Avoiding Common Anesthesia Errors

 

Description:

The full-color Avoiding Common Anesthesia Errors, significantly updated for this second edition, combines patient safety information and evidence-based guidance for over 300 commonly encountered clinical situations. With a format that suggests conversations between an attending and a trainee, the book helps you identify potential problems and develop a treatment plan to minimize the problem. Brief, easy-to-read chapters cover basic and advanced topics and help you digest information in minutes!

 

 

 

Table of Contents:

 

VENTILATION AND AIRWAY

1 Introduction

2 Basics of Airway Management (Part I)—Always Keep in Mind Complications That Can Occur With Existing Endotracheal Tubes and Tracheal Extubation

Inability to Ventilate due to Endotracheal Tube Occlusion

Avoiding Unexpected Loss of the Airway in Already Intubated Patients

Anticipate Potential Difficulties and Be Prepared to Treat Airway Failure After Extubation

Preparing for Safe Tracheal Extubation

Avoiding Complications of Premature Extubation

Exchanging a Double-Lumen ETT With a Single-Lumen ETT

3 Basics of Airway Management—Part II (More Tips and Tidbits to Read on the Train)

4 Optimize the Airway: Bag–Mask Ventilation

5 Optimize the Airway: Direct Laryngoscopy

Basic Principles

Direct Laryngoscopy Techniques

Placing the Endotracheal Tube

6 Oxygen Is a Drug

Administration

Volume of Distribution

Pharmacodynamics

Circulatory Effects

Pulmonary Effects

Medical Use

Side Effects and Risks

7 Advantages and Disadvantages of the Laryngeal Mask Airway (LMA)

Introduction

8 Avoiding Challenges With Video Laryngoscopy

When Should I Do an Awake Intubation Instead of VL?

Should VL Replace DL?

Overcoming Difficult Tube Placement With VL

Avoiding Soft Tissue Injury With VL

9 Do Not Overinflate the Cuff of the Endotracheal Tube

10 Consider the Use of Lidocaine in the Cuff of the Endotracheal Tube, but Be Aware of the Risks and Alternatives

Intracuff Lidocaine

Alternatives

11 An Easy Intubation Does Not Guarantee an Easy Reintubation—Especially After a Carotid Endarterectomy or Cervical Spine Surgery

Edema/Hematoma

Cerebrospinal Fluid Leak

Recurrent Laryngeal Nerve Injury

Carotid Body Dysfunction

Cervical Misalignment

Surgical Dressings

12 Plan for an Airway Fire With Every Head and Neck Case

Introduction

Fire Triad

Procedures With Increased Risk for Fire

Surgical Fire

Communication and Prevention

Management of OR Fires

13 There Are Special Considerations Involved With Both Intubation and Chronic Airway Management of Burn Patients

Acute Management

Chronic Management

14 To PEEP or Not to PEEP—That Is the Question

Definitions

Physiologic Effects

Respiratory

Cardiac

Central Nervous System

Renal

Hepatic

Indications

Prevention of Atelectasis

ALI/ARDS

Cardiogenic Pulmonary Edema

Contraindications

Treatment of Auto-PEEP

Ongoing Debate

15 This Is No Time for Wishful Thinking: Always Troubleshoot an Increase in Peak Airway Pressure

Consequences of Elevated Ventilatory Pressure

Airway/Ventilation Equipment Problems

Patient-Related Problems

Cough/Light Anesthesia

Bronchospasm/Wheezing

Mechanical Airway Obstruction

Positioning/Surgical Factors

Decreased Pulmonary and Chest Wall Compliance

Acute Decreases in Lung Parenchymal Volume

Auto-PEEP

Conclusion

16 The Key to the Smooth and Skilled Placement and Use of Double-Lumen Endotracheal Tubes Is to Take It One Step at a Time

