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Anesthesia and Uncommon Diseases 6th Edition Lee A.
Fleisher Md Digital Instant Download
Author(s): Lee A. Fleisher MD
ISBN(s): 9781437727876, 1437727875
Edition: 6
File Details: PDF, 23.99 MB
Year: 2012
Language: english
Anesthesia and
Uncommon Diseases
SI X T H E D IT IO N

Anesthesia and
Uncommon Diseases

LEE A. FLEISHER, MD
Robert D. Dripps Professor and Chair
Department of Anesthesiology and Critical Care
Professor of Medicine
Perelman School of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

ANESTHESIA AND UNCOMMON DISEASES ISBN: 978-1-4377-2787-6

Copyright © 2012 by Saunders, an imprint of Elsevier Inc.

Copyright © 2008, 2004, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information
or methods they should be mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any
liability for any injury and/or damage to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material
herein.

International Standard Book Number

978-1-4377-2787-6

Content Strategy Director: William Schmitt

Content Development Manager: Lucia Gunzel
Publishing Services Manager: Patricia Tannian
Project Manager: Sarah Wunderly
Design Direction: Louis Forgione

Printed in the United States

Last digit is the print number: 9 8 7 6 5 4 3 2 1

This book is dedicated to my wife, Renee, who is my true partner in life, an outstanding
example to our children, and a sounding board.
To my many teachers over the years, from professors during my residency to faculty
colleagues and the many residents and medical students who taught me through their
questions.
I particularly want to acknowledge one teacher, Stanley Rosenbaum, an internist,
anesthesiologist, and intensivist at Yale University. Stanley, who was one of my first
attendings, taught me the art and science of caring for patients with complex medical
comorbidities and became an important collaborator in my early research efforts.
—Lee A. Fleisher
PR E FAC E

It was a pleasure to edit the sixth edition of Anesthesia and and ensured that all chapters have been updated to reflect the
Uncommon Diseases, following the traditions of Drs. Katz, newest information available on these complex diseases.
Benumof, and Kadis from previous publications. When I was In putting together a multiauthor text, numerous people must
a resident at Yale New Haven Hospital, the third edition of this be acknowledged. I would like to thank my executive assistant,
book was always an important component of my planning for Eileen O'Shaughnessy, for managing a diverse group of authors.
the next day's anesthetic. In developing the sixth edition, I have I would also like to thank Natasha Andjelkovic and Executive
asked the authors to include tables and key points that high- Content Strategist William Schmitt, my publishers at Elsevier, for
light significant management practices for the various diseases their patience and support, and Content Development Manager
to complement the comprehensive reviews in the text. Given Lucia Gunzel, whose guidance was very valuable.
the quality of the chapters from the previous edition, I invited Lee A. Fleisher, MD
many of the same authors to contribute some new chapters Editor

vii
F OR E WO R D

What are uncommon diseases? The Oxford English Dictionary In the preface to the first edition of Anesthesia and
defines “uncommon” as not possessed in common, not com- Uncommon Diseases (1973), editors Jordan Katz and Leslie B.
monly (to be) met with, not of ordinary occurrence, unusual, Kadis stressed their intention to present disease entities whose
rare. “Rare” has various meanings, such as few in number and underlying pathophysiologic processes might profoundly
widely separated from each other (in space or time), though affect normal anesthetic management. They noted that, “In
also including unusual and exceptional. Another synonym for general, the information we wanted to present has never been
uncommon is “infrequent,” the definition of which includes published.” This resulted in “a compendium of what is and is
not occurring often, happening rarely, recurring at wide inter- not known about unusual diseases as they may or may not
vals of time. The chapter titled Respiratory Diseases in this relate to anesthesia.” The authors expressed the hope that their
edition aims to review “less common” pulmonary conditions, work would stimulate others to publish their experiences.
rather than “uncommon.” None of these definitions includes The subsequent three decades have seen a remarkable growth
quantification. and development of knowledge in biomedical science, includ-
Why do we need a separate text to help us conduct the anes- ing anesthesiology and its related disciplines. Many others have
thetics of illnesses that do not happen often, if that is indeed indeed published their experiences with conditions covered in
the case? The simplest answer, congruent with the present editions of this book. This has resulted in understanding the
obsession with the wisdom of the market, might be that the physiology and safe anesthetic management of many of these
need has been already proven by the fact that the anesthetic diseases, so that recommendations for their management can
community has bought sufficient copies of the p ­ revious five be provided with confidence. It has also been accompanied by
editions of this book to warrant a sixth. Nevertheless, it seems recognition of other, not previously recognized, illnesses that
an intriguing question. Are the readers of the book residents have joined the ranks of “uncommon diseases.” An example
studying arcane facts in order to pass certification examina- of the former is the present virtually complete understanding
tions? Are they investigators searching for relevant questions to of succinylcholine-associated hyperkalemia in certain muscle
research? Are they isolated clinicians faced with the n ­ ecessity ­diseases; an example of the latter is the entire field of mitochon-
of ­managing patients with unusual conditions the clinicians drial diseases, which was added in the fifth edition.
encounter so infrequently that they do not recall (or never Anesthesiology has been characterized as hours of bore-
knew) the most relevant facts requisite for providing safe care? dom interspersed with moments of terror. I would argue
Do the many uncommon conditions, even though each might strongly that this is an incomplete and misleading character-
occur infrequently, happen sufficiently often in the aggregate ization, but will not expand on that here. However, as a recov-
that we would ignore them to the peril of our patients? ering clinician who spent decades (unsuccessfully) attempting
To begin to approach this question, we need to consider the to make every anesthetic as “boring” as possible, I can vouch
practice of medicine and the fact that medicine is a profession. that terror is indeed an inevitable component of the specialty.
Professions are occupations in which groups of individuals are Knowledge—technical, experiential, judgmental, didactic—
granted a monopoly by society to learn and apply advanced is the most effective deterrent to these vexing episodes and
knowledge in some area for the benefit of that society. The pro- the best tool to successfully confront them when they occur.
fession has the obligation to transmit that knowledge to others This book is a single source of extremely useful and provoc-
who will join that profession, to develop new knowledge, and ative knowledge for trainees, practitioners, and investigators
to maintain standards of practice by self-regulation. There is alike. I suspect this is why the previous editions of this book
a moral covenant with society to behave altruistically—that is, have been so successful, why this updated and much changed
for the professional to subsume her or his own personal inter- edition, with new topics and new contributors, will also be a
ests for the benefit of the society. These characteristics trans- success, and why we will need further new editions in future.
late into an obligation to provide competent care for all who
entrust themselves into our hands, no matter how rare or Edward Lowenstein, MD
­esoteric their condition may be. In the practice of anesthesiology Henry Isaiah Dorr Distinguished Professor
(and of all of medicine, for that matter), it is not possible for of Anaesthesia and Professor of Medical Ethics,
any one individual to know everything necessary to fulfill that Harvard Medical School; Provost, Department of
responsibility. Thus, we are dependent on rapid access to gain Anesthesia, Critical Care and Pain Medicine,
sufficient knowledge to approach that duty. Massachusetts General Hospital, Boston, Massachusetts
ix
C O N T R IB U TO R S

