(BQ) Part 2 book “Handbook of clinical anesthesia” has contents: Peripheral nerve blockade, anesthesia for neurosurgery, neonatal anesthesia, obstetrical anesthesia, pediatric anesthesia, anesthesia for otolaryngologic surgery, anesthesia for ophthalmologic surgery,…. and other contents.
Anesthesia for Surgical Subspecialties VII S E C T I O N C H A P T E R 35 Peripheral Nerve Blockade Regional anesthesia enables site-specific, long-lasting, and effective anesthesia and analgesia (Tsui BCH, Rosenquist RW Peripheral nerve blockade In: Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Ortega R, Stock MC, eds Clinical Anesthesia Philadelphia: Lippincott Williams & Wilkins; 2013:937–995) Peripheral nerve blocks (PNBs) can be used as the only anesthetic, as a supplement to provide analgesia and muscle relaxation along with general anesthesia, or as the initial step in the provision of prolonged postoperative analgesia such as with intercostal blocks or continuous peripheral nerve catheters The two most common techniques for nerve localization and block performance are nerve stimulation (NS) and ultrasound (US) imaging I GENERAL PRINCIPLES AND EQUIPMENT An exciting advance in technology in relation to regional anesthesia in recent years has been the introduction of anatomically based US imaging to visualize the target nerve In many situations, it is prudent to combine the two technologies of NS and US imaging to achieve the goal of 100% success with all regional blocks A Setup and Monitoring (Table 35-1) B Common Techniques: Nerve Stimulation Basics of Technique and Equipment A low-current electrical impulse applied to a peripheral nerve produces stimulation of motor fibers and theoretically identifies proximity to the nerve without actual needle contact of the nerve or related patient discomfort Practical Guidelines After a low-threshold response is obtained, to mL of local anesthetic is injected, and the operator watches for disappearance of the motor twitch, which is a signal to inject the remainder of the 535 LWBK1191_C35_p535-552.indd 535 1/4/13 9:18 PM 536 Anesthesia for Surgical Subspecialties T a b l e - Setup and Monitoring for Regional Blocks Setup All supplies located in this area must be readily identifiable and accessible to the anesthesiologist The area should be of ample size to allow block performance, monitoring, and resuscitation of patients There should be equipment for oxygen delivery, emergency airway management, and suction, and the area should have sufficient lighting A practically organized equipment storage cart is desirable and should contain all of the necessary equipment (including equipment required for emergency procedures) A selection of sedatives, hypnotics, and intravenous anesthetics should be immediately available to prepare patients for regional anesthesia Emergency drugs (atropine, epinephrine, phenylephrine, ephedrine, propofol, thiopental, succinylcholine, amrinone, intralipid) should also be immediately available Monitoring During the performance of regional anesthesia, it is vital to have skilled personnel monitor the patient at all times (electrocardiography, noninvasive blood pressure, pulse oximetry, and level of consciousness of the patient should be gauged frequently using verbal contact because vasovagal episodes are common with many regional procedures) The patient should be closely observed for systematic toxicity (within minutes for at least 30 minutes after the procedure) Before performing blocks with significant sympathetic effects, a baseline blood pressure reading should be obtained proposed dose in divided aliquots After nerve localization using a stimulating needle, introduction of a stimulating catheter with continuous stimulation of the nerve is suitable for provision of continuous analgesia C Common Techniques: Ultrasound Imaging Basics of Technique and Equipment US images reflect contours, including those of anatomic structures, based on differing acoustic impedances of tissue or fluids The Doppler effect can be very useful for identifying blood vessels during nerve localization using US guidance because many nerves are situated in close proximity to vascular structures Practical Guidelines a Probe sterility is paramount when performing real-time US guidance For nerve localization during LWBK1191_C35_p535-552.indd 536 1/4/13 9:18 PM US-guided PNB, it is effective to first identify one or more reliable anatomic landmarks (bone or vessel) with a known relationship to the nerve structure (Table 35-2) The nerve structure is often placed in the center of the screen to guarantee that aligning the needle puncture with the center of the probe will ensure close needle tip–nerve alignment b After one observes that the needle is seen to be close to the nerve(s), a 1- to 2-mL test dose of local anesthetic or dextrose 5% in water (D5W) can be injected to visualize the spread The solution will be seen as a hypoechoic expansion and often illuminates the surrounding area, enabling better visibility of the nerves and block needle D Other Related Equipment Needles used for regional techniques are often modified from standard injection needles (Continuous blocks require larger bore needles to facilitate catheter introduction.) Catheters amenable to stimulation (with an electrode placed into the catheter tip) may enable more accurate advancement of catheters for substantial distances to provide continuous analgesia E Avoiding Complications Despite the excellent safety record of regional anesthesia, the incidence of some complications may be higher in PNB than other regional anesthesia or analgesia techniques, and these complications can be devastating Choosing a suitable patient and applying the right dose of local anesthetic in the correct location are the primary considerations Follow-up before and after discharge is equally important Anesthesia for Surgical Subspecialties Peripheral Nerve Blockade 537 II SPECIFIC TECHNIQUES: HEAD AND NECK, UPPER EXTREMITIES, CHEST, AND ABDOMEN A Head and Neck (Figs 35-1 to 35-4) Cervical Plexus Blocks Anesthesia of the deep or superficial cervical plexus or both can be used for procedures of the lateral or anterior neck such as parathyroidectomy and carotid endarterectomy In carotid surgery, local infiltration of the carotid bifurcation may be necessary to block reflex hemodynamic changes associated with glossopharyngeal stimulation Occipital Nerve Blocks The greater and lesser occipital nerves can be blocked by superficial injection at the points LWBK1191_C35_p535-552.indd 537 1/4/13 9:18 PM 538 LWBK1191_C35_p535-552.indd 538 1/4/13 9:18 PM Subclavian and axillary artery Subclavian and axillary vein Axillary artery Infraclavicular Peripheral Nerves Median nerve at the antecubital fossa Radial nerve at the anterior elbow Humerus at spiral groove Deep brachial artery Brachial artery Subclavian artery Supraclavicular Axillary Subclavian artery Scalene muscles Anatomical Landmark(s) Interscalene Peripheral Nerve Block Location Guided Peripheral Nerve Blocks The large anechoic artery lies immediately lateral to the nerve Trace the nerve proximally and posteriorly toward the spiral groove of the humerus, just inferior to the deltoid muscle insertion (the nerve is adjacent to the deep brachial artery) Locate the plexus or trunk divisions superolateral to the artery at the supraclavicular fossa and trace proximally to where the roots or trunks lie between the scalenus anterior and medius muscles Scan from lateral to medial on the superior aspect of the clavicle to locate the pulsatile artery Plexus trunks or divisions lie lateral and often superior to the artery Color Doppler is useful Place the artery at the center of the field and locate the brachial plexus cords surrounding the artery Terminal nerves surround the artery Approach for Ultrasound Imaging T a b l e - Useful Anatomical Landmarks for Localizing Nerves During Common Ultrasound- 539 LWBK1191_C35_p535-552.indd 539 1/4/13 9:18 PM Femoral artery Femoral Ankle Tibial (posterior tibial) Deep peroneal Popliteal Subgluteal Posterior tibial artery Anterior tibial artery Greater trochanter and ischial tuberosity Popliteal artery Ischial bone and inferior gluteal or pudendal vessels Transverse processes Lumbar Plexus Sciatic Classical or Labat Ulnar artery Ulnar nerve at the medial forearm Anesthesia for Surgical Subspecialties The nerve lies posterior to the artery The nerve lies lateral to the