Introduction

Sizing of Double-Lumen Endotracheal Tubes

Placement of Double-Lumen Endotracheal Tubes

Bronchial Cuff Inflation

Mechanical Ventilation

Hypoxia During One-Lung Ventilation

17 Avoid Common Airway and Ventilation Errors in Morbidly Obese Patients

Introduction

Obstructive Sleep Apnea

Associated Conditions

Physiologic Alterations

Establishing the Airway

Ventilation After the Airway is Established

Hazards of Tracheal Extubation

18 Anesthesia for Awake Intubations

Innervation

Anesthetization of the Airway

Nasal Cavity/Nasopharynx

Oral Cavity/Oropharynx

Hypopharynx

Larynx

Vocal Cords and Trachea

19 Awake Intubations–Being Able to Do Them Comfortably and Safely for the Patient Is the Benchmark for the Airway Expert

Indications for Awake Intubation

Nasal Versus Oral

Techniques

Fiber-optic Intubation

Blind Nasal or Oral Lightwand

Awake Laryngoscopy

20 Airway Management in the ICU, Including the Dreaded Leaking Cuff—How to Bring Your Best Game

Introduction

General Principles

Issue: “The Endotracheal Tube Cuff Is Leaking, and I Can’t Ventilate My Patient!”

Issue: “I Need to Change the ETT or Extubate This Patient, but I’m Concerned About a Difficult Reintubation.”

Issue: “My Patient’s Tracheostomy Device Is Dislodged.”

Summary

21 Ludwig’s Angina

22 Jet Ventilation—How to Adequately Handle This Exotic Ventilation Technique and Earn the Admiration of Your Spectators

Accepted Indications for JV

Insufficient Oxygenation

Insufficient Carbon Dioxide Elimination

Increasing Airway Pressure

JET Gas Conditioning

23 High-Frequency Jet Ventilation—The View From Philadelphia

Physical Principles

Clinical Use and Principles

CO2 Monitoring

Other Clinical Considerations

24 Know How to Perform a Cricothyroidotomy

25 Don’t Make the Mistake of Thinking That a Tracheostomy Is a Guaranteed Airway

Tracheal Tube Obstruction

Foreign Body in Tracheal Tube or Airway

Loss of Airway With Tracheostomy Tube Removal

Hemorrhage

Chronic Complications

26 Helium for the Compromised Airway—You Have to Understand the Principles and Properties but We’ve Seen Some Amazing Saves

Physical Properties of Helium

Heliox

Physics of Fluid Flow With Heliox

Administration

Possible Clinical Applications

For Upper-Airway Obstruction and Stridor

For Croup and Bronchiolitis

For Asthma Exacerbation

For Severe COPD

New Avenues in Clinical Helium Use

Risks of Heliox Use

LINES AND ACCESS

27 Introduction

28 Remember That the IV Start Is Your First Chance to Make a Favorable Impression on the Patient

29 Never Use an Intravenous Line Without Palpating and Inspecting It Visually

Perioperative IV Fluid Concerns

Intraoperative Monitoring

Consequences

Treatment Options

Conclusions

30 Intraosseous Access

Needle Types

Insertion Sites

Complications of IO Needle Placement

31 Central Line Placement: Never Neglect the Basics

32 Avoid Technique-Related Central Venous Catheter Complications by Using Modern Tools

33 Pulmonary Artery Catheters—Still Relevant and Still Worthy of a Cautious Approach

How PAC Technology Works

Placement and Risk

Errors of Management

Errors of Interpretation

Alternative or Supplemental Techniques

34 Don’t Overflush Lines

35 Inadvertent Intra-Arterial Injection Can Result in Severe Patient Injury

Risk Factors for IA Injection

Signs and Symptoms of Arterial Cannulation

Pathophysiology

Treatment Options

Prevention of IA Injection

36 Do Not Use the Subclavian Vein for Central Access of Any Type in a Patient Who Is On or Planned for Dialysis

37 Consult the Surgeons Immediately if Your Patient Loses a Patent Hemodialysis Fistula—This Is a Serious Complication for the Patient

Hemodialysis Fistulas

AVF Failure

Treatment of AVF Thrombosis

FLUIDS AND RESUSCITATION

38 Introduction

39 Crystalloid Fluids: More Than Just a Dash of Salt

The Evidence

The Practice

40 Hypertonic Saline: Still the “Solution” to the Solution Problem?

41 Synthetic Colloid Solutions Have Distinct Properties and Risk/Benefit Ratios That Require Your Attention!

42 Do Not Use CVP to Guide Fluid Resuscitation

TRANSFUSION MEDICINE

43 Introduction

44 Know What Screening Tests Are Performed on Volunteer Donor Blood

Queries and Questionnaire

Serum Screening

Platelets

Blood Type and Antigen Testing

Understanding and Managing the Patient’s Anxiety

45 Red Blood Cell Primer

Washing (Please see Chapter 53 on Washed Products for More Detail)