Shamsuddin Akhtar, MBBS Rafael Cartagena, MD

Associate Professor Medical Director of the Operating Room
Department of Anesthesiology Henrico Doctor's Hospital
Yale University School of Medicine President, Total Anesthesia
New Haven, Connecticut Richmond, Virginia
Chapter 13: Diseases of the Endocrine System Chapter 4: Respiratory Diseases

Dean B. Andropoulos, MD, MHCM Maurizio Cereda, MD

Chief of Anesthesiology Assistant Professor
Texas Children's Hospital Department of Anesthesiology and Critical Care
Professor, Anesthesiology and Pediatrics Perelman School of Medicine
Baylor College of Medicine University of Pennsylvania
Houston, Texas Philadelphia, Pennsylvania
Chapter 3: Congenital Heart Disease Chapter 7: Renal Diseases

Amir Baluch, MD Franklyn P. Cladis, MD

Research Associate Assistant Professor of Anesthesiology
Louisiana State University School of Medicine Director of Pediatric Anesthesia Fellowship
New Orleans, Louisiana Program
Attending Anesthesiologist University of Pittsburgh School of Medicine
Baylor Surgicare Attending Anesthesiologist
Dallas, Texas Children's Hospital of Pittsburgh of UPMC
Chapter 15: Psychiatric and Behavioral Disorders Pittsburgh, Pennsylvania
Chapter 16: Mineral, Vitamin, and Herbal Supplements Chapter 21: The Pediatric Patient

Dimitry Baranov, MD Bruce F. Cullen, MD

Assistant Professor of Clinical Anesthesiology and Critical Care Professor Emeritus
Department of Anesthesiology and Critical Care Department of Anesthesiology
Perelman School of Medicine University of Washington School of Medicine
University of Pennsylvania Seattle, Washington
Philadelphia, Pennsylvania Chapter 18: Burns
Chapter 8: Neurologic Diseases
Peter J. Davis, MD, FAAP
Paul X. Benedetto, MD Professor of Anesthesiology and Pediatrics
Chief Resident University of Pittsburgh
Department of Dermatology Anesthesiologist-in-Chief
Cleveland Clinic Foundation Children's Hospital of Pittsburgh of UPMC
Cleveland, Ohio Pittsburgh, Pennsylvania
Chapter 10: Skin and Bone Disorders Chapter 21: The Pediatric Patient

Sanjay M. Bhananker, MD, FRCA Anahat Dhillon, MD

Associate Professor Assistant Clinical Professor
Department of Anesthesiology and Pain Medicine Department of Anesthesiology
University of Washington School of Medicine David Geffen School of Medicine at UCLA
Seattle, Washington Los Angeles, California
Chapter 18: Burns Chapter 5: Liver Diseases

xi
 xii Contributors

Richard P. Dutton, MD, MBA David L. Hepner, MD

Clinical Associate Associate Professor of Anesthesia
University of Chicago Harvard Medical School
Chicago, Illinois Staff Anesthesiologist
Executive Director Department of Anesthesiology, Perioperative and Pain Medicine
Anesthesia Quality Institute Associate Director, Weiner Center for Preoperative Evaluation
Park Ridge, Illinois Brigham and Women's Hospital
Chapter 17: Trauma and Acute Care Boston, Massachusetts
Chapter 19: Pregnancy and Obstetric Complications
Gregory W. Fischer, MD
Associate Professor of Anesthesiology Caron M. Hong, MD, MSc
Department of Anesthesiology Assistant Professor
Associate Professor of Cardiothoracic Surgery Department of Anesthesiology and Surgery
Mount Sinai School of Medicine University of Maryland School of Medicine
Mount Sinai Medical Center Baltimore, Maryland
New York, New York Chapter 4: Respiratory Diseases
Chapter 11: Hematologic Diseases
Jiri Horak, MD
Lee A. Fleisher, MD Assistant Professor
Robert D. Dripps Professor and Chair Department of Anesthesiology and Critical Care
Department of Anesthesiology and Critical Care Perelman School of Medicine
Professor of Medicine University of Pennsylvania
Perelman School of Medicine Philadelphia, Pennsylvania
University of Pennsylvania Chapter 7: Renal Diseases
Philadelphia, Pennsylvania
Joel A. Kaplan, MD
Charles Fox, MD Professor of Anesthesiology
Vice Chairman of Academics University of California, San Diego
Department of Anesthesiology San Diego, California
Tulane University School of Medicine Chapter 2: Cardiac Diseases
New Orleans, Louisiana
Chapter 15: Psychiatric and Behavioral Disorders Adam M. Kaye, PharmD, FASCP, FCPhA
Associate Clinical Professor
Erin A. Gottlieb, MD Department of Pharmacy Practice
Attending Pediatric Cardiovascular Thomas J. Long School of Pharmacy and Health Sciences
Anesthesiologist University of the Pacific
Texas Children's Hospital Stockton, California
Assistant Professor of Anesthesiology and Chapter 16: Mineral, Vitamin, and Herbal Supplements
Pediatrics
Baylor College of Medicine Alan D. Kaye, MD, PhD
Houston, Texas Professor and Chairman
Chapter 3: Congenital Heart Disease Department of Anesthesiology
Professor
Thomas E. Grissom, MD, FCCM Department of Pharmacology
Associate Professor Louisiana State University School of Medicine
Department of Anesthesiology Director of Anesthesia
University of Maryland School of Medicine Director of Interventional Pain Services
R Adams Cowley Shock Trauma Center Louisiana State University Interim Hospital
Baltimore, Maryland Chapter 15: Psychiatric and Behavioral Disorders
Chapter 17: Trauma and Acute Care Chapter 16: Mineral, Vitamin, and Herbal Supplements
 Contributors xiii

