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Essential Anesthesia
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 (ISBN-13: 9780511261602)




Index




4–2–1 Rule 48

acid–base evaluation 140–5

activated clotting time (ACT) 163–4

activated partial thromboplastin time (aPTT) 163

adenosine 205–6

adrenalin see epinephrine

advanced cardiac life support 206

afterload 119–22

   in congestive heart failure 128

AICD 17

   anesthesia and 27

air embolism 92

airway management 24

   blind nasal intubation 36

   device selection 36

   endotracheal intubation 28–35

     awake fiberoptic intubation 33–5, 36

     can’t intubate situations 32–3

     confirmation of tracheal position 32

     direct laryngoscopy 28–32, 36

     endotracheal tube sizes 29

     young children 25, 37

   examination of the airway 24–6

   laryngeal mask airway (LMA) 27–8, 36, 71, 210–11

   management plan 35–7

   mask ventilation 26–7

   postoperative care 77

     desaturation 80

   trauma patients 235

airway resistance 135

albuterol 198

alcohol consumption 8

Aldrete Recovery Score 82–3

alfentanil 183, 187

Allen’s test 105

allergies 6–8

allowable blood loss (ABL) 48

alveolar air equation 137–8

amides 194–5

amiodarone 67, 205

analgesia 78, 84–7, 189

   see also pain

analgesics

   mild pain 189

   moderate to severe pain 187

   see also pain; specific analgesics

anemia 161

anesthesia

   depth of 73

   history of 1–2

   risks of 21–2

   theories of 166–7

   see also general anesthesia; regional anesthesia

anesthesia machine 110

anesthetics

   choice of 10–11

   inhalation 174–83

     uptake and distribution 175–8

   intravenous 170–4

   local anesthetics 194–8

     additives 197–8

     toxicity 66–7, 197, 213

   see also specific anesthetics

angiotensin-converting enzyme (ACE) inhibitors 20

anion gap 142

antacids 167

anti-emetics 169–70

antiarrhythmic drugs 205

anticholinergic drugs 199

anticoagulants 20–1, 163

antihypertensives 20, 202–5

anxiety reduction 168–9

apnea management 210–11

   see also breathing; desaturation; ventilation

arrhythmias 130–1

arterial blood gas analysis (ABG) 140–5

   anion gap 142

   bicarbonate 142

   buffers 142–3

   carbon dioxide 141–2

   oxygen 140–1

arterial catheter 104–5

ASA Physical Status classification 5, 6

aspiration 80, 158

   risk reduction 167–8

aspirin (ASA) 20

asthma 18–19

   anesthesia and 149–50

   case study 212–14

   atelectasis 80, 224

   atracurium 160, 190

atrial stretch receptors 124

atropine 193, 199, 205

automatic internal cardiac defibrillator AICD

   see pre-operative evaluation

awake fiberoptic intubation 33–5, 36

Bainbridge reflex 124

barbiturates 155–6, 170–3

baroreceptor 123–4

benzodiazepines 168–9

benzylisoquinolines 190–2, 194

beta blockers 20, 203

   perioperative beta blockade 19

Bezold–Jarisch reflex 124

bicarbonate 141–2

   addition to local anesthetics 197

   cardiac arrest management 206

   treatment of metabolic acidosis 143

Bicitra® 167, 218

Bier block 66

   carpal tunnel release case study 212–14

BIS (bispectral index) monitor 103–4

blood 161–4

   clotting 162–3

   coagulation studies 163–4

   oxygen-carrying capacity 161

   types 49, 50

   volume 46, 161

blood flow

   cerebral (CBF) 153–4, 155–6

   monitoring with Doppler 101–3

blood loss 48–9, 161

   post-operative care 77

blood pressure 119

   control 123–4

     atrial stretch receptors 124

