 127
Anesthesia Consent Form 127
Case Study 130
Suggested Further Reading 133
Chapter 9 135
Airway Evaluation and Management 135
Introduction 135
Airway Anatomy 136
Airway Evaluation 136
Mask Ventilation 139
Laryngeal Mask Airway 141
Direct Laryngoscopy and Tracheal Intubation 142
Rapid Sequence Induction 143
Fiber-optic Intubation 145
Video Assisted Endotracheal Intubation (Glidescope, C-Trach) 145
Evaluation and Management of the Difficult Airway 145
Case Study 146
Suggested Further Reading 148
Chapter 10 149
The Anesthesia Machine 149
The Anesthesia Machine Components 149
Pipeline Inlets 150
Cylinder Inlets 151
Cylinders 153
Pressure Regulation 154
Fail-Safe System 154
Flowmeters 154
Vaporizers 155
Gas Outlet 156
Alarms 156
Waste-Gas Scavengers 157
Oxygen Flush Valve 157
Anesthesia Machine Checkout 157
Anesthesia Breathing Systems 157
Humidifiers 159
Case Study 159
Suggested Further Reading 161
Chapter 11 162
Anesthesia Equipment and Monitors 162
Introduction 162
Blood Pressure Monitoring 164
Electrocardiographic Monitoring 165
Pulse Oximetry 166
Capnography and Ventilation Monitoring 168
Monitoring Muscle Relaxation 170
Monitoring the Depth of Anesthesia 172
Temperature Monitoring 173
Central Venous Pressure Monitoring 174
Pulmonary Artery Pressure Monitoring 175
Other Special Patient Monitors 176
Other Anesthesia Equipment 176
Standards for Basic Anesthetic Monitoring 177
Standard I 177
Objective 177
Standard II 178
Oxygenation 178
Objective 178
Methods 178
Ventilation 178
Objective 178
Methods 178
Circulation 179
Objective 179
Methods 179
Body Temperature 180
Objective 180
Methods 180
Case Study 180
Suggested Further Reading 183
Chapter 12 186
Anesthetic Techniques: General, Sedation, MAC 186
The Anesthesiologist and the Airline Pilot 186
Preflight Check 186
Takeoff 188
Cruising Altitude 189
Landing 189
Taxi to the Terminal 190
Anesthetic Techniques 190
Monitored Anesthesia Care (MAC)/Anesthesia Sedation 191
Choice of Anesthetic Technique 193
General Anesthesia 193
Physiology of General Anesthetics 194
Case Study 197
Suggested Further Reading 199
Chapter 13 200
Anesthetic Techniques: Regional 200
Introduction 200
Neuraxial Anatomy 200
Indications and Contraindications 202
Mechanism of Action 202
Epidural Anesthesia 204
Technique 205
Pharmacology of Epidural Anesthesia 206
Spinal Anesthesia 206
Technique 207
Factors Effecting Level and Duration of Local Anesthesia 208
Caudal Anesthesia 209
Combined Spinal–Epidural 209
Complications and Side Effects: Spinal and Epidural Anesthesia 210
Cauda Equina Syndrome (CES) 210
Transient Neurologic Symptoms 210
Cardiovascular Changes 210
Post-dural Puncture Headache (PDPH) 210
High/Total Spinal Anesthesia 211
Urinary Retention 211
Intravascular Injection 211
Spinal/Epidural Hematoma 211
Epidural Abscess 212
Peripheral Nerve Blocks 212
Identification of the Target Nerve 212
Cervical Plexus Blockade 213
Brachial Plexus and Upper Extremity Blocks 214
Interscalene Block 214
Supraclavicular Block 216
Infraclavicular Block 216
Axillary Block 217
Lower Extremity Peripheral Nerve Block 218
Femoral Nerve Block 218
Sciatic Nerve Block 219
Ankle Block 220
Intravenous Regional Anesthesia (Bier Block) 220
Ultrasonography 221
Case Study 222
Suggested Further Readings 224
Chapter 14 225
Electrolytes, Fluids, Acid-Base Analysis, and Transfusion Therapy 225
Electrolytes and Fluid Compartments 225
Oncotic vs. Osmotic Pressures 227
Blood Volume and the Fluid Compartments 227
Patient Evaluation: Fluid Management 228
Calculating Fluid Requirements 230
Fluid Replacement Options 230
Introduction to Acid-Base Analysis 236
Transfusion of Blood Products: Goals and Indications 239
Using CVP and PA Catheters for Volume Assessment 240
Transfusion of Blood Products: Practical Aspects 241
Hazards of Transfusion 242
Transfusion Reactions (Also see Chap. 16, Common Intraoperative Problems) 242
Other Problems Associated with Transfusion 249
Transfusion: Legal and Ethical Issues 249
Case Study 250
Suggested Further Reading 252
