Morgan and Mikhails Clinical Anesthesiology

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Mo rga n a n d Mikh a il’s Clin ica l
An e sth e sio lo gy Fla sh ca rd s
Rich a rd D. Urm a n , MD, MBA, CPE Je sse M. Ehre nfe ld, MD, MPH
Assistant Professor of Anesthesia Associate Professor of Anesthesiology,
Harvard Medical School Surgery, and Biomedical Informatics
Medical Director, Procedural Sedation Safety Vanderbilt University School of Medicine
Co-Director, Center for Perioperative Management Director, Center for Evidence Based Anesthesia
& Medical Informatics Director, Perioperative Data Systems Research
Brigham and Women’s Hospital Department of Anesthesiology
Boston, Massachusetts Vanderbilt University Medical Center
Nashville, Tennessee

New York / Chicago / San Francisco / Lisbon / London / Madrid / Mexico City
Milan / New Delhi / San Juan / Seoul / Singapore / Sydney / Toronto
 No tice

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This page intentionally left blank
 Co n te n ts

1 Th e Pra ctice o f Ane sthe siolo gy 18 Pre o p e ra tive Asse ssm e n t, Pre m e d ica tion ,
2 Th e Op e ra tin g Ro o m En viro n m e n t a n d Pe riop e ra tive Docum e n ta tio n

3 Bre a th in g Syste m s 19 Airwa y Ma n a ge m e n t

4 Th e Ane sthe sia Ma chin e 20 Ca rd io va scu la r Physio lo gy a nd An e sth e sia

5 Ca rdio va scu la r Mon ito rin g 21 An e sth e sia fo r Pa tie n ts with Ca rdio va scula r Dise a se

6 No nca rd io va scu la r Mo n itorin g 22 An e sth e sia fo r Ca rd iova scu la r Su rge ry

7 Pha rm a colo gica l Princip le s 23 Re sp ira to ry Ph ysiolo gy a n d Ane sth e sia

8 Inh a la tion An e sth e tics 24 An e sth e sia fo r Pa tie n ts with Re sp ira to ry Dise a se

9 Intra ve n o u s An e sthe tics 25 An e sth e sia for Tho ra cic Surge ry

10 An a lge sic Age n ts 26 Ne urop h ysio logy a nd An e sth e sia

11 Ne u ro m u scu la r Blo cking Age n ts 27 An e sth e sia for Ne u rosu rge ry

12 Ch o line ste ra se In h ib ito rs a n d Oth e r Pha rm a colo gic 28 An e sth e sia for Pa tie n ts with Ne urolo gic
An ta go n ists to Ne u ro m u scu la r Blo ckin g Age n ts a n d Psych ia tric Dise a se s

13 An ticho lin e rgic Dru gs 29 Re n a l Ph ysio logy a nd An e sth e sia

14 Ad re n e rgic Ago n ists a n d An ta go n ists 30 An e sth e sia for Pa tie n ts with Kid n e y Dise a se

15 Hyp o te n sive Age nts 31 An e sth e sia for Ge n ito u rin a ry Su rge ry

16 Lo ca l Ane sth e tics 32 He pa tic Ph ysiolo gy a n d An e sth e sia

17 Ad jun cts to An e sth e sia 33 An e sth e sia for Pa tie n ts with Live r Dise a se

v
34 An e sth e sia for Pa tie n ts with End o crin e Dise a se 47 Chro n ic Pa in Ma na ge m e nt
35 An e sth e sia for Pa tie n ts with Ne uro m u scula r Dise a se 48 Pe rio pe ra tive Pa in Ma n a ge m e nt
36 An e sth e sia for Oph th a lm ic Surge ry a n d En h a n ce d Ou tco m e s

37 Anesthesia for Otorhinolaryngologic Surgery 49 Ma n a ge m e n t o f Pa tie n ts with Flu id

a n d Ele ctro lyte Distu rb a n ce s
38 An e sth e sia for Ortho pe d ic Su rge ry
50 Acid –Ba se Ma n a ge m e n t
39 An e sth e sia fo r Tra u m a a nd Em e rge ncy Su rge ry
51 Fluid Ma n a ge m e nt a nd Blo od Co m p on e nt The ra p y
40 Ma te rn a l a n d Fe ta l Ph ysio lo gy a n d Ane sthe sia
52 Th e rm o re gu la tion , Hyp o th e rm ia ,
41 Ob ste tric An e sth e sia a nd Ma ligna nt Hyp e rth e rm ia
42 Pe d ia tric An e sth e sia 53 Nu tritio n in Pe rio p e ra tive a n d Critica l Ca re
43 Ge ria tric An e sth e sia 54 An e sth e tic Com plica tio ns
44 Am b u la to ry, Non –Op e ra tin g Ro o m , 55 Ca rdio pu lm o na ry Re suscita tio n
a n d Office -Ba se d An e sth e sia
56 Posta ne sthe sia Ca re
45 Spin a l, Ep id u ra l, a n d Ca ud a l Blocks
57 Critica l Ca re
46 Pe rip h e ra l Ne rve Blo cks

