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Interdisciplinary Pain Management

“Chronic pain is a complex biopsychosocial phenomenon that may interfere with many aspects of a person’s life—ability to work, personal relationships, and both physical and mental health”. The National Pain Strategy “Pain for me, arrives as a complete package, and that demands a team approach.” Patrick Wall, PhD Introduction Interdisciplinary pain rehabilitation incorporates a team-based approach based on a biopsychosocial model of care. This chapter will…

Organizing an Inpatient Acute Pain Service

The Rationale Over the last decade, several surgical practices and public health initiatives, in addition to drug and technology advancements, have impacted inpatient acute pain services worldwide, for example, the continued development and implementation of less invasive surgical techniques, such as arthroscopy. Laparoscopy and robot-assisted surgery have reduced post-surgical pain and allowed nearly two-thirds of surgeries to be performed on an outpatient basis. Nonetheless, moderate to…

Classification of Acute Pain and Chronic Pain Syndromes

Definition of Pain The International Association for the Study of Pain (IASP) updated the definition of pain in 2020. The previous definition remained unchanged for more than 40 years (originally released in 1979), but it provided a necessary and widely accepted description in the medical field. The 1979 definition of pain was as follows: “An unpleasant sensory and emotional experience associated with actual or potential tissue…

History Is a Distillation of Rumor

THOMAS CARLYLE (1795-1881) Management of pain, such as the management of any disease, is as old as the human race. In the view of Christians, the fall of Adam and Eve in the Garden of Eden produced a long life of suffering pain for men and women. This act allegedly sets the stage for several disease concepts, including the experience of pain in labor and delivery,…

Anticoagulant and Antiplatelet Therapy

Arterial and venous thrombosis are major causes of morbidity and mortality. Venous thromboembolism (VTE) is the leading cause of preventable in-hospital mortality. Deep vein thrombosis (DVT) leading to VTE causes as many as 300,000 deaths annually in the United States and approximately 300,000 within the European Union as well. Arterial thrombosis is the most common cause of myocardial infarction (MI), ischemic stroke, and limb gangrene. Arterial…

Transfusion and Coagulation Therapy

Hemoglobin and Volume Replacement Therapies Historical Aspects of Transfusion The observation by Harvey in 1628 that blood circulates in a closed vascular system was pivotal in the practice of blood transfusion. As blood was recognized as vital to sustain life, Denis in Paris and Lower in Oxford attempted xeno-transfusion (animal blood to humans) with little success in the 17th century. The first documented transfusion of human…

Blood and Coagulation

Hemostasis is a critical homeostatic mechanism of survival that involves vascular, cellular, and plasma components that interact to stop bleeding. Vascular effects include vasoconstriction, expression of procoagulant factors such as tissue factor, and loss of normal anticoagulant functions of the endothelium. Coagulation and clot formation occur by cellular and humoral factors that interact together with local and systemic factors. Surgery produces complex alterations and defects in…

Electrolytes and Diuretics

Electrolyte concentrations are tightly controlled within physiologic ranges, which are essential for human health. The major electrolytes, sodium (Na + ), potassium (K + ), calcium (Ca 2+ ), phosphate (PO 4 3− ), and magnesium (Mg 2+ ), are critical to basic physiologic functions, including action potential generation, cardiac rhythm control, muscle contraction, and energy storage, among many others. Electrolytes, most notably Mg 2+ ,…

Intravascular Volume Replacement Therapy

Historical Perspective Plasma volume replacement is important in the perioperative period. The body and cardiovascular system are exposed to many challenges, such as neurohumoral adaptations, evaporation, fluid redistribution, and blood loss, that necessitate interventions. To achieve this, fluids are administered intravenously following protocols based on tradition, expert recommendations, and often limited evidence. There is an ongoing debate concerning the ideal composition and amount of intravenous fluids…

Renal Physiology

The kidney is a complex multifunctional organ that can be affected by anesthesia and the physiologic alterations of the perioperative period. The main functions of the kidney in the context of anesthesiology include (1) regulation of salt and water balance, (2) toxin and metabolite elimination (including drugs), (3) electrolyte homeostasis, (4) acid–base balance, and (5) hormone production. These functions must be understood and recognized for optimal…

