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Biological, Natural, and Human-Induced Disasters: The Role of the Anesthesiologist

▪ Natural disasters such as earthquakes, hurricanes, floods, tsunamis, and tornadoes have the ability to cause massive interruptions in the normal provision of health care. ▪ Anesthesiologists possess a combination of knowledge and procedural skills that make them extremely valuable in the immediate and ongoing response to large-scale disasters; to do so, they and their colleagues must be willing to modify their traditional workflow in order…

Prehospital Care for Medical Emergencies and Trauma

Key Points ▪ After World War II, the subspecialty of prehospital emergency medicine evolved with leadership from doctors in anesthesiology. In many countries, prehospital emergency medicine is considered the fourth pillar along with anesthesiology, critical care, and pain therapy. ▪ Emergency medical service (EMS) systems differ among and within countries. When these differences were put together, two primary models evolved. In the United States, paramedics provide…

Anesthesia for Trauma

Key Points ▪ Perioperative anesthesia care for patients who have undergone acute trauma depends on an understanding of trauma system design and surgical priorities. ▪ Successful emergency airway management is based on having a clear plan, such as the American Society of Anesthesiologists algorithm for difficult airways adapted for trauma. In general, rapid sequence induction of anesthesia and in-line cervical stabilization, followed by direct laryngoscopy or…

Geriatric Anesthesia

Key Points ▪ The proportion of adults over age 70 has increased throughout the world with a corresponding increase in older surgical patients. ▪ Normal aging is associated with changes in physiology and an increase in many pathologic conditions. ▪ The number and impact of normal and pathologic conditions varies significantly across elderly individuals. ▪ Preoperative screening recommendations and guidelines for older patients can provide a…

Anesthesia for Orthopedic Surgery

Key Points ▪ Degenerative joint disease is the foremost medical condition leading to operations in the United States. With continued population growth and an increasing percentage of older people, a fivefold increase in the demand for hip and knee arthroplasty and spine procedures is projected by 2030. ▪ Many orthopedic operations including total joint arthroplasties and spine surgeries are classified as intermediate surgical risk, with 30-day…

Anesthesia for Fetal Surgery and Other Fetal Therapies

Key Points ▪ Most fetal anomalies are not appropriate for in utero treatment. A condition appropriate for fetal treatment should cause ongoing irreversible harm to the fetus that is mitigable by early treatment before the fetus can tolerate ex utero neonatal intervention. ▪ A multidisciplinary approach with open communication is essential to the success of each fetal intervention. ▪ Maternal safety and the principle of “do…

Anesthesia for Obstetrics

Key Points ▪ The normal physiologic changes of pregnancy begin in the first trimester, affect all organ systems, and alter pharmacokinetic and pharmacodynamic responses to many drugs commonly used in anesthesia. ▪ Maternal-fetal exchange of most drugs and other substances occurs primarily by diffusion. The rate of diffusion and peak levels in the fetus depend on maternal-to-fetal concentration gradients, maternal protein binding, molecular weight of the…

Anesthesia for Organ Procurement

Key Points ▪ The shortage of organs available for transplantation is a worldwide problem. ▪ The discrepancy between the number of patients waiting for organ transplantation and the available organs remains significant, but has narrowed since 2013. ▪ Most organs in the United States are donated after neurologic death, with a small portion donated after circulatory death and from living organ donors. ▪ Neurologic-death donors have…

Anesthesia for Abdominal Organ Transplantation

Key Points ▪ Survival after abdominal organ transplantation continues to improve. ▪ The imbalance between organ supply and demand is increasing as new indications emerge and transplantation is offered to growing numbers of older candidates. ▪ To increase the supply of organs, living donors and extended criteria deceased donors are being used more frequently. ▪ Evolving organ preservation techniques employing graft perfusion offer the promise of…

Anesthesia and the Renal and Genitourinary Systems

Key Points ▪ Innervation of the intraabdominal components of the genitourinary system—the kidney and the ureter—is primarily thoracolumbar (T8-L2). The nerve supply of the pelvic organs—the bladder, prostate, seminal vesicles, and urethra—is primarily lumbosacral with some lower thoracic input. ▪ The spinal level of pain conduction for the external genitourinary organs is S2-4, except for the testes (T10-L1). ▪ The kidneys receive 15% to 25% of…

