Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Renal function and anesthesia

1 Describe the anatomy of the kidney. The kidneys are paired organs lying retroperitoneally against the posterior abdominal wall. Although their combined weight is only 300 g (about 0.5% of total body weight), they receive 20% to 25% of the total cardiac output. That means that within 5 minutes, the body’s entire blood volume has circulated through the kidneys. This exceeds skeletal muscle perfusion, even during…

Hepatic dysfunction and liver transplantation

1 Describe normal liver anatomy. How is blood supply provided to the liver? The human liver consists of four anatomic lobes (left, right, caudate, quadrate) and eight surgical lobes (I–VIII). The liver receives approximately 20% to 25% of the cardiac output and contains 10% to 15% of the total blood volume. Its blood supply is provided by the portal vein (75%) and hepatic artery (25%), where…

Acute respiratory distress syndrome

1 How would you define acute respiratory distress syndrome? The most commonly used definition for acute respiratory distress syndrome (ARDS), known as the Berlin definition ( Table 40.1 ), was described in 2012. The Berlin definition describes ARDS as: (1) the development of respiratory failure that occurs within 7 days of a known clinical insult and represents new or worsening respiratory symptoms that are associated with…

Obstructive lung disease: asthma and chronic obstructive pulmonary disease

1 Define reactive airway disease. The term reactive airway disease (RAD) is used to describe a family of diseases that share the common characteristic of airway sensitivity to physical, chemical, or pharmacological stimuli. This sensitivity results in a bronchoconstrictor response throughout the tracheobronchial tree and is seen in patients with asthma, chronic obstructive pulmonary disease (COPD), emphysema, viral upper respiratory illness, and some other respiratory disorders.…

Pulmonary hypertension

1 Define pulmonary hypertension and pulmonary artery hypertension. Pulmonary hypertension (PH) refers to a mean pulmonary arterial pressure (> 25 mm Hg) from any cause. Pulmonary artery hypertension (World Health Organization [WHO] group 1) was previously referred to as primary pulmonary hypertension . Pulmonary artery hypertension (PAH) is defined by a mean pulmonary artery pressure (PAP) over 25 mm Hg at rest, with a pulmonary capillary…

Valvular heart disease

1 Discuss the basic pathophysiology of valvular heart diseases. Valvular heart diseases cause chronic volume or pressure overload, where each evokes a characteristic ventricular response causing ventricular hypertrophy. Ventricular hypertrophy is an increase in left ventricular (LV) mass. Pressure overload produces concentric ventricular hypertrophy, which is characterized by an increase in ventricular wall thickness with a relatively normal cardiac chamber size. Volume overload, however, leads to…

Heart failure

1 What is heart failure? Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood. The cardinal manifestations of HF are dyspnea, fatigue, and lower extremity edema, all of which may limit exercise tolerance. These symptoms are usually secondary to fluid retention, which in turn leads…

Coronary artery disease and perioperative myocardial infarction

1 What are the known risk factors for the development of coronary artery disease? Age, male gender, and positive family history (first-degree relative with coronary artery disease [CAD], male < 55 years or female < 65 years) are risk factors that cannot be modified. Smoking, hypertension, diet, dyslipidemia, physical inactivity, obesity, and diabetes mellitus are modifiable risk factors. 2 Describe the normal coronary blood flow. The…

Post-anesthetic care

1 Which patients should be cared for in the postanesthetic care unit? According to American Society of Anesthesiologists standards, all patients who have received an anesthetic of any kind shall receive postanesthetic management of some kind. Postanesthetic care unit (PACU) care is traditionally divided into phase 1, which is functionally analogous to an intensive care unit, and phase 2, wherein transition is made from intensive observation…

Temperature disturbances

1 What is normal core body temperature? What is the definition of hypothermia and hyperthermia? Normal core body temperature is approximately 37°C. Core body temperature is not constant and fluctuates throughout the day (± 0.5°C), with circadian rhythm, and in women with menstrual cycle. Hypothermia is defined as a core temperature less than 36°C and hyperthermia as a core temperature greater than 38°C. 2 Should all…

