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Contents

Chapter Authors
Contributors
Research and Review
Foreword
Preface

1 The Practice of Anesthesiology

SECTION
Anesthetic Equipment & Monitors
I

2 The Operating Room Environment

Charles E. Cowles, Jr., MD, MBA, FASA

3 Breathing Systems
4 The Anesthesia Workstation

5 Cardiovascular Monitoring
6 Noncardiovascular Monitoring

SECTION
 II
Clinical Pharmacology

7 Pharmacological Principles
8 Inhalation Anesthetics

9 Intravenous Anesthetics
10 Analgesic Agents
11 Neuromuscular Blocking Agents
12 Cholinesterase Inhibitors & Other Pharmacological Antagonists
to Neuromuscular Blocking Agents

13 Anticholinergic Drugs
14 Adrenergic Agonists & Antagonists

15 Hypotensive Agents
16 Local Anesthetics
17 Adjuncts to Anesthesia

SECTION
Anesthetic Management
III
18 Preoperative Assessment, Premedication, & Perioperative
Documentation

19 Airway Management
20 Cardiovascular Physiology & Anesthesia
21 Anesthesia for Patients with Cardiovascular Disease
22 Anesthesia for Cardiovascular Surgery
23 Respiratory Physiology & Anesthesia
24 Anesthesia for Patients with Respiratory Disease
25 Anesthesia for Thoracic Surgery
26 Neurophysiology & Anesthesia
27 Anesthesia for Neurosurgery
28 Anesthesia for Patients with Neurological & Psychiatric Diseases
29 Anesthesia for Patients with Neuromuscular Disease
30 Kidney Physiology & Anesthesia
31 Anesthesia for Patients with Kidney Disease

32 Anesthesia for Genitourinary Surgery

33 Hepatic Physiology & Anesthesia
Michael Ramsay, MD, FRCA

34 Anesthesia for Patients with Liver Disease

Michael Ramsay, MD, FRCA

35 Anesthesia for Patients with Endocrine Disease

36 Anesthesia for Ophthalmic Surgery
37 Anesthesia for Otolaryngology–Head & Neck Surgery
38 Anesthesia for Orthopedic Surgery
Edward R. Mariano, MD, MAS

39 Anesthesia for Trauma & Emergency Surgery

Brian P. McGlinch, MD

40 Maternal & Fetal Physiology & Anesthesia

Michael A. Frölich, MD, MS

41 Obstetric Anesthesia
Michael A. Frölich, MD, MS

42 Pediatric Anesthesia

43 Geriatric Anesthesia
44 Ambulatory & Non–Operating Room Anesthesia

SECTION
Regional Anesthesia & Pain
 IV Management

45 Spinal, Epidural, & Caudal Blocks

46 Peripheral Nerve Blocks
Sarah J. Madison, MD and Brian M. Ilfeld, MD, MS (Clinical
Investigation)

47 Chronic Pain Management

Bruce M. Vrooman, MD, MS, FIPP and Richard W. Rosenquist, MD

48 Enhanced Recovery Protocols & Optimization of Perioperative

Outcomes
Gabriele Baldini, MD, MSc and Timothy Miller, MB ChB FRCA

SECTION
Perioperative & Critical Care
V Medicine

49 Management of Patients with Fluid & Electrolyte Disturbances

50 Acid–Base Management
51 Fluid Management & Blood Component Therapy
52 Thermoregulation, Hypothermia, & Malignant Hyperthermia
53 Nutrition in Perioperative & Critical Care

54 Anesthetic Complications
55 Cardiopulmonary Resuscitation
N. Martin Giesecke, MD and George W. Williams, MD, FASA, FCCP

56 Postanesthesia Care
57 Common Clinical Concerns in Critical Care Medicine
58 Inhalation Therapy & Mechanical Ventilation in the PACU &
ICU

59 Safety, Quality, & Performance Improvement

Index
Chapter Authors

Gabriele Baldini, MD, MSc

Associate Professor
Medical Director, Montreal General Hospital Preoperative Centre
Department of Anesthesia
McGill University Health Centre
Montreal General Hospital
Montreal, Quebec, Canada

John F. Butterworth IV, MD

Professor and Chairman
Department of Anesthesiology
Virginia Commonwealth University School of Medicine
VCU Health System
Richmond, Virginia