vi
 Co n trib u to rs

Aa ro n J. Bro m a n , MD Je nn ife r Ma zia d , MD

Resident, Department of Anesthesiology Resident, Department of Anesthesiology
Vanderbilt University Medical Center Vanderbilt University
Nashville, Tennessee Nashville, Tennessee
Chapters 23, 44, 53 Chapters 17, 39, 40, 41, 52
W. Cro ss Du d n e y IV, MD An ge la Nicho ls, MD
Resident, Department of Anesthesiology Resident, Department of Anesthesiology
Vanderbilt University Medical Center Harvard Medical School
Nashville, Tennessee Brigham and Women’s Hospital
Chapters 2, 3, 4, 14 Boston, Massachusetts
Chapters 19, 31, 34
Nika n H. Kh a tib i, MD, MBA
Resident, Department of Anesthesiology Io a na Pa sca , MD
Loma Linda University Medical Center Resident, Department of Anesthesiology
Loma Linda, California Loma Linda University
Chapters 8, 26, 27, 28, 35 Loma Linda, California
Chapters 9, 10, 16, 20, 21, 22
Lo ri Kie fe r, MD
Resident, Department of Anesthesiology Jo n a h H. Pa te l, MD
Vanderbilt University Resident, Department of Anesthesiology
Nashville, Tennessee Harvard Medical School
Chapters 50, 54, 55 Brigham and Women’s Hospital
Boston, Massachusetts
Chapters 13, 15, 45
vii
Tim o th y D. Qu inn , MD Yi Ca i Isa a c To n g, MD
Clinical Fellow in Anaesthesia Resident, Department of Anesthesiology
Harvard Medical School Brigham and Women’s Hospital
Brigham and Women’s Hospital Harvard Medical School
Boston, Massachusetts Boston, Massachusetts
Chapters 38, 46, 48 Chapters 7, 47, 49, 56
Alla n F. Sim p a o , MD Jo n a th a n P. Wa nd e re r, MD, M.Ph il
Assistant Professor of Anesthesiology Instructor, Department of Anesthesiology
and Critical Care Associate Director, Perioperative Data Systems
University of Pennsylvania Research
Perelman School of Medicine and Vanderbilt University School of Medicine
The Children’s Hospital of Philadelphia Nashville, Tennessee
Philadelphia, Pennsylvania Chapters 11, 12, 25, 36, 37
Chapters 5, 6, 42
Ju stin J. Wright, MD
He id i A.B. Sm ith , MD, MSCI Cardiothoracic Fellow
Pediatric Anesthesiology Clinical Fellow Department of Anesthesiology
Pediatric Intensivist Emory University School of Medicine
Department of Anesthesiology Atlanta, Georgia
Vanderbilt University Chapters 24, 29, 30, 32, 33, 51
Nashville, Tennessee
Chapters 18, 43, 57

viii
THE PRACTICE OF ANESTHESIOLOGY 1-1

Key Dates and People in the History of Anesthesiology

• 1842: Ether first used as an anesthetic agent when Crawford W. Long and William E. Clark independently
used it on patients for surgery and dental extraction.
• 1844: Gardner Colton and Horace Wells credited with first use of nitrous oxide as an anesthetic.
• 1884: Carl Koller is the first to use cocaine for topical anesthesia.
• 1898: August Bier is credited with administering the first spinal anesthetic.
• 1908: Bier is the first to describe intravenous regional anesthesia (Bier Block).
• 1962: Ketamine first synthesized by Stevens and first used clinically in 1965 by Corssen and Domino.
• 1986: The release of propofol (1989 in the United States) is a major advance in outpatient anesthesia
because of its short duration of action.
John Snow: Often considered the father of anesthesia, was the first to scientifically investigate ether and the
physiology of general anesthesia.
William T.G. Morton: First demonstration of general anesthesia for surgery using ether, on October 16, 1846.
Thomas D. Buchanan: First physician to be appointed professor of anesthesia, 1905 at New York Medical
College.
This page intentionally left blank
THE OPERATING ROOM ENVIRONMENT 2-1