Irradiation

Leukoreduction

Infectious Complications of pRBCs

Noninfectious Complications (Other Than Transfusion Reactions)

46 Type and Screen or Type and Cross-Match?

Type and Screen

Cross-Matching

Optimizing Perioperative Blood Ordering

47 Special Circumstances: Patients With Antibodies

48 Plasma—It’s Not Just to Fix an Abnormal INR

Plasma Use

Thromboelastography and ROTEM

Massive Transfusion Protocols

MTP Controversies and Issues

Are Guidelines Effective?

Types of Plasma Products

Plasma Dosing

Alternatives to Plasma

Summary

49 Plasma Part II: Is This Plasma or Pea Soup?

50 Remember That the “Universal” Donor Is Different for Red Cell and Plasma Products

51 Platelets—Often a Mystery!

52 Cryoprecipitate—The Most Misunderstood Product in the Blood Bank

Uses of Cryoprecipitate

Inappropriate Uses of Cryoprecipitate

Dosing of Cryoprecipitate

53 Washed Blood Products Are a Source of Confusion—Here’s Some Help

54 This TEG Tracing Looks Like a Rorschach Blot … Is It Time for a Transfusapalooza?

Introduction

TEG Sample Processing

TEG Parameters

TEG Tracing Patterns and Weaknesses

55 Transfusion Reactions

Treatment of Transfusion Reactions

56 Transfusion Outcomes

Varied Practice—Transfusion Triggers pRBC

Why Decrease Transfusion?

Risk of Nosocomial Infection

Cancer Recurrence

Cardiovascular Effects

Red Cell Alloimmunization

Plasma

Platelets

All Blood Products

Increase in Length of Stay

Increased Costs

Declining Donor Supply

57 Directed Donation Is Generally Not a Good Idea

Blood Safety

58 Not All Acute Lung Injury After a Transfusion Is Transfusion-Related Acute Lung Injury

59 Jehovah’s Witnesses and Bloodless Medicine

Preoperative Strategies for a Bloodless Perioperative Clinical Course

Intraoperative Strategies for a Bloodless Perioperative Clinical Course

Anesthesiology Techniques

Surgical Techniques

Postoperative Strategies for a Bloodless Perioperative Clinical Course

60 The Ethics of Jehovah’s Witnesses and Transfusion

Management Strategies for Jehovah’s Witness Patients—The Basic Three-Part Approach

MEDICATIONS

61 Introduction

62 What Just Happened! What You Need to Know About Medication Errors

Introduction

Are Medication Errors a Problem in Anesthesia?

How Common Are Medication Errors in Anesthesia?

How Do We Identify Our Drugs?

What Is the Proper Technique to Draw Up and Administer a Drug?

What Medication Issues Predispose to Medication Errors?

What Environmental and Practitioner Issues Predispose to Medication Errors?

Types of Errors

ASA Closed Claims

How Can We Reduce the Incidence of Medication Errors?

Conclusion

63 Make Sure You Understand the Complex Medical and Legal Issues Surrounding Off-Label Drug Use

64 Perioperative Beta-Blocker Therapy for High-Risk Patients Having Noncardiac Surgery—New Data, New Recommendations

Perioperative Studies

More Recent Studies

Task Force Guidelines

65 Should I Withhold or Continue Angiotensin Receptor Blockers in the Perioperative Period?

Indications

Perioperative Guideline

Should Therapy Be Continued Uninterrupted in the Perioperative Period?

