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Peripheral Nerve Blocks

INTRODUCTION The Role of Regional Anesthesia Peripheral nerve blocks can provide surgical anesthesia and postoperative pain relief ( Table 18.1 ). The main emphasis of this chapter will be on ultrasound guidance for peripheral nerve blocks. However, paresthetic-based techniques and nerve stimulation also are possible for nerve localization. In addition, ultrasound guidance and nerve stimulation technologies can be combined for some regional blocks. Table 18.1 Examples…

Spinal, Epidural, and Caudal Anesthesia

PRINCIPLES Spinal, epidural, and caudal blocks are collectively referred to as central neuraxial blocks . Significant procedural, physio­logical, and pharmacological differences exist between the techniques, but all blocks result in some combination of sympathetic, sensory, and motor blockade. Spinal anesthesia requires a small amount of drug to produce rapid, profound, reproducible, but finite neuraxial blockade. In contrast, epidural anesthesia typically progresses more slowly, is commonly prolonged…

AIRWAY MANAGEMENT

Expertise in airway management is the cornerstone of safe anesthesia practice. The past decades have seen an evolution of airway management, notably with the adoption of supraglottic airway (SGA) devices in the early 1990s and, more recently, the rapid uptake of video laryngoscopy as a first-line technique in the management of both routine and difficult airways and as an educational training tool for novice learners. The…

Anesthesia Delivery Systems

THE ANESTHESIA WORKSTATION In the decades after the first public demonstration of ether anesthesia in 1846 the anesthesia delivery system consisted of handheld devices ranging from ether- or chloroform-soaked cloths to more sophisticated inhalers that could regulate the administered dose of anesthetic. The modern anesthesia workstation remains at its core a device for delivering inhaled anesthesia, but incorporates many additional functions focused on safety and ease…

CHOICE OF ANESTHETIC TECHNIQUE

The decision-making process regarding anesthetic technique begins with the proposed surgical procedure and incorporates the patient's coexisting diseases and preferences for care. The ultimate responsibility for anesthetic choice lies with the anesthesia provider. Once the anesthesia type is selected, additional management details such as choice and sequence of medications must be planned. The anesthesia provider must have the ability to implement a range of anesthetic plans…

Preoperative Evaluation

High-quality anesthesia care begins with the preoperative evaluation. The goals of preoperative evaluation include understanding the proposed surgery, assessing the risk of coexisting medical conditions, deciding whether additional testing is needed to prepare the patient for the procedure, discussing options for anesthesia care, and understanding and addressing patient concerns. Preoperative (or preanesthesia) evaluation can be defined as the process of clinical assessment that precedes the delivery…

Anesthetic Neurotoxicity

~~ A major concern within the specialty of anesthesiology is the impact of general anesthesia and sedative drugs on neurodevelopment and cognition across the life span. Although definitive conclusions cannot be made, anesthesia providers should follow the progress of our knowledge regarding long-term effects of anesthesia on the developing central nervous system (CNS). Neuronal cell death and neurocognitive impairments after general anesthesia have been unequivocally demonstrated…

Neuromuscular Blocking and Reversal Agents

INTRODUCTION Neuromuscular blocking agents (NMBAs) interrupt the usual transmission of nerve impulses at the neuromuscular junction (NMJ) by one of two mechanisms to interfere with neuromuscular transmission and produce paralysis of skeletal muscles. On the basis of differences in their mechanisms of action, these drugs can be classified as depolarizing NMBAs (which mimic the actions of acetylcholine [ACh] at the acetylcholine receptor [AChR]) and nondepolarizing NMBAs…

Local Anesthetics

Local anesthesia can be defined as loss of sensation in a discrete region of the body caused by disruption of nerve impulse generation or propagation. Local anesthesia can be produced by various chemical and physical means. However, in routine clinical practice local anesthesia is produced by several compounds whose mechanism of action is similar. Although they have different durations of action, recovery is normally spontaneous, predictable,…

Opioids

BASIC PHARMACOLOGY Structure and Activity Opioids play an indispensable role in the practice of anesthesiology, critical care, and pain management. A sound understanding of opioid pharmacology, including both basic science and clinical aspects, is critical for the safe and effective use of these important drugs. This chapter will focus almost exclusively on the intravenous opioid receptor agonists used perioperatively. The opioids of clinical interest in anesthesiology…

