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Occupational Safety, Infection Control, and Substance Abuse

Key Points ▪ Exposure to waste anesthetic gas in clinical practice is unavoidable. In the United States, the limits of exposure to waste gases are set by the National Institute for Occupational Safety and Health (NIOSH), which recommends a time-weighted average of 25 ppm for nitrous oxide and a ceiling of 2 ppm for volatile anesthetics. ▪ Although researchers disagree whether exposure to anesthetic gases at…

Acute and Anesthetic Care of the Burn-Injured Patient

Key Points ▪ Major burn injury results in pathophysiologic changes affecting virtually all organs from the onset of injury until wounds are healed. Anesthesiologists are often called on to care for burn injury patients through their hospitalization including acute airway management and resuscitation, intraoperative anesthetic care, intensive care, and management of postoperative pain. ▪ Burn shock is a paradigm of ischemia/reperfusion injury. The initial ischemic (ebb)…

Cardiopulmonary Resuscitation and Advanced Cardiac Life Support

Key Points ▪ Cardiac arrest is a major public health issue worldwide. Despite significant advances in resuscitation science, survival rates remain considerably low. Improvement of patient survival and neurologic outcome relies on the development and implementation of vigorous and evidence-based resuscitation guidelines involving basic life support (BLS), advanced cardiovascular life support, and post–cardiac arrest care. ▪ In cardiac arrests without hypoxic causes, oxygen content in the…

Extracorporeal Membrane Oxygenation and Cardiac Devices

Key Points ▪ Extracorporeal membrane oxygenation (ECMO) consists of a specific heart-lung machine that provides circulatory support and/or gas exchange for patients with severe but potentially reversible respiratory or cardiac failure or both. Although the term <ce:italic>extracorporeal life support</ce:italic> (ECLS) might describe the system more accurately, ECMO is actually most often used and universally accepted for describing all its applications. ▪ Different configurations of ECMO (e.g.,…

Neurocritical Care

Key Points ▪ Critical care of the nervous system is based on control of cerebral and spinal cord physiology and the prevention of secondary insults. This goal, in turn, depends on the comprehensive maintenance and adequacy of physiologic parameters and organ function. ▪ Cerebral function is critically dependent on oxygen delivery matching metabolism. ▪ Increased intracranial volume beyond the capacity of compensatory mechanisms increases intracranial pressure…

Critical Care Anesthesiology

Key Points ▪ Anesthesiologists have been key contributors to the field of critical care, both in the advancement of clinical practice and development of technology relevant to the field. ▪ Intensive care unit structure, staffing, and utilization varies considerably among developed countries. Studies generally show improved patient outcomes with “high-intensity” staffing models. ▪ Low-tidal-volume lung protective ventilation improves mortality for patients with acute respiratory distress syndrome…

Cognitive Dysfunction and Other Long-Term Complications of Surgery and Anesthesia

Key Points ▪ Postoperative cognitive concerns have been voiced by older patients, their families, and caregivers for over a century, and more recently documented with objective testing. ▪ The term postoperative cognitive dysfunction (POCD) is neither recognizable by the general medical community nor sufficiently granular to cover the spectrum of perioperative cognitive disorders. It will be replaced by a DSM-5-motivated nomenclature, which will include postoperative delirium.…

Acute Postoperative Pain

Key Points ▪ The process of nociception is a dynamic process (i.e., neuroplasticity) with multiple points of modulation. Persistent noxious input may result in relatively rapid neuronal sensitization and possibly persistent pain. ▪ Postoperative pain, especially when poorly controlled, results in harmful acute effects (i.e., adverse physiologic responses) and chronic effects (i.e., delayed long-term recovery and chronic pain). ▪ By preventing central sensitization, preventative analgesia may…

The Postanesthesia Care Unit

Key Points ▪ Emergence from general anesthesia and surgery may be accompanied by a number of physiologic disturbances that affect multiple organ systems. Most common are postoperative nausea and vomiting (PONV), hypoxia, hypothermia and shivering, and cardiovascular instability. ▪ In a prospective study of more than 18,000 consecutive admissions to the postanesthesia care unit (PACU), the complication rate was found to be as high as 24%.…

Pediatric and Neonatal Critical Care

Key Points ▪ Congenital heart disease causes significant alterations in oxygenation, perfusion, and myocardial function after birth, and it can be categorized into hypoxic and normoxic lesions. ▪ The overall goal of therapy in shock is to treat the underlying cause, return adequate oxygen delivery to the tissues, and remove metabolic products that developed during anaerobic metabolism. It appears that the faster the body returns to…

