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Pre-operative evaluation

Question/Answers 1 What are the goals of the preoperative evaluation? The preoperative evaluation consists of gathering necessary information about the patient and formulating an appropriate anesthetic plan. The overall objective is to make sure the patient is medically optimized when time permits to limit perioperative risks. 2 Discuss what needs to happen before commencing anesthetic care? Before the delivery of anesthetic care, the following should occur:…

Introduction to anesthesia

1 Where did the term “anesthesia” come from? Oliver Wendell Holmes, Sr. (1809–1894), the legendary physician, poet and polymath, suggested the term anesthesia in a now famous letter (although sadly, lost to historical archivists) after the public demonstration of ether in 1846. Holmes is said to have derived the term from Greek where “an” means “without,” and “aesthesis” means “sensation.” 2 What were the earliest anesthetics?…

Standards and Regulatory Considerations

Acknowledgments The authors acknowledge Gregory Welyczko of GE Healthcare (retired), Stanley Weitzner, MD, and Mark Graber of GE Healthcare (retired) for their contributions to the anesthesia equipment standards in Table 27.8 . Overview It was once possible to practice “safe” and “modern” anesthesia without any awareness of the regulatory and voluntary standards governing anesthesia equipment and practice. This has changed, however, and individual practitioners are now…

Risk Management and Medicolegal Aspects of Anesthesia Equipment Use

Overview To prevent harm resulting from anesthesia care and to continuously improve patient safety, active effort is needed to manage process risk. The concept of risk management (RM) is widely applied in many domains, including health care. Successful RM is composed of several elements, beginning with the identification of problems that should be addressed to avoid poor outcomes and followed by the implementation of an overall…

Machine Checkout and Quality Assurance

Overview Although the large majority of anesthesia critical incidents and catastrophes involve errors in human judgment, some events involve overt equipment failure or failure of the anesthesia provider to discover an equipment problem. Many equipment problems in anesthesia practice are preventable, and this chapter is intended to help practitioners achieve that goal. The analogy between administering general anesthesia and piloting a commercial jet may be somewhat…

Electrical and Fire Safety

Introduction The myriad of electrical and electronic devices in the modern operating room (OR) greatly improve patient care and safety. However, these devices also subject both the patient and OR personnel to increased risks. To reduce the risk of electrical shock, most ORs have electrical systems that incorporate special safety features. It is incumbent upon the anesthesia caregiver to have a thorough understanding of the basic…

Hazards of the Anesthesia Delivery System

Acknowledgments We would like to thank the following individuals for their feedback on the Cybersecurity section: Anura Fernando, Julian Goldman, MD, Andy Levi, Ben Ransford, PhD, and Yi Zhang, PhD. Perspective Failure of the anesthesia delivery system alone is a rare cause of anesthesia-related injury to, or death of, a patient. More commonly, the delivery system is misused, the operator errs, or the delivery system fails…

Anesthesia in Difficult Locations and in Developing Countries

Inhalational Anesthesia in Difficult Locations Modern anesthesia workstations are complex and sophisticated pieces of medical equipment. They have evolved over many years to improve performance and reduce the risk of accidents and mishaps. The most recent workstations offer the ability to administer a wide range of volatile agents using a variety of breathing circuits. In addition, physiologic functions can be monitored and displayed, trends can be…

Anesthesia at High Altitude

Overview In the course of common anesthetic practice, it is unusual to worry about alterations in total environmental pressure, because the majority of anesthetic procedures are conducted within a limited pressure range. In fact, most organized hospital settings have developed in a narrow span of altitudes not far from sea level, although a significant portion of the world’s population continues to live at high altitude (HA).…

Anesthesia Delivery in the MRI Environment

Overview Magnetic resonance imaging (MRI) is a widely used diagnostic modality with 30 million scans done annually in the United States alone according to a U.S. Food and Drug Administration (FDA) report from 2016. During MRI, the patient must remain in a confined, noisy, sometimes hot environment for periods varying from 30 to 60 minutes or longer. Familiarity with anesthesia equipment, the environment, and basic monitoring…