Awareness during anesthesia

1 Review the classifications of memory and awareness. Memory can be classified as implicit (unconscious memory) and explicit (conscious memory). Conscious recollection of events, including intraoperative events, would fall under the category of explicit memory. Awareness with recall (AWR) during general anesthesia is referred to as anesthetic awareness . Although patients may speak of “remembering” certain things under general anesthesia, recall of specific intraoperative events is…

Pulmonary complications

Aspiration 1 What is aspiration? Aspiration is the passage of material from the pharynx into the trachea. Aspirated material can originate from the stomach, esophagus, mouth, or nose. The materials involved can be particulate matter (e.g., food), a foreign body, fluid (e.g., blood, saliva) or gastrointestinal contents. Aspiration can cause a pneumonitis or a pneumonia, with the former occurring most often as a complication on induction…

Blood pressure disturbances

1 What blood pressure value is considered hypertensive? The definitions for blood pressure (BP) categories changed in 2017 according to the guidelines released by the American Heart Association/American College of Cardiology. A normal BP is less than 120/80 mm Hg. An elevated BP is a systolic BP of 120 to 129 mm Hg and a diastolic BP less than 80 mm Hg. Stage 1 hypertension (HTN)…

Pacemakers and internal cardioverter defibrillators

1 What are the common indications for placement of a permanent pacemaker? Common indications are as follows: symptomatic bradycardia that is not reversible, third-degree heart block (sometimes referred to as complete heart block ) is a problem of the atrioventricular (AV) node and requires permanent pacing, second-degree type II heart block (even in an asymptomatic patient), as it can progress to third-degree heart block. 2 What…

Electrocardiogram

1 Describe the electrical conduction system of the heart. The electrical conduction system of the heart is a network of specialized myocardial cells that generate, regulate, and propagate a series of electrical impulses. These impulses are generated by subtle changes in the resting membrane potential because of the movement of ions through cellular membrane channels. The basic structure of this system consists of specialized cells that…

Mechanical ventilation strategies

1 Why might a patient require intubation and mechanical ventilation? There are three main indications: 1) Hypoxic respiratory failure 2) Hypercarbic respiratory failure 3) Airway protection These three indications may be caused by primary respiratory pathology (e.g., pneumonia, chronic obstructive pulmonary disease [COPD], acute respiratory distress syndrome [ARDS]), systemic disease or impairment (e.g., Glasgow coma scale < 8, Guillain-Barré syndrome, drug intoxication), or airway compromise (e.g.,…

The anesthesia machine

1 What is an anesthesia machine? A more modern and correct name for an anesthesia machine is anesthesia delivery system . The job of the first anesthesia machines was to supply a mixture of anesthetizing and life-sustaining gases to the patient. Modern anesthesia delivery systems perform these functions, as well as ventilating and monitoring the patient. The most important purpose is to help the anesthesiologist and…

Volume assessment

1 Why do we administer fluids? What is the most important reason perioperatively? Although there are many reasons to administer fluids to patients (correct electrolyte imbalances, administer drugs, nutrients, antibiotics, etc.), the ultimate goal of perioperative fluid administration is to increase cardiac output in an effort to better perfuse end-organs (e.g., heart, brain, kidneys). This goal can be realized when a fluid bolus increases venous return,…

Perioperative point-of-care ultrasound and echocardiography

1 What is the role of point-of-care ultrasound and echocardiography in the perioperative and critical care setting? Ultrasound is a valuable diagnostic tool capable of providing real-time, rapid evaluation of patients. It is mobile, easy to use, safe, and less expensive than other imaging modalities, making its application pertinent to a variety of clinical environments—perioperative, critical care, emergency department, outpatient clinics, or inpatient wards. Ultrasound is…

Central venous catheterization

1 Define central venous catheterization. A central venous catheter (CVC) or central line is a catheter that is placed into a large vein such that the catheter’s distal orifice is within a central vein. The target central vein for CVCs placed in the internal jugular (IJ) or subclavian is the superior vena cava (SVC), and for the femoral vein, the inferior vena cava (IVC). Please see…