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Definition and Incidence of the Difficult Airway

Key Points The inability to manage a difficult airway (DA) is responsible for a large proportion of deaths and morbidity directly attributable to anesthesia. While it is important to have common definitions for common problems, the literature continues to report variable nomenclature related to DA management. It is important to have an understanding of the incidence of significant airway problems for the specialty to make advances…

Physiologic and Pathophysiologic Responses to Intubation

Key Points Laryngoscopy can variably induce bradycardia (via the vagal nerve) or hypertension (HTN) and tachycardia (mediated by the cardioaccelerator nerves and sympathetic chain ganglia). The former is most common in infants and children, whereas the latter is typical for adolescents and adults. Laryngoscopy and intubation result in stimulation of the central nervous system and may increase cerebral blood flow (CBF), which may result in elevated…

Airway Pharmacology

KEY POINTS The selection of pharmacologic agents should consider the effects on airway patency, airway reflexes, and airway reactivity. Delivery of inhalational drugs should be optimized to prevent inefficient administration, and dedicated devices may be necessary to increase the amount of drug that reaches the target site. Topical local anesthetics can be safely administered in the upper airway with a low potential for toxicity. The upper…

Physiology of the Airway

Key Points The ventilated gas that participates in gas exchange is referred to as alveolar ventilation (V˙ a ). The volume of gas that is wasted is referred to as dead space (V d ). The aggregate total of dead space is referred to as the physiologic dead space (V d physiologic ) and is divided into two subcomponents. The volume of gas that ventilates the…

Physics of the Airway

Key Points An important formula that quantifies the relationship of pressure, flow, and resistance in laminar flow systems is given by the Hagen-Poiseuille equation. This law states that the fluid flow rate through a horizontal straight tube of uniform bore is proportional to the pressure gradient and the fourth power of the radius and is related inversely to the viscosity of the gas and the length…

Ultrasonography in Airway Management

Key Points Ultrasonography (USG) has many advantages for imaging the airway: It is safe, quick, repeatable, portable, widely available, and gives real-time dynamic images. The cricothyroid membrane (CTM) can easily be identified by USG prior to management of a difficult airway, and this technique should be applied if there is uncertainty about the ability to identify it with inspection or palpation methods. USG must be used…

Radiographic and Cross-Sectional Imaging of the Airway

Key Points Airway practitioners should be acquainted with common imaging modalities. A review of available imaging studies should always be included as part of the preoperative assessment of the airway. The most useful imaging studies to review include neck, spine, and chest radiographs and cross-sectional imaging studies of the cervical spine or the soft tissue of the neck. A review of the scout image or topogram can…

Functional Anatomy of the Airway

Key Points Cricoarytenoid arthritis can lead to airway difficulties in patients with rheumatoid arthritis or systemic lupus erythematosus. To diagnose vocal cord dysfunction, it is necessary to examine the position of the vocal cords during inspiration and phonation. The recurrent laryngeal and superior laryngeal nerves may be injured during thyroid surgery, leading to severe vocal cord dysfunction. Bilateral partial recurrent nerve palsy is more dangerous than…

Myocardial Injury After Noncardiac Surgery

## Intraoperative cardiovascular management of the patient undergoing noncardiac surgery has become an area of widespread interest given the fact that cardiac death is the leading cause of postoperative death within the first 30 postoperative days. Among patients 45 years of age or older undergoing in-hospital noncardiac surgery, complications of cardiac death, nonfatal myocardial infarction (MI), heart failure, or ventricular tachycardia represent the most common complications…

What Is the Best Method for Perioperative Handoffs?