Timing of Last Dose

66 Stop Metformin Before Elective Surgery or Intravascular Contrast Dye Study to Decrease the Risk of Lactic Acidosis

Lactic Acidosis

Guidelines

67 Should I Administer Steroids in the Perioperative Period?

Hyperglycemia

Wound Healing and Infection

Steroid Withdrawal

Other Complications

68 Beware of the Bowel Prep

69 What Drugs Require Slow Administration?

Phenytoin (Dilantin)

Protamine

Vancomycin

Potassium

Clindamycin

Thymoglobulin

Furosemide (Lasix)

Gentamicin

Oxytocin (Pitocin)

Dexamethasone

Lysine Analogs

Other Pearls to Avoid Common Errors Involving IV Administration in the Operating Room

70 Ketamine—Use It Well

71 TIVA—What You Need to Understand to Do It Well

Pharmacokinetics

Time to Peak Effect

Redistribution

Elimination

Pharmacodynamics

Infusion Systems

72 Dexmedetomidine: Is There Such a Thing as a Free Lunch?

What is Dexmedetomidine?

How Does Dexmedetomidine Work?

Potential Benefits of Dexmedetomidine

Complications/Contraindications

FDA-Approved Uses

How to Administer Dexmedetomidine

Clinical Applications of Dexmedetomidine

Clinical Controversy

73 Consider Chloroprocaine in Emergency Situations—It Is a Rapid-Onset Local Anesthetic With Low Systemic Toxicity

Chemical Structure

Clinical Pharmacology

Toxicity Controversy

Clinical Use

74 Use Bicarbonate as a Buffer to Local Anesthetics—Especially for Skin Infiltration

Buffering Local Anesthetics to Decrease Onset Time

Buffering Local Anesthetics to Decrease Pain on Injection

Stability of Buffered Lidocaine

How to Prepare Buffered Lidocaine for Skin Infiltration

75 The Hows, Whys, Ins, and Outs of Succinylcholine or Succinylcholine—Still a Useful Anesthesia Adjunct

Introduction

Neuromuscular Blockers Broken Down

The Neuromuscular Junction and Skeletal Muscle Contraction

Succinylcholine—Mechanism of Action

Indications for Succinylcholine

Cardiovascular Effects of Succinylcholine

Musculoskeletal Effects of Succinylcholine

Hyperkalemia and Succinylcholine

Muscular Dystrophies and Succinylcholine

Malignant Hyperthermia and Succinylcholine

Myopathies and Succinylcholine

76 Don’t Get Burned by Incomplete Reversal of Neuromuscular Blockade

Introduction

How Do Nondepolarizing Muscle Relaxants Work?

How Do We Monitor Neuromuscular Blockade During Surgery?

How Do We Reverse Neuromuscular Blockade?

How Do We Define Adequate Recovery From Neuromuscular Blockade?

What Is the Incidence of Inadequate Reversal?

What Are the Clinical Implications of Incomplete Reversal?

Which Groups Have Higher Risk of Incomplete Reversal?

More About Neuromuscular Monitoring

What About Clinical Assessment of Neuromuscular Blockade?

Let’s Talk About Neostigmine—the Old Standard

A Neostigmine Dosing Strategy

Let’s Talk About Sugammadex—the New Kid on the Block

Sugammadex Issues

A Sugammadex Dosing Strategy

Putting It All Together—How to Avoid Postoperative Residual Block

77 Opioid Conversions—It’s Not Only About the Table

Opioid Conversions in Perioperative Setting

Making Conversions Easy

Opioid Conversions From Intravenous to Oral Form

78 Not All Patients Are Naive—Management of Perioperative Pain in Opioid-Dependent Patients

Preoperative Evaluation

Anesthetic Management

Postoperative Pain Management

What About Patients on Maintenance Therapy?

What About Patients Previously Opioid-Dependent or Addicted?