     baroreceptor 123–4

     chemoreceptor 124

     long-term control 124

   drugs to lower blood pressure 202–5

   drugs to raise blood pressure 199, 202

   monitoring 93–4, 129

   pre-eclampsia case study 217–20

   see also hypertension

blood replacement 49–52

   see transfusion

blood substitutes 47

brachial plexus block 65

   AV shunt placement case study 226–8

bradycardia 205, 216

brain 153–7

   herniation 155

breath sounds 92

breathing

   apnea management 210–11

   control of 133–4

   work of 134–5

   see also ventilation

Brevital® 83

bronchodilators 198

buffers 142–3

bupivacaine 56

   cardiac toxicity 197

calcium 162, 200

   in i.v. fluids 47

capnography 97–8

carbon dioxide

   absorption anesthesia systems 114–16

   arterial blood gas analysis 141–2

cardiac output 106–7, 120

cardiovascular disease

   congestive heart failure (CHF) 16, 128, 129

   coronary artery disease 13–16

     hypertension 82, 124–6

   ischemic heart disease 126–7

     case study 229–32

   pacemaker/AICD 17, 127

cardiovascular drugs 199–206

   antiarrhythmic drugs 205

   anticholinergic drugs 199

   drugs to lower blood pressure 202–5

   drugs to raise blood pressure 199, 202

cardiovascular problems during anesthesia 128–31

   arrhythmias 130–1

   hypertension 131

   hypotension 128–30

cardiovascular risk evaluation 13, 16

carotid bruit 9

celiac plexus block 87

central venous catheterization 41–4

   catheter types 43

   complications 42

   femoral access 42

   indications 42

   internal jugular (IJ) access 43

     catheter placement technique 43–4

   subclavian (SC) access 42

central venous pressure (CVP) 105–6

cerebral

   autoregulation 125, 153–7

   blood flow (CBF) 153–7

   perfusion pressure (CPP) 153–7

   trauma patient 167–8, 236

cervical spine instability 25, 36–7

Cesarean delivery 56–9

   case study 217–20

chloroform 181

cholinesterase deficiency 191

cholinesterase inhibitors 192–3

chronic obstructive pulmonary disease (COPD) 17–18, 134

chronic renal failure (CRF) 19

   case study 226–8

cis-atracurium 160, 190

citrate toxicity 162

clonidine 198, 204–6

coagulation studies 163–4

colloid 47

complex regional pain syndrome (CRPS) 87

compliance

   pulmonary 135

   vascular 122

     in congestive heart failure 128

congestive heart failure (CHF) 128

conscious sedation 139

   breast biopsy case study 209–11

continuous positive airway pressure (CPAP) 148

coronary artery disease 13, 16

cricoid pressure 29, 71

cryoprecipitate 50, 51

crystalloid 46–7

cyclodextrins 193–4

dantrolene 194

deadspace 135–6

denitrogenation 29, 146–7

dermatomes 58

desaturation 78–81

   differential diagnosis 78

   management 80–1, 150–2, 210–11

diabetes 13

   case study 226–8

dibucaine number 191

diethyl ether see ether

difficult airway 32–3

diffusion hypoxia 180

diltiazem 205, 206

diuretics 20

dobutamine 200, 201

dopamine 200, 201

droperidol 169–70

drug interaction 165–6

Eagle criteria 13–16

edrophonium 193

electrocardiogram (ECG) 95–6

electroencephalogram (EEG) 103–4, 155–6

EMLA cream 39

endothelium-derived relaxing factor (EDRF) 204–5

endotracheal intubation see airway management

ephedrine 199, 200

epidural anesthesia see neuraxial anesthesia

epinephrine 67, 200, 201, 205

   addition to local anesthetics 196, 197–8

esmolol 202, 203

esters 194–5

ethers 180–1

   history 1

   uptake 175–6

etomidate 170, 173–4

eutectic mixture of local anesthetics (EMLA) 39