artery Trace the tibial and common peroneal nerves from the popliteal crease to where they form the sciatic nerve At the crease, the tibial nerve lies adjacent to the popliteal artery Scanning proximally to the sciatic bifurcation, the artery becomes deeper and at a greater distance from the nerve The nerve lies lateral to the thinnest aspect of the ischial bone The inferior gluteal artery lies medial to and at the same depth as the nerve The nerve lies between the two bone structures Scan at the anteromedial surface of the forearm approximately at the junction of its distal third and proximal two thirds to locate the ulnar nerve as it approaches the ulnar artery on its medial aspect The plexus lies between and just deep to the lateral aspect (tips) of the processes The nerve lies lateral to the artery (vein most medial) See Fig 35-11 540 Anesthesia for Surgical Subspecialties Figure 35-1. Schematic of the cervical plexus, which arises from the anterior primary rami of C2–C4 The motor branches (including the phrenic nerve) curl anteriorly around the anterior scalene muscle and travel caudad and medially to supply the deep muscles of the neck The sensory branches exit at the lateral border of the sternocleidomastoid muscle to supply the skin of the neck and shoulder on the posterior skull where they emerge from below the muscles of the neck This block is rarely used for surgical procedures; it is more often applied as a diagnostic step in evaluating complaints of head and neck pain B Upper Extremity (Figs 35-5 to 35-7) The four anatomic locations where local anesthetics are placed are the (1) interscalene groove near the cervical transverse processes, (2) subclavian sheath at the first rib, (3) near the coracoid process in the infraclavicular fossa, and (4) surrounding the axillary artery in the axilla US imaging and NS have greatly facilitated the use of upper extremity regional anesthesia LWBK1191_C35_p535-552.indd 540 1/4/13 9:18 PM Anesthesia for Surgical Subspecialties Peripheral Nerve Blockade 541 Figure 35-2. Needle insertion points and angles for the deep cervical plexus blockade The nerve roots exit the vertebral column via the troughs formed by the transverse processes The needle is inserted at each nerve roots of C2–C4 in a caudad and posterior direction Figure 35-3. The cervical, thoracic, lumbar, and sacral dermatomes of the body LWBK1191_C35_p535-552.indd 541 1/4/13 9:18 PM 542 Anesthesia for Surgical Subspecialties Figure 35-4. Greater and lesser occipital nerve distribution, supply, and block needle insertion sites Figure 35-5. Schematic of the brachial plexus Many branches, including the medial cutaneous nerves of the forearm and arm, which arise from the medial cord, are not shown here LWBK1191_C35_p535-552.indd 542 1/4/13 9:18 PM Anesthesia for Surgical Subspecialties A B Figure 35-6. Courses of the terminal nerves of the upper extremity The posterior view (A) illustrates the branches from the posterior cord (axillary and radial nerves), and the anterior view (B) illustrates the branches from the lateral (musculocutaneous and median nerves) and medial (median and ulnar nerves) cords LWBK1191_C35_p535-552.indd 543 1/4/13 9:18 PM 544 Anesthesia for Surgical Subspecialties Figure 35-7. Cutaneous innervation of the upper extremity nerves The terminal branches can also be anesthetized by local anesthetic injection along their peripheral course as they cross joint spaces, where they lie in close proximity to easily identifiable structures or by the injection of a dilute local anesthetic solution intravenously below a pneumatic tourniquet on the upper arm (“intravenous regional” or Bier block) (see Table 38-2) C Brachial Plexus Blockade (Table 35-3) D Terminal Upper Extremity Nerve Blocks PNBs in the upper extremity are of particular value as rescue blocks to supplement incomplete surgical anesthesia and to provide long-lasting selective analgesia in the postoperative period The peripheral nerves may be individually blocked at midhumeral, elbow, or wrist locations, depending on the specific nerve If using US guidance, the elbow and forearm regions appear to be the most suitable block regions, and blocks at these sites may improve the accuracy of nerve localization and local anesthetic spread The wrist is highly populated with tendons and fascial tissues (flexor and extensor retinaculae), which can be difficult to distinguish from, and may obscure the images of, the nerves Color Doppler combined with US imaging can be used to clearly identify the nerves at many desirable locations because they are often situated near blood vessels (see Table 35-1 and Figs 35-7 and 35-8) E Intravenous Regional Anesthesia (Bier Block) Arm anesthesia can be provided by the injection of local anesthetic into the venous system below an occluding tourniquet without using US imaging or NS (Table 35-4) LWBK1191_C35_p535-552.indd 544 1/4/13 9:18 PM 1120 Index Inhaled anesthetics, 227–251 anesthetic transfer, 230, 231t cardioprotection from, 242 chemical structure of, 228f circulatory effects, 239–242 clinical utility, 250 degradation by CO2 absorbers, 248–249 desflurane, 234–235 drawbacks, 250t exhalation and recovery, 232–233, 234f fetal development, effects on, 247–248 genetic effects, 247–248 hepatic effects, 247 history of, interactions with carbondioxide absorbents, 382–383, 383t isoflurane, 234 and malignant hyperthermia, 247 metabolism, 250 minimum alveolar concentration, 236, 237t neuromuscular effects, 247 neuropharmacology of, 236–239 nitrous oxide, 235 obstetric use, 247–248 overpressurization and concentration effect, 230, 233f perfusion effects, 232 pharmacoeconomics and value-based decisions, 250–251 pharmacokinetics, 227–234 physical characteristics, 228, 229t, 230t pulmonary effects, 243–246 second gas effect, 231 sevoflurane, 235 speed, gas state, and route of administration, 227–230 uptake and distribution, 230, 231t, 232f ventilation effects, 231 xenon, 235 Inhaled nitric oxide, lung transplantation, 852 Inspiratory monitoring, 387–388 Intensive care unit (ICU), 918 complications in catheter-related bloodstream infections, 937 invasive fungal infections, 937–938 neuromuscular abnormalities, 940–941 nosocomial infections, 936–938 sinusitis, 936 stress ulceration and GI hemorrhage, 938 urinary tract infection, 937 venous thromboembolism, 938–940, 939t ventilator-associated pneumonia, 936–937 process of care in, 918–919 International normalized ratio (INR), 210, 730 Intestinal transplantation, 849–850 Intra-abdominal pressure (IAP), 697 Intraaortic balloon pump catheter (IABP), 416 Intracellular fluid (ICF), 664 Intracranial pressure (ICP) acute liver failure and, 849 Intradiscal electrothermal therapy (IDET), 978 Intraocular pressure (IOP), 782 Intrapulmonary vascular dilation (IPVD), 739 Intrathecal analgesia, for pain management, 955–956, 955t, 956t Intrathecal drug delivery systems (IDDS), 980 complications of, 981t LWBK1191_Ind_p1109-1138.indd 1120 considerations for, factors for, 981t indications for, 980 Intrathecal opioids, side effects of, 642 Intravenous anesthetics, 252–270 chemical structures, 253f clinical uses, 266–270 as induction agents, 266, 267t maintenance of anesthesia, 268–270, 268t, 269f sedation, 270 desirable characteristics, 253t hemodynamic effects, 258t history of, for liver dysfunction, 745 pharmacology, 252–259 hypersensitivity reactions, 259 mechanisms of action, 252, 254f–255f pharmacodynamic effects, 256–259, 257f, 258t pharmacokinetics and metabolism, 253, 255–256, 256t, 257t physiochemical and pharmacologic properties, 259–266 barbiturates, 259–260 benzodiazepines, 262–263 dexmedetomidine, 266 etomidate, 263–264 ketamine, 264–266 propofol, 260–262 Iron deficiency anemia, 363 Ischemia optic neuropathy (ION), 790–791, 791t Ischemic stroke, acute, 924 Isoflurane See also Inhaled anesthetics clinical overview, 234 physiochemical properties, 229t Isoproterenol, 193–194 J Jehovah’s Witnesses, 33 Job market, for anesthesia professionals, 11 Johnson, Enid, Joint Commission (JC) on anesthesia care, 34–35, 35t standards, 10 K Kava-kava, 1105 Ketamine, 800 See also Intravenous anesthetics chemical structures, 253f context-sensitive half-times for, 269f dosage range, 446t induction characteristics, 267t labor and vaginal delivery, 639 mechanism of action, 252 in monitored anesthesia care, 446t, 450 office-based anesthesia, 479–480 pediatric anesthesia, 681 for pediatric patients, 346 pharmacokinetic