Bhavani Shankar Kodali, MD Kathryn E. McGoldrick, MD

Associate Professor and Vice Chair Professor and Chair
Department of Anesthesiology, Perioperative, and Pain Medicine Department of Anesthesiology
Harvard Medical School New York Medical College
Brigham and Women's Hospital Valhalla, New York
Boston, Massachusetts Chapter 1: Eye, Ear, Nose, and Throat Diseases
Chapter 19: Pregnancy and Obstetric Complications
Alexander Mittnacht, MD
Corry J. Kucik, MD, DMCC, FCCP Associate Professor of Anesthesiology
Assistant Professor of Anesthesiology and Critical Care Director of Pediatric Cardiac Anesthesia
University of Southern California Mount Sinai School of Medicine
Anesthesiology Program Director New York, New York
Navy Trauma Training Center Chapter 2: Cardiac Diseases
Los Angeles, California
Chapter 17: Trauma and Acute Care Patrick Neligan, MA, MD, FCAI
Honorary Senior Lecturer in Anaesthesia and Intensive Care
Jonathan Leff, MD National University of Ireland
Assistant Professor of Anesthesiology Consultant Anaesthetist in Intensive Care
Albert Einstein College of Medicine Galway University Hospitals
Chief of Cardiothoracic Anesthesia Galway, Ireland
Director Cardiothoracic Anesthesia Fellowship Chapter 7: Renal Diseases
Montefiore Medical Center Chapter 12: Infectious Diseases and Biologic Weapons
Bronx, New York
Chapter 11: Hematologic Diseases Anthony N. Passannante, MD
Professor of Anesthesiology
Richard J. Levy, MD University of North Carolina at Chapel Hill
Associate Professor of Anesthesiology and Critical Care Professor and Vice-Chair for Clinical Operations
Medicine, Pediatrics, and Integrative Systems Biology University of North Carolina Health System
The George Washington University School of Medicine and Chapel Hill, North Carolina
Health Sciences Chapter 4: Respiratory Diseases
Director of Cardiac Anesthesia
Vice Chief of Anesthesiology and Pain Medicine Srijaya K. Reddy, MD
Children’s National Medical Center Assistant Professor of Anesthesiology and Pediatrics
Washington, DC Division of Anesthesiology and Pain Medicine
Chapter 14: Mitochondrial Disease Children's National Medical Center
George Washington University School of Medicine and
Henry Liu, MD Health Sciences
Associate Professor of Anesthesiology Washington, DC
Tulane University School of Medicine Chapter 14: Mitochondrial Disease
Staff Anesthesiologist
Director of Cardiothoracic and Vascular Anesthesia David L. Reich, MD
Tulane University Medical Center Horace W. Goldsmith Professor and Chair of
New Orleans, Louisiana Anesthesiology
Chapter 15: Psychiatric and Behavioral Disorders Mount Sinai School of Medicine
New York, New York
Maureen McCunn, MD, MIPP, FCCM Chapter 2: Cardiac Diseases
Assistant Professor
Department of Anesthesiology and Critical Care Amanda J. Rhee, MD
Perelman School of Medicine Assistant Professor of Anesthesiology
University of Pennsylvania Mount Sinai School of Medicine
Philadelphia, Pennsylvania New York, New York
Chapter 17: Trauma and Acute Care Chapter 2: Cardiac Diseases
 xiv Contributors

Peter Rock, MD, MBA, FCCM Ashish C. Sinha, MBBS, MD, PhD, DABA
Martin Helrich Professor and Chair President, International Society for the Perioperative Care of
Department of Anesthesiology the Obese Patient (ISPCOP)
Professor of Anesthesiology, Medicine and Surgery Professor and Vice Chairman of Research
The University of Maryland School of Medicine Director of Clinical Research
Baltimore, Maryland Anesthesiology and Perioperative Medicine
Chapter 4: Respiratory Diseases Drexel University College of Medicine
Hahnemann University Hospital
Steven J. Schwartz, MD Philadelphia, Pennsylvania
Assistant Professor Chapter 6: Obesity and Nutrition Disorders
Anesthesiology and Adult Critical Care
Johns Hopkins Bayview Medical Center Doreen Soliman, MD
Johns Hopkins Medical Institutions Assistant Professor of Anesthesiology
Baltimore, Maryland Director of Pediatric Anesthesia Residency Program
Chapter 20: The Geriatric Patient University of Pittsburgh School of Medicine
Attending Anesthesiologist
Benjamin K. Scott, MD Children's Hospital of Pittsburgh of UPMC
Assistant Professor Pittsburgh, Pennsylvania
Department of Anesthesiology Chapter 21: The Pediatric Patient
University of Colorado
Denver, Colorado Randolph H. Steadman, MD
Chapter 8: Neurologic Diseases Professor and Vice Chair
Chief, Anesthesia for Liver Transplant
Scott Segal, MD, MHCM Department of Anesthesiology
Professor and Chair David Geffen School of Medicine at UCLA
Department of Anesthesiology Los Angeles, California
Tufts University School of Medicine Chapter 5: Liver Diseases
Tufts Medical Center
Boston, Massachusetts Patricia B. Sutker, PhD
Chapter 19: Pregnancy and Obstetric Complications Professor
Department of Anesthesiology
Michael G.S. Shashaty, MD, MSCE Louisiana State University School of Medicine
Instructor, Division of Pulmonary, Allergy, and Critical Care New Orleans, Louisiana
Faculty Fellow, Center for Clinical Epidemiology and Chapter 15: Psychiatric and Behavioral Disorders
Biostatistics
Perelman School of Medicine John E. Tetzlaff, MD
University of Pennsylvania Professor of Anesthesiology
Philadelphia, Pennsylvania Cleveland Clinic Lerner College of Medicine of Case
Chapter 7: Renal Diseases Western Reserve University
Staff, Department of General Anesthesia
Linda Shore-Lesserson, MD, FASE Anesthesiology Institute
Professor of Anesthesiology Cleveland Clinic
Albert Einstein College of Medicine Cleveland, Ohio
Bronx, New York Chapter 10: Skin and Bone Disorders
Chapter 11: Hematologic Diseases
Joshua M. Tobin, MD
Frederick E. Sieber, MD Assistant Professor
Professor and Director of Anesthesia Division of Trauma Anesthesiology
Johns Hopkins Bayview Medical Center University of Maryland School of Medicine
Johns Hopkins Medical Institutions R Adams Cowley Shock Trauma Center
Baltimore, Maryland Baltimore, Maryland
Chapter 20: The Geriatric Patient Chapter 17: Trauma and Acute Care
 Contributors xv