evoked responses 104

examination

   airway 24–6

   preoperative assessment 8

exercise tolerance 13

eyes, monitoring of 91

famotidine 167, 168

fasting fluid replacement 47

femoral vein access 42

fentanyl 183, 186–7, 188, 210–11

FFP (fresh frozen plasma) 50, 51

fluid management 46–52

   blood loss 48–9

   blood replacement 49–52

     guidelines 51

     risks 51–2

   blood volume estimation 46

   fluid requirements 47–8

   postoperative care 77

   volume status in the trauma patient 235

   see also vascular access

fluid types 46–7

   composition 47

flumazenil 169

forced expiratory volume in 1 second (FEV1) 18, 139–40

forced vital capacity (FVC) 18, 139–40

fresh frozen plasma (FFP) 50, 51

functional residual capacity (FRC) 70, 146–7

gastroesophageal reflux disease (GERD) 9, 158

gastrointestinal drugs 167–8

general anesthesia 69, 75

   basic approach 165

   depth of anesthesia 73

   emergence 73–4

   induction 70–1

   monitoring 73

   positioning 72–3

   pre-oxygenation 29, 70, 146–7

   problems 74–5

   rapid sequence induction 71

Glasgow Coma Score (GCS) 234

glycopyrrolate 193, 199, 205, 216

GP IIb IIIa inhibitors 20

halogenated aliphatic compounds 181

halothane 181, 182

   cardiovascular effects 182

   hepatitis 159

head lift test 91

heart sounds 92

hemoglobin 136

   oxyhemoglobin dissociation curve 137

   saturation 140–1

hemophilia 162

hemorrhagic diseases 162

heparin 21, 163

herbal remedies 21

hetastarch 47

history of anesthesia 1–2

Holmes, Oliver Wendell 1

hydralazine 203

hydromorphone 183

hyperkalemia 8, 191

hypertension 82

   anesthesia and 16, 124–6, 130, 131

   differential diagnosis 82, 130, 228

   intracranial 154–5

   management 82, 131, 202–5

   pre-eclampsia case study 217–20

   see also blood pressure

hypertonic solutions 47

hypotension 81–2

   differential diagnosis 81, 129

   during anesthesia 128–30

   management 81–2, 199–202

   trauma patient 238

hypothermia 99

hypotonic solutions 46

hypoventilation 78–80

hypoxemia 138–9, 150–2

   see also desaturation

informed consent 21–3

inhalation anesthetics 174–83

   cardiovascular effects 182

   CNS effects 183

   pulmonary effects 182–3

   uptake and distribution 175–8

   see also specific medications

internal jugular (IJ) access 43

   catheter placement technique 43–4

intracranial pressure (ICP) 154–7

   reduction methods 156

   trauma patient 236

intravenous access see vascular access

intravenous regional anesthesia (IVRA) 66

   carpal tunnel release case study 212–14

intubation see airway management

ischemic heart disease 126–7

isoflurane 175, 177

isoproterenol 200, 202

isotonic solutions 47

Jehovah’s Witnesses 10, 12

ketamine 149, 170, 174

kidneys 160–1

labetalol 202, 203

laboratory tests 8–9

lactic acidosis 145

laryngeal mask airway (LMA) 27–8, 33, 36, 71, 210–11

laryngoscope 29–30

laryngoscopy

   intubation 28–32, 36

   pre-operative assessment 24–6

laryngospasm 79

latex allergy 7–8

lidocaine 194–5, 206

   adverse effects 197

lion, eaten by 2, 184

liver 158–60

   enzymes 159

   halothane hepatitis 159

local

   anesthetics 197–8

   additives 197–8

   toxicity 67–7, 197

   see also specific medications

Long, Crawford 1

lung volumes 147

maintenance fluid requirements 47, 48

Mallampati classification 25

mannitol 156

Mapleson system 111–13

mask ventilation 26–7

mechanical ventilation 147–8

medications 6

   bronchodilators 198