Charles E. Cowles, Jr., MD, MBA, FASA

Associate Professor/Assistant Clinical Director
Department of Anesthesiology and Perioperative Medicine
University of Texas MD Anderson Cancer Center
Houston, Texas

Michael A. Frölich, MD, MS

Professor and Associate Vice Chair for Research
Department of Anesthesiology and Perioperative Medicine
University of Alabama at Birmingham
Birmingham, Alabama

N. Martin Giesecke, M.D.

Professor and Vice Chairman for Administrative Affairs
Department of Anesthesiology
McGovern Medical School
University of Texas Health Science Center at Houston
Houston, Texas

Brian M. Ilfeld, MD, MS (Clinical Investigation)

Professor of Anesthesiology, In Residence
Division of Regional Anesthesia and Pain Medicine
Department of Anesthesiology
University of California at San Diego
San Diego, California

David C. Mackey, MD
Professor
Department of Anesthesiology and Perioperative Medicine
University of Texas MD Anderson Cancer Center
Houston, Texas

Sarah Madison, MD
Assistant Professor
Department of Anesthesiology, Perioperative & Pain Medicine
Stanford University
Stanford, California

Edward R. Mariano, MD, MAS

Professor
Department of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology & Perioperative Care Service
Associate Chief of Staff, Inpatient Surgical Services
Veterans Affairs Palo Alto Health Care System
Palo Alto, California

Brian P. McGlinch, M.D.

Assistant Professor
Department of Anesthesiology
University of Minnesota
Minneapolis, Minnesota
Colonel, Medical Corps, United States Army Reserve
Command Surgeon
84th Training Command
Fort Knox, Kentucky

Timothy Miller, MB ChB FRCA

Associate Professor
Chief, Division of General, Vascular and Transplant Anesthesia
Department of Anesthesiology
Duke University School of Medicine
Durham, North Carolina

Michael Ramsay, MD, FRCA

Chairman, Department of Anesthesiology
Baylor University Medical Center
Baylor Scott and White Health Care System
Professor
Texas A&M University Health Care Faculty
Dallas, Texas

Richard W. Rosenquist, MD
Chairman, Department of Pain Management
Cleveland Clinic
Cleveland, Ohio

Bruce M. Vrooman, MD, MS, FIPP

Chief, Section of Pain Medicine
Dartmouth-Hitchcock Medical Center
Associate Professor of Anesthesiology
Geisel School of Medicine at Dartmouth
Lebanon, New Hampshire
John D. Wasnick, MD, MPH
Steven L. Berk Endowed Chair for Excellence in Medicine
Professor and Chair
Department of Anesthesia
Texas Tech University Health Sciences Center
School of Medicine
Lubbock, Texas

George W. Williams, MD, FASA, FCCP

Vice Chair for Critical Care Medicine
Associate Professor of Anesthesiology and Neurosurgery
Program Director, Critical Care Medicine Fellowship
University of Texas Health Science Center at Houston–McGovern Medical
School
Houston, Texas
Contributors

Kallol Chaudhuri, MD, PhD

Professor
Department of Anesthesia
West Virginia University School of Medicine
Morgantown, West Virginia

Swapna Chaudhuri, MD, PhD

Professor
Department of Anesthesia
Texas Tech University Health Sciences Center
Lubbock, Texas

Lydia Conlay, MD
Professor
Department of Anesthesia
Texas Tech University Health Sciences Center
Lubbock, Texas

Johannes De Riese, MD
Assistant Professor
Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas

Suzanne N. Northcutt, MD
Associate Professor
Department of Anesthesia
Texas Tech University Health Sciences Center
Lubbock, Texas

Aschraf N. Farag, MD
Assistant Professor
Department of Anesthesia
Texas Tech University Health Sciences Center
Lubbock, Texas

Pranav Shah, MD
Assistant Professor
Department of Anesthesiology
VCU School of Medicine
Richmond, Virginia

Robert Johnston, MD
Associate Professor
Department of Anesthesia
Texas Tech University Health Sciences Center
Lubbock, Texas

Sabry Khalil, MD
Assistant Professor
Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas

Sanford Littwin, MD
Assistant Professor
Department of Anesthesiology
St. Luke’s Roosevelt Hospital Center and Columbia University College of
Physicians and Surgeons
New York, New York

Alina Nicoara, MD
Associate Professor
Department of Anesthesiology
Duke University Medical Center
Durham, North Carolina

Nitin Parikh, MD
Associate Professor
Department of Anesthesia
Texas Tech University Health Sciences Center
Lubbock, Texas

Cooper W. Phillips, MD
Assistant Professor
Department of Anesthesiology
UT Southwestern Medical Center
Dallas, Texas

Elizabeth R. Rivas, MD
Assistant Professor
Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas

Bettina Schmitz, MD, PhD

Associate Professor
Department of Anesthesia
Texas Tech University Health Sciences Center
Lubbock, Texas

Christiane Vogt-Harenkamp, MD, PhD

Assistant Professor
Department of Anesthesia
Texas Tech University Health Sciences Center
Lubbock, Texas
Denise J. Wedel, MD
Professor of Anesthesiology
Mayo Clinic
Rochester, Minnesota
Research and Review

Chase Clanton, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas

Aaron Darais, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center
Lubbock, Texas

Jacqueline E. Geier, MD
Formerly Resident, Department of Anesthesiology
St. Luke’s Roosevelt Hospital Center
New York, New York

Brian Hirsch, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas

Shane Huffman, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center
Lubbock, Texas

Rahul K. Mishra, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center
Lubbock, Texas

Cecilia N. Pena, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center Hospital
Lubbock, Texas

Spencer Thomas, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas

Trevor Walker, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center
Lubbock, Texas

Charlotte M. Walter, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center
Lubbock, Texas

Karvier Yates, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center
Lubbock, Texas

Shiraz Yazdani, MD
Assistant Professor
Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas
Foreword

When a new residency training program in anesthesia was beginning in Rwanda

in 2006, we were looking for a suitable textbook to recommend to the trainees.
We chose Clinical Anesthesiology by Morgan and Mikhail. I am happy to state
that today, 12 years later, the residents are still making the same choice. Over
one third of all copies of the last edition were sold outside of North America thus
underlining the popularity of this textbook around the world.
A major change in editors and authors occurred with the 5th edition and it is
clear that they stayed true to the ideals of the original editors. Now in 2018, the
6th edition is presented to us. The text continues to be simple, concise, and
easily readable. The use of Key Concepts at the beginning of each chapter is
very useful and focuses the reader’s attention on the important points. The
authors have worked hard not to increase the size of the book but to update the
material. Expanded chapters on critical care, on enhanced recovery after
anesthesia, and on the use of ultrasound will be very useful to readers. This
textbook continues to provide a comprehensive introduction to the art and
science of anesthesia.
Congratulations to the authors and editors on their fine work.
Angela Enright MB, FRCPC
Past President, World Federation of Societies of Anaesthesiologists (WFSA)
Preface

My, how time flies! Can half a decade already have passed since we last edited
this textbook? Yet, the time has passed and our field has undergone many
changes. We are grateful to the readers of the fifth edition of our textbook. The
widespread use of this work have ensured that the time and effort required to
produce a sixth edition are justified.
As was true for the fifth edition, the sixth edition represents a significant
revision. A few examples are worth noting:
• Those familiar with the sequence and grouping of content in the fifth edition
will notice that chapters have been reordered and content broken out or
consolidated to improve the flow of information and eliminate redundancy.
• The alert reader will note that the section on critical care medicine has been
expanded, reflecting the increasing number of very sick patients for whom
we care.
• Enhanced recovery after surgery has progressed from an important concept to
a commonly used acronym (ERAS), a specialty society, and (soon) standard
of care.
• Ultrasound has never been more important in anesthesia practice, and its use
in various procedures is emphasized throughout the textbook.
Some things remain unchanged:
• We have not burdened our readers with large numbers of unnecessary
references. We hope that long lists of references at the end of textbook
chapters will soon go the way of the library card catalog and long-distance
telephone charges. We assume that our readers are as fond of (and likely as
facile with) Google Scholar and PubMed as are we, and can generate their
own lists of references whenever they like. We continue to provide URLs for
societies, guidelines, and practice advisories.
• We continue to emphasize Key Concepts at the beginning of each chapter
that link to the chapter discussion, and case discussions at the end.
• We have tried to provide illustrations and images whenever they improve
the flow and understanding of the text.
Once again, the goal expressed in the first edition remains unchanged: “to
provide a concise, consistent presentation of the basic principles essential to the
modern practice of anesthesia.” And, once again, despite our best intentions, we
fear that errors will be found in our text. We are grateful to the many readers
who helped improve the last edition. Please email us at [email protected]
when you find errors. This enables us to make corrections in reprints and future
editions.