values, 256t physicochemical properties, 264–266 Ketorolac, pediatric anesthesia, 683–684 Kidney clinical assessment of, 795, 796t role of, 792 stones types, spectrum of, 817t Kirstein, Alfred, Knee arthroscopy, 835 14/01/13 8:16 PM Index 1121 Knowledge-based alarms, 20 Kyphoplasty, 979–980 Kyphoscoliosis, 347 L Labetalol, 199 Labor anesthesia for, 637–642 preterm delivery, surgery and anesthesia and, 649–650 Laboratory testing, perioperative, 338–340, 339t Lambert-Eaton syndrome See Myasthenic syndrome Lamotrigine, 356t Laparoscopic and robotic nephrectomy, 807–808 See also Urologic surgery Laparoscopic and robotic surgeries anesthesia, 696–709, 697t ambulatory laparoscopic procedures, 709 intraoperative complications, 704–709, 704t–706t management, 701–703 pain prevention, 703–704 physiologic effects, 698–701, 698t–701t postoperative considerations, 709 surgical techniques, 696–698 Laryngeal tube, 423 Laryngomalacia, 674 Laryngospasm, 429 in children, 689f factors associated with, 688t Laryngotracheobronchitis, 776 Laser surgery anesthesia for, 778t principles of, 789 Latex gloves, allergic reactions to, 18, 19t Leapfrog Group, 918–919 ICU Physician Staffing (IPS) standard, 919, 919t LeFort classification, of fractures, 779 Left ventricular assist device (LVAD), 853–854 Left ventricular (LV) systolic function, evaluation of, 413–414, 414f Leukoreduction, 211 Levetiracetam, 356t Liability, professional, 35–37 breach of duty, 36 causation, 36 damages, 36 doctrine of res ipsa loquitur, 36, 36t duty, 35–36 lawsuits, 37 malpractice suit, 35, 36t negligence, 35 standard of care, 37 tort system, 35 Licorice, 1105 Lidocaine for ambulatory surgery, 462 during cardiopulmonary resuscitation, 992t, 993 clinical profile, 318t dose-dependent systemic effects of, 320t history of use of, pharmacokinetics, 317t physiochemical properties, 312t in postoperative pain, 953 toxicity, 320t Lidocaine patch, 977 LWBK1191_Ind_p1109-1138.indd 1121 Ligand-activated ion channels, 45 Linear visual analogue scale, 950f Line isolation monitor, 84–85, 84f Liver, 730–748, 731f, 731t acute hepatitis, 733–734 acute liver failure, 730–733, 733t alcoholic hepatitis, 734 ascites, 740 biopsy, 730 cardiac manifestations, 736–737 chronic cholestatic disease, 741 chronic hepatocellular disease, 741 cirrhosis and portal hypertension, 734–736 diseases, pregnancy-related, 734, 735t drug-induced liver injury, 734 dysfunction, postoperative, 747–748, 747t hemostasis, 736 hepatic and hepatobiliary diseases, 730 hepatic encephalopathy, 739–740 hepatic function, assessment of, 732t hepatic resection, 747 hepatobiliary imaging, 732t hepatocellular carcinoma, 741–742 intraoperative management, 743–745, 745t nonalcoholic fatty liver disease, 742 preoperative management, 742–743, 742t, 743t pulmonary complications, 739 renal dysfunction, 737–738, 738f transjugular intrahepatic porotsystemic shunt, 746, 746f varices, 740–741 Liver transplantation acute liver failure, 849 coagulation management, 849 intraoperative procedures, 847, 849 pediatric, 849 preoperative considerations, 847, 848t Local anesthetics, 310–324 See also Nerves additives to increase activity of a2-adrenergic agonists, 314 epinephrine, 313–314, 313t opioids, 314 steroids, 314 clinical use, 317t, 318t–319t history of, mechanism of action, 310–312 mechanism of nerve blockade, 311–312 molecular mechanisms of, 310–311 pharmacokinetics, 314–316, 317t pharmacology and pharmacodynamics, 312–314, 313t toxicity allergic reactions, 324 cardiovascular toxicity, 321–322 central nervous system toxicity, 316, 320–321, 320t myotoxicity, 324 neural toxicity, 323 transient neurologic symptoms, 323–324, 323t, 324t treatment of systemic toxicity, 322, 322t Long, Crawford Williamson, Loop diuretics, renal effects and mechanisms, 802–803 Loop of Henle, 794 Lorazepam, 262 chemical structure, 253f induction characteristics, 267t pharmacokinetic values, 256t as preoperative medication, 344t 14/01/13 8:16 PM 1122 Index Lovage root, 1105 Low birth weight, defined, 666 Low-molecular-weight heparin (LMWH), 210, 225 Low-output syndrome, 189 Lumbar epidural anesthesia, cesarean delivery, 643 Lumbar epidural catheter, intravascular placement of, 640t Lumbar plexus nerve block, 957–958 femoral nerve block, 958 posterior approach, 957–958 saphenous nerve blockade, 958 Lungs functional anatomy, 112–114 alveolar–capillary membrane, 113 lung structures, 112–113, 113t muscles of ventilation, 112 pulmonary vascular systems, 114 respiratory airways, 113–114 mechanics, 114–115 aging physiology, 115, 115t elastic work, 114 esophageal pressure, 114 increased airway resistance, 114–115 resistance to gas flow, 114 volumes and capacities, 1008 Lung transplantation, 850 double-lung transplantation, 852 indications for, 850 intraoperative management, 850–851 living lung donor criteria, 852t pediatric, 852 preanesthetic considerations, 850 primary graft dysfunction, 852 recipient selection, 850, 851t single-lung transplantation, 850–851 M Magnesium, 176 hypermagnesemia, 176, 177t, 178 hypomagnesemia, 176, 177t Magnetic resonance imaging (MRI) anesthetic technique, 490 hazards of, 490 pediatric sedation and anesthesia, 490–491 Maintenance of Certification in Anesthesiology (MOCA) program, Malignant hyperthermia (MH), 359 criteria used in, 361t inhaled anesthetics and, 247 protocol, 1097–1099 safe vs unsafe drugs in, 362t susceptible patient, anesthesia management, 359–360 treatment of acute episode of, 360t Malpractice insurance, 11 Malpractice suit, 35, 37 damages in, 36 elements to prove in, 36t Manual in-line stabilization (MILS), 860 Masks, for preventing infection, 142 Mastoidectomy, anesthesia for, 774t Maxillofacial trauma, 778–779 See also Otolaryngologic surgery McMechan, Francis Hoffer, Meadowsweet, 1105 Mean arterial pressure (MAP), 699, 794 Mechanical ventilation, in ICU, 931 Meconium aspiration, 663 LWBK1191_Ind_p1109-1138.indd 1122 Medication preoperative, 342–345, 343t–345t Megaloblastic anemia, 363 Meperidine, 4, 272 labor and vaginal delivery, 638 for urologic surgery, 800 Mepivacaine, for ambulatory surgery, 462 Metabolic acidemia, postanesthesia care unit, 914–915 Metabolic acidosis, 155 anesthetic implications, 158, 158t differential diagnosis, 157t physiologic effects, 157t treatment, 158, 158t Metabolic alkalemia, postanesthesia care unit, 915 Metabolic alkalosis, 154–155, 155t–157t factors maintaining, 156t generation of, 155t physiologic effects, 156t treatment, 157t Methadone, 281, 975t in acute pain, 951, 951t in chronic pain, 974–975, 975t Methicillin-resistant Staphylococcus aureus (MRSA), 147 Methohexital, 259 chemical structure, 253f induction characteristics, 267t pharmacokinetic values, 256t Methyl methacrylate occupational exposure, 18 orthopedic surgery, 838 Metoclopramide, as preoperative medication, 344t Meyer-Overton Rule, 41, 42f Mexiletine, for chronic pain, 977 Microdialysis, in ICU, 920 Microshock, 85–86 Midazolam, 262 chemical structure, 253f context-sensitive half-times for, 269f and diazepam, 447t dosage range, 446t dose-response relationships, 257f induction characteristics, 267t in monitored anesthesia care, 446t, 447–448, 448f pediatric anesthesia, 684 for pediatric patients, 346 pharmacokinetic values, 256t preoperative use, 344, 344t Milrinone, 196 Minimally invasive lumbar decompression (MILD) procedure, 978–979 Minimally invasive surgery, advantages of, 697t Minimum alveolar concentration (MAC), 670, 679 inhaled anesthetics, 236, 237t Monitored anesthesia care (MAC), 441 ASA standards, 452, 453t context-sensitive half-time, 444 drug interactions in, 445–446 drugs used for, 446–450 benzodiazepines, 446t, 447–448 dexmedetomidine, 446t, 450 fospropofol, 447 ketamine, 446t, 450 midazolam, 446t, 447–448, 448f opioids, 446t, 448–450, 449t propofol, 446–447, 446t 14/01/13 8:16 PM Index 1123 effect site equilibration, 444–445 elimination half-life, 443–444 monitoring during, 452–454, 453t non-anesthesiologists, guidelines for, 454–455, 455t patient agitation during, 442t patient-controlled analgesia, 450–451 patient-controlled sedation, 450–451 preoperative assessment, 441 respiratory function and, 451–452 and sedation/analgesia, 441 supplemental oxygen in, 452 techniques of, 441–442 optimizing drug administration, 442–443, 443f time to recovery, 444, 445f Monitoring techniques, 387–404 arterial oxygenation, 388–390 blood pressure intermittent noninvasive monitoring, 395 invasive monitoring, 393–394 