Michael K. Urban, MD, PhD Ian Yuan, MEng, MD

Associate Professor of Clinical Anesthesiology Resident
Weil Medical College of Cornell University Department of Anesthesiology and Critical Care
Medical Director PACU/SDU Perelman School of Medicine
Hospital for Special Surgery University of Pennsylvania
New York, New York Philadelphia, Pennsylvania
Chapter 9: Muscle Diseases Chapter 6: Obesity and Nutrition Disorders
 C H A P T E R
1
Eye, Ear, Nose, and Throat Diseases
KATHRYN E. MCGOLDRICK, MD n

for optimal patient outcome. Contingency planning is crit-

Eye Diseases: General Considerations ical for patient safety.
Corneal Pathology and Systemic Disease
n Few ocular/ENT conditions have isolated ophthalmic or
Lens Pathology and Systemic Disease
otorhinolaryngologic pathology. Multisystem involvement
Glaucoma and Systemic Disease
is common, and the anesthesiologist needs to have a com-
Retinal Complications of Systemic Disease
prehensive understanding of the disease process, surgical
Eye Diseases: Specific Considerations requirements, and effects of anesthetic interventions on
Marfan's Syndrome
both patient and proposed surgery.
Graves’ Disease
n In Lowe’s (oculocerebrorenal) syndrome, cataract is often
Homocystinuria
the presenting sign, with other abnormalities such as men-
Hemoglobinopathies: Sickle Cell Disease
tal retardation, renal tubular dysfunction, and osteoporo-
Acquired Immunodeficiency Syndrome (AIDS)
sis appearing later. Drugs excreted by the kidney should
Retinopathy of Prematurity
be given cautiously and nephrotoxins avoided. Meticulous
Incontinentia Pigmenti
attention must be paid to gentle intraoperative positioning.
Retinitis Pigmentosa
n The primary areas of concern for the anesthesiologist
Eye Trauma
caring for a patient with Graves’ disease involve the con-
Ear, Nose, and Throat Considerations sequences of chronic corticosteroid use, side effects of anti-
Sleep Apnea
thyroid drugs, possible perioperative thyroid storm, and a
Recurrent Respiratory Papillomatosis
potentially difficult intubation owing to tracheal deviation
Cystic Hygroma
associated with a large neck mass.
Wegener's Granulomatosis
n In determining whether a patient with obstructive sleep apnea
Acromegaly
(OSA) is a candidate for outpatient surgery, it is imperative to
Ludwig's Angina
consider the patient’s BMI and neck circumference, severity of
Conclusion OSA, presence or absence of associated cardiopulmonary dis-
ease, nature of the surgery, anticipated postoperative analgesic
requirement, and the resources of the ambulatory facility.
n Wegener’s granulomatosis is a systemic disease of unknown
KEY POINTS
etiology characterized by necrotizing granulomas and vascu-
n During ophthalmic surgery, the anesthesiologist is often litis that affect the upper and lower airways and the kidneys.
positioned away from the patient's face, preventing imme- The anesthesiologist must anticipate a host of potential prob-
diate access to the airway, and during many laryngologic lems including the side effects of chronic corticosteroid and
surgeries, must share the airway with the surgeon. These aggressive immunosuppressive therapy as well as the pres-
logistical exigencies can compromise patient safety. ence of underlying pulmonary and renal disease. Midline
n Patients with eye conditions are often at the extremes of necrotizing granulomas of the airway are often present, and
age and may have extensive associated systemic processes subglottic or tracheal stenosis should also be expected.
or metabolic diseases.
n Patients requiring ENT surgery may have preoperative air-
way compromise from edema, infection, tumor, or trauma; Many patients presenting for relatively “simple” ophthalmic
effective anesthesiologist-surgeon communication is vital or otorhinolaryngologic procedures suffer from complex