John F. Butterworth, IV, MD

David C. Mackey, MD
John D. Wasnick, MD, MPH
 CHAPTER

1
The Practice of Anesthesiology

KEY CONCEPTS

Oliver Wendell Holmes in 1846 was the first to propose use of the term
anesthesia to denote the state that incorporates amnesia, analgesia, and
narcosis to make painless surgery possible.
Ether was used for frivolous purposes (“ether frolics”) and was not used
as an anesthetic agent in humans until 1842, when Crawford W. Long
and William E. Clark independently used it on patients. On October 16,
1846, William T.G. Morton conducted the first publicized
demonstration of general anesthesia for surgical operation using ether.
The original application of modern local anesthesia is credited to Carl
Koller, at the time a house officer in ophthalmology, who demonstrated
topical anesthesia of the eye with cocaine in 1884.
Curare greatly facilitated tracheal intubation and muscle relaxation
during surgery. For the first time, operations could be performed on
patients without the requirement that relatively deep levels of inhaled
general anesthetic be used to produce muscle relaxation.
John Snow, often considered the father of the anesthesia specialty, was
the first to scientifically investigate ether and the physiology of general
anesthesia.
The “captain of the ship” doctrine, which held the surgeon responsible
for every aspect of the patient’s perioperative care (including
anesthesia), is no longer a valid notion when an anesthesiologist is
present.

The Greek philosopher Dioscorides first used the term anesthesia in the first
century AD to describe the narcotic-like effects of the plant mandragora. The
term subsequently was defined in Bailey’s An Universal Etymological English
Dictionary (1721) as “a defect of sensation” and again in the Encyclopedia
Britannica (1771) as “privation of the senses.” Oliver Wendell Holmes in 1846
was the first to propose use of the term to denote the state that incorporates
amnesia, analgesia, and narcosis to make painless surgery possible. In the United
States, use of the term anesthesiology to denote the practice or study of
anesthesia was first proposed in the second decade of the twentieth century to
emphasize the growing scientific basis of the specialty.
Although anesthesia now rests on scientific foundations comparable to those
of other specialties, the practice of anesthesia remains very much a mixture of
science and art. Moreover, the practice has expanded well beyond rendering
patients insensible to pain during surgery or obstetric delivery (Table 1–1).
Anesthesiologists require a working familiarity with a long list of other
specialties, including surgery and its subspecialties, internal medicine, pediatrics,
palliative care, and obstetrics, as well as imaging techniques (particularly
ultrasound), clinical pharmacology, applied physiology, safety science, process
improvement, and biomedical technology. Advances in scientific underpinnings
of anesthesia make it an intellectually stimulating and rapidly evolving specialty.
Many physicians entering residency positions in anesthesiology will already
have multiple years of graduate medical education and perhaps certification in
other medical specialties.

TABLE 1–1 Aspects of the practice of medicine that are included within the
scope of anesthesiology.1
 This chapter reviews the history of anesthesia, emphasizing its British and
American roots, and considers the current scope of the specialty.

The History of Anesthesia

The specialty of anesthesia began in the mid-nineteenth century and became
firmly established in the following century. Ancient civilizations had used opium
poppy, coca leaves, mandrake root, alcohol, and even phlebotomy (to the point
of unconsciousness) to allow surgeons to operate. Ancient Egyptians used the
combination of opium poppy (containing morphine) and hyoscyamus
(containing scopolamine) for this purpose. A similar combination, morphine and
scopolamine, was widely used for premedication until recent times. What passed
for regional anesthesia in ancient times consisted of compression of nerve trunks
(nerve ischemia) or the application of cold (cryoanalgesia). The Incas may have
practiced local anesthesia as their surgeons chewed coca leaves and applied them
to operative wounds, particularly prior to trephining for headache.
The evolution of modern surgery was hampered not only by a poor
understanding of disease processes, anatomy, and surgical asepsis but also by the
lack of reliable and safe anesthetic techniques. These techniques evolved first
with inhalation anesthesia, followed by local and regional anesthesia,
intravenous anesthesia, and neuromuscular blockers. The development of
surgical anesthesia is considered one of the most important discoveries in human
history, and it was introduced to practice without a supporting randomized
clinical trial.