Chapter 15 254
IV, Gastric Tube, Arterial & Central Line Placement Techniques
Intravenous (IV) Lines 255
Relevant Anatomy 255
Physiology of Veins 255
Technique of Peripheral Cannulation 255
Complications 256
Arterial Line Placement 257
Anatomy 257
Physiology 258
Technique 258
Central Venous Line (CVL) 258
Anatomy 258
Internal Jugular Vein 258
Subclavian Vein 260
Key Points in IJ Cannulation (Figs. 15.2 and 15.3) 260
Femoral Vein 261
Choosing a Central Line Insertion Site 262
Nasogastric (and Orogastric) Tube Placement 263
Technique 263
Case Study 264
Suggested Further Reading 266
Chapter 16 268
Common Intraoperative Problems 268
General Concepts 268
Hypoxemia 272
Hypotension 273
Hypertension 274
Failure to Ventilate 275
Hypocarbia 276
Hypercarbia 276
Myocardial Ischemia 276
Anaphylactic/Anaphylactoid Reactions 277
Delayed Emergence 277
Intraoperative Awareness 277
Failed Regional Anesthesia 278
Patient Movement/Waking Up During Surgery 278
Venous Air Embolism 278
Gastric Acid Aspiration 279
Intraoperative Dysrhythmias 279
Miscellaneous Intraoperative Problems 282
Postoperative Complications 284
Case Study 285
Suggested Further Reading 287
Chapter 17 289
Physiology and Anesthesia for Cardiac and Thoracic Surgery 289
Cardiac Anesthesia 289
Normal Cardiovascular Anatomy 289
The Cardiac Cycle 292
Common Disease States Affecting the Heart 293
Ischemic Heart Disease 293
Valvular Disease 294
Arrythmia Management 295
Heart Failure 296
Anesthetic Management of Cardiopulmonary Bypass (CPB) 296
Preoperative Evaluation 296
Monitoring 297
Induction and Maintenance 297
Pre-Bypass Considerations 297
Management of Intraoperative Myocardial Ischemia 298
Cardiopulmonary Bypass (CPB) 298
Weaning From Cardiopulmonary Bypass 299
Post Operative Care 300
Minimally Invasive Cardiac Procedures 300
Thoracic Anesthesia 300
Anatomy 300
Preoperative Evaluation 300
Anesthetic Management 302
One-Lung Ventilation 303
Double Lumen Endotracheal Tube 303
Case Study 305
Suggested Further Reading 308
Chapter 18 309
Physiology and Anesthesia for Neurologic, ENT, and Ophthalmologic Surgery 309
Neuroanesthesia 309
Intracranial Pressure (ICP) 309
Cerebral Blood Flow 310
Blood Brain Barrier (BBB) 310
Neuromonitoring 311
Neurophysiology: Anesthetic Effects 312
Neurosurgical Procedures: Anesthetic Management 313
General Goals 313
Craniotomy 313
Preoperative Considerations 313
Intraoperative Considerations 314
Neurovascular Surgery: Aneurysm Clipping/AVM Resection 314
Neurosurgical Anesthesia Controversies 315
Neurologic Disease and Anesthesia: Special Considerations 316
Otolaryngology (ENT): Anesthetic Considerations 316
Specialized equipment 317
Preoperative Planning 318
Intraoperative Issues 319
Neck dissection 319
Endoscopic Sinus Surgery 320
Inner Ear Surgery 320
Airway Surgery 321
Ophthalmology 321
Case Study 323
Suggested Further Reading 325
Chapter 19 327
Physiology and Anesthesia for Obstetrics 327
Normal Physiologic Changes of Pregnancy 327
Cardiovascular 327
Respiratory 328
Central Nervous System 329
Hematologic 329
Gastrointestinal 330
Renal 330
Musculoskeletal 330
Uteroplacental Blood Flow 331
Maternal Fetal Exchange 331
Intrapartum Fetal Evaluation 332
Neonatal Evaluation: The Apgar Score 334
Anesthesia for Vaginal Delivery 335
Non-Pharmacologic Options for Labor Pain 336
Systemic Medications for Labor Pain 336
Regional Anesthesia 336
Epidural Analgesia 336
Spinal Analgesia 337
Combined Spinal-Epidural Analgesia 338
Common Myths Regarding Neuraxial Analgesia 338
Anesthesia for Cesarean Section 339
Spinal Anesthesia 340
Epidural Anesthesia 340
General Anesthesia 341
Obstetric Hemorrhagic Emergencies 342
Antepartum/Intrapartum Hemorrhage 342
Post-Partum Hemorrhage 343
Anesthesia for Non-Obstetric Surgery 343
Case Study 344
Suggested Further Reading 346
Chapter 20 348
Physiology and Anesthesia for General and Bariatric Surgery 348
Obesity 348
Physiologic Changes Associated with Obesity 349
Cardiovascular System 349
Respiratory System 350
Gastrointestinal System 350
