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Craniotomy

1 How do anesthetic requirements differ during various time points in a craniotomy? A craniotomy is unique in that the level of nociceptive stimulus varies greatly and the portions of the procedure that require deep anesthesia are mostly at the beginning. Deep anesthesia is essential during laryngoscopy (and intubation) to block any harmful increases in heart rate, blood pressure, and brain metabolic activity, which may increase…

Spine surgery

1 What are the common indications for spine surgery? By-and-large, spinal deformity is the most common reason a patient requires surgery. Causes of the deformity are usually developmental, such as scoliosis, or degenerative processes. Other reasons for spine surgery include injury from trauma, mass resection, osteomyelitis, and neurological decompensation. These procedures are usually elective but can be urgent or emergent in certain situations. 2 What are…

Thoracic surgery: lung isolation techniques

1 What are the indications for lung isolation? The absolute indications for lung isolation include: 1. Protection of a healthy lung from contamination by a diseased lung (i.e., hemorrhage, pulmonary infection, or bronchopulmonary lavage) 2. Provision of differential lung ventilation in the setting of unilateral lung disease (i.e., bronchopulmonary fistula or large pulmonary cysts or bullae) Lung isolation is relatively indicated to improve surgical exposure for…

Cardiac surgery: cardiopulmonary bypass

1 What are the main functions of the cardiopulmonary bypass (CPB) circuit? The CPB circuit functions as the temporary equivalent of the native cardiopulmonary system. The CPB circuit allows for perfusion of the patient's vital organs, while oxygenating the blood and removing carbon dioxide (CO 2 ). Isolation of the cardiopulmonary system allows for surgical exposure of the heart and great vessels along with cardiac electrical…

Major vascular surgery

1 What are some examples of major vascular surgery? Endovascular aneurysm repair (EVAR): stents passed through an artery (usually femoral) and guided to the aorta via fluoroscopy without operating directly on the aorta. Open aortic surgery: direct repair of the aorta via abdominal or retroperitoneal incision. Carotid endarterectomy: removing an atherosclerotic plaque in the carotid artery to correct stenosis and reduce risk of stroke. Vascular bypass:…

Laparoscopic surgery

1 What are the benefits of minimally invasive procedures? Improvements in scope technology have allowed many procedures to be performed without large surgical incisions, affording the patient rapid recovery of function, less postoperative pain and analgesic requirements, improved postoperative pulmonary function, smaller incisions, fewer wound infections, decreased postoperative ileus, decreased length of hospitalization, and a more rapid resumption of normal daily activities. 2 What are some…

Geriatric anesthesia

1 From an anesthetic perspective, what makes a patient elderly? There is no universal age that defines a patient as aged/geriatric/elderly, although 65 years is used most commonly. Many debate whether considering physiological age may be more appropriate than using chronological age. Overall, elderly patients have decreased functional reserve and are at higher risk for surgical and anesthetic complications. 2 What constitutes frailty? Frailty represents a…

The burned patient

1 Who gets burned? In the United States, there are over 450,000 burn injuries each year responsible for 40,000 hospitalizations and approximately 3400 deaths. The majority of burns are thermal injuries. Electrical burns usually cause tissue destruction by thermal and associated injuries. In chemical burns, the degree of injury depends on the particular chemical, its concentration, and duration of exposure. The majority of burn patients are…

Trauma anesthesia

1 Outline and prioritize the initial assessment and management of a trauma patient. The American College of Surgeons Committee on Trauma has developed a systematic and concise guideline for management of trauma patients and is taught as Advanced Trauma Life Support (ATLS). Initial assessment includes: Primary survey (ABCDEs) Resuscitation Secondary survey Continued postresuscitation monitoring and reevaluation Definitive care The goal of the primary survey is to…

High-risk obstetrics

1 Define high-risk pregnancy. High-risk pregnancies are those that involve either a maternal or fetal condition that increases the likelihood of maternal or fetal morbidity and/or mortality. They comprise approximately 6% to 18% of total pregnancies ( Table 56.1 ); however, the true incidence and particular comorbidity is highly dependent up on the demographic, socioeconomic status, and geographic region. Specifically, high-risk pregnancy is associated with age…