Anesthesia for Bariatric Surgery

Key Points ▪ In the United States more than two out of three people are overweight or obese. Worldwide, more people are obese than are malnourished. Obesity is becoming the largest single preventable cause of death and represents major morbidity and mortality. ▪ Metabolic syndrome includes abdominal obesity, decreased high-density lipoprotein, insulin resistance, glucose intolerance, and hypertension, and is present in approximately 34% of the adult…

Anesthesia for Neurologic Surgery and Neurointerventions

Key Points ▪ For the purposes of planning a strategy for controlling intracranial pressure (ICP), the four subcompartments of the intracranial space should be considered: cells, interstitial and intracellular fluid, cerebrospinal fluid (CSF), and blood. ▪ The clinician should make a preoperative assessment of the probable intracranial compliance reserve as the basis for selection of appropriate anesthetic drugs and techniques. ▪ The venous side of the…

Anesthesia for Vascular Surgery

Key Points ▪ Perioperative management of patients undergoing vascular surgery requires an understanding of the underlying pathophysiology of the specific vascular lesion. ▪ Major vascular surgery is particularly challenging to the anesthesiologist because these are high-risk operations in a patient population with a high prevalence of either overt or occult coronary artery disease, which is the leading cause of perioperative and long-term mortality after vascular surgery.…

Anesthesia for Correction of Cardiac Arrhythmias

Key Points ▪ Cardiac arrhythmias are caused by disorders of impulse formation, disorders of impulse conduction, or both. Cardiac arrhythmias may be life-threatening because of a reduction in cardiac output and/or myocardial blood flow or precipitation of a more serious arrhythmia. ▪ Radiofrequency ablation is the therapy of choice for many types of cardiac arrhythmias. ▪ Electrophysiologic studies are used to map out normal and abnormal…

Anesthesia for Cardiac Surgical Procedures

Key Points ▪ Common cardiac surgical procedures in adults include coronary revascularization with either cardiopulmonary bypass (CPB) or off pump, as well as cardiac valve repair or replacement for valvular regurgitation or stenosis, surgical management of heart failure (e.g., ventricular assist devices, extracorporeal membrane oxygenation, cardiac transplantation), initial repair of or reoperation for congenital heart disease, surgical ablation of atrial fibrillation, pericardiocentesis or pericardiectomy, and repair…

Anesthesia for Thoracic Surgery

Key Points ▪ Patients undergoing pulmonary resection should have a preoperative assessment of their respiratory function in three areas: lung mechanical function, pulmonary parenchymal function, and cardiopulmonary reserve (the “three-legged stool” of respiratory assessment). ▪ Patients with underlying lung disease have a decreased risk of respiratory complications when pulmonary resections are performed with video-assisted thoracoscopic surgery (VATS) ▪ After lung resection surgery, it is usually possible…

Palliative Medicine

Key Points ▪ Palliative care is an interprofessional approach to symptom management and decision making for patients with a wide range of serious illnesses and is not limited to patients who are imminently expected to die. ▪ Palliative care teams reduce costs and decrease the burden of symptoms for patients with serious illnesses. ▪ Physicians receive limited training in discussing difficult topics and tend to focus…

Management of the Patient with Chronic Pain

Key Points ▪ The normal physiology of neuronal function, receptors, and ion channels is altered by persistent pain. ▪ Because of the large number of sources and manifestation of chronic pain, classification must include cancer-related, neuropathic, inflammatory, arthritis, and musculoskeletal pain. ▪ Interdisciplinary management of chronic pain must include specialists in psychology, physical therapy, occupational therapy, neurology, and anesthesiology. ▪ Drugs used for chronic pain are…

Patient Blood Management: Coagulation

Key Points ▪ Normal hemostasis is a balance between generation of a localized hemostatic clot and uncontrolled thrombus formation. ▪ The extrinsic pathway of coagulation begins with exposure of blood plasma to tissue factor and represents the initiation phase of plasma-mediated hemostasis. ▪ The intrinsic pathway amplifies and propagates the hemostatic response to maximize thrombin generation. ▪ The common pathway generates thrombin, forms fibrin, and crosslinks…

Patient Blood Management: Transfusion Therapy

Key Points ▪ Blood transfusion is safer now than at any other time in history. Advances in donor screening, improved testing, automated data systems, and changes in transfusion medicine practices account for these increases in safety. ▪ Although the overall condition of the patient is of prime importance, hemoglobin (Hb) values remain a primary component for transfusion decisions with the use of either a restrictive or…