body temperature, 400–401 cardiac output by arterial waveform analysis, 400 by pulmonary artery catheter, 398–399 central venous and right-heart pressures, 395–398, 397f, 398f, 399t expired gases, 390–392, 390t future trends in, 403–404 inspired oxygen concentratoin, 387–388 monitored anesthesia care, 452–454, 453t processed EEG monitoring, 401–403 Morphine, 271, 279, 281, 975t See also Opioids in acute pain, 947, 951t for cancer pain, 974 chemical structure, 272f for chronic pain, 974, 975t context-sensitive half-times, 280f effect on knockout mice, 273, 274f pediatric anesthesia, 683 pharmacodynamics, 283 as preoperative medication, 344t Motor-evoked potentials (MEP), 828 Multiple sclerosis, 354 anesthesia management, 354–355 Muscle relaxants See also Neuromuscular blocking drugs (NMBDs) allergic reactions, 136 electroconvulsive therapy, 494 history of, 4–5 in renal failure, 801t for urologic surgery, 800–801 Muscles of ventilation, 112 Musculoskeletal disorders, anesthesia management, 347–354, 348t Myasthenia gravis, 350 anesthesia management, 352 and myasthenic syndrome, 353t Osserman staging system for, 352t presentations, 351t treatment, 352 Myasthenic syndrome, 352, 353t anesthesia management, 352–353 Myocardial contractility, 109 Myofascial pain syndrome (MFPS), 969–970, 970t Myotonias, 348–349 anesthesia management, 349 Myringotomy, 773 Myxedema coma, 753 management of, 753t LWBK1191_Ind_p1109-1138.indd 1123 N Naloxone, 281 chemical structure, 272f labor and vaginal delivery, 639 Nasal surgery, anesthesia for, 777 National Fire Protection Association (NFPA), 89 National Institute of Occupational Safety and Health (NIOSH), 16 National Practitioner data Bank, 33 Neck injury, 873 Neonatal period, 658 Neonatal resuscitation, algorithm for, 655f Neonates anesthesia, 658–673, 669t anesthetic drugs, 666, 667t management, 666–670 neonatal airway, anatomy of, 665–666, 665f surgical procedures in, 673, 673t techniques, 670t blood component therapy in, 664–665 blood gas values in, 661t cardiovascular system, 658, 659f fluid and electrolyte therapy in, 663–664 hepatic system, 665 meconium aspiration, 663 postoperative apnea, 672 postoperative pain management for, 671t pulmonary system, 658–661 renal system, 663 respiratory distress syndrome, 671–672 retinopathy of prematurity, 672 Neostigmine, 894 block, 305 effects, 305–307 factors affecting reversal, 305, 306t mechanism of action, 305 for pain management, 956t pediatric anesthesia, 682 pharmacodynamics, 305 pharmacokinetics, 305, 306t Nephrectomy, 804–806, 820–821 See also Urologic surgery Nephrolithiasis, emergency treatment of, 822 Nephron-sparing partial nephrectomy, 807 See also Urologic surgery Nerve agents, 894, 895t Nerve blocks ambulatory surgery, 463 in children, 963 Nerves anatomy of, 310 classification of, 311t and transmission of electrical impulses, 310 Nesiritide, 203 Neuraxial anesthesia, cesarean delivery, 642–643 Neuroanesthesia, development of, 5–6 Neurologic system, preoperative evaluation, 327 Neuromonitoring devices, in ICU, 919–920 Neuromuscular abnormalities, in ICU, 940–941 Neuromuscular blockade, in ICU, 936 Neuromuscular blocking drugs (NMBDs), 290–309, 292t altered responses to, 299–300 depolarizing blocking drugs, 293–295, 294t, 295f, 296t (see also Succinylcholine (SCh)) 14/01/13 8:16 PM 1124 Index Neuromuscular blocking drugs (NMBDs) (continued) drug interactions, 300t duration of action, 292 monitoring blockade by, 300–304 choice of muscle in, 302–303 clinical applications, 303–304 monitoring modalities, 300, 301t recording responses, 302 stimulator characteristics, 300 nondepolarizing drugs, 295–299 atracurium, 296–298 blockade characteristics, 294t, 295 cisatracurium, 298 mechanisms for clearance of, 298t monitoring, 301t onset and duration of action, 296, 297t pancuronium, 298–299 pharmacokinetics, 296, 297t rocuronium, 299 vecuronium, 299 onset time, 292 pediatric anesthesia, 681–682 pharmacologic characteristics, 292–293, 293f physiology and pharmacology, 290–291, 291f potency, 292 recovery index, 292–293 reversal agents, 304–309 anticholinesterases, 305–307, 306t, 307t blockade assessment, 304–305 neostigmine, 305–307 sugammadex, 307–309, 308f, 309f, 309t site of action of, 290 Neuromuscular junction (NMJ), 290, 291f Neurosurgery anesthesia critical care and, 918–919, 920t neuroanatomy, 553–554, 554f Neuronal plasticity, 942 Neuroradiology, interventional, 489–490 Newborn period, 658 Newborn resuscitation, steps in, 656t Newborns, persistent pulmonary hypertension of, 661–663, 662f Nicardipine, 200 Nifedipine, 200, 200t Night call, 21 Nimodipine, 200 for cerebral vasospasm, 923 Nitroglycerin, 202t, 203 Nitroprusside, 201, 202t, 203 Nitrous oxide, 227 See also Inhaled anesthetics antineuroprotective effect, 239 chemical structure, 228f clinical overview, 235 exposure, effects of, 15 NMDA receptor antagonists, in postoperative pain, 951, 952t Noise pollution, 20 Nonalcoholic fatty liver disease (NAFLD), 730, 742 Non-obstetric surgery, in pregnant women, 656–657, 657f, 657t Nonoperating room anesthesia (NORA), 482–495, 484t ASA standards for, 485t continuum of anesthesia, 486, 486t dental surgery, 495 diagnostic and interventional radiology angiography, 489 computed tomography, 490 LWBK1191_Ind_p1109-1138.indd 1124 interventional neuroradiology, 489–490 magnetic resonance imaging, 490–491 positron emission tomography, 491 radiation therapy, 491, 492f radiofrequency ablation, 490 transjugular intrahepatic portosystemic shunt, 490, 491t electroconvulsive therapy, 494 anesthetic requirements for, 494 physiologic response to, 494 environmental considerations for, 486–487, 487t gastroenterology, 493 ERCP, 493 upper gastrointestinal endoscopy, 493 interventional cardiology cardiac catheterization procedures, 492 cardioversion, 493 electrophysiologic procedures, 492 pediatric cardiac procedures, 492 intravenous contrast agents, 487–489, 488t patient safety in, 482–483 sedation and anesthesia, 485–486, 486t three-step approach for, 482, 483f environment, 485t patient, 483t procedure, 484t Nonopioid analgesics pediatric anesthesia, 683–684 in postoperative pain, 951, 952t, 953 Nonsteroidal anti-inflammatory drugs (NSAID), 683, 703 Norepinephrine (NE), 183, 192–193 in shock, 929 Nucleoplasty, 978 Nutrition in critical illness, 934 enteral, 934 O Obese patients ambulatory anesthesia and, 457 office-based anesthesia, 471–472 Obesity, 711–729 android, 711 classification of, 712t critical care and resuscitation, 729t definition and epidemiology of, 711 gynecoid, 711 intraoperative considerations, 719, 722–725, 724f intravenous drug dosing in, 720t–722t management of, 711–713 monitored anesthesia care and sedation, 725 morbidity and mortality, 728–729 pathophysiology of, 713–718, 714t cardiovascular and hematologic systems, 716, 716f, 717f gastrointestinal system, 716–717 metabolic syndrome, 718t renal and endocrine systems, 717–718 respiratory system, 713–715, 713f, 715t pharmacology of, 718, 719f postoperative considerations, 728t in pregnant women, 649 preoperative evaluation, 723t regional anesthesia, 725–728, 727t Obstetric hemorrhage, 647–648 Obstetric patients, anesthetic complications in, 646t 14/01/13 8:16 PM Index 1125 Obstetrics anesthesia, 2, 6, 637–657 cesarean delivery, 642–644 complications, 646t fetal and maternal monitoring, 650–653, 652t high-risk patients, 644–649 HIV/AIDS patients, 650 labor and vaginal delivery, 637–642 newborn resuscitation, 653–656, 654t non-obstetric surgery in pregnant women, 656–657, 657f, 657t placental transfer and fetal exposure, 637, 639t preterm delivery, 649–650 substance abuse patients, 650, 651t Obstructive sleep apnea (OSA), 713, 770 adult patients for, 771t postanesthesia care unit, 911–912, 911t preoperative evaluation, 334–336, 334t, 335t Obstructive sleep apnea syndrome (OSAS), 770 Occipital nerve stimulation, 980 Occupational health, 15–28 emotional considerations, 27–28 addiction, 28 burnout, 27 mortality rates, 28 stress, 27 substance abuse, 27–28 suicide, 28 fatigue, 21 infection hazards, 21–26 DNA viruses, 23 human immunodeficiency viruses, 25–26 OSHA standards and precautions, 21–22 pathogenic human retroviruses, 25–26 prion diseases, 26 respiratory viruses, 22 tuberculosis, 26 viral hepatitis, 23–24 viruses in smoke plumes, 26 night call, 21 physical hazards, 15–20 allergic reactions, 18, 19t anesthetic gases, 15 behavioral effects, 16 cancer, 16 chemicals, 18 levels of anesthetic gases, 