1
 2 ANESTHESIA AND UNCOMMON DISEASES

s­ ystemic diseases. Although the surgeon may have the luxury

of being able to focus on one specific aspect of the patient's BOX 1-1 n OPHTHALMIC CONDITIONS OFTEN
condition, the anesthesiologist must be knowledgeable about ASSOCIATED WITH COEXISTING DISEASE
the ramifications of the entire disease complex and the ger- Aniridia Macular hypoplasia
mane implications for anesthetic management. Issues of safety Cataracts Nystagmus
often are complicated by the logistic necessity for the anesthe- Colobomata Optic nerve hypoplasia
siologist to be positioned at a considerable distance from the Corneal dystrophies Retinal detachment
Ectopia lentis Retinopathy
patient's face, thus preventing immediate access to the airway Glaucoma Strabismus
for certain types of ophthalmic surgery. Additionally, during
many laryngologic surgeries, the anesthesiologist must share
the airway with the surgeon. Moreover, many of these patients issues for anesthetic management, or the eye pathology may
with complex disease undergo surgical procedures that are be only one manifestation of a constellation of systemic condi-
routinely performed on an ambulatory basis, further challeng- tions that constitute a syndrome with major anesthetic impli-
ing the anesthesiologist to provide a rapid, smooth, problem- cations (Box 1-1).
free recovery. Other, less common eye defects frequently linked with
This chapter focuses on several eye diseases as well as ear, coexisting diseases include aniridia, colobomas, and optic
nose, and throat (ENT) conditions, many of which are rela- nerve hypoplasia. Aniridia, a developmental abnormality
tively rare. Nonetheless, the anesthesiologist needs to under- characterized by striking hypoplasia of the iris, is a mis-
stand the complexities involved, because failure to do so may nomer because the iris is not totally absent. The term
be associated with preventable morbidity and mortality. describes only one facet of a complex developmental dis-
order that features macular and optic nerve hypoplasia
as well as associated cataracts, glaucoma, ectopia lentis,
EYE DISEASES: GENERAL progressive opacification, and nystagmus. Type I aniridia
CONSIDERATIONS involves autosomal dominant transmittance of a gene
Patients with eye conditions are often at the extremes of thought to be on chromosome 2. Type II aniridia u ­ sually
age, ranging from fragile infants with retinopathy of pre- appears sporadically and is associated with an intersti-
maturity or congenital cataracts to nonagenarians with tial deletion on the short arm of c­ hromosome 11 (11p13),
submacular hemorrhage. These patients also may have
­ although rarely a ­b alanced translocation of chromosome
extensive associated systemic processes or metabolic dis- 11 may produce familial type II. In addition to the typical
eases.1 Moreover, the increased longevity in developed ocular lesions, children with type II aniridia frequently are
nations has produced a concomitant increase in the longi- mentally retarded and have genitourinary anomalies—the
tudinal prevalence of major eye diseases. A study of elderly “ARG triad.” Individuals with the chromosome 11 defect
Medicare beneficiaries in the United States followed for 9 and this triad may develop Wilms’ tumor3 and should be
years during the 1990s documented a dramatic increase followed with regular abdominal examinations and fre-
in the prevalence of major chronic eye diseases associated quent renal ultrasonography at least until they are 4 years
with aging.2 For example, the prevalence of diabetes melli- old. Chromosomal analysis is indicated in all infants with
tus increased from 14.5% at baseline in the study patients to congenital aniridia.
25.6% nine years later, with diabetic retinopathy among per- Coloboma denotes an absence or defect of some ocular
sons with diabetes mellitus increasing from 6.9% to 17.4% tissue, usually resulting from malclosure of the fetal intraoc-
of the subset. Primary open-angle glaucoma increased from ular fissure, or rarely from trauma or disease. The two major
4.6% to 13.8%, and glaucoma suspects increased from 1.5% types are chorioretinal or fundus coloboma and isolated optic
to 6.5%. The prevalence of age-related macular degenera- nerve coloboma. The typical fundus coloboma is caused by
tion increased from 5% to 27.1%. Overall, the proportion of malclosure of the embryonic fissure, resulting in a gap in
subjects with at least one of these three chronic eye diseases the retina, retinal pigment epithelium, and choroid. These
increased significantly, from 13.4% to 45.4% of the elderly defects may be unilateral or bilateral and usually produce a
Medicare population. visual field defect corresponding to the chorioretinal defect.
Ophthalmic conditions typically involve the cornea, lens, Although colobomas may occur independent of other
vitreoretinal area, intraocular pressure–regulating appara- abnormalities, they also may be associated with microph-
tus, or eye muscles and adnexa. These patients may present thalmos, cyclopia, anencephaly, or other major central ner-
for, respectively, corneal transplantation, cataract extraction, vous system aberrations. They frequently are linked with
vitrectomy for vitreous hemorrhage, scleral buckling for ret- chromosomal abnormalities, especially the trisomy 13 and
inal detachment, trabeculectomy and other glaucoma filtra- 18 syndromes. Colobomas may be seen with the CHARGE
tion procedures for glaucoma amelioration, or rectus muscle syndrome (congenital heart disease, choanal atresia, men-
recession and resection for strabismus. Conversely, they may tal retardation, genital hypoplasia, and ear anomalies) or
require surgery for a condition entirely unrelated to their ocu- the VATER association (tracheoesophageal fistula, con-
lar pathology. Nonetheless, their ocular disease may present genital heart disease, and renal anomalies). Rarely, isolated
 Chapter 1 Eye, Ear, Nose, and Throat Diseases 3

c­ olobomas of the optic nerve occur. They may be familial as erythema multiforme and pemphigus have corneal mani-
and associated with other ocular pathology as well as sys- festations (see Chapter 10). Finally, mandibulo-­oculofacial
temic defects, including cardiac conditions. dyscephaly (Hallermann-Streiff syndrome) is of interest to anes-
Optic nerve hypoplasia is a developmental defect char- thesiologists because of anticipated difficulty with intubation.
acterized by deficiency of optic nerve fibers. The anomaly
may be unilateral or bilateral, mild to severe, and associ-
Lens Pathology and Systemic Disease
ated with a broad spectrum of ophthalmoscopic find-
ings and clinical manifestations. Visual impairment may A cataract is defined as a clouding of the normally clear crys-
range from minimal reduction in acuity4 to blindness. talline lens of the eye. The different types of cataracts include
Strabismus or nystagmus secondary to visual impairment nuclear-sclerotic, cortical, posterior subcapsular, and mixed.
is common. Although optic nerve hypoplasia may occur Each type has its own location in the lens and risk factors
as an isolated defect in otherwise normal children, the for development, with nuclear-sclerotic cataracts being the
lesion can be associated with aniridia, microphthalmos, most common type of age-related cataract. The leading cause
coloboma, anencephaly, hydrocephalus, hydranencephaly, of blindness worldwide, cataracts affect more than 6 million
and encephalocele. Optic nerve hypoplasia may occur in individuals annually.8 Indeed, cataract surgery is the most
a syndrome termed septo-optic dysplasia or de Morsier's ­frequently p­ erformed surgical procedure in the United States,
syndrome. There may be coexisting hypothalamic condi- with more than 1.5 million operations annually.9 More than
tions and extremely variable endocrine aberrations.5,6 An half the population older than 65 develop age-related cata-
isolated deficiency of growth hormone is most common, but racts with associated visual disability.10 Despite extensive
multiple hormonal imbalances, including diabetes insipi- research into the pathogenesis and pharmacologic prevention
dus, have been reported. The etiology of optic nerve hypo- of ­cataracts, however, there are no proven means to prevent
plasia remains unknown. However, it has been observed age-related cataracts.
to occur with slightly increased frequency in infants of Although age-related cataracts are most frequently encoun-
­diabetic ­mothers,4 and the prenatal use of drugs such as tered, cataracts may be associated with dermatologic diseases
LSD (lysergic acid diethylamide), meperidine, phenytoin, such as incontinentia pigmenti, exogenous substances, genetic
and quinine has been implicated sporadically. diseases, hematologic diseases, infections, and metabolic per-
turbations (Box 1-3).
Exogenous substances that can trigger cataracts include
Corneal Pathology and Systemic Disease
corticosteroids,11–13 phenothiazines, naphthalene, ergot,
A vast spectrum of conditions may be associated with cor- parachlorobenzene, and alcohol.14 Metabolic conditions
neal pathology7 (Box 1-2). Associated inflammatory diseases ­associated with cataracts include diabetes mellitus, Fabry's dis-
include rheumatoid arthritis, Reiter's syndrome, Behçet's syn- ease, galactosemia, hepatolenticular degeneration (Wilson's
drome, and sarcoidosis. Connective tissue disorders such as disease), hypoparathyroidism, hypothyroidism, phenylketon-
ankylosing spondylosis, scleroderma, Sjögren's syndrome, and uria, Refsum's disease, and xanthomatosis. Another metabolic
Wegener's granulomatosis have been associated with corneal
disturbances. Associated metabolic diseases include cystinosis,
disorders of carbohydrate metabolism, gout, hyperlipidemia,
BOX 1-3 n CONDITIONS ASSOCIATED WITH
and Wilson's disease. Also, such conditions as Graves’ hyper- CATARACTS
thyroid disease, leprosy, chronic renal failure, and tuberculosis
may have associated corneal disease. Even skin diseases such Aging Galactosemia
Hypoparathyroidism
Chromosomal Anomalies
Hypothyroidism
Trisomy 13
Lowe's syndrome
Trisomy 18
Phenylketonuria
BOX 1-2 n SYSTEMIC DISEASES ASSOCIATED WITH Trisomy 21
Refsum's disease
CORNEAL PATHOLOGY Turner's syndrome
Wilson's disease
Dermatologic Disease Xanthomatosis
Connective Tissue Metabolic Diseases
Incontinentia pigmenti
Disorders Carbohydrate metabolism Infectious Diseases
Ankylosing spondylosis disorders Exogenous Substances Herpes
Scleroderma Chronic renal failure Alcohol Influenza
Sjögren's syndrome Cystinosis Ergot Mumps
Wegener's granulomatosis Gout Naphthalene Polio
Graves’ disease Parachlorobenzene Rubella
Inflammatory Diseases
Wilson's disease Phenothiazines Toxoplasmosis
Behçet's syndrome
Vaccinia
Reiter's syndrome Skin Disorders Metabolic Conditions
Varicella-zoster
Rheumatoid arthritis Erythema multiforme Diabetes mellitus
Sarcoidosis Pemphigus Fabry's disease
 4 ANESTHESIA AND UNCOMMON DISEASES