Endocrine and Metabolic System 351
Neurological and Psychological Problems 351
Airway Challenges in Obesity 352
Surgery for Obesity 352
Anesthetic Considerations 353
Preoperative Evaluation 353
Intraoperative Considerations 353
Postoperative Considerations 354
Anesthesia Considerations for General Abdominal Surgery 354
Preoperative Evaluation 354
Intraoperative Considerations 355
Laparoscopic Surgery 355
Laparotomy 356
Postoperative Considerations 356
Anesthetic Considerations for Common Abdominal Surgeries 358
Esophageal Surgery 358
Stomach Surgery 358
Small and Large Bowel Surgery 358
Hemorrhoid Surgery 358
Liver and Biliary Tract Surgery 359
Spleen Surgery 359
Pancreatic Surgery 360
Hernia Surgery 360
Case Study 360
Suggested Further Reading 363
Chapter 21 364
Anesthesia for Urological Surgery 364
Anatomy 364
Patient Positioning 365
Preoperative Assessment 366
Anesthetic Management 367
Cystoscopy/Ureteroscopy/TURBT 367
TURP 367
Laser Surgery in Urology 368
Radical Prostatectomy: Open, Laparoscopic, Robotic 368
Radical Cystectomy 369
Nephrectomy: Open or Laparoscopic 369
Renal Transplantation 370
Orchiectomy, Orchidopexy, Penile Surgery 370
Extracorporeal Shock Wave Lithotripsy 371
Complications of Urologic Surgery 371
Case Study 373
Suggested Further Reading 375
Chapter 22 376
Physiology and Anesthesia for Pediatric Surgery 376
Anatomy 376
Venous Access 378
Physiology 379
Transition from Fetal to Neonatal Circulation 379
Respiratory 381
Cardiac 381
Renal 381
Hepatic 381
Gastrointestinal 381
Blood 382
Neurologic 382
Temperature Regulation 382
Pharmacology 382
Preoperative Evaluation 383
Psychological Assessment 383
Physiological Assessment 383
OR Equipment and Setup 384
Intravenous Fluids 385
Pediatric Drug Preparation 386
Techniques 386
Induction 386
Maintenance 386
Emergence 387
Case Study 389
Suggested Further Reading 391
Chapter 23 392
Physiology and Anesthesia for Elderly Patients 392
Physiological Changes with Aging 393
Cardiovascular System 393
Pulmonary Changes 394
Renal Changes 395
Nervous System 396
Postoperative Cognitive Dysfunction and Delirium 396
Pharmacokinetic and Pharmacodynamic Changes 397
Anesthetic Management 397
Preoperative Examination 397
Intraoperative Management 398
Premedications 398
Monitoring 398
Intraoperative Management 398
General Anesthesia Versus Regional Anesthesia 399
The Postoperative Period 399
Case Study 400
Suggested Further Reading 402
Chapter 24 404
Ambulatory Surgery and Out-of-OR (OOR) Procedures 404
Introduction 404
Ambulatory Surgery 405
Preoperative Considerations 405
Intraoperative Management 408
Postoperative Management 409
Out-of-OR (OOR) Anesthesia 410
General Considerations 410
Gastrointestinal (GI) Endoscopy 411
Electrophysiology Lab (EP) 412
Radiology 413
Neuroradiology 414
Case Study 415
Suggested Further Reading 418
Chapter 25 419
Anesthesia for Trauma and Orthopedic Surgery 419
Trauma 419
Introduction 419
Epidemiology 419
Patient Assessment 420
Specific Challenges 421
The Trauma Arrest 422
The Trauma Airway 422
Clearing the C-Spine 423
Head Trauma 424
Bleeding 424
Orthopedic Surgery 426
Choice of Anesthetic 426
Management of Postoperative Pain 427
Special Considerations 428
Positioning Injuries 428
Tourniquet Issues 428
Methylmethacrylate Cement 428
Fat Embolism Syndrome 429
Blood Loss 429
Case Study 430
Suggested Further Reading 432
Chapter 26 434
Perioperative Acute and Chronic Pain Management 434
Introduction 434
Basic Pain Sensation in the Normal Individual 434
General Pain Definitions 437
General Pain Types 437
Abnormal Pain Descriptor Definitions 437
Acute Versus Chronic Pain 437
Treatment of Pain 439
Acute Pain 439
Chronic Pain 440
Common Chronic Pain Medications Classifications 441
Opioids 441
Alpha-2-Agonist: (Tizanidine) 442
Anticonvulsants: (Gabapentin, Carbamazepine, and Oxcarbamazepine, Pregabalin) 442
Tricyclic Antidepressants: (Nortiptyline, Amitriptyline) 442
Serotonin-Norepinephrine Reuptake Inhibitors: (Venlafaxine, Duloxetine) 442
Cancer Pain 443
Common Pain Syndromes 443