79 The Basal Infusion Mode in Patient-Controlled Analgesia Is Both Friend and Foe

80 Keep Discussing the Use of Ketorolac (Toradol) With Your Surgical Team Before the Need Arises and Keep Your Eye on the Literature

Basic Pharmacology

Indications and Use

Postoperative Pain

Intravascular Regional Anesthesia (Bier Block)

Periarticular Injection “Cocktail”

Complications and Issues

81 Special Topic I: Do Patient With Congenital Insensitivity to Pain Need Anesthetics and Postoperative Opioids?

Hereditary Sensory and Autonomic Neuropathy

Classification of Congenital Hyposensitivity to Pain

Anesthesia and Hereditary Sensory and Autonomic Neuropathy Disorders

Perioperative Management of Body Temperature

Perioperative Prevention of Aspiration

82 Special Topic II: Can Your Patients Eat Their Way Out of Chronic Pain? Some Common Sense Advice

83 Attacking Acute Perioperative Hypertension— The Cleveland Group Shares Their Battle Plan

Pharmacologic Acute Hypertension Management Tools—The Sharp End of the Stick

The Downers (aka Vasodilators)—The Ideal Drug

Calcium Channel Blockers—But Not Just Any Calcium Channel Blocker

Calcium Channel Blockers—Dihydropyridine L-type

Nitrovasodilators (aka Nitric Oxide Donors)

Beta- and Alpha-Antagonists

Alpha-2 Agonist

Oddball IV Antihypertensives

84 Cardiovascular Vasoactive Drugs That Pump You Up

Phenylephrine—Straight Up Alpha-1 Agonist

Ephedrine—Indirect Acting at Beta-1 Receptors Through Release of Norepinephrine

Dopamine—Dopamine Receptor Agonist and Beyond

Dobutamine—Beta-1 Receptor Agonist

Time to Change Gears…

Norepinephrine (Levophed, aka Leave ‘em Dead) Mixed Alpha-1>>Beta-1 Agonist

Epinephrine—Mixed Alpha-1 <Beta-1 and -2 Agonist

Vasopressin (aka Antidiuretic Hormone, Arginine Vasopressin, or Argipressin)

Methylene Blue (Why Is My Pee GREEN?)

85 Milrinone—The Not-So-Kidney-Friendly Intraaortic Balloon Pump in a Bottle

The 30,000 Foot View of Clinical Milrinone Use

Milrinone: Mechanism of Action

Milrinone: Indications

Milrinone: Dosing

Milrinone: Cautions In Use

86 Amiodarone and Alternative Antiarrhythmics— Double-Edge Swords for the Treatment of Atrial and Ventricular Fibrillation

30,000 Foot View of Amiodarone and Alternative Antiarrhythmic Agents

The Basics of AFIB and Amiodarone

Drug–Drug Interactions (DDIs) Involving Amiodarone

Summary

87 Ondansetron Is a Great Drug, We ALL Use It, But Watch for Headache and QT Prolongation

Serotonin Pharmacology and the Antiemetic Effect

Other Indications

Overall Safety Profile

Headache

ECG Effects—QTc Prolongation

88 A Word About Haloperidol in the Perioperative Period

Basic Pharmacology and Pharmacokinetics

Risks and Side Effects

Pharmacokinetics

Haloperidol Clinical Pearls for the Anesthesiologist

89 Remember That Not All Blue-Colored Compounds Are the Same

Methylene Blue

Patent Blue

Isosulfan Blue

Indigo Carmine

Indocyanine Green

FDA Public Health Advisory!

90 Clonidine Considerations

Chemical Properties/Pharmacology

Physiologic Effects

Dosing/Duration of Action

Antihypertensive and Cardiovascular Effects

Sedation/Reduction in Anesthetic Requirements

Analgesia

Other Uses

Side Effects/Contraindications

91 A Primer on the Psych Syndromes: Serotonin Syndrome Versus Neuroleptic Malignant Syndrome

Serotonin Syndrome

Neuroleptic Malignant Syndrome

Serotonin Syndrome and Other Perioperative Drugs

Hunter Serotonin Toxicity Criteria

Neuroleptic Malignant Syndrome in the Perioperative Period

So—What Is the Exact Mechanism for Neuroleptic Malignant Syndrome and Is It Related to Malignant Hyperthermia in Any Way?

92 Drug-Drug Interactions Are Now Necessary Knowledge for the Anesthesia Provider and We Can Help

93 The Six Patterns of Cytochrome P450 Drug-Drug Interactions Relevant to the Perioperative Clinician

Pattern 1: An Inhibitor Is Added to a Substrate

Pattern 2: A Substrate Is Added to an Inhibitor

Pattern 3: An Inducer Is Added to a Substrate

Pattern 4: A Substrate Is Added to an Inducer

Pattern 5: Reversal of Inhibition

Pattern 6: Reversal of Induction

Remember That These Clinical Effects Are Reversed If the Substrate Is a Prodrug!