disorder important in the differential diagnosis of congeni-

tal cataracts is Lowe's (oculocerebrorenal) syndrome. In this BOX 1-4 n CONDITIONS ASSOCIATED WITH
ECTOPIA LENTIS
X-linked disorder, cataract is frequently the presenting sign,
with other abnormalities appearing later. These anomalies Ocular Conditions
include mental and growth retardation, hypotonia, renal aci- Aniridia
Congenital glaucoma
dosis, aminoaciduria, proteinuria, and renal rickets, requir-
High myopia
ing calcium and vitamin D therapy.15,16 Other concomitants Intraocular tumor
include osteoporosis and a distinctive facies (long with fron- Trauma
tal bossing). Although lens changes may also be seen in het- Uveitis
erozygous female children, affected male children usually Systemic Diseases
have obvious, dense, bilateral cataracts at birth. They may also Homocystinuria
be afflicted with associated glaucoma. Interestingly, carrier Hyperlysinemia
females in their second decade of life have significantly higher Marfan's syndrome
Sulfite oxidase deficiency
numbers of lens opacities than age-related controls; however,
Weill-Marchesani syndrome
absence of opacities is no guarantee that an individual is not
a carrier. Anesthetic management includes careful attention
to acid-base balance and to serum levels of calcium and elec-
trolytes. Renal involvement of oculocerebrorenal syndrome of t­opographically as subluxation or luxation. Luxation denotes
Lowe comprises tubular dysfunction characterized by protein- a lens that is dislocated either posteriorly into the vitreous cav-
uria and generalized aminoaciduria progressing to the renal ity or, less often, anteriorly into the anterior chamber. In sub-
Fanconi's syndrome. Bicarbonate wasting and hyperkaluria luxation, some zonular attachments remain, and the lens stays
result from a proximal tubule transport defect, with later glo- in its plane posterior to the iris, but tilted. The most common
merular disease.17 The administration of drugs excreted by cause of lens displacement is trauma, although ectopia lentis
the kidney should be observed carefully and nephrotoxins may also result from other ocular disease, such as intraocular
avoided. The patient with osteoporosis should be positioned tumor, congenital glaucoma, uveitis, aniridia, syphilis, or high
on the operating table gently and carefully. myopia. Inherited defects and serious systemic diseases, such
Infectious causes of cataracts include herpesvirus, influ- as Marfan's syndrome, homocystinuria, Weill-Marchesani
enza, mumps, polio, rubella, toxoplasmosis, vaccinia, and syndrome, hyperlysinemia, and sulfite oxidase deficiency, are
varicella-zoster virus.18 Chromosomal anomalies associated also associated with ectopia lentis. Indeed, lens displacement
with cataracts include trisomy 13 (Patau's syndrome), trisomy occurs in approximately 80% of patients with Marfan's syn-
18 (Edward's syndrome), and trisomy 21 (Down syndrome). drome (see later discussion).
In Patau's and Edward's syndromes, congenital cataracts fre-
quently occur in conjunction with other ocular anomalies,
Glaucoma and Systemic Disease
such as coloboma and microphthalmia. Cataracts have also
been reported with Turner's syndrome (XO). Glaucoma is a condition characterized by elevated intraocu-
An additional type of lens abnormality that can be asso- lar pressure (IOP), resulting in impairment of capillary blood
ciated with major systemic disease is ectopia lentis (Fig. 1-1 flow to the optic nerve and eventual loss of optic nerve tissue
and Box 1-4). Displacement of the lens can be classified and function. Two different anatomic types of glaucoma exist:
open-angle (or chronic simple) glaucoma and closed-angle (or
acute) glaucoma. (Other variations of these processes occur
but are not especially germane to anesthetic management.
Glaucoma is actually many diseases, not one.)
With open-angle glaucoma, the elevated IOP exists in con-
junction with an anatomically patent anterior chamber angle.
Sclerosis of trabecular tissue is thought to produce impaired
aqueous filtration and drainage. Treatment consists of medi-
cation to produce miosis and trabecular stretching. Common
eyedrops include epinephrine, echothiophate iodide, timolol,
dipivefrin, and betaxolol. Carbonic anhydrase inhibitors such
as acetazolamide can also be administered by various routes
to reduce IOP by interfering with the production of aqueous
humor. All these drugs are systemically absorbed and thus can
have anticipated side effects.
FIGURE 1-1 Ectopia lentis. Displaced lens of the eye is common
It is important to appreciate that maintenance of IOP is
in patients with Marfan's syndrome. (Courtesy American Academy determined primarily by the rate of aqueous formation and
of Ophthalmology, 2011, aao.org.) the rate of aqueous outflow. The most important influence on
 Chapter 1 Eye, Ear, Nose, and Throat Diseases 5