Obstetric analgesia and anesthesia

1 What modes of analgesia are available to the parturient? Parenteral opioids, inhaled nitrous oxide, epidural, spinal, and combined spinal-epidural (CSE) are all acceptable modes of analgesia, depending on the patient's comorbidities, time of presentation, clinical condition, and personal preference. 2 What are the most commonly used parenteral opioids for labor analgesia? Which side effects are of special concern? Although intravenous medications may decrease the intensity…

Fundamentals of obstetric anesthesia

1 What are the cardiovascular adaptations to pregnancy? Increased progesterone levels associated with pregnancy are presumed to increase the production of nitric oxide and prostacyclin. This is coupled with a decreased response to catecholamines and angiotensin, resulting in vasodilation. The subsequent decrease in systemic vascular resistance (SVR) is demonstrated by a decrease in blood pressure. Increased levels of relaxin, responsible for increased tissue elasticity, may lead…

Congenital heart disease

1 What is the incidence of congenital heart disease? Congenital heart disease (CHD) is the most common type of birth defect. Although a variable range can be found in the literature, a reasonable estimate of the incidence is one in 250 live births. Ventricular septal defect is the most common type of CHD, comprising 25% of all congenital heart defects. 2 What are some of the…

Pediatric anesthesia

1 Compare and contrast the adult and pediatric airways. Compared with adults, children have larger heads, shorter necks, smaller nares, and larger tongues. Infants and neonates are obligate nose breathers. They have a large tongue, which can obstruct the airway and make laryngoscopy more difficult. Their large occiput places them in a flexed cervical position when supine, so a shoulder roll can be helpful for positioning…

Neonatal anesthesia

1 Why are neonates and preterm infants at increased anesthetic risk? Pulmonary factors. Differences in the neonatal airway, including large tongue and occiput, floppy epiglottis, small mouth, and short neck predispose infants to upper airway obstruction. The more premature the infant, the higher the incidence of airway obstruction. The carbon dioxide response curve is shifted further to the right in neonates than in adults (i.e., infants…

Alcohol and substance abuse

1 How is alcohol absorbed and metabolized? Alcohol is absorbed across the gastrointestinal mucosa, more so in the small intestine than in the stomach. It enters into the portal vein and proceeds to the liver, where it is metabolized. Most consumed alcohol is converted to acetaldehyde by the enzyme alcohol dehydrogenase and secondarily by cytochrome P450 2E1, as alcohol blood levels rise. Alcohol metabolism follows Michaelis–Menten…

Obesity and obstructive sleep apnea

1 Define obesity. Obesity is defined using the body mass index (BMI) ( Table 49.1 ). BMI=MassHeight2(kgm2) BMI = Mass Height 2 kg m 2 Table 49.1 Classification of Body Mass Index Body Mass Index Classification ≤ 18.5 Underweight 18.5–25 Normal weight 25–30 Overweight 30–35 Class I obesity 35–40 Class II obesity ≥ 40 Class III obesity 2 Describe the implications of obesity as they pertain…

Nondiabetic endocrine disease

1 Review the thyroid hormone laboratory tests. Thyroid hormone laboratory tests include: Total thyroxine (T 4 ) level Total triiodothyronine (T 3 ) level—formed from the peripheral conversion of T 4 Thyroid-stimulating hormone (TSH) level—formed in anterior pituitary Resin T 3 uptake (T 3 RU). T 3 RU is useful in conditions that alter levels of thyroid-binding globulin, which would alter total T 4 results (…

Diabetes mellitus

1 Describe the principal types of diabetes mellitus. Type 1 diabetes mellitus: An autoimmune disorder in which destruction of the insulin-producing beta cells in the pancreatic islets results in the inability to produce insulin. Onset is more common in children and young adults up to age 35 years. Type 2 diabetes mellitus: A disorder in the body's ability to use insulin (insulin resistance). Early in the…

Degenerative neurological diseases and neuropathies

1 What is amyotrophic lateral sclerosis and its anesthetic considerations? Also known as Lou Gehrig disease , amyotrophic lateral sclerosis (ALS) is a disease of both upper and lower motor neurons resulting from degeneration of alpha motor neurons in the brainstem and spinal cord. It usually affects men in the sixth through eighth decade of life. Patients with ALS develop progressive weakness, muscle atrophy, spasticity, and…