94 Don’t Spend Time Rereading Tom Clancy Novels Until You Have Mastered These Basic Drug-Drug Interactions

Summary of Cytochrome P450 Metabolism of Intraoperative Drugs

95 Drug-Drug Interactions and the P-glycoprotein Pump—Be Vigilant With Patients on Digoxin

Physiology of the Transporter

Substrates and Inhibitors of the P-glycoprotein Transporter

Inducers of the P-glycoprotein Transporter

96 Can You Name Six Perioperative Drug-Drug Interactions That Involve Oral Contraceptives? Okay, You Can Now!

Oral Contraceptives

97 Wish We Knew Then What We Know Now— A Case of Serotonin Syndrome in the Operating Room

Metabolism of Selective Serotonin Reuptake Inhibitor

Beware of Methylene Blue Pharmacologic Action

Drug-to-Drug Interaction: Methylene Blue and SSRI

EQUIPMENT

98 Introduction

99 Pulse Oximetry: Perhaps You Need a Refresher?

Accuracy

Limitations: Signal Artifacts and Optical Interference

Clinical Application

100 The End-Tidal CO2 Monitor Is More Than Just a Device to Tell You That “the Tube in the Airway”

Review of Capnography

Capnometry Versus Capnography

Normal Capnogram

Factors Influencing Alveolar Dead Space

Decreased Capnogram

Increases in ETCO2 Level

Effect of PEEP

Bronchospasm

Negative Arterial–End-Tidal Gradient

Alterations in Inspiratory CO2

Other Variations in Waveform

Monitoring Moderate or Deep Sedation

101 Noninvasive Blood Pressure Management— It’s Not Just a Piece of Nylon Around the Arm

Oscillometry

Proper Use

Errors of Measurement

Complications

102 Avoid Errors in Invasive Blood Pressure Measurement

103 How, Why, and When to Use Brain Function Monitors

What Is a “Depth of Anesthesia” Brain Function Monitor?

What Are the Benefits and Limitations?

What Do Current Guidelines Say?

Our Personal Practice

The Future?

104 Do Not Improvise Techniques to Warm Patients—Use Warming Devices Only as Per Manufacturers’ Recommendations

Complications of Hypothermia

The Pathophysiology and Physics of Hypothermia

Preventing Hypothermia

Preventing Patient Injury While Preventing Hypothermia

105 Transesophageal Echocardiography: Contraindications, Complications, and Misinterpretations

Probe Placement

Image Interpretation

Normal Anatomic Variants

106 Scavenging Waste Gases Is Perhaps the Only Action We Take That Benefits Us but Not the Patient

Chronic Exposure to Waste Gases

Scavenging Systems

Avoiding Mishaps

107 Carbon Dioxide Absorbers Save Gas and Moisture but Create the Potential for Mechanical Hazards, Chemical Soup, or a Thermal Disaster

Basic Management of Absorbers

Mechanical Complications

Adverse Chemical Reactions

108 Infusion Pumps: Get Them Going and Keep Them Going!

Gravity

Infusion Pumps

Syringe Pumps

Common Principles and Current Considerations

109 Don’t Bring the Fiberoptic Scope Into the MRI Scanner!

Metals and MRI

Anesthesia Equipment

Airway and Emergency Management

110 Understanding the Operating Room Circuit and the Line Isolation Monitor—It’s Really Pretty Simple

Basic Electrical Terminology

Grounded Power Systems

Isolated Power Systems

Conversion of an Isolated Power System to a Grounded System

Line Isolation Monitor

111 Cell Phones in the Operating Room—Here Are the Issues

Mechanisms of Electromagnetic Interference

Effects of Electromagnetic Interference on Medical Devices

Risk of Electromagnetic Interference

Regulation and Standardization

112 Don’t Let the Tourniquet Cause Extra Pain or Complications

Muscle

Nerves

Cardiovascular Considerations

Hematologic Complications

Pharmacokinetics

PERIOPERATIVE

113 Introduction

114 Hurdles of the Electronic Health Record

115 Hand Hygiene! History, Human Factors, and Helping Your Patients

Summary

116 Remember That the Same Simple Mistakes at Induction (and Emergence) Happen Over and Over Again!

Induction

Emergence

117 Smoking Cessation Part I—ANYTIME Is a Good Time to Quit

Smoking Increases Perioperative Complications

Any Time Is a Good Time for Stopping Smoking

How Could Anesthesiologists Help in Smoking Cessation?