formation of aqueous humor is the difference in osmotic pres-

sure between aqueous and plasma, as illustrated by the follow- BOX 1-5 n CONDITIONS ASSOCIATED WITH
GLAUCOMA
ing equation:
Ocular Conditions
IOP = K[(OPaq − OPpl) + CP] Aniridia
Anterior cleavage syndrome
where K = coefficient of outflow, OPaq = osmotic pressure of
Cataracts
aqueous humor, OPpl = osmotic pressure of plasma, and CP = Ectopia lentis
capillary pressure. Because a small change in solute concen- Hemorrhage
tration of plasma can dramatically affect the formation of Mesodermal dysgenesis
aqueous humor and thus IOP, hypertonic solutions such as Persistent hyperplastic primary vitreous
Retinopathy of prematurity
mannitol are administered to reduce IOP.
Spherophakia
Fluctuations in aqueous outflow can also greatly change Trauma
IOP. The primary factor controlling aqueous humor outflow Tumor
is the diameter of Fontana's spaces, as illustrated by the fol-
Systemic Diseases
lowing equation: Chromosomal anomalies
4 Congenital infection syndromes (TORCH*)
A = [r × (Piop − Pv)] ÷ 8 ηL
Hurler's syndrome
where A = volume of aqueous outflow per unit of time, r = radius Marfan's syndrome
Refsum's disease
of Fontana's spaces, Piop = IOP, Pv = venous pressure, η = vis-
Sarcoidosis
cosity, and L = length of Fontana's spaces. When the pupil dilates, Stickler's syndrome
Fontana's spaces narrow, resistance to outflow is increased, and Sturge-Weber syndrome
IOP rises. Because mydriasis is undesirable in both closed- Von Recklinghausen's disease
angle and open-angle glaucoma, miotics such as pilocarpine are
applied to the conjunctiva in patients with glaucoma. *Toxoplasmosis, other agents, rubella, cytomegalovirus, herpes simplex.
The previous equation describing the volume of aque-
ous outflow per unit of time clearly underscores that outflow
is exquisitely sensitive to fluctuations in venous pressure.
Because an elevation in venous pressure results in an
BOX 1-6 n GLAUCOMA PATIENTS: ANESTHETIC
increased volume of ocular blood as well as decreased aque- OBJECTIVES
ous outflow, IOP increases considerably with any maneu-
ver that increases venous pressure. Therefore, in addition Perioperative instillation of miotics to enhance aqueous humor
to preoperative instillation of miotics, other anesthetic outflow
Avoidance of venous congestion/overhydration
objectives for the patient with glaucoma include periop- Avoidance of greatly increased venous pressure (e.g., coughing,
erative avoidance of venous congestion and of overhydra- vomiting)
tion. Furthermore, hypotensive episodes should be avoided Avoidance of hypotension that may trigger retinal vascular thrombosis
because these patients are purportedly vulnerable to retinal
vascular thrombosis.
Although glaucoma usually occurs as an isolated disease, it
may also be associated with such conditions as Sturge-Weber
TABLE 1-1 n Comparison of Open-Angle and
syndrome and von Recklinghausen's disease (neurofibro- Closed-Angle Glaucoma*
matosis) (Box 1-5). Ocular trauma, corticosteroid therapy,
sarcoidosis, some forms of arthritis with uveitis, and pseudo- Open-Angle Glaucoma Closed-Angle Glaucoma
exfoliation syndrome can also be associated with secondary Anatomically patent Shallow anterior chamber
glaucoma. anterior chamber angle
Primary closed-angle glaucoma is characterized by a shal-
Trabecular sclerosis Narrow iridocorneal angle
low anterior chamber and a narrow iridocorneal angle that
impedes the egress of aqueous humor from the eye because Ten times more common Iris covers trabecular meshwork
the trabecular meshwork is covered by the iris (Box 1-6). than closed-angle
Relative pupillary block is common in many angle-closure Painless Painful
episodes in which iris-lens apposition or synechiae impede
Initially unaccompanied by Red eye with corneal edema
the flow of aqueous from the posterior chamber. In the
visual symptoms Blurred vision; fixed, dilated pupil
United States, angle-closure glaucoma (ACG) is one-tenth
as c­ ommon as open-angle glaucoma (Table 1-1). In acute Can result in blindness if Can cause irreversible optic
ACG, if the pressure is not reduced promptly, permanent chronically untreated nerve injury within 24-48 hours
Requires emergency treatment
visual loss can ensue as a result of optic nerve damage.
Because irreversible optic nerve injury can occur within *Also called angle-closure glaucoma (ACG).
Other documents randomly have
different content
 Microbiology - Workbook
First 2024 - Center