16 NIOSH recommendations, 16–17 noise pollution, 20 radiation, 18–20 reproductive outcomes, 15–16 work hours, prolonged, 21 Occupational Safety and Health Administration (OSHA) on methyl methacrylate exposure, 18 Standard Precautions, 21–22 Oculocardiac reflex, 783 O’Dwyer, Joseph, Office-based anesthesia (OBA), 469–481 advantages and disadvantages, 470t anesthetic agents, 478–480 clonidine, 480 ketamine, 479–480 remifentanil, 478–479 anesthetic techniques, 478–480 business and legal aspects, 481 causes of injury in office, 470t LWBK1191_Ind_p1109-1138.indd 1125 emergencies in office, 473, 474t equipment required for, 473t historical perspective, 469 office accreditation, 474, 475t office selection and requirements, 472–474, 473t–475t patient selection, 471–472, 471t postanesthesia care unit, 480 procedure selection, 474, 476–477, 478t aesthetics, 476 breast, 476 dentistry and oral and maxillofacial surgery, 477 gastrointestinal endoscopy, 476–477 gynecology and genitourinary, 477 liposuction, 474, 476 ophthalmology and otolaryngology, 477 orthopedics and podiatry, 477 pediatrics, 477, 478t regulations, 480–481 safety issues, 469–471, 470t surgeon selection, 472, 472t Oliguria, postanesthesia care unit, 913 Onions, 1105 Open and laparoscopic pyelolithotomy, 820 See also Urolithiasis, therapies for Operating room contamination, sources of, 17, 17t DNR order in, 982–983 fires in, 90, 90t, 91t dangers of fires, 92–93 fire triangle, 92, 92f prevention of, 91t, 93 management, 14 power safety in, 89–90 Ophthalmologic surgery, 780–791, 781t anesthesia techniques, 785–787, 785t, 786f, 786t, 787t anesthetic ramifications, 784 intraocular pressure, anesthesia and adjuvant drugs, 782–783, 783t intraocular surgery, 788, 788t laser therapy, 789 ocular anatomy, 780–781, 781f ocular physiology, 782 oculocardiac reflex, 783 open eye, full stomach, 787–788 ophthalmic drugs, anesthetic interactions, 784 postoperative complications, 789–791, 789t preoperative evaluation, 784–785 retinal detachment, 788 rocuronium, 787 strabismus, 788, 788t Opioids, 271–289 in acute postoperative pain, 947, 951, 951t for cancer pain, 974, 976 chemical structure, 272f for chronic pain, 974–976, 975t classification, 275, 275t context sensitive half-time, 279, 280f for controlling anxiety, 460 endogenous, 273 gender differences and, 289 history of, 4, 271–273 in ICU, 935–936 labor and vaginal delivery, 638–639 for low back pain, 976 mechanism of analgesia, 276 metabolism, 279 14/01/13 8:16 PM 1126 Index Opioids (continued) methadone, 281 in monitored anesthesia care, 446t, 448–450, 449t morphine, 279, 281 naloxone, 281 opioid and nonopioid receptors, 275–276 opioid-induced hyperalgesia, 277–278 pediatric anesthesia, 683 for pediatric patients, 346 in peripheral analgesia, 276–277, 277f pharmacodynamics, 282–284, 282f pharmacogenetics, 284, 286t pharmcokinetics, 279 piperidines, 281 PKPD models, 281–282 preoperative use, 344 receptor knockout mice, 273–275, 274f respiratory depression from, 286–287, 287t, 288f route of administration, 278 side effects, 289t tolerance, 278 for urologic surgery, 800 Organ donors, anesthetic management brain-dead donors, 842–843 DCD donors, 843 deceased lung donor, 843t living kidney donors, 843–844 living liver donors, 844 Organized Anesthesiology, Orlistat, 712 Orthopedic surgery anesthetic techniques, 824t fat embolism syndrome, 837, 837t lower extremities, 833–835, 834t methyl methacrylate, 838 microvascular surgery, 835, 836t pediatric patients, 835–836 preoperative assessment, 824t spinal surgery, 823–830 tourniquets, 836–837 upper extremities, 830–833, 831t venous thromboembolism, 839 Osmotic diuretics, renal effects and mechanisms, 802 Osteogenesis imperfecta, 361 Otolaryngologic surgery anesthesia for, 770–779 airway surgery, 774–775 ear surgery, 773, 774t extubation, 779 maxillofacial trauma, 778–779 pediatric airway emergencies, 775–777 pediatric and adult surgery, 777–778 pediatric ear, nose, and throat surgery, 770–773 temporomandibular joint arthroscopy, 778 upper airway infections, 778–779 Overnight polysomnography (OPS), 713 Oxcarbazepine, 356t Oxycodone, 975t for chronic pain, 975–976, 975t Oxygen analyzers, 387 Oxygen concentratoin, inspired, monitoring of, 387–388 Oxygen failure cutoff valves, anesthesia workstation, 371 Oxyhemoglobin dissociation curve, 388, 389f Oxymorphone, 975t LWBK1191_Ind_p1109-1138.indd 1126 P Pacemakers, 1043 See also Cardiac implantable electronic devices (CIED) failure, treatment of, 1056t generic code, 1045t indications for permanent implantation, 1043–1044 Pain acute, 942 anatomy, 942, 943f, 944f, 945t assessment, 946, 950f, 950t continuous peripheral nerve blockade caveats, 958 defined, 942 management, 946 methods of analgesia, 953–958 non-opioid analgesics, 951, 952t, 953 opioid analgesics, 947, 951, 951t opioid-dependent patients, 960–962, 960t organizational aspects, 962 pediatric patients, 962–963, 962t preemptive analgesia, 946 processing, 942–943, 945f, 946f, 947t regional anesthesia complications, 958–960, 959t surgical stress response, 944, 946, 949t transduction/transmission chemical mediators, 944, 947t, 948f cancer, 973–974, 974t chronic management, 964–981 (see also Pain management) somatosensory pain processing, 964–967, 965f, 965t sensitization, 945f syndromes buttock pain, 969 chronic regional pain syndrome, 972 diabetic painful neuropathy, 971–972, 971t facet syndrome, 969 fibromyalgia, 970, 970t herpes zoster, 970–971 HIV sensory neuropathy, 972–973 low back pain, 967–969, 967t myofascial pain syndrome, 969–970, 970t neuropathic, 970–973 phantom pain, 973 piriformis syndrome, 969 postherpetic neuralgia, 970–971 radicular pain syndromes, 967–969, 967t sacroiliac joint syndrome, 969 Pain management interventional procedures, 977 discography, 978 intradiscal electrothermal therapy, 978 intrathecal pumps, 980–981, 981t kyphoplasty, 979–980 MILD procedure, 978–979 occipital nerve stimulation, 980 percutaneous disc decompression, 978, 979t peripheral nerve stimulation, 980 spinal cord stimulation, 980 vertebroplasty, 979–980 pharmacologic, 975t anticonvulsants, 977, 977t antidepressants, 976–977, 976t 14/01/13 8:16 PM Index 1127 capsaicin patch, 977 lidocaine patch, 977 mexiletine, 977 opioids, 974–976, 975t postanesthesia care unit, 905, 907 Pancreas and islet transplantation, 849 Pancuronium, 298–299 See also Neuromuscular blocking drugs (NMBDs) Papain, 1105 Paracervical block, labor and vaginal delivery, 642 Paraplegia, spinal cord surgery, 828 Parathyroid glands, 753–754 Paravertebral blockade, 958 Parkinson disease, 357–358 anesthesia management, 358–359 clinical features, 358t Parsley, 1106 Partial thromboplastin time (PTT), 736 Passion flower, 1106 Patient-controlled analgesia (PCA) in children, 963 for pain management, 953, 953t Patient positioning, 434–440 brachial plexus and upper extremity injuries, 436t general principles, 434 head-down positions, 439–440 brachial plexopathy, 440 head and neck injury, 440 head-elevated positions complications of, 440t variations of, 438–439 lateral position, 437–438 complications of, 438t variations of, 438t prone position complications of, 439t variations of, 439t supine positions, 434–435 complications of, 434–435, 437t variations in, 435t ulnar neuropathy, 435–437 Pay for performance, 13, 35 Pediatric advanced life support pulseless arrest algorithm, 1000f Pediatric patients airway emergencies, 775–777 anatomy and physiology, 674–676, 675t anesthesia, 674–695 cardiovascular, 680 central nervous system, 680 ear, nose, and throat surgery, 770–773 emergency and recovery, 692, 693t full stomach and rapid sequence induction, 687, 687t hepatic, 680–681 induction of, 686–687 induction techniques, 687–688 intravenous agents, 681–684 maintenance of, 688–692 pain management, 692 postanesthesia care unit, 692–695, 694f preoperative assessment, 684–686, 684t, 685t preoperative preparation, 687 regional anesthesia and pain management, 692 renal, 680 respiration of, 679–680 sedatives, 684 LWBK1191_Ind_p1109-1138.indd 1127 upper respiratory tract infection, 686t in vivo metabolism, 681 blood transfusion therapy, 691 cardiopulmonary resuscitation, 998, 999f, 1000f central nervous system, 676 heart rates and blood pressure in, 676t heart transplantation, 855 liver transplantation, 849 lung transplantation, 852 NOR cardiac procedures, 492 office-based anesthesia, 477, 478t orthopedic surgery, 835–836 pain management, 962–963, 962t