Intravenous Anesthetics

WHY INTRAVENOUS ANESTHETICS? Intravenous (IV) anesthetics are fundamental tools in the daily practice of modern anesthesia ( Box 8.1 ). One or more IV anesthetics will be administered in essentially any clinical encounter where a provider delivers anesthesia or sedation, regardless of the setting (operating room, non–operating room, or intensive care unit [ICU]). When used appropriately, IV anesthetics have many advantages and only a few drawbacks…

Inhaled Anesthetics

HISTORY Before the introduction of anesthesia, surgery was usually excruciating and harrowing for patients, limited in duration and technique by what the patient could tolerate. On October 16, 1846, the dentist William T. G. Morton administered diethyl ether for a surgery at the Massachusetts General Hospital to remove a tumor from Ebenezer Hopkins Frost’s neck. The patient’s ability to tolerate the surgery, recalling afterwards a dulled…

Autonomic Nervous System

ANATOMY OF THE AUTONOMIC NERVOUS SYSTEM The Sympathetic Nervous System The autonomic nervous system (ANS) controls involuntary activities of the body outside consciousness. It is at once the most primitive and among the most essential of control systems—primitive in that its characteristics are largely preserved across all mammalian species and essential in that it oversees responses to immediate life-threatening challenges and the body’s vital maintenance needs.…

Clinical Cardiac and Pulmonary Physiology

When it comes to direct, integrated, daily management of cardiac and pulmonary physiology, no specialty compares with anesthesiology. A sound understanding of the separate and integrated fundamentals of cardiorespiratory physiology is essential for an anesthesia provider to rapidly manage both critical and common situations such as hypotension, arterial hypoxemia, hypercapnia, and high peak airway pressures. The knowledge and skills required to excel as anesthesia providers provide…

Basic Pharmacologic Principles

The basic principles of pharmacology are a fundamental element of an anesthesia provider's knowledge base. This chapter provides an overview of key principles in clinical pharmacology used to describe anesthetic drug behavior. Box 4.1 lists definitions of some basic pharmacologic terms. Pharmacokinetic concepts include volumes of distribution, drug clearance, transfer of drugs between plasma and tissues, and binding of drugs to circulating plasma proteins. The section…

Clinician Well-Being

Clinician well-being has emerged as a critical issue because of widespread clinician burnout. There is growing recognition that a combination of individual strategies and systems-level solutions is required to successfully promote clinician well-being. Interventions to prevent burnout are more effective than those that address burnout after it has occurred. DEFINING TERMS Burnout In its 11 revision of the International Classification of Diseases (ICD-11) the World Health…

LEARNING ANESTHESIA

The challenges of learning perioperative anesthesia care have grown considerably as the specialty has evolved. The beginning anesthesia trainee is faced with an ever-increasing quantity of literature and the need for increased knowledge and adequate patient care experiences. Healthcare systems increasingly focus on improving the patient experience of care (including quality and satisfaction), improving population health, reducing the cost of healthcare, and improving environmental sustainability. Most…

Scope of Anesthesia Practice

. Surgery preceded the development of anesthesia as a medical specialty, with significant implications. Surgery has been performed for thousands of years. Archaeologists have discovered human skulls from prehistoric times with evidence of trephination, a surgical procedure involving drilling or scraping a hole in the skull to expose the brain. However, the brutality of surgery without anesthesia limited the types of surgery that could be performed…

Interpreting the Medical Literature

Key Points ▪ The medical literature can be accessed in many ways, ranging from the primary literature as indexed in sources like PubMed, to sources catering to medical professionals, and via the lay press and social media as well. ▪ The quality of medical literature varies widely, as does the interpretation or distillation into secondary sources of information. ▪ The traditional “evidence pyramid” no longer effectively…

Clinical Research

Key Points ▪ Clinical research describes the characteristics and mechanisms of disease and injury in humans and investigates drugs, devices, diagnostic products, and bundles of care with the aim of providing high-quality evidence to guide clinical practice that improves patients’ lives. ▪ Investigators are constrained by the need to draw conclusions based on a sample of patients, providers, or systems rather than the whole of the…