118 Smoking Cessation Part 2—So Good for the Patient as Long as You Understand the Effects on CYP1A2 Drug Metabolism (Especially R-Warfarin)

119 Flying to the Mayo Clinic for Surgery? The Clot Thickens

120 Don’t Let Your Understanding of the Utility of Preoperative Stress Testing in Suspected Heart Disease Lapse

121 A Positive Troponin Does Not Always Mean a Myocardial Infarction—Will the New High-Sensitive Assays Help Sort It Out?

Troponin Assays

Renal Failure

Other Disease States

Clinical Context—Cardiac Troponin Versus High-Sensitive Cardiac Troponin

122 Preoperative Anxiolysis: It’s Not Just “Two of Midaz”

Recent History

Basic Principles

Patient Concerns

Pharmacologic Interventions

Nonpharmacologic Interventions

Acupuncture

Summary

123 Schizophrenia Is a Devastating Mental and Medical Illness—and These Patients Have Significantly Greater Perioperative Risks Than Age-Matched Controls

Preoperative Risk Factors and Evaluation

Intraoperative Management

Postoperative Risk Factors and Management

Antipsychotic Drugs

124 What to Do About the Tattoos and Body Jewelry

Tattoos

Piercings and Jewelry

125 We Now Know That Obstructive Sleep Apnea Is More Common Than We Thought—Manage These Patients Carefully and Conservatively

Epidemiology

Risk Factors

Pathology

Diagnosis

Treatment

Outcome

Implications for Anesthesia

Preoperative Evaluation

Intraoperative Management

Postoperative Care

Discharge Criteria

Outpatient Surgery

OSA Characteristics for Children

126 Don’t be Shy About Borrowing ICU Equipment, Medications, and Personnel for the Critically Ill Patient Going to the Operating Room

Pulmonary Arterial Vasodilators

Antibiotics and Immunosuppressive Agents

Temporary Pacemakers

ICU Ventilator

ICU Personnel

Respiratory Therapist

Ventricular Assist Device Coordinator

Lung De-recruitment

127 The Dao of Positioning

The Problem

The Lessons

128 The Supine Position—Complications Can Still Arise!

General Considerations for Patient Positioning

Positioning Checklist

Complications Related to Physiologic Changes

Respiratory

Cardiovascular

Specific Complications

Peripheral Nerves

Ulnar Nerve

Brachial Plexus

Head

Skin

Eyes

129 Thinking Laterally—How to Safely Position a Patient in the “Sideways” Position for Surgery

130 Positioning Patients for Spine Surgery

131 Sit Back and Relax? Implications of the Sitting Position in Shoulder and Brain Surgery

132 Individuals With Cerebral Palsy and Other Spastic Disorders Need Your Best Positioning Prowess

133 Use Extra Care in Positioning Patients Who Have Had Amputations

134 Never, Ever Fire

Risk Assessment

Preventative Measures

Management of the Surgical Fire

Race to Fire Safety

Postsurgical Fire Management

135 Malignant Hyperthermia: If You Get to the Point Where You See an Elevated Temperature, It’s Already Happening

Treatment of Acute MH

Treatment of Postacute MH

What to Stock in the Malignant Hyperthermia Cart

Drugs

General Equipment

Monitoring Equipment

Nursing Supplies

Laboratory Testing Supplies

Forms

Preparing the Anesthesia Machine for MH-Susceptible Patients

Contact Information

136 Good Old-Fashioned Basic Perioperative Blood Pressure Control

Blood Pressure Control in the 21st Century

It’s a Big World but Here is BP Management That Should Work for Everyone

137 Some Additional Thoughts on Blood Pressure Management Techniques—What We Believe, How We Do It, and Where We Think the Science Is Going

