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Anesthesia for Procedures in NonOperating Room Locations

Procedures performed outside the operating room (OR) fall under the term nonoperating room anesthesia (NORA), which refers to providing anesthesia care at any location away from traditional OR suites ( Box 38.1 ). In response to the need for minimally invasive interventions in addition to the rapid advancement in imaging and other technologies, the number of NORA procedures has markedly increased in many medical and surgical…

Outpatient Anesthesia

INTRODUCTION Ambulatory anesthesia is a rapidly growing field involving three distinct entities: outpatient anesthesia (the primary focus of this chapter), office-based anesthesia (OBA), and non–operating room anesthesia (NORA) (also see Chapter 38 ). The idea of outpatient anesthesia started over 100 years ago when an ambulatory surgical center (ASC) was opened in Iowa; 50 years later, the first modern ASC was opened in Phoenix, Arizona, in…

Organ Transplantation

Patients waiting for a transplantable organ share a hope for the future that is predicated on the availability of an organ donor. Donor death must be declared before organ procurement. Donation after brain death (DBD) is the most common setting in which donation occurs. Organ shortages have led to the resurgence of interest in donation after cardiac death (DCD). The ethical considerations related to DCD donation…

GERIATRICS

INTRODUCTION The proportion of the U.S. population over the age of 65 continues to grow ( Fig. 35.1 ). This segment of the population is expected to double between the years 2020 and 2060, and the number of people aged 80 and over is expected to triple within this time frame. Globally, the population aged 65 years and over is the fastest-growing age group, and in…

Pediatrics

Providing anesthetic care for infants and children poses unique challenges because of the profound differences in physiology, pharmacokinetics and pharmacodynamics of anesthetic drugs, and wide variety of procedures that these patients undergo, which are often very different from the adult population. The developmental physiology, pharmacology, fluid and transfusion therapy, and airway management in pediatric anesthesia will be defined. Anesthetic considerations and techniques in pediatric patients, especially…

Obstetrics

# Providing peripartum analgesia and anesthesia requires an understanding of the physiologic changes that occur during pregnancy and labor and the effects of anesthetic care on the mother, fetus, and neonate. It also demands an understanding of the course of labor and delivery; knowledge of high-risk maternal conditions; ability to provide a variety of analgesic and anesthetic techniques; and preparation for potential obstetric emergencies and complications…

Orthopedic Surgery

RHEUMATOLOGIC DISORDERS Patients with rheumatoid arthritis (RA) and other rheumatologic disorders, such as ankylosing spondylitis, present for orthopedic surgery related to their disease state. Knowledge of these diseases and their underlying medical issues is essential for optimal anesthetic and perioperative management. Rheumatoid Arthritis RA is a chronic inflammatory disease that initially destroys joints and adjacent connective tissue and then progresses to a systemic disease affecting major…

Ophthalmology and Otolaryngology

Surgical procedures of the head and neck present unique anesthetic challenges. Operative field isolation places the anesthesia provider at a distance from the airway and hampers access to the patient. The region's extensive parasympathetic innervations predispose patients to intraoperative bradycardia and asystole. Ophthalmic and otolaryngologic procedures require smooth induction and emergence from anesthesia. Coughing and bucking increase venous and intraocular pressure (IOP), which may negatively affect…

CENTRAL NERVOUS SYSTEM DISEASE

The central nervous system (CNS) deserves special consideration in the perioperative setting for several reasons. First, anesthesia care is often required for patients undergoing treatment for CNS diseases, such as intracranial tumors or aneurysms, carotid disease, or diseases of the spine. Second, anesthesia providers commonly encounter patients with concurrent CNS diseases (e.g., Parkinson disease or prior stroke) who present for nonneurologic procedures. Third, neurocognitive dysfunction or…

Nutritional, Gastrointestinal, and Endocrine Disease

NUTRITIONAL DISORDERS Obesity Obesity is a condition characterized by excessive accumulation and storage of adipose tissue. Obesity is most commonly quantified by body mass index (BMI), the ratio of a person's weight (in kilograms) to the square of their height (in meters). The Centers for Disease Control and Prevention and the World Health Organization provide definitions of obesity ( Table 29.1 ). , Measuring the degree…