INTRODUCTION A handoff is defined as a transfer of care of a patient between health care providers. This definition includes communication about the condition of the patient and relevant patient history and also may involve the physical transfer of the patient from one part of the hospital to another. Handoffs are of particular interest because of the association between communication deficits and adverse events in patient…

Optimal Postoperative Analgesia for the Opiate-Naïve Patient

INTRODUCTION The management of postsurgical pain has evolved significantly throughout the years. Since the discovery of morphine in the early 1800s, the field has relied heavily on opioid-based medications. Bayer’s aspirin, which was in widespread use by 1899, provided one of the first alternatives to opioids for the treatment of mild to moderate pain. In 1921, the modern technique for lumbar epidural anesthesia for upper abdominal…

Optimal Postoperative Analgesia for the Opiate-Tolerant Patient

INTRODUCTION Opioid tolerance, the physiologic process of diminishing effects combined with rising dose requirements over time with long-term opioid usage, has increased in prevalence in the developed world over the past two decades as opioid use has risen in the same period. Likewise, the proportion of opioid-tolerant patients presenting for surgery has increased and is estimated to be between one-fifth to one-third of patients, and even…

What Must I Consider to Safely Anesthetize Someone in the Office Setting?

INTRODUCTION A hospital and a freestanding ambulatory surgery center (ASC) were once considered the only locations in which to perform a safe anesthetic and surgical procedure. Since the latter part of the twentieth century, however, this assumption has been challenged. Private surgical offices have become increasingly viable anesthetizing surgical and procedural locations. This has been made possible, in part, by the introduction of “shorter-acting” anesthetics with…

What Drugs Decrease Perioperative Bleeding?

INTRODUCTION Anesthesiologists commonly encounter bleeding during and after surgery, which can impact perioperative outcomes, even increasing morbidity and mortality. The most common approach to managing a bleeding patient is by transfusing blood products. Nevertheless, there are instances when there is refractory bleeding despite appropriate blood product administration, necessitating the use of other drugs that can reduce bleeding. In specific patient populations such as those with right-sided…

Optimal Discharge Strategy

INTRODUCTION The concept of the ambulatory procedure with admission, operation, and discharge on the same day has evolved considerably over the last several decades. Both the types and volume of surgical procedures performed on an outpatient basis have expanded tremendously over that period. The reason ambulatory surgical care has rapidly grown is multifaceted and related to changes in both surgical and anesthesia fields. Some of the…

What Works in a Patient With Acute Respiratory Distress Syndrome?

INTRODUCTION Acute respiratory distress syndrome (ARDS) was first recognized in the 1960s, when Ashbaugh et al. described a clinical constellation of hypoxemic respiratory failure accompanied by loss of pulmonary compliance and the histologic hallmark of alveolar hyaline membranes. From the first case series it was noted that a wide range of pulmonary insults incited a similar pathophysiology characterized by noncardiogenic pulmonary edema with diffuse, inflammatory alveolar…

How Young Is the Youngest Infant for Outpatient Surgery?

INTRODUCTION Outpatient surgery accounts for a significant percentage of anesthetics delivered annually in the United States. Many pediatric procedures, such as hernia repair, circumcision, endoscopy, and heel cord tenotomy, are performed in infants and may occur on an outpatient basis. Apnea is the most common serious adverse event after general anesthesia in an infant. Premature and former premature infants are at higher risk for apnea than…

When Should Regional Anesthesia Be Used in Pediatric Patients?

INTRODUCTION The role of regional anesthesia in adult practice is well established. Some of the benefits of regional anesthesia compared with general anesthesia (GA) include improvement in postoperative respiratory mechanics, faster return of bowel function, and a decrease in the hormonal stress response. Regional anesthesia can be safely and effectively used in children of all ages, and its use has expanded beyond a few centers. Providing…

Does Labor Analgesia Affect Labor Outcome?

INTRODUCTION In 1847, only months after the first demonstration of anesthesia, James Simpson, an obstetrician, administered ether to a woman in labor for childbirth. He was quite impressed with the analgesia the new drug induced, as was his patient. Nevertheless, his journal notes on the case indicated his concern over the possible adverse effects of anesthesia on labor and delivery : “It will be necessary to…

Does Anesthesia Increase the Risk to the Parturient Undergoing Nonobstetric Surgery?

INTRODUCTION It is estimated that 0.75% to 2% of pregnant women in developed countries undergo nonobstetric surgery during the course of parturiency; approximately 42% undergo surgery in the first trimester, 35% in the second, and 23% in the third trimester. , Thus nonobstetric surgery during pregnancy accounts for approximately 75,000 to 80,000 procedures per year in the United States alone. , Procedures for appendicitis, cholelithiasis, traumatic…