138 Protect the Kidneys, Not the “UOP”

139 Avoid a 70% Mortality Rate: Do Everything You Can to Prevent Perioperative Renal Failure

140 Do Not Use Urine Output as an Indicator of Volume Status in Hypothermic Patients

141 Perioperative Hyperglycemia Is Associated With Poorer Clinical Outcomes so Consider Insulin Therapy for Both Diabetic and Nondiabetic Patients With Elevated Blood Glucose

142 Seven Ways to Treat Hyperkalemia in the Perioperative Period

Pathogenesis of Hyperkalemia

Treatment of Hyperkalemia

Calcium

Insulin and Glucose

Sodium Bicarbonate

Beta-Adrenergic Agonists

Loop or Thiazide Diuretics

Cation-Exchange Resin

Dialysis

Blood Products

143 Laparoscopic Procedures: Managing the Risks and Physiologic Effects During Camera Placement, CO2 Insufflation, and Vertical Positioning

Cardiovascular Effects

Intracranial Effects

Pulmonary Effects

Soft Tissue Effects

144 Could This Be Methemoglobinemia, Maybe?

Methemoglobinemia

Methemoglobin Formation and Reduction

Causes of Methemoglobinemia

Signs and Symptoms

Diagnosis

Treatment

145 The Eye Room—Is It the Easiest of Days? Or the Hardest of Days? Regardless, Vigilance Is Key!

Managing Expectations

Types of Anesthesia

Topical

Regional Blocks

General Anesthetics

Postoperative Course

Vigilance

Other Considerations for Eye Surgery

146 My Eye Hurts! Prevention, Diagnosis, and Treatment of Corneal Injuries After Anesthesia

Introduction

Mechanisms of Injury

Incidence

Risk Factors

Prevention of Corneal Injury

Corneal Lubrication Options

Do You Really Need an Ophthalmology Consult?

Diagnosis

Prognosis and Treatment

Supportive Care

Follow-up

Documentation

What Can My Center Do to Decrease the Incidence of Corneal Injuries?

147 Never Forget That Patient Transport Within the Hospital Is One of the Most Dangerous Intervals in the Perioperative Period

Introduction to Intrahospital Transport (IHT)

Risks Associated With Intrahospital Transport

Neurologic Complications

Pulmonary Complications

Cardiovascular Complications

Other Complications

Avoiding Common Errors: Considerations for Transporting Patients

148 Seek Out Hypercapnia in the PACU and Remember That an Acceptable Pulse Oximeter Reading Is Not Assurance of Adequate Ventilation

149 Let’s Go Over It Again: Avoid Residual Neuromuscular Blockade in the PACU!

How Does Residual Neuromuscular Blockade Manifest and Why Does It Matter?

How Can the Incidence of Residual Paralysis in the PACU Be Reduced?

Judicious Use of Neuromuscular Blocking Drugs

Evaluating for Neuromuscular Blockade

Clinical Tests

Neuromuscular Monitors

Reversal Agents

Conclusion

150 Give the Intensivist the Best Handover to Improve Patient Outcomes

Use Standardized Handover Tools

Prioritize the Handover Process

Assemble the Entire Team

Improve the Handover Process Continually

Pitfalls to Avoid

Summary

151 Don’t Miss Out on Ultrasound—Which ICU Techniques Are Helpful for the Anesthesiologist?

Introduction

Focused Lung Ultrasound

Focused Cardiac Ultrasound

Ultrasound for Difficult Vascular Access

Summary

152 Don’t Overlook the Potential of Perioperative Acupuncture

Acupuncture Training—Licensed Acupuncturists Versus Medical Acupuncturists

Efficacy of Acupuncture in the Perioperative Period

Preoperative Optimization

Postoperative Pain Control

Chronic Pain

Wellness for Providers

Safety

153 Consider Acupuncture as an Adjunct for the Prophylaxis and Treatment of Postoperative Nausea and Vomiting

154 Don’t Warm Up a Cardiac Arrest Patient Unless They Are Dying of Hemorrhage!

How Does Therapeutic Hypothermia Provide Neuroprotection?

Potential Complications of Therapeutic