Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Perioperative Acid-Base Balance

Key Points ▪ The presence of a significant acid-base abnormality often signals a sinister underlying problem. ▪ All acid-base abnormalities result from alterations in the dissociation of water. ▪ Only three factors independently affect acid-base balance—the arterial partial pressure of carbon dioxide (PaCO2), the strong ion difference (SID), and the total concentration of weak acids (A TOT ). ▪ Respiratory acidosis and alkalosis are caused by…

Perioperative Fluid and Electrolyte Therapy

Key Points ▪ Intravenous fluid therapy is a core part of perioperative practice, with the potential to influence patient outcomes. ▪ Water makes up approximately 60% of total body weight, varying widely with age and body composition. The ratio between the water volume within the intracellular and functional extracellular compartments is approximately 2:1. ▪ The endothelial glycocalyx forms a protein-poor intravascular fluid layer at the vessel…

Peripheral Nerve Blocks and Ultrasound Guidance for Regional Anesthesia

Key Points ▪ Regional anesthesia is only successful when local anesthetic is inserted in close proximity to the targeted nerves. From the inception of regional anesthesia over a century ago, several techniques have been designed and available to facilitate the correct placement of local anesthetic, including the paresthesia-seeking approach, peripheral nerve stimulator, and most recently ultrasound guidance. ▪ There are no data to support the superiority…

Spinal, Epidural, and Caudal Anesthesia

Key Points ▪ The distal termination of the spinal cord varies from L3 in infants to the lower border of L1 in adults. ▪ The speed of neural blockade depends on the size, surface area, and degree of myelination of the nerve fibers exposed to the local anesthetic. ▪ Blockade of the peripheral (T1-L2) and cardiac (T1-T4) sympathetic fibers is responsible for the decrease in arterial…

Airway Management in the Adult

Key Points ▪ One of the fundamental responsibilities of the anesthesiologist is to mitigate the adverse effects of anesthesia on the respiratory system by maintaining airway patency and ensuring adequate ventilation and oxygenation. The term airway management refers to this practice and is a cornerstone of anesthesia. ▪ Successful airway management requires a range of knowledge and skill sets—specifically, the ability to predict difficulty with airway…

Neuromuscular Monitoring

Key Points ▪ Good evidence-based practice dictates that clinicians always quantitate the extent of neuromuscular block by objective monitoring. ▪ The neuromuscular block should be adjusted to ensure optimal surgical conditions. In most procedures, one or two responses to train-of-four (TOF) stimulation will suffice. To avoid involuntary diaphragmatic movements, a deeper level of neuromuscular block is required (i.e., one to five responses to post-tetanic count [PTC]).…

Renal Pathophysiology and Treatment for Perioperative Ischemia and Nephrotoxic Injury

Key Points ▪ The incidence of perioperative acute kidney injury (AKI) (previously referred to as acute renal failure) varies, depending on the definition used. ▪ Although uncommon, AKI requiring dialysis is associated with extremely high morbidity and mortality rates. ▪ The mechanism for perioperative AKI is complex and commonly involves multiple factors including ischemia-reperfusion injury, inflammation, and toxins. ▪ Repeated direct perioperative assessments of renal hemodynamics…

Respiratory Monitoring

Key Points ▪ Intraoperative respiratory monitoring is a fundamental component of the American Society of Anesthesiologists’ standards for basic anesthetic monitoring. Monitoring of oxygenation and ventilation is essential for the safe conduct of an anesthetic. ▪ A thorough understanding of the physiological and technological principles underlying respiratory monitoring is essential for its appropriate clinical application. ▪ The majority of respiratory monitors in clinical use provide information…

Monitoring the State of the Brain and Central Nervous System During General Anesthesia and Sedation

Key Points ▪ Anesthesiologists rely extensively on physiologic signals and anesthetic dosing strategies to infer and to track states of the brain and central nervous system under general anesthesia. ▪ Heart rate and systemic arterial blood pressure changes are the principal physiologic signals used to monitor the anesthetic state of patients receiving general anesthesia. ▪ Use of the neurologic examination during induction of and emergence from…

Neurologic Monitoring

Key Points ▪ There are four key principles of intraoperative neurologic monitoring. ▪ The pathway at risk during the surgical procedure must be amenable to monitoring. ▪ The monitor must provide reliable and reproducible data. ▪ If evidence of injury to the pathway is detected, there must be some intervention possible. ▪ If changes in the neurologic monitor are detected, and no intervention is possible, although…