   cardiovascular drugs 199–206

     antiarrhythmic drugs 205

     anticholinergic drugs 199

     drugs to lower blood pressure 202–5

     drugs to raise blood pressure 199–200, 202

   drug interaction 165–6

   pre-operative management 19–21

     anticoagulants 20–1

     antihypertensives 20

     anxiety reduction 168–9

     aspiration risk reduction 167–8

     monoamine oxidase inhibitors (MAOIs) 21

     nausea and vomiting prevention 169–70

     peri-operative beta blockade 19

   see also specific medications

Mendelson syndrome 158

meperidine 183, 185, 188

metabolic equivalents (METs) 13

methohexital 170–3, 216

methoxyflurane 181

metoclopramide 167–8

midazolam 168–9

mivacurium 192

monitoring 73, 89–109

   auscultation 92

   BIS (bispectral index) 103

   blood pressure 93–4

   capnography 97–8

   Doppler and ultrasound 101–3

   electrocardiogram (ECG) 95–6

   electroencephalogram (EEG) 103–4

   evoked responses 104

   goals of 90

   inspection 91

   invasive monitors 104–9

     arterial catheter 104–5

     central venous catheter 105–6

     pulmonary artery (PA) catheter 106–9

   neuromuscular function 99–101

   palpation 92–3

   pulse oximetry 94–5

   respired gases 97–9

   temperature 99

monoamine oxidase inhibitors (MAOIs) 21

morphine 183, 185, 186, 198

   bronchospasm and 214

Morton, William T.G. 1

muscle relaxants 18, 189–94

   depolarizing 190–2

   neuromuscular function monitoring 99–101

   non-depolarizing 192

   reversal 192–4

   see also neuromuscular blockade

myocardial ischemia 232

   monitoring for 96

naloxone 187

narcotics see opioids

nausea prevention 169–70

neostigmine 193

nerve blocks

   chronic pain management 87–8

   neurolytic (destructive) blocks 87

   see also peripheral nerve blocks

nerve stimulator technique 65–6

nerves, classification of 57

neuraxial anesthesia 56–64

   blockade placement 62

   cardiovascular effects 59

   cesarean section case study 217–20

   complications 60–1

   indications 63, 64

   pulmonary effects 60

   technique 61–3

neuromuscular blockade

   monitoring 99–101

   residual 78–9, 101

   see also muscle relaxants

nitric oxide 204–5

nitroglycerin 202, 203–4

nitroprusside 202, 204

nitrous oxide 1, 71, 178–80

   augmented inflow (concentration) effect 180

   diffusion hypoxia 180

   second gas effect 180

non-steroidal anti-inflammatory agents (NSAIDs) 20, 55, 189

norepinephrine 200, 201

NPO status 9–10

obesity 18

   gastric bypass case study 221–5

obstructive sleep apnea (OSA) 150, 221, 224

ondansetron 170

opioids 183–9

   addition to neuraxial anesthetics 198

   patient-controlled administration 84–5

   receptor antagonism 187

   side effects 183–5

outpatients, postoperative care 82–3

oxygen

   arterial blood gas analysis 140–1

   monitoring 98

   supplemental oxygen provision 145–6

oxygenation 136–8

   adequacy 77

   alveolar air equation 137–8

   carrying capacity 161

   monitoring 94–5

   oxyhemoglobin dissociation curve 137

     clinical relevance 138–9

   pre-oxygenation 70, 146–7

pacemakers

   anesthesia and 127

   preoperative evaluation 17

packed red blood cells 49–52

pain

   assessment 85–6

   chronic pain management 87–8

   perception of 54–5

   post-operative management 78, 84–7, 188-9

   see also analgesia; analgesics

pancuronium 18, 192

paravertebral sympathetic block 87

paresthesia technique 65

patient-controlled administration (PCA)