Oxygen
• A reliable source of oxygen is critical to the practice of anesthesia. Medical grade oxygen is at least 99%
pure and is made by fractional distillation of liquefied air. Oxygen may be stored in pressurized gas cylinders
or in refrigerated liquid form; to be stored as a liquid, temperature must be kept below the critical tempera-
ture of oxygen, −119°C.
• A pressure of 1000 psig inside an oxygen E-cylinder indicates that it is approximately half full and repre-
sents 330 L of oxygen at atmospheric pressure and a temperature of 20°C. If the oxygen is exhausted at a
rate of 3 L/min, a cylinder that is half full will be empty in 110 min.
Nitrous Oxide
• Because the critical temperature of nitrous oxide (36.5°C) is above room temperature, it can be kept lique-
fied without an elaborate refrigeration system. N2O E-cylinders contain nitrous oxide in both its liquid and
gaseous state. Because of this, the volume remaining in a cylinder is not proportional to cylinder pressure.
By the time the liquid nitrous oxide is expended and the tank pressure begins to fall, only about 400 L of
nitrous oxide remains. The only way to determine the volume of residual N2O inside the cylinder is to weight
the cylinder.
THE OPERATING ROOM ENVIRONMENT 2-2

Medical Gas Delivery

• Medical gases are delivered from a central supply to the operating room via piping systems. Pipes are sized
such that the pressure drop across the whole system never exceeds 5 psig. Gas pipes are usually constructed
of seamless copper tubing using a special welding technique.
• A pin safety system has been widely adopted that discourages incorrect cylinder attachments; each type of
gas has a unique configuration of holes that correspond to a set of specific pins in the yoke of the anesthesia
machine.
• Modern anesthesia machines are required to monitor the fraction of inspired oxygen (FIO2). Analyzers have
a variable threshold setting for the minimal FIO2 but should be configured to prevent disabling this alarm.
Because of gas exchange, flow rates, and shunting, a marked difference can exist between the monitored
FIO2 and O2 levels at the tissue level.
THE OPERATING ROOM ENVIRONMENT 2-3

Electrosurgery
• Electrosurgical units (ESUs, e.g., Bovie) generate an ultrahigh-frequency electrical current that passes from
an electrode at the tip of the device and through the patient’s tissue and exits by way of a large surface
area dispersal electrode. Ventricular fibrillation is prevented by the use of ultrahigh electrical frequencies
(0.1–3 MHz).
• Malfunction of the dispersal pad electrode may result from disconnection from the ESU, inadequate patient
contact, or insufficient conductive gel within the pad. In this case, current will exit through another point of
egress, e.g., electrocardiographic (ECG) leads or the metal operating room table, which can cause electrical
burns. This current can cause malfunction of implanted cardiac devices.
• Bipolar electrosurgical cautery devices confine current propagation to a distance of only millimeters, thus
obviating the need for a return electrode. Because of this, they often do not interfere with implanted cardiac
devices and as such do not require the same precautions that are necessary when monopolar ESUs are used.
THE OPERATING ROOM ENVIRONMENT 2-4

Precautions in Electrosurgery
• Precautions to prevent electrosurgical burns include proper return electrode contact and placement, avoiding
bony protuberances and prosthesis, and elimination of patient-to-ground contacts.
• Current flow through an implanted cardiac rhythm management device can be minimized by placing the
dispersal electrode as close to the surgical field and as far from the implanted device as possible. If such
placement is not possible, discuss with the surgery team whether the use of a monopolar electrosurgical
device is mandatory for the case.
• Because pacemaker and ECG interference is possible, pulse and heart sounds should be closely monitored
whenever a monopolar ESU is used. Implanted cardioversion and defibrillating devices should be suspended
if monopolar ESU is used, and any implanted cardiac rhythm management device should be interrogated after
use of a monopolar ESU.
BREATHING SYSTEMS 3-1

Anesthetic Breathing Systems

• Insufflation: The blowing of gases across a patient’s face (e.g., via a facemask). There is no permanent
connection between the breathing circuit and the patient’s airway. If fresh gas flow rates are high enough
(>10 L/min), very little rebreathing of gases occurs.
• Draw-over anesthesia: Draw-over devices have nonrebreathing circuits that use ambient air or supplemen-
tal oxygen as the carrier gas. Air is drawn through a low-resistance vaporizer as the patient inspires. The
fraction of inspired oxygen (FIO2) can be supplemented using an open-ended reservoir tube attached to a
t-piece at the upstream side of the vaporizer. The devices can be fitted with connections and equipment that
allow intermittent positive-pressure ventilation, continuous positive airway pressure, and positive end-
expiratory pressure. The greatest advantage of the draw-over systems is their simplicity and portability; they
are useful in places where compressed gases or ventilators are not available.
• Mapleson circuits: Incorporate breathing tubes, fresh gas inlets, adjustable pressure-limiting (APL) valves,
and reservoir bags into the breathing circuit for greater control of gas delivery. The relative location of these
components determines circuit performance and is the basis of the Mapleson classification system.
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