pharmacology, 677–679 developmental, 677–678, 677f inhalational anesthetics, 678, 678t pharmacodynamics, 679, 679f pharmacokinetics, 678 preoperative preparation for, 345–346 sedation and anesthesia for MRI, 490–491 Peer review organization, 10 Pelvic fractures, 874 Pemphigus, 369 Percutaneous disc decompression contraindications to, 979t for pain management, 978 Percutaneous nephrolithotomy (PNL), 819 Pericardial effusion, echocardiographic findings in, 414, 415f Perioperative Atrial Fibrillation (PoAF), 57 Peripheral nerve, 964 Peripheral nerve blockade, 956, 957t brachial plexus, 544, 545t, 956–957 complications, 958 general principles and equipment, 535–537, 536t–538t head and neck techniques, 537, 540f–542f inguinal nerve block, 547 intercostal nerve blockade, 544–547 intravenous regional (Bier) block, 544–545, 407t lower extremity, 520, lumbar plexus, 957–958 pain management, 956–958, 955t paravertebral block, 547 penile block, 548 sacral plexus, 958 terminal upper extremity nerve blocks, 544 upper extremity, 540, 544, 542f Peripheral nerve stimulation (PNS), 980 Peripheral opioid analgesia, 276–277, 277f Peritonsillar abscess, 773 Phantom pain, 973 Pharmacokinetics compartmental models, 72, 73f compartment model, 72, 72f, 73f effect of hepatic/renal disease on, 71 elimination half-life, 71 inhaled anesthetics, 227–234 interactions, 76 absorption, 76 distribution, 76 metabolism, 76–77, 77t intravenous anesthetics, 253, 255–256, 256t, 257t models, 69–71 opioids, 279 principles, 65–66 rate constants and half-lives, 70, 71t volume of distribution, 70–71 14/01/13 8:16 PM 1128 Index Pharmacology, 65 drug absorption and administration routes inhalational administration, 66 intramuscular and subcutaneous administration, 66 intrathecal, epidural, and perineural injection, 66 intravenous administration, 65–66 oral administration, 66 transcutaneous administration, 66 transfer across membranes, 65 drug distribution, 66–67 drug elimination, 67–69, 70t drug interactions, 75–78 in vitro pharmaceutical interactions, 75 in vivo pharmaceutical interactions, 75–76 drug–receptor interactions, 73–74 agonists, 73 antagonists, 73 competitive antagonists, 73–74 concentration–response relationships, 74, 74f desensitization and downregulation of receptors, 73 dose–response relationships, 74, 74f noncompetitive antagonists, 74 partial agonists, 73 drug redistribution, 67 IV anesthetics administration, 78–79 pharmacodynamic interactions, 77–78 principles, 72 pharmacokinetics (see Pharmacokinetics) Phenobarbital, 356t Phenotypic switch, 967 Phentermine, 712 Phentolamine, 197 Phenylephrine, 192 ophthalmologic surgery, 784 Phenytoin, 356t Pheochromocytoma, 757–758, 757t anesthetic management of, 758t Phosgene, 896 Phosphodiesterase inhibitors, 196, 222 Phosphodiesterase type (PDE 5), 820 Pipeline supply source, anesthesia workstation, 374 Piperidines, 281 Piriformis syndrome, 969 Pituitary gland, 765 Placebo-induced analgesia, 276 Placenta previa, 647 Plague, 898 Platelet transfusion, 214–215, 215t trauma patient, 886 Pneumoperitoneum, physiology of, 808t Policy and procedure manual, 10 Polymyositis See Inflammatory myopathies Polyradiculoneuritis See Guillain-Barré syndrome Porphyria, 360, 362t Portopulmonary hypertension (PPHTN), 739 Positive end-expiratory pressure (PEEP), 725 Positron emission tomography, 491 Postanesthesia care unit (PACU), 16, 692–695, 694f, 903 admission to, 904–905, 906t cardiovascular complications, 907 complications, 693 discharge criteria systems, 908t LWBK1191_Ind_p1109-1138.indd 1128 electrolyte disorders hyperkalemia, 916 hypokalemia, 916 hyponatremia, 916 emergence agitation, 694 glucose disorders and control, 915 hyperglycemia, 915–916 hypoglycemia, 916 levels of postanesthesia care, 903–904 metabolic complications, 913–915 metabolic acidemia, 914–915, 914t metabolic alkalemia, 915 postoperative acid–base disorders, 913 respiratory acidemia, 913–914 respiratory alkalemia, 915 miscellaneous complications in, 917t office-based anesthesia, 480 oxygen desaturation, 694 postanesthetic triage, 904 postoperative evaluation, 907, 909t postoperative pain, 695 postoperative pain management, 905, 907 pulmonary dysfunction, 907, 909–913 anemia, 912 decreased compliance, 910 inadequate postoperative oxygenation, 910–911 inadequate postoperative ventilation, 907, 909 inadequate respiratory drive, 909 increased airway resistance, 909–910 neuromuscular and skeletal problems, 910 obstructive sleep apnea, 911–912, 911t perioperative aspiration, 912–913 supplemental oxygen, 912 renal complications, 913 safety in, 904 value and economics of, 903 vomiting, 694 Postexposure antiretroviral prophylaxis (PEP), 26 Postherpetic neuralgia (PHN), 970–971 Postoperative cognitive dysfunction (POCD), 239 Postoperative nausea and vomiting (PONV), 5, 691–692, 691t, 702 office-based anesthesia, 480 standards of care for, 482 Potassium, 170–173, 173t, 174f hyperkalemia, 172, 173t hypokalemia, 170–172 Practice guidelines, 10 Practice standards, 8, 9t Pralidoxime chloride for nerve agent poisoning, 895 Prazosin, 197 Preeclampsia, 644–647 symptoms of severe, 647t Pregabalin, in postoperative pain, 951, 953 Pregnancy cardiomyopathy of, 649 maternal drug use, 671 physiologic changes of, 637, 638t Pregnancy testing, preoperative, 340 Preload, 109 Preoperative assessment, 325 antibiotic prophylaxis, 346, 346t cardiovascular disease, 328–333 endocrine disease, 336–337 healthy patient, 325–328, 327t, 328t 14/01/13 8:16 PM Index 1129 laboratory testing, 338–340, 339t liver disease, 338 and management, 325–346 monitored anesthesia care, 441 musculoskeletal disorders, 338 preoperative medication, 342–345 preoperative preparation for children, 345–346 and preparation for anesthesia, 340–342 pulmonary disease, 333–336 questions to address in, 340t renal disease, 337 Preoxygenation, 419 Prerenal azotemia, 797 Preterm delivery, surgery and anesthesia management, 649–650, 650t Preterm infant, abnormalities associated, 668t Primary pulmonary hypertension, 648–649 Primidone, 356t Prion diseases, 26 Propofol See also Intravenous anesthetics chemical structures, 253f context-sensitive half-times for, 269f and dexmedetomidine, 451t dosage range, 446t electroconvulsive therapy, 494 in ICU, 935 induction characteristics, 267t mechanism of action, 252 in monitored anesthesia care, 446–447, 446t pediatric anesthesia, 681 pharmacokinetic values, 256t physicochemical properties, 260–262 Propranolol, 199 Prospective payments, 13 Prostatectomy, 810–813 laparoscopic, 811–812, 812t radical, 811 robotic, 811–812 simple, 811 Proteomics, 55 Prothrombin complex concentrates (PCCs), 226, 886 Prothrombin time (PT), 736 Proximal tubule diuretics, renal effects and mechanisms, 802 Pudendal nerve block, labor and vaginal delivery, 642 Pulmonary agents, 896 Pulmonary artery catheters (PACs), 396–398, 399f cardiac output monitoring, 398–399 in ICU, 924–925 Pulmonary aspiration, 428t perioperative, prevention of, 341, 342t, 343t Pulmonary disease preoperative evaluation, 333–334 asthma, 334 obstructive sleep apnea, 334–336, 334t, 335t smoking cessation, 334 Pulmonary function tests, preoperative, 340 Pulmonary system, preoperative evaluation, 328r Pulse oximetry, 370 for arterial oxygen monitoring, 388–390 in neonatal anesthesia, 669 P2Y12 adenosine monophosphate receptor antagonists, 222–223 LWBK1191_Ind_p1109-1138.indd 1129 Q Quality improvement programs, 34 continuous quality improvement, 34 Joint Commission requirements, 34–35, 35t measurement of improvement, 34 pay for performance, 35 structure, process, and outcome, 34 Quassia, 1106 R Radial nerve palsy, 832 Radiation hazards of, 486 occupational exposure, 18–20 related terms, 487t therapy, 491 Radical nephrectomy, 806 See also Urologic surgery with inferior vena cava tumor thrombus, 806–807 Radicular pain syndromes, 967–969, 967t Radiofrequency ablation, 490 Ranitidine, as preoperative medication, 344t Rapid sequence induction, of anesthesia, 429 Rapid sequence induction (RSI), 682 RBC preservation solutions, 212 Record keeping, 32 Red clover, 1106 Refractory hypotension, 131, 136 Regional anesthesia complications from, 958–960, 959t development of, difficult airway and, 432t labor and vaginal delivery, 639–642 Regional techniques, ambulatory surgery, 462 Regulators, anesthesia workstation, 374 Remifentanil, 4, 281 chemical structure, 272f context-sensitive half-times, 280f dosage range, 446t laparoscopic and robotic surgeries, 