   epidural analgesia (PCEA) 86

   intravenous opioid 84–5

peak inspiratory pressure (PIP) 75

PEEP see positive end-expiratory pressure

penicillin allergy 7

peripheral nerve blocks 56, 63–6

   AV shunt placement case study 226–8

   indications 64, 66

   nerve stimulator technique 65–6

   paresthesia technique 65

peripheral venous cannulation 39–41

pH 140–5

phenylephrine 200, 202

physical examination see examination

platelet-function inhibitors 20

platelets 50, 51, 162

pneumothorax 80, 92, 235–6

positioning 72–3

positive end-expiratory pressure (PEEP) 148

Post Anesthesia Care Unit (PACU) 74, 76–7

   bypassing 76

   discharge 82

   see also postoperative care

post-dural puncture headache 61

post-operative care 76–83

   complications 78–82

     desaturation 78–81, 224

     hypertension 82

     hypotension 81–2

     outpatients 82–3

     pain management 34–8, 78

PRBC (packed red blood cells) 49–52

pre-operative evaluation 5–23

   anesthetic choice 10–11

   laboratory evaluations 8–9

   NPO status 9–10

   physical examination 8

   see also specific conditions

pre-operative medication management see medications

pre-oxygenation 70, 147

pressure support ventilation (PSV) 148

procainamide 206

propofol 71, 170, 173

propranolol 203

prothrombin time (PT) 163

pulmonary artery (PA)

   catheterization 44–6, 106–9

   pressure 106

pulmonary disease 17–18

   anesthesia and 148–50

pulmonary embolism 80

pulmonary function tests (PFTs) 18, 139–40

   spirometry 139–40, 147

   see also arterial blood gas analysis (ABG)