Infection, Antimicrobial Drugs, and Anesthesia

Historical Perspective After antibiotics came into widespread use in the 1940s and 1950s, the possibility that giving antibiotics perioperatively might prevent surgical site infection (SSI) became a matter of debate. Miles and colleagues used a guinea pig model to demonstrate that appropriate antibiotics were effective in preventing invasive infection and necrosis only when given within 2 hours before or after intradermal injection. This gave rise to…

Chemotherapy, Immunosuppression, and Anesthesia

The concept of “immunosurveillance” describes a homeostatic balance whereby cells that undergo transformation into cancer cells are normally eliminated or kept in check by the immune system. In 1985 an autopsy study found that 36% of “normal” thyroid glands showed occult carcinomas, even though the incidence of clinically diagnosed thyroid cancer is one-thousandth of that rate in the same population. In 1987 another group found in…

Physiology and Pharmacology of Obstetric Anesthesia

Physiology Hormone activity, increased metabolic demands, the gravid uterus, and biochemical changes related to the fetoplacental unit result in significant alterations in maternal physiology, anatomy, and pharmacology during pregnancy, as shown in Fig. 37.1 . These physiologic changes have a direct impact on maternal pharmacodynamics and anesthetic management considerations during the peripartum period. Cardiovascular Changes Pregnancy-related changes to the cardiovascular system include an increase in cardiac…

Endocrine Pharmacology

Dysfunction of the complex physiologic processes of the endocrine systems can lead to significant and potentially life-threatening problems. Administration of exogenous hormones or drugs that mimic or antagonize hormonal effects to manipulate the metabolic milieu is important in many therapies. Endocrine pharmacotherapeutics range from simple supplementation of a missing hormone, such as insulin in the case of patients with type 1 diabetes mellitus (DM), to careful…

Endocrine Physiology

Endocrine physiology encompasses processes that range from master regulation by the pituitary gland to the much larger pancreas, which controls energy utilization processes of the body. This chapter reviews normal endocrine physiology and pathophysiology, as well as the basic anesthetic implications associated with the 5 major endocrine organs relevant to anesthesiologists: the pituitary gland, parathyroid glands, thyroid gland, adrenal glands, and the pancreas. Pituitary Physiology The…

Pharmacology of Postoperative Nausea and Vomiting

Historical Perspective In the first half of the 20th century, one of the most feared complications of general anesthesia was postoperative vomiting (POV), primarily because aspiration of gastric contents into the lungs could lead to death. Early prophylaxis sometimes consisted of advising patients to consume olive oil before general anesthesia to shield the intestinal wall from emetogenic gases. Prevention of POV was one of the primary…

Nutritional and Metabolic Therapy

Macronutrients have traditionally been regarded as a means to satisfy basic energy needs for cellular homeostasis, while amino acids are considered necessary for anabolism and protein synthetic machinery of the cell. Surgical, traumatically injured, and critically ill patients, however, are in a dynamic state between systemic inflammation, immune suppression, and persistent chronic inflammatory states. It often takes weeks or months for the inflammatory states resulting from…

Liver and Gastrointestinal Pharmacology

One of the main functions of the liver is to protect against toxins. The endoplasmic reticulum of hepatocytes contains families of enzymes that protect the organism against an accumulation of lipid-soluble exogenous and endogenous compounds. This is done by transforming compounds to water-soluble metabolites, which are more readily excreted by the kidneys. Gastrointestinal absorption of orally administered drugs and the pharmacology of the gastrointestinal tract are…

Liver and Gastrointestinal Physiology

In perioperative management, the hepatic and gastrointestinal (GI) systems usually receive consideration after the cardiovascular and respiratory systems. However, potential perioperative problems such as aspiration, ileus, and nausea and vomiting are common and significant. Additionally, end-stage liver disease—often associated with multisystem organ failure—can be life threatening. It is incumbent in anesthesiology to understand the physiologic basis of these conditions to minimize associated complications and optimize patient…

Pulmonary Pharmacology

The most widely used medications in pulmonary medicine are those delivered via inhalation for small airway diseases, such as asthma, chronic obstructive pulmonary disease, and cystic fibrosis. Using the lung as a vehicle for drug delivery is well known to anesthesiologists who routinely deliver volatile anesthetics to the lungs for systemic distribution. This chapter examines in detail pharmacologic approaches to the pulmonary system relevant to anesthesia;…