Closed-Circuit Anesthesia

Principles Introduction The basic principle of closed-circuit anesthesia is maintenance of a constant anesthetic state by adding gases and vapors to the breathing circuit at the same rate at which the patient’s body removes those same substances. Often, the desired anesthetic state is first established using a high fresh gas flow (FGF) composed of gases, such as oxygen and nitrous oxide or air, and vapors (e.g.,…

Ergonomics of the Anesthesia Workspace

History Decades ago, accidental delivery of hypoxic gas mixtures was a constant threat during general anesthesia. Many instances of hypoxia were attributed to human error. In some cases, the anesthesiologist mistakenly turned the wrong gas flow control knob or failed to recognize that the oxygen cylinder was empty. In another case, a technician placed the flowmeter tubes in the wrong positions while servicing the anesthesia machine.…

Vigilance, Alarms, and Integrated Monitoring Systems

Acknowledgments We gratefully acknowledge the contributions, advice, and support of Carl E. Englund, Larry T. Dallen, Holly Forcier, Steve Howard, and David Gaba. Norman Ty Smith was a critical contributor to a previous version of the chapter. Overview This chapter discusses several areas in which the interface between human and machine—or more accurately, between the anesthesia caregiver and the anesthesia equipment—plays a crucial role in patient…

Infusion Pumps

Background History And Evolution Of Infusion Pumps In 1638 a British physician named William Harvey first described the circulatory system and found that the heart pumps blood throughout the body by continuous circulation. Before this, most people believed that blood flowed in arteries and veins like “human breath,” essentially just moving back and forth in the body. This opened the way for Sir Christopher Wren, the…

Preventing Transmission of Infectious Diseases

Overview This chapter focuses on preventing the spread of infectious disease during anesthesia care, especially when equipment is used. Box 15.1 provides a glossary of common terminology. BOX 15.1 Glossary Airborne transmission: Spread of disease by means of liquid particles small and light enough to become suspended in air currents. These particles are termed droplet nuclei. Air currents can carry droplet nuclei a considerable distance from…

Airway Equipment

“It is amazing the frequency in medical history, with which ideas are lost and reinvented” George Bernard Shaw Establishing and maintaining airway patency and providing support of oxygenation and ventilation are essential skills for many health care practitioners including anesthesiologists. The anesthesia face mask (FM) and tracheal tube once constituted the bulk of airway management apparatus. However, shifts in demographics, advances in surgical procedures, patient size…

Temperature Monitoring

Overview Body temperature is a critical part of homeostasis, a process that biological systems use to preserve a stable internal state that allows for normal functioning and survival. Humans use thermoregulation to maintain a somewhat consistent internal body temperature to survive (37°C [98.6°F]), even when the external environment changes. Alterations in body temperature can affect a wide array of physiologic processes, from vital chemical reactions catalyzed…

Hemodynamic Monitoring

Overview Hemodynamic monitoring is the repeated measurement of circulatory function over time. Perturbations in circulatory function are expected during physiologic stress such as surgery. Uncontrolled, these perturbations can lead to tissue hypoxia, ultimately resulting in perioperative morbidity and mortality. As such, hemodynamic monitoring is a fundamental component of delivering anesthetic care. It is essential to note, however, that hemodynamic monitoring alone does not change anesthetic or…

Pulse Oximetry

No monitor of oxygenation has had more impact on the practice of anesthesiology than the pulse oximeter. Unknown in the operating room (OR) before the 1980s, the pulse oximeter is now a minimum standard of care for all anesthetics, whether general, regional, or local. Its operation requires no special training or new skills on the part of the user. It is noninvasive and therefore almost free…

Capnography

Overview The capnograph functions in many respects as an “electronic stethoscope” that shows the cyclic appearance and disappearance of carbon dioxide (CO 2 ): a cycle is present when the lungs are being ventilated and is absent or disappears when they are not. The American Society of Anesthesiologists (ASA) updated their standards for basic anesthetic monitoring in July 1989, recommending that not only should carbon dioxide…