Renal, Liver, and Biliary Tract Disease

RENAL DISEASE Normal renal function is important for the excretion of anesthetics and medications, maintaining fluid and acid–base balance, and regulating hemoglobin levels in the perioperative period. Renal disease is quite prevalent in patients presenting for surgery and is associated with an increased likelihood of poor postoperative outcomes. Even mild renal dysfunction is associated with a more likely risk of postoperative complications. Multiple preoperative risk factors…

Chronic Pulmonary Disease

INTRODUCTION Chronic respiratory problems include obstructive and restrictive lung diseases, obstructive sleep apnea (OSA), and pulmonary hypertension. Obstructive lung diseases are commonly divided into reactive airway disorders (asthma) and chronic obstructive pulmonary disease (COPD). However, many patients have more than one type of lung disease. Using regional or local rather than general anesthesia is preferable for patients with chronic respiratory diseases. History Common symptoms elicited in…

Cardiovascular Disease

Cardiovascular disease is the leading cause of global death, with an estimated 17 million deaths per year; it is also the leading cause of death in the United States. Many of the risk factors identified to predict perioperative mortality are cardiovascular in origin, including coronary artery disease (CAD), peripheral vascular disease, recent myocardial infarction (MI) (in the past 6 months), presence of congestive heart failure (CHF),…

Blood Therapy

The practice of transfusing blood has been around for centuries. The science of transfusion medicine started in the early twentieth century with the discoveries of human blood types and sodium citrate. Human blood typing is the pillar and foundation for safe blood transfusions, and citrate allowed for the storage of blood. The concept of collecting and storing blood (blood banking) was another major development, beginning in…

FLUID MANAGEMENT

INTRODUCTION Perioperative fluid administration has two goals: to ensure adequate intravascular volume to maintain cardiac output and tissue perfusion and to prevent electrolyte and acid–base disturbances. Intravenous fluid therapy represents a core element of anesthesia practice, a companion to the classic triad of unconsciousness, pain relief, and muscle relaxation. The anesthesia provider must select appropriate intravenous fluids and decide the appropriate timing and volume to be…

Hemostasis

INTRODUCTION Hemostasis is an ordered process involving cellular and biochemical components that functions to limit blood loss secondary to vascular injury, maintain intravascular blood flow, and promote revascularization after thrombosis. Normal physiologic hemostasis is a constant balance between procoagulant pathways responsible for generating localized hemostatic clot and counter-regulatory mechanisms that inhibit uncontrolled thrombus propagation or premature thrombus degradation. Vascular endothelium, platelets, plasma coagulation proteins, and fibrinolytic…

Acid–Base Balance and Blood Gas Analysis

~~ The concentrations of hydrogen and bicarbonate ions in plasma must be precisely regulated to optimize enzyme activity, oxygen transport, and rates of chemical reactions within cells. Each day approximately 15,000 mmol of carbon dioxide (which can generate carbonic acid as it combines with water) and 50 to 100 mEq of nonvolatile acid (mostly sulfuric acid) are produced and must be eliminated safely. The body is…

POINT-OF-CARE ULTRASOUND

Point-of-care ultrasound (POCUS) refers to the use of ultrasound at the patient’s bedside for procedural guidance and/or aid in diagnosis. The use and application of POCUS has rapidly expanded over the past 20 years. POCUS is now routinely used by a number of different specialties within medicine. Increased use of ultrasound outside of the traditional radiology setting has been fueled by increasing portability, ease of use,…

Anesthetic Monitoring

INTRODUCTION Anesthesiologists have long been at the forefront of patient monitoring. This has been of necessity because we are responsible for continuously assessing the patient's physiologic status and the effects of surgery and anesthetic agents. This chapter provides an introduction to the basic function and utility of the wide array of monitors employed in modern anesthesia care. Monitoring devices will be organized by organ system, not…

Patient Positioning and Associated Risks

Patient positioning in the operating room facilitates surgical procedures; however, positioning can be a source of patient injury and can alter intraoperative physiology. Positioning injuries during surgery remain a significant source of perioperative morbidity. Anesthesia providers share a critical responsibility for the proper positioning of patients in the operating room. This chapter will review general physiologic changes during positioning, commonly used intraoperative positions, specific positioning concerns,…