Prepared by: Prof. Brown

Date: July 28, 2025

Discussion 1: Assessment criteria and rubrics

Learning Objective 1: Comparative analysis and synthesis
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
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Learning Objective 2: Assessment criteria and rubrics
• Literature review and discussion
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Formula: [Mathematical expression or equation]
Learning Objective 3: Ethical considerations and implications
• Fundamental concepts and principles
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Learning Objective 4: Ethical considerations and implications
• Statistical analysis and interpretation
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Learning Objective 5: Literature review and discussion
• Experimental procedures and results
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Important: Case studies and real-world applications
• Problem-solving strategies and techniques
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Formula: [Mathematical expression or equation]
Practice Problem 6: Historical development and evolution
• Comparative analysis and synthesis
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Important: Ethical considerations and implications
• Statistical analysis and interpretation
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Note: Theoretical framework and methodology
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[Figure 9: Diagram/Chart/Graph]
Key Concept: Theoretical framework and methodology
• Research findings and conclusions
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Formula: [Mathematical expression or equation]
[Figure 10: Diagram/Chart/Graph]
Summary 2: Study tips and learning strategies
Note: Learning outcomes and objectives
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Learning outcomes and objectives
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Important: Fundamental concepts and principles
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Remember: Assessment criteria and rubrics
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 14: Best practices and recommendations
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Note: Assessment criteria and rubrics
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Critical analysis and evaluation
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Remember: Problem-solving strategies and techniques
• Interdisciplinary approaches
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- Example: Practical application scenario
Example 18: Comparative analysis and synthesis
• Literature review and discussion
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- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Statistical analysis and interpretation
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Introduction 3: Fundamental concepts and principles
Remember: Assessment criteria and rubrics
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 21: Diagram/Chart/Graph]
Remember: Comparative analysis and synthesis
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Statistical analysis and interpretation
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
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- Note: Important consideration
Definition: Comparative analysis and synthesis
• Key terms and definitions
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- Example: Practical application scenario
- Note: Important consideration
Note: Statistical analysis and interpretation
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Learning outcomes and objectives
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Remember: Ethical considerations and implications
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Best practices and recommendations
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Key Concept: Problem-solving strategies and techniques
• Historical development and evolution
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- Note: Important consideration
Definition: Statistical analysis and interpretation
• Learning outcomes and objectives
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- Note: Important consideration
References 4: Best practices and recommendations
Key Concept: Problem-solving strategies and techniques
• Current trends and future directions
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- Note: Important consideration
Example 31: Research findings and conclusions
• Ethical considerations and implications
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Practice Problem 32: Practical applications and examples
• Statistical analysis and interpretation
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- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Theoretical framework and methodology
• Interdisciplinary approaches
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- Note: Important consideration
Practice Problem 34: Experimental procedures and results
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
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Formula: [Mathematical expression or equation]
Note: Theoretical framework and methodology
• Comparative analysis and synthesis
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Practice Problem 36: Theoretical framework and methodology
• Learning outcomes and objectives
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Key Concept: Fundamental concepts and principles
• Historical development and evolution
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- Note: Important consideration
Important: Interdisciplinary approaches
• Historical development and evolution
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- Note: Important consideration
Important: Study tips and learning strategies
• Research findings and conclusions
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- Note: Important consideration
References 5: Ethical considerations and implications
Remember: Theoretical framework and methodology
• Problem-solving strategies and techniques
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- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 41: Literature review and discussion
• Comparative analysis and synthesis
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• Practical applications and examples
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[Figure 43: Diagram/Chart/Graph]
Note: Theoretical framework and methodology
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[Figure 46: Diagram/Chart/Graph]
Example 46: Theoretical framework and methodology
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Note: Literature review and discussion
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- Note: Important consideration
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Important: Learning outcomes and objectives
• Best practices and recommendations
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[Figure 49: Diagram/Chart/Graph]
Remember: Research findings and conclusions
• Research findings and conclusions
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- Note: Important consideration
Background 6: Interdisciplinary approaches
Note: Research findings and conclusions
• Interdisciplinary approaches
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Key Concept: Study tips and learning strategies
• Practical applications and examples
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[Figure 52: Diagram/Chart/Graph]
Remember: Practical applications and examples
• Theoretical framework and methodology
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Key Concept: Comparative analysis and synthesis
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Interdisciplinary approaches
• Comparative analysis and synthesis
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- Note: Important consideration
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Key Concept: Best practices and recommendations
• Literature review and discussion
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- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 56: Diagram/Chart/Graph]
Definition: Problem-solving strategies and techniques
• Learning outcomes and objectives
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- Note: Important consideration
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Remember: Current trends and future directions
• Ethical considerations and implications
- Sub-point: Additional details and explanations
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- Note: Important consideration
Note: Historical development and evolution
• Assessment criteria and rubrics
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• Comparative analysis and synthesis
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Background 7: Literature review and discussion
Example 60: Theoretical framework and methodology
• Historical development and evolution
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- Note: Important consideration
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• Case studies and real-world applications
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- Note: Important consideration
Practice Problem 62: Literature review and discussion
• Interdisciplinary approaches
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Definition: Learning outcomes and objectives
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[Figure 64: Diagram/Chart/Graph]
Definition: Interdisciplinary approaches
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Practice Problem 65: Critical analysis and evaluation
• Ethical considerations and implications
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- Note: Important consideration
Important: Research findings and conclusions
• Study tips and learning strategies
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Practice Problem 68: Critical analysis and evaluation
• Key terms and definitions
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- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Historical development and evolution
• Key terms and definitions
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- Note: Important consideration
Methodology 8: Research findings and conclusions
Definition: Interdisciplinary approaches
• Learning outcomes and objectives
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- Note: Important consideration
Practice Problem 71: Best practices and recommendations
• Ethical considerations and implications
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Practice Problem 72: Ethical considerations and implications
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
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- Note: Important consideration
Key Concept: Comparative analysis and synthesis
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
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Practice Problem 74: Assessment criteria and rubrics
• Literature review and discussion
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- Note: Important consideration
Important: Research findings and conclusions
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[Figure 76: Diagram/Chart/Graph]
Key Concept: Critical analysis and evaluation
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[Figure 78: Diagram/Chart/Graph]
Key Concept: Practical applications and examples
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 79: Best practices and recommendations
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Part 9: Comparative analysis and synthesis
Practice Problem 80: Literature review and discussion
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 81: Diagram/Chart/Graph]
Key Concept: Current trends and future directions
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Interdisciplinary approaches
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Definition: Interdisciplinary approaches
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 84: Critical analysis and evaluation
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 85: Diagram/Chart/Graph]
Important: Critical analysis and evaluation
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 86: Best practices and recommendations
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 87: Diagram/Chart/Graph]
Remember: Assessment criteria and rubrics
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Definition: Interdisciplinary approaches
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Research findings and conclusions
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Appendix 10: Experimental procedures and results
Key Concept: Learning outcomes and objectives
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 91: Diagram/Chart/Graph]
Definition: Critical analysis and evaluation
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Theoretical framework and methodology
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
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