Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Control of breathing

Key points The respiratory centre in the medulla generates the respiratory rhythm using an oscillating network of groups of interconnecting neurones. Many other diverse areas of the central nervous system influence respiratory control, and these connections are coordinated by the pons. Irritant and stretch receptors in the lungs and diaphragm are involved in a series of reflex actions on the respiratory centre to influence respiratory activity.…

Respiratory system resistance

Key points Gas flow in the airway is a mixture of laminar and turbulent flow, becoming more laminar in smaller airways. Respiratory system resistance is a combination of resistance to gas flow in the airways and resistance to deformation of tissues of both the lung and chest wall. In smaller airways smooth muscle controls airway diameter under the influence of neural, humoral and cellular mechanisms. The…

Elastic forces and lung volumes

Key points Inward elastic recoil of the lung opposes outward elastic recoil of the chest wall, and the balance of these forces determines static lung volumes. Surface tension within the alveoli contributes significantly to lung recoil and is reduced by the presence of surfactant, although the mechanism by which this occurs is poorly understood. Compliance is defined as the change in lung volume per unit change…

Functional anatomy of the respiratory tract

Key points In addition to conducting air to and from the lungs, the nose, mouth and pharynx have other important functions including speech, swallowing and airway protection. Starting at the trachea, the airway divides about 23 times, terminating in an estimated 30 000 pulmonary acini, each containing more than 10 000 alveoli. The alveolar wall is ideally designed to provide the minimal physical barrier to gas…

Novel Staffing Coverage for Anesthesia Outside the Operating Room

The demand for non–operating room anesthesia (NORA) services is expanding rapidly and for diverse reasons. NORA procedures are often less invasive; many of these minimally or even noninvasive procedures are either no longer adaptable or not able to be performed in traditional operating rooms, or they do not need to be performed in expensive and highly staffed operating rooms. The growth in procedures that no longer…

Development of Future Systems

Anesthetizing patients is a complex business. The number of tasks to perform on a daily basis has increased dramatically, and the number of locations in which they are performed also has risen. Effectively monitoring a patient, charting the patient’s progress, anticipating changes in the surgical field, and adapting the anesthesia care requires a substantial amount of multitasking. Further, delivery of anesthesia care outside the operating room…

Anesthesia and Competitive Strategies

Sedation for medical procedures performed outside the operating room has been traditionally provided by proceduralists and their proxies. However, as these procedures have steadily increased in both number and complexity, anesthesiologists have been increasingly asked to provide care in non–operating room settings. Given the technical demands of many of these procedures and the comorbidities of the patient population, this increase makes sense. Unfortunately, the cost of…

Financial and Operational Analysis for Non–Operating Room Anesthesia

Approximately 20,000 medical students take the Hippocratic Oath each year. They vow to spend the next 10 years learning the art and science of medicine, but little do they know that reality also involves economics and administrative problem-solving. In today’s world of bulging hospital networks and multitiered reimbursements, the days of doctors making house calls are long gone. Consolidation in health care is transforming medicine as…

Anesthesia Concerns in the Magnetic Resonance Imaging Environment

Providing anesthesia in the magnetic resonance imaging (MRI) environment differs from that in the operating room. The static magnetic field necessitates that all monitors, devices, and machines be nonferrous. The gradient magnetic field can interfere with electrocardiographic (ECG) tracing and is the main source of acoustic noise. Radiofrequency field energy is transferred into heat, so the patient usually becomes warm when more energy is absorbed. If…

Pediatric Anesthesia in the Radiology Suite

The pediatric patient population presents unique challenges to its anesthesia providers. These challenges are multiplied when administering an anesthetic in a non-—operating room anesthesia (NORA) location. Evidence indicates that NORA procedures have an increased risk for patients, especially with regard to respiratory events. “Inadequate oxygenation/ventilation was the most common respiratory related remote location claim in the ASA closed claims database, occurring seven times more frequently than…

Adult Anesthesia in the Radiology Suite

One of the driving forces in the genesis of the field of interventional radiology was its minimally invasive nature. As catheters and stents replaced the physiologically taxing “open” procedure, patients were able to have an intervention they may not otherwise have survived. Initially, local anesthesia and light sedation were usually sufficient to provide a comfortable experience for the patient with minimal risk, but continued improvements in…

Anesthesia in the Bronchoscopy Suite

An increasing number of pulmonary disorders are amenable to flexible or rigid bronchoscopic diagnostic or therapeutic intervention. New techniques such as endobronchial ultrasound, electromagnetic navigational bronchoscopy, and treatment of central airway obstruction, including tumor debulking and placement of airway stents, require specialized equipment and the physical space to store and use it. The increase in variety and volume of procedures led to the development of dedicated…

Anesthesia for Colonoscopy

History of Anesthesia for Gastrointestinal Endoscopic Procedures Sedation and analgesia are common components to most upper and lower endoscopic procedures. Although diagnostic upper and lower endoscopy can be performed without sedation, the use of sedative medications improves patient comfort and the quality of the procedure. The use of sedation in part depends on the country and reflects local practices. The decision to include an anesthesiologist in…

Anesthesia for Upper Gastrointestinal Endoscopy

Gastrointestinal (GI) endoscopies are among the most common non–operating room procedures requiring anesthesia. This chapter reviews considerations and challenges related to anesthesia for upper GI endoscopy procedures. These include esophagogastroduodenoscopy (EGD), endoscopic ultrasound (a variation on EGD employing a specialized endoscope with a miniature ultrasound transducer affixed to its distal tip), and endoscopic retrograde cholangiopancreatography (ERCP). The biggest challenge for the anesthesia provider is that because…

High-Frequency Ventilation for Respiratory Immobilization

As imaging technology improves, it is increasingly possible to perform procedures with noninvasive or minimally invasive techniques that would have once required an operating room. Specialized suites such as cardiac electrophysiology, interventional radiology, and radiation oncology have arisen to support these new approaches. A common feature of these techniques is the desire for a motionless field that allows the proceduralist to perform his or her tasks.…

Anesthesia for Cardioversion

Direct-current cardioversion is a common cardiological procedure, consisting of delivering an electric shock to the patient’s heart with the goal of restoring normal sinus rhythm. The common indication for the procedure is atrial fibrillation or flutter and less commonly other supraventricular arrhythmias or ventricular tachycardia. The shock is usually delivered by a pair of conductive pads applied to the patient’s skin on the anterior and posterior…

Anesthesia for Electrophysiology Procedures

Acknowledgments The authors thank Drs. David Callans, Lee Fleisher, and Sean Kennedy for their comments on a draft of this chapter. In the electrophysiology laboratory, procedures are performed to diagnose and treat abnormal cardiac rhythms. These procedures can be accomplished less invasively and more safely than major surgical procedures that were required in the past, especially with higher-risk, older, and sicker patients. Procedures commonly performed in…

Anesthesia in the Catheterization Laboratory: Valves and Devices

The treatment of structural heart disease is undergoing a revolution reminiscent of the management of coronary artery disease 30 years ago—the development, evaluation, and application of catheter-based techniques of valve repair and replacement. Catheter deployed devices have also displaced surgical repair as the preferred treatment for several other cardiac conditions, such as patent ductus arteriosus, atrial septal defect, and patent foramen ovale. These procedures typically require…