Spinal Stenosis 443
Radicular Pain 444
Facet Arthropathy 444
Discogenic Pain 444
Complex Regional Pain Syndrome 444
Myofascial Pain 445
Sacroiliac Joint Dysfunction 445
Postherpetic Neuralgia 445
Physical Therapy 446
Psychological Therapy 446
Palliative Care 446
Case Study 446
Suggested Further Reading 449
Chapter 27 450
Postoperative Anesthesia Care Unit (PACU)and Common Postoperative Problems 450
Admission 450
Postoperative Respiratory Complications 451
Postoperative Hemodynamic Complications 452
Postoperative Neurologic and Other Complications 455
Postoperative Nausea and Vomiting (PONV) 457
Pain Control 458
Hypothermia and Shivering 459
Discharge Criteria 459
General Condition 459
Hemodynamics 460
Respiratory Status 460
Airway 460
Pain Control 460
Renal Function 460
Labs and Diagnostic Tests 460
Case Study 461
Suggested Further Reading 463
Chapter 28 464
Introduction to Critical Care 464
Initial Assessment of the Critically Ill Patient 464
Oxygen Balance 464
Oxygen Transport 465
Markers of Oxygen Balance and Tissue Perfusion 466
Hemodynamic Monitoring (also see Chap. 11) 467
Goals 467
Invasive Arterial Blood Pressure Monitoring 467
Cardiac Output 468
Central Venous Pressure Monitoring 470
Pulmonary Artery Catheter 472
Shock 472
Classification of Shock 472
Management of Shock 473
Vasoactive Agents Commonly Used in Shock 474
Septic Shock 474
Acute Respiratory Failure 476
Hypoxemic Respiratory Failure 476
Hypercapnic Respiratory Failure 476
Management of Acute Respiratory Failure 478
Acute Lung Injury and Acute Respiratory Distress Syndrome 478
Mechanical Ventilation 479
Commonly Used Modes of Ventilation 479
Assist-Control Ventilation (also known as Continuous Mandatory Ventilation) 479
Intermittent Mandatory Ventilation 479
Pressure Support Ventilation 479
Positive End-Expiratory Pressure 480
Inspiratory Pressures 480
Initiating Mechanical Ventilation 480
AutoPEEP 481
Noninvasive Positive-Pressure Ventilation (NIPPV) 481
Ventilator-Associated Pneumonia 482
Supportive Care in the ICU 482
Measures to Prevent Nosocomial Infections include 483
Sedation Management 483
Glucose Management 483
Thromboprophylaxis 483
Stress Ulcer Prophylaxis 484
Nutrition 485
Ethical Decisions and End-of-Life Care (also see Chap. 31, Ethical Issues in Anesthesia) 485
Case Study 486
Suggested Further Reading 488
Chapter 29 490
Professionalism, Safety, and Teamwork 490
Professionalism 491
“The Etiquette of Medicine” 493
Safety and Teamwork 494
Team Training 495
Putting It All Together 496
Case Study 497
Suggested Further Reading 500
Chapter 30 502
Quality Assurance, Patient and Provider Safety 502
The History of Patient Safety 502
Quality Assurance 503
The ASA Closed Claims Study 503
ASA Standards for Basic Anesthetic Monitoring 505
Challenges Facing the Anesthesia Provider 506
Steps to Ensure High Quality Anesthesia Care and Patient Safety 506
Common Perioperative Complications 507
Dental Trauma 507
Eye Injury 507
Peripheral Nerve Injuries 508
Intraoperative Recall 508
The Future 509
Pay-for-Performance 509
Medicare 510
Case Study 510
Suggested Further Reading 513
Chapter 31 515
Ethical and Legal Issues in Anesthesia 515
Informed Consent 515
Guide to Obtaining Informed Consent 515
Malpractice 516
Advanced Directives 516
Do Not Resuscitate (DNR)/Do Not Intubate (DNI) 517
Case Study 517
Suggested Further Reading 519
Chapter 32 520
Clinical Simulation in Anesthesia Education 520
Introduction 520
What Is Simulation? 520
What Is the History Behind Medical Simulation? 521
What Is the Evidence Behind Medical Simulation? 522
How Is High-Fidelity Simulation Used in Medical Training? 522
What Is Crisis Resource Management? 523
What Is in a Simulation Laboratory? 523
What Can a Mannequin Do? 526
What Should You Expect in the Simulation Laboratory? 526
What Are the Expectations of You, the Learner, in Simulation Scenarios? 527
How Do You Make the Best of the Simulation Experience? 528
Case Study 528
Suggested Further Reading 531
Appendix A 532
Appendix B 533
Index 536