Implantable Cardiac Pulse Generators: Pacemakers and Cardioverter-Defibrillators

▪ Identify the type of cardiovascular implantable electronic device (CIED) (pacemaker, transvenous defibrillator, subcutaneous defibrillator), as well as the generator manufacturer and model of the CIED. ▪ Contact the physician or clinic managing the patient’s CIED in the preoperative period to obtain appropriate records and a perioperative recommendation (Heart Rhythm Society [HRS]). ▪ Obtain a copy of this interrogation and the perioperative recommendation from the CIED…

Perioperative Echocardiography

Key Points ▪ Perioperative applications of transesophageal echocardiography (TEE) include monitoring, diagnosis, and procedural guidance. The role of TEE in cardiac surgery, noncardiac surgery, interventional procedures, and critical care continues to evolve. ▪ In noncardiac surgery, intraoperative TEE serves as a routine monitor or as a rescue tool in life-threatening emergencies. ▪ TEE aids in decision making during cardiac surgery, and three-dimensional (3-D) TEE adds incremental…

Cardiovascular Monitoring

Key Points ▪ Monitoring of the electrocardiogram (ECG) provides continuous monitoring of heart rate, identification of arrhythmias and conduction abnormalities, and detection of myocardial ischemia. ▪ Accurate and reliable ECG monitoring requires attention to lead placement and selection, choice of filter, and gain that will influence the displayed ECG tracing. ▪ An anterolateral precordial lead (V 3 , V 4 , or V 5 ) should…

Neuromuscular Disorders Including Malignant Hyperthermia and Other Genetic Disorders

Key Points ▪ Malignant hyperthermia (MH) is a pharmacogenetic disorder inherited primarily in an autosomal dominant pattern. ▪ MH susceptibility is linked to 230 mutations in the skeletal muscle ryanodine receptor (RyR1) and four mutations in the calcium voltage-gated channel subunit alpha1 S (CACNA1S) genes that encode two Ca 2+ channels necessary for skeletal muscle excitation-contraction coupling. ▪ Physical interactions between L-type Ca 2+ channel (Ca…

Patient Positioning and Associated Risks

Key Points ▪ Patient positioning is a major responsibility that requires the cooperation of the entire surgical team. ▪ Many patient positions that are used for surgery result in undesirable physiologic consequences including significant cardiovascular and respiratory compromise. Anesthetic agents blunt natural compensatory mechanisms, rendering surgical patients vulnerable to positional changes. ▪ Peripheral nerve injuries, although rare, represent 22% of cases in the 1990 to 2007…

Anesthetic Implications of Complementary and Alternative Therapies

Key Points ▪ Herbal medication use has increased dramatically in the overall population and particularly in preoperative patients. ▪ Patients might not volunteer information unless they are queried specifically about herbal medication use. ▪ Although many commonly used herbs have side effects that affect drug metabolism, bleeding, and neuronal function, they are not subject to regulations on purity, safety, and efficacy. ▪ Knowledge of specific interactions…

Anesthetic Implications of Concurrent Diseases

Key Points ▪ The history and physical examination most accurately predict the risks of anesthesia and the likelihood of required changes in monitoring or therapy. ▪ For diabetic patients, end-organ dysfunction and the degree of glucose control in the perioperative and periprocedural periods are the critical issues with regard to risk. ▪ The keys to managing blood glucose levels in diabetic patients perioperatively are to set…

Preoperative Evaluation

Key Points ▪ The anesthesia preoperative evaluation, which is the clinical foundation for guiding perioperative patient management, reduces perioperative morbidity and enhances patient outcome. ▪ The fundamental purpose of preoperative evaluation is to obtain pertinent information regarding the patient’s medical history, formulate an assessment of the patient’s perioperative risk, and develop a plan for any requisite clinical optimization. ▪ The preanesthesia evaluation should include a focused…

Risk of Anesthesia

Key Points ▪ Perioperative risk is multifactorial and may occur as a result of anesthesia-, surgery-, and/or patient-specific factors. ▪ Anesthesia-related (and surgery-related) risk is typically defined as morbidity and mortality occurring within 30 days of surgery, although events that occur at later points may still be related to anesthesia and/or surgery. ▪ The overall risk of anesthesia relates to both specific, organ-based complications and the…

Local Anesthetics

Key Points ▪ Local anesthetics block voltage-gated sodium channels and thereby interrupt initiation and propagation of impulses in axons, but they have a wide variety of other biologic actions, desirable and undesirable. ▪ Currently available local anesthetics are of two chemical classes: aminoesters and aminoamides. ▪ The low potency and lack of specificity of available local anesthetics are due in part to the very weak structural…