INHALATION ANESTHESIA
Because the hypodermic needle was not invented until 1855, the first general
anesthetics were destined to be inhalation agents. Diethyl ether (known at the
time as “sulfuric ether” because it was produced by a simple chemical reaction
between ethyl alcohol and sulfuric acid) was originally prepared in 1540 by
Valerius Cordus. Ether was used for frivolous purposes (“ether frolics”), but not
as an anesthetic agent in humans until 1842, when Crawford W. Long and
William E. Clark independently used it on patients for surgery and dental
extraction, respectively. However, neither Long nor Clark publicized his
discovery. Four years later, in Boston, on October 16, 1846, William T.G.
Morton conducted the first publicized demonstration of general anesthesia for
surgical operation using ether. The dramatic success of that exhibition led the
operating surgeon to exclaim to a skeptical audience: “Gentlemen, this is no
humbug!”
Chloroform was independently prepared by Moldenhawer, von Liebig,
Guthrie, and Soubeiran around 1831. Although first used by Holmes Coote in
1847, chloroform was introduced into clinical practice by the Scot Sir James
Simpson, who administered it to his patients to relieve the pain of labor.
Ironically, Simpson had almost abandoned his medical practice after witnessing
the terrible despair and agony of patients undergoing operations without
anesthesia.
Joseph Priestley produced nitrous oxide in 1772, and Humphry Davy first
noted its analgesic properties in 1800. Gardner Colton and Horace Wells are
credited with having first used nitrous oxide as an anesthetic for dental
extractions in humans in 1844. Nitrous oxide’s lack of potency (an 80% nitrous
oxide concentration results in analgesia but not surgical anesthesia) led to
clinical demonstrations that were less convincing than those with ether.
Nitrous oxide was the least popular of the three early inhalation anesthetics
because of its low potency and its tendency to cause asphyxia when used alone
(see Chapter 8). Interest in nitrous oxide was revived in 1868 when Edmund
Andrews administered it in 20% oxygen; its use was, however, overshadowed by
the popularity of ether and chloroform. Ironically, nitrous oxide is the only one
of these three agents still in use today. Chloroform superseded ether in popularity
in many areas (particularly in the United Kingdom), but reports of chloroform-
related cardiac arrhythmias, respiratory depression, and hepatotoxicity
eventually caused practitioners to abandon it in favor of ether, particularly in
North America.
Even after the introduction of other inhalation anesthetics (ethyl chloride,
ethylene, divinyl ether, cyclopropane, trichloroethylene, and fluroxene), ether
remained the standard inhaled anesthetic until the early 1960s. The only
inhalation agent that rivaled ether’s safety and popularity was cyclopropane
(introduced in 1934). However, both are highly combustible and both have since
been replaced by a succession of nonflammable potent fluorinated hydrocarbons:
halothane (developed in 1951; released in 1956), methoxyflurane (developed in
1958; released in 1960), enflurane (developed in 1963; released in 1973), and
isoflurane (developed in 1965; released in 1981).
Currently, sevoflurane is by far the most popular inhaled agent in developed
countries. It is far less pungent than isoflurane and has low blood solubility. Ill-
founded concerns about the potential toxicity of its degradation products delayed
its release in the United States until 1994 (see Chapter 8). These concerns have
proved to be theoretical. Sevoflurane is very suitable for inhaled inductions and
has largely replaced halothane in pediatric practice. Desflurane (released in
1992) has many of the desirable properties of isoflurane as well as more rapid
uptake and elimination (nearly as fast as nitrous oxide). Sevoflurane, desflurane,
and isoflurane are the most commonly used inhaled agents in developed
countries worldwide.

LOCAL & REGIONAL ANESTHESIA

The medicinal qualities of coca had been recognized by the Incas for centuries
before its actions were first observed by Europeans. Cocaine was isolated from
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