702 in monitored anesthesia care, 446t, 449–450 for obstetric labor pain, 288 office-based anesthesia, 478–479 pediatric anesthesia, 683 pharmacodynamics, 284, 285f for urologic surgery, 800 Renal blood flow (RBF), 794 autoregulation, 795f Renal cell carcinoma, 806 Renal drug clearance, 69, 69t Renal dysfunction, 737–738, 738f Renal failure, acute, 932–933, 932t Renal system, neonates, 663 Renal transplantation intraoperative protocols, 846 pain management after, 846 preoperative considerations, 845–846, 846t Renal vasodilator mechanisms, 795 Renin–Angiotensin–Aldosterone System, 795 Reproductive outcomes, anesthetic hazards to, 15–16 Rescue breathing, techniques of, 988, 988t Research studies, design of, 94–95 blinding, 94–95 control groups, 94 cross-sectional studies, 95 longitudinal studies, 95 random allocation, 94 sampling, 94 14/01/13 8:16 PM 1130 Index Residual paralysis, 304–305 Res ipsa loquitur, doctrine of, 36, 36t Respiratory acidemia, postanesthesia care unit, 913–914 Respiratory acidosis, 159–160 causes, 160t treatment, 160 Respiratory alkalemia, postanesthesia care unit, 915 Respiratory alkalosis, 158 causes, 159t physiologic effects, 159t treatment, 158 Respiratory depression, from opioid treatment, 286–287, 287t Respiratory distress syndrome (RDS), 661 Respiratory failure, acute, 931–932 Respiratory function See also Lungs aging physiology, 115, 115t anesthesia and obstructive pulmonary disease, 125–126 and restrictive pulmonary disease, 126 formulas for, 1007 lung anatomy and function, 112–114 lung mechanics, 114–115 lung volumes and capacities, 1008 oxygen and carbon dioxide transport, 119–122 bulk flow of gas, 119 distribution of ventilation and perfusion, 120 gas diffusion, 119 physiologic dead space, 120–122 physiologic shunt, 122 postoperative, 127–128, 127t pulmonary function testing, 122–125, 123t, 124f, 125t carbon monoxide diffusing capacity, 123 flow-volume loops, 122 lung volumes and capacities, 124f preoperative pulmonary assessment, 124, 125t weaning from mechanical ventilation, 125t smoking and, 126–127, 127t ventilation control, 115–119 Respiratory viruses, 22 Retinal detachment surgery, 788 Retinal ischemia, 790 Retinopathy of prematurity (ROP), 672 Rheumatoid arthritis, 366 anesthesia management, 366–368 extra-articular manifestations of, 367t Rifle classification, of acute kidney injury, 932t Risk management, in anesthesia, 29, 31–32, 32t See also Anesthesia risk management Rocuronium, 299 See also Neuromuscular blocking drugs (NMBDs) for ophthalmologic surgery, 787 pediatric anesthesia, 682 Roux-en-Y gastric bypass (RYGB), 713 S Sacral plexus nerve block, 958 Sacroiliac joint syndrome, 969 Safety standards, development of, 3–4 LWBK1191_Ind_p1109-1138.indd 1130 Saw palmetto, 1106 Scavenging systems, 385, 385t Schmidt, Erwin, Scoliosis, 825–826, 826t, 827t Scopolamine, as preoperative medication, 344t Screening clinics, preoperative, 13 Sedation See also Monitored anesthesia care (MAC) ambulatory surgery, 463–464 in ICU, 935 levels of, 455, 455t patient-controlled, 450 and protective airway reflexes, 452 and respiratory control, 452 and upper airway, 451 Sedative–hypnotics and tranquilizers preoperative use, 343–344, 344t Sensorimotor distal polyneuropathy, 971, 971t Sepsis, 926 definition, 927t management of, 928t Septic shock, 926 Serotonin syndrome, 78 Severe acute respiratory syndrome (SARS), 22 Sevoflurane See also Inhaled anesthetics chemical structure of, 228f clinical overview, 235 generic formulations of, 249–250 physiochemical properties, 229t Shock activated protein C, 930 cardiogenic, 925–926 clinical management of, 926, 928–930 corticosteroids, 930 fluid administration in, 864, 868t hemorrhagic, 864, 867t management of, 865t–866t septic, 926, 928t in trauma patient, 864–869 vasopressors/inotropes use dobutamine, 929 dopamine, 929 epinephrine, 929–930 norepinephrine, 929 vasopressin, 930 vicious cycle/lethal triad, 869, 869f Shock wave lithotripsy (SWL), 818–819 contraindications to, 819t Sickle cell disease (SCD), 364 anesthesia management, 366 clinical manifestations, 364–366, 365t treatment, 366 Simple and donor nephrectomy, 806 See also Urologic surgery Simpson, James Young, Sinusitis, intensive care unit, 936 Skeletal muscle hypokalemia and, 171 myasthenia gravis and, 350 volatile anesthetics and, 247 Skull base surgery, anesthesia for, 777–778 Sleep deprivation, and workplace errors, 21 Sleep disordered breathing (SDB), 770 Smallpox, 896 Snow, John, 2, Society of Critical Care Medicine (SCCM), 918 Sodium, 167 hypernatremia, 169, 169t, 170t hyponatremia, 167–169, 168t, 169t 14/01/13 8:16 PM Index 1131 Sodium bicarbonate during cardiopulmonary resuscitation, 992t, 993–994 Somatosensory evoked potentials (SSEP), 828 Somatotropic function, in critical illness, 934 Spinal anesthesia ambulatory surgery, 462–463 cesarean delivery, 642–643 combined spinal-epidural anesthesia, 519 cesarean delivery, 643 labor and vaginal delivery, 645 complications, 323t, 529–532 continuous administration, 516 contraindications, 533t development of, epidural anesthesia vs., 533t neonatal postoperative apnea and brady cardia, 672 neural toxicity, 323, 323t patient positioning, 514–515, 515t physiology, 525–529 cardiovascular effects, 526–527, 527f endocrine-metabolic physiology, 529 gastrointestinal effects, 530 respiratory effects, 528t selection criteria, 533t spinal surgery and, 830, 830t total spinal anesthesia, 530 Spinal cord, neurobiology of, 964 Spinal cord stimulation (SCS), 980, 980t Spinal hematoma, epidural and spinal anesthesia complication, 531–532 Spinal surgery, 823–830 blood loss, 829 degenerative vertebral column disease, 827–828, 827f epidural and spinal anesthesia, 830, 830t postoperative care, 829 scoliosis, 825–826, 826t, 827t spinal cord injuries, 823–825 spinal cord monitoring, 828–829 venous air embolus, 829 visual loss after, 829 Spinal trigeminal nucleus, neurobiology of, 964, 966 Spine and spinal cord injury anesthetic considerations, 873 hemodynamic management, 872 initial evaluation, 872 management, 872 respiratory complications, 872 Standard of care, 8–10 and professional liability, 37 Statins, perioperative use, 341 Statistics, 95 analysis of variance, 97 confidence interval, 97 descriptive, 96, 96t inferential, 97, 97t interpretation of results, 98, 98t interval data, 97 robustness and nonparametric tests, 97 systematic reviews and meta-analyses, 97–98 t test, 97 St John’s wort, 1106 Strabismus surgery, 788t Stress-induced analgesia, 276 Stress, occupational, 27 Stridor, airway surgery, 774–775, 774t, 775t Stroke volume, 412–413 Sturge-Weber syndrome, 820 LWBK1191_Ind_p1109-1138.indd 1131 Subarachnoid hemorrhage (SAH), 923 causes of, 923 cerebral vasospasm after, 923 hyponatremia after, 923–924 interventional neuroradiology, 923 triple-H therapy, 923 Substance abuse, 27 Succinylcholine (SCh), 4–5, 293, 782, 801 blockade characteristics, 294, 294t clinical uses, 295 neuromuscular effects, 293–294 pediatric anesthesia, 681–682 pharmacology, 294–295, 295f side effects, 296t Sudden Arrhythmic Death Syndrome (SADS), 649 Sufentanil, 4, 281 in acute pain, 951 Sugammadex, 307–308 clinical use, 308, 309t dosage, 308 pediatric anesthesia, 682 pharmacokinetic, 308 pharmacology, 308 Sulfur hexafluoride, ophthalmologic surgery, 784 Supplemental oxygen, postanesthesia care unit, 912 Supraglottic airways, 422–423, 423t, 424t bronchospasm and, 422 complications, 424t contraindications to use of, 423t double lumen, 423, 424t laryngeal mask airway (LMA), 422, 423t removal of, 423 Sweet clover, 1107 Sympathomimetic drugs, 189, 190t, 191t, 192 Syndrome of inappropriate antidiuretic hormone secretion (SIADH), 167–168, 169t Systemic lupus erythematosus (SLE), 368 Systemic sclerosis (scleroderma), 368 Systemic vascular resistance (SVR), 699 T Temperature monitoring, 400–401 Temporomandibular joint arthroscopy, 778 See also Otolaryngologic surgery Thiamylal, chemical structure, 253f Thiopental chemical structure, 253f context-sensitive half-times for, 269f induction characteristics, 267t pharmacokinetic values, 256t Thoracic airway injuries, 862–863 Thoracic surgery anesthesia bronchopleural fistula, 593, 593t diagnostic procedures, 591–592, 592t high-frequency jet ventilation, 593 intraoperative monitoring, 585, 585t lung cysts and bullae, 594 postoperative management and complications, 596, 596t preoperative assessment, 580, 581t–582t, 581f selection criteria, 590–591 tracheal