Anesthesia for Pediatric Cardiac Surgery

Key Points ▪ Organ system maturation, from birth through adolescence, affects physiologic function and therefore anesthetic and surgical management and outcome. ▪ The understanding of congenital heart disease (CHD) and consequent anesthetic management is based on the pathophysiologic determinants of four categories of defects: shunts, mixing lesions, stenotic lesions, and regurgitant lesions. ▪ The chronic sequelae of CHD (repaired, palliated, or unrepaired) affect anesthetic management: ventricular…

Pediatric Anesthesia

Key Points ▪ At birth the circulation undergoes a fundamental change as blood oxygenation occurs through the lungs rather than the placenta. This transition places some newborns at risk of sudden increases in pulmonary artery pressure with resultant shunting of blood past the lungs through a patent foramen ovale or the ductus arteriosus. This may be triggered by hypoxia, hypercapnia, acidosis, and infection. ▪ The reduced…

Regional Anesthesia in Children

Key Points ▪ Over the last three decades, regional anesthesia in pediatrics has become an integral part of everyday practice. ▪ Regional anesthesia appears as a viable option for treating intraoperative and postoperative pain control in children. ▪ In recent years, there has been an upsurge in the use of peripheral nerve blockade in infants and children. ▪ Large pediatric databases have contributed pertinent data on…

Clinical Care in Extreme Environments: High Pressure, Immersion, Drowning, Hypo- and Hyperthermia

Key Points ▪ Immersion in water causes acute redistribution of blood from the extremities and splanchnic vessels to the heart and pulmonary vessels. This can precipitate pulmonary edema (immersion pulmonary edema [IPE], swimming-induced pulmonary edema [SIPE]) in some individuals, especially during heavy exercise or in the presence of myocardial dysfunction. SIPE usually responds to removal from the water and oxygen therapy. ▪ Prolonged immersion induces diuresis…

Clinical Care in Extreme Environments: Physiology at High Altitude and in Space

Key Points ▪ High altitude or space environments present a number of extreme physiologic challenges that must be overcome in order to survive. ▪ Given sufficient time, humans can adapt to both hypobaric hypoxia and microgravity. ▪ Lack of adaptation can lead to environment-specific illnesses, such as acute mountain sickness, high-altitude pulmonary edema, decompression illness, or the acute worsening of comorbid conditions. ▪ These conditions can…

Non-Operating Room Anesthesia

Key Points ▪ The non-operating room arena represents an expansion of the traditional environment for anesthesia practice with significant implications for patients and providers. As technology advances and patient acuity increases, non-operating room anesthesia (NORA) cases have become more demanding in terms of both patient management and required resources and support services. ▪ Financial and operational constraints create additional challenges. Significant differences in practice result from…

Ambulatory (Outpatient) Anesthesia

Key Points ▪ The use of ambulatory surgery continues to increase, mostly as a result of less invasive surgical techniques, improved patient selection and preparation, and an expansion of office-based practice. ▪ Few absolute contraindications exist to ambulatory surgery. Patients should not be excluded on the basis of arbitrary limits, such as age, body mass index, or American Society of Anesthesiologists physical status classification system. ▪…

Anesthesia for Robotic Surgery

Key points: Robotic surgery has witnessed explosive growth. Currently (2018) more than 3 million procedures have been performed using the da Vinci system worldwide. Robotic surgery is not true autonomous surgery but instead the robot is used as mechanical “helping hands” aiding skilled surgeons. ▪ By creating three-dimensional views, allowing increased movement of laparoscopic instruments within a patient’s body, and allowing precise movements, robotic surgery can…

Anesthesia for Otolaryngologic and Head-Neck Surgery

Key Points ▪ Difficult airways are more frequently encountered in patients undergoing ear, nose, and throat (ENT) surgery, especially for cancer. Reviewing the results of a preoperative computed tomography (CT) scan or an endoscopic airway examination may help identify pathologic features likely to produce airflow obstruction or complicate tracheal intubation. ▪ Although the tracheas of ENT patients are often intubated using ordinary polyvinyl chloride endotracheal tubes…

Anesthesia for Ophthalmic Surgery

Key Points ▪ Ophthalmic procedures are considered to be “low-risk.” However, the patient population is higher risk because of the extremes of age involved and associated comorbidities. ▪ Some ophthalmic surgeries (cataract, glaucoma, simple vitrectomy) are short procedures, but high in volume. The demand for efficiency while maintaining patient safety is a challenge. ▪ The majority of ophthalmic procedures can be performed under topical anesthesia or…