pulmonary problems during anesthesia 150–2

pulse oximetry 94–5

pupils, monitoring of 91

ranitidine 167, 168

rapid sequence induction 71

reflex sympathetic dystrophy (RSD) 87

regional anesthesia 54–68

   Cesarean section case study 217–20

   intravenous regional anesthesia (IVRA) 66

     carpal tunnel release case study 212–14

   local anesthetic toxicity 66–7, 197, 213

   see also neuraxial anesthesia; peripheral nerve blocks

remifentanil 183, 187

renal failure 19, 160

   case study 226–8

residual neuromuscular blockade 78–9, 101

respiratory acidosis 141–2

respiratory quotient (R) 132

risks of anesthesia 21–2

ricuronium 190

scopolamine 199

sedation 56, 139

   breast biopsy case study 209–11

self-inflating breathing bag (Ambu) 113

Sellick maneuver 71

serotonin receptor blockers 170

sevoflurane 175, 176, 181, 182

shunting 135–6

SIMV (synchronized intermittent mandatory ventilation) 148

smoking 8, 18

Snow, John 1–2

sodium bicarbonate 206

sodium citrate 167

sodium nitroprusside 204

spinal anesthesia see neuraxial anesthesia

spirometry 139–40

spontaneous ventilation 91

Starling’s forces 122

Starling’s law of the heart 120–2

   congestive heart failure and 128

stellate ganglion block 87

stomach 158

street drug use 8

stroke volume 120–2

subclavian (SC) vein access 42

substance abuse 8

succinylcholine 190–2

sufentanil 183, 187

synchronized intermittent mandatory ventilation (SIMV) 148

systemic vascular resistance (SVR) 119

tachycardia 205

temperature monitoring 99

thiopental 71, 170–1, 173

   biotransformation 158

‘third space’ fluid losses 48

thrombocytopenia 162

thromboelastogram (TEG) 164

tissue oxygenation see oxygenation

total intravenous anesthesia (TIVA) 7

tracheal tug 134

tracheostomy 36–7

transesophageal echocardiography (TEE) 102, 109, 126

transfusions 49–52

   guidelines 51

   risks 51–2

trauma

   case study 233–9

   cervical spine instability 25, 36–7

   emergency assessment 10, 12, 13

Trendelenburg’s position 43, 53

twitch monitor see neuromuscular blockade

vapors 180–3

   cardiovascular effects 182

   CNS effects 183

   inhalation induction 182

   pulmonary effects 182–3

VAS (visual analog scale) pain scores 85–6

vascular access 38–46

   central venous catheterization 41–4

     catheter types 43

     complications 42

     confirmation of intravenous location 44

     femoral access 42

     indications 42

     internal jugular (IJ) access 43–4

     subclavian (SC) access 42

   peripheral venous cannulation 39–41

   pulmonary artery (PA) catheterization 44–6

vasopressin 200, 206

vecuronium 190

ventilation

   mechanical 147–8

   mechanics of 134–5

     work of breathing 134–5

   minute ventilation 134–5

   spontaneous 91

   see also breathing

ventilation/perfusion 135–6

   mismatch 80, 135–6

verapamil 202, 206

visual analog scale (VAS) pain scores 85–6

vitamin K 163

volatile anesthetics see inhalation anesthetics

vomiting prevention 169–70

von Willebrand’s disease 162

warfarin-type agents 163

Wells, Horace 1

work of breathing 134–5

xenon 180


Index of select tables and figures


Preoperative Evaluation

   ASA physical status classification 6

   Considerations in the latex-allergic/sensitive patient 7

   Studies in the trauma patient 13

   ACC/AHA guidelines for perioperative cardiovascular evaluation 15

   Clinical predictors of increased perioperative cardiovascular risk 16

   Cardiac risk stratification for non-cardiac surgical procedures 16

   Pacemaker generators 17

Airway management

   Trauma evaluation of the cervical spine: findings compelling radiographic assessment 25

   Mallampati classification 25

   Endotracheal tube sizes and approximate depths 29

   Cormack and Lehane classification of laryngeal view 31

   Rescue techniques when intubation fails 33

   Innervation of the airway 34

   Airway device selection 36

Vascular access and fluid management

   Equipment for peripheral intravenous access 40

   Complications of central venous catheterization and how to prevent them 42

   Indications for central venous catheterization 42

   Types of central venous catheters 43

   Blood volume estimates 47

   Composition of common intravenous fluids 47

   The 4-2-1 rule for calculation of maintenance fluid requirements 48

   Blood types and their frequencies in the population 50

   Transfusion guidelines 51

   Transfusion reactions 52

Regional anesthesia

   Classification of nerves 57

   Dermatomes 58

   Factors determining the spread of neuraxial anesthesia 58

   Risks and complications of neuraxial anesthesia 60

   Neuraxial blockade placement 62

   Indications and contraindications for neuraxial anesthesia 64

   Indications for peripheral nerve blocks 64

General anesthesia

   Steps in a rapid sequence induction 72

   Trends in monitored signals during complications 75

Postoperative care

   Aldrete score for post-anesthesia recovery 83

   Pain assessment guide 85

   Pain assessment guide in children 86

Monitoring

   Neuromuscular blockade monitor pattern descriptions 100

   Twitch monitor responses with neuromuscular blockade 101

   CVP waveform 106

   Normal pulmonary artery pressure data 107

   Monitoring in anesthesia 108

Anesthesia and the cardiovascular system

   Determinants of blood pressure 120

   Starling curve 121

   Baroreflex 123

   Cerebral autoregulation in hypertension 125

   Factors affecting myocardial oxygen supply and demand 127

   Differentiating causes of hypotension 129

   Causes of intra-operative hypertension 130

Anesthesia and the lung

   Ventilation-perfusion mismatch 136

   Oxyhemoglobin dissociation curve 137

   Pulmonary function test interpretation 140

   Flow-volume loops 141

   Bicarbonate response to acute or chronic respiratory disturbances 142

   Interpretation of acid-base disorder from an arterial blood gas analysis 144

   Differential diagnosis of metabolic disorders (non-exhaustive list) 145

   Lung volumes and capacities 147

Anesthesia and other systems

   Effect of systemic and local factors on cerebrovascular resistance 154

   Methods to reduce intracranial pressure 156

A brief pharmacology related to anesthesia

   GI drugs 167

   Anxiolytics 168

   Anti-emetics 169

   Intravenous anesthetics 171

   Characteristics of inhaled anesthetics 175

   Relative potencies of commonly used opioids 183

   Opioid antagonist 187

   Analgesics for moderate to severe pain (VAS 5–7) in adults 188

   Analgesics for mild pain (VAS < 5) in adults 189

   Non-depolarizing muscle relaxants by duration of action 190

   Antagonists to neuromuscular blocking agents 194

   Local anesthetics 195

   Drugs to raise blood pressure 200

   Drugs to lower blood pressure 202

   Antiarrhythmic drugs 205

   Drugs used in advanced cardiac life support 206

Clinical case – Trauma

   Glasgow coma score 22

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