resection, 594, 594t myasthenia gravis, 594–595, 595t one-lung ventilation, 585–589, 587t, 590t, 590t 14/01/13 8:16 PM 1132 Index Thrombelastography, 881, 882f Thromboembolism, in orthopedic surgical patients, 838t Thrombolysis, 924 Thrombolytics, pharmacologic activities of, 839t Thrombosis, 209 acquired risk factors for, 210t congenital risk factors for, 209–210 Thyroid function, in critical illness, 933–934 Thyroid function, tests of, 751t Thyroid gland, 749–753, 752t metabolism and function, 749 Thyroid hormone, synthesis and release of, 750f Tiagabine, 356t Timolol, 199 ophthalmologic surgery, 784 Tissue hypoxia, 213, 214t Tonsillectomy, 770–773 anesthesia for, 771t complications of, 772t Topiramate, 356t Total body water (TBW), 663 Total intravenous regional anesthesia (TIVA), 681 Total knee arthroplasty (TKA), 833, 835 Total shoulder arthroplasty, 832 Tourniquets, 836–837 Tracheal extubation airway management, 429, 430t Tracheal intubation, 823–824 airway management, 423, 425–429, 425f–427f, 428t development of, history of, 2–3 Tramadol, for cancer pain, 976 Transcranial Doppler (TCD) ultrasonography, in ICU, 919 Transcriptome, 55 Transesophageal echocardiography (TEE), 406–407 contraindication to probe placement, 407, 407t in ICU, 925 orientation, 408, 408f probe insertion, 407 probe manipulation, 407–408 safety, 407 three-dimensional, 409 two-dimensional, 409, 410t–411t Transfusion reactions infectious, 217–218, 218t noninfectious, 218–219, 220t Transient neurologic symptoms (TNS), after spinal anesthesia, 323–324, 323t Transjugular intrahepatic portosystemic shunt (TIPS), 490, 491t, 746, 746f Transplantation, 842 See also Organ donors, anesthetic management composite tissue, 855 corneal, 845 heart, 852–855, 853t–855t immunosuppressive agents, 844–845, 844t, 845t liver, 847–849, 848t lung, 850–852, 851t, 852t organ donors, anesthetic management of, 842–843, 843t pancreas and islet, 849 renal, 845–846, 846t LWBK1191_Ind_p1109-1138.indd 1132 small bowel and multivisceral, 849–850 transplant recipients, and nontransplant surgery, 856–857, 856t Transurethral ablation prostatectomy (TURAPY), 812 Transurethral microwave thermal therapy (TUMT), 812 Transurethral prostate resection, 814–816 Transurethral resection of bladder tumor (TURBT), 812, 814 Transurethral resection of prostate (TURP), 812 Transurethral resection (TUR) syndrome, 814–816, 815t treatment of, 816t Trauma, 858 abdominal and pelvic injuries, 874 breathing abnormalities, management of, 863–864 cervical spine injury, 860–861, 861f chest injury, 873–874, 875t direct airway injuries, 862–863 electrolyte and acid–base disturbances, 886–887, 887t extremity injuries, 875–877, 876t head injury, 870–872, 871t initial evaluation and resuscitation, 858–860, 859f airway obstruction, 858 full stomach, 859 head, open-eye, and vessel injuries, 859–860 intraoperative complications, management of, 884–886 coagulation abnormalities, 885–886 hypothermia, 884–885, 885f persistent hypotension, 884 mortality from, 858 neck injury, 873 operative management, 880–884 anesthetic and adjunct drugs, 881–884 coagulation monitoring, 881 hemodynamic monitoring, 880 organ perfusion and oxygen utilization, 881 oxygenation, 881 urine output, 880–881 postoperative considerations, early, 888–889 abdominal compartment syndrome, 888–889, 888f acute renal failure, 888 pain control, 888 thromboembolism, 889 shock, management of, 864–869 spine and spinal cord injury, 872–873 thermal, 877–879, 880t (see also Burns) Traumatic brain injury anticonvulsants in, 922 corticosteroids in, 922 drug-induced sedation in, 921 hyperventilation in, 921–922 hypothermia in, 922 in ICU, 920–922, 922t poor outcome in, 920t and prevention of secondary injury, 921, 922t resuscitation in, 921 Triiodothyronine, effects of, 750t Tuberculosis (TB), 26 14/01/13 8:16 PM Index 1133 Tularemia, 898 Tumeric, 1107 Tuohy, Edward, Tympanoplasty, anesthesia for, 774t U Ulnar neuropathy, 435–437 Ultrasound-guided central vein cannulation, 416 Ultrasound-guided regional anesthesia, 959–960, 959t Upper airway infections, anesthesia for, 778–779 Upper respiratory infection (URI), 773 ambulatory surgery and, 457–458, 458t Uremic syndrome, 797 complications of, 799t Ureteroscopy, 814 for stones removal, 819–820 Urinary tract infection, intensive care unit, 937 Urogynecology, 820 Urolithiasis, therapies for, 816–820 Urologic surgery, 792–822 clinical assessment of kidney, 795, 796t cystectomy, 808–810 disorders, 820–821 diuretic drug effects and mechanisms, 802–803, 802f emergencies, 821–822 testicular torsion, 821 fournier gangrene, 821 high-risk procedures, 803–804 laser techniques, 814 perioperative nephrology, 796–801 procedures laparoscopic and robotic nephrectomy, 807–808 nephrectomy, 804–806 nephron-sparing partial nephrectomy, 807 radical nephrectomy, 806 radical nephrectomy with inferior vena cava tumor thrombus, 806–807 simple and donor nephrectomy, 806 prostatectomy, 810–813 renal anatomy and physiology, 792–795, 793f shock wave lithotripsy, 818–819, 819t US Food and Drug Administration, 712 V Vaginal delivery, anesthesia for, 637–642 Valerian, 1107 Valproate, 356t Valvular lesions, hemodynamic goals with, 648t Vaporizers, 376, 376t GE Datex-Ohmeda Aladin Cassette vaporizer, 378 GE Datex-Ohmeda Tec vaporizer, 376–378 variable-bypass vaporizer, 376, 377t Variable-bypass vaporizers, 376 hazards, 377t operating principles, 376 safety features, 377t Varicella-zoster virus (VZV), 23 Varices, 740–741 See also Liver LWBK1191_Ind_p1109-1138.indd 1133 Vascular surgery aortic reconstruction, 632–635 carotid endarterectomy, 628–631 chronic medical problems, 622 elective openaortic repair, 635 emergency aortic surgery, anesthesia for, 635 lower extremity revascularization, 636 pharmacologic prophyaxis, 625t preoperative drug therapy, 622 Vasoconstrictors, myocardial ischemia management, 600–602 Vasodilators, 201–203, 202t Vasopressin, 196 during cardiopulmonary resuscitation, 992t, 993 in shock, 930 Vecuronium, 299 See also Neuromuscular blocking drugs (NMBDs) Venous air embolus, 829 See also Spinal surgery Venous thromboembolism (VTE) diagnosis, 939–940 in ICU, 938–940, 939t orthopedic surgery, 839 prophylaxis, 939 risk factors for, 939t treatment, 940 Ventilation, control of, 115, 116f breath-holding, 117–118 chemical control, 117 CO2–ventilatory response curves, 118f generation of ventilatory pattern, 115–117 quantitative aspects, 118–119, 119t reflex control, 117 related terminology, 115 Ventilation, during cardiopulmonary resuscitation, 986, 988, 988t Ventilator-associated pneumonia (VAP), intensive care unit, 936–937 Ventilators, anesthesia, 383–384, 384t classification, 383–384 hazards associated with, 384t Ventilatory muscle, 112 Ventricular assist devices (VADs), 853–854, 854t Verapamil, 199–200, 200t Vertebroplasty, 979–980 Viral hepatitis, 23 type A, 23 type B, 24 type C, 24 Virtual anesthesia machine simulator, 375f Viruses, in smoke plumes, 26 Vitamin B12 deficiency, 363 Vitamin E, 1107 Von Hippel-Lindau disease, 820 W Wake-up test, spinal cord surgery, 828 Walter Henderson maneuver, 726f Warfarin, 210, 223–224 Waters, Dr Ralph, Waynards, J Earl, Wedged hepatic venous pressure (WHVP), 741 Wells, Horace, Willow bark, 1107 Wood, Alexander, 271 Work hours, prolonged, 21 14/01/13 8:16 PM 1134 Index World Health Organization (WHO) moments for hand hygiene, 141f obesity definition, 711 prematurity definition, 666 surgical safety checklist, 32t Wound See also Infection control patient management intraoperative management, 150–151, 151t postoperative management, 152–153, 152t preoperative preparation, 151t volume management, 151–152, 152t LWBK1191_Ind_p1109-1138.indd 1134 perfusion and oxygenation, 149–150 repair mechanism, 148–149, 148t X Xenon, 227 See also Inhaled anesthetics clinical overview, 235 Z Zonisamide, 356t 14/01/13 8:16 PM ... roots of C2–C4 in a caudad and posterior direction Figure 35-3. The cervical, thoracic, lumbar, and sacral dermatomes of the body LWBK1191_C35_p535-5 52. indd 541 1/4/13 9:18 PM 5 42 Anesthesia. .. LWBK1191_C35_p535-5 52. indd 546 1/4/13 9:18 PM T a b l e - Intravenous Regional Anesthesia A small-gauge (20 - or 22 -gauge) intravenous catheter is placed and taped on the dorsum of the hand in the... Lumbar Plexus Genitofemoral Nerve (L1–L2) Innervates the skin immediately below the crease of groin anterior to the upper part of the femoral triangle Lateral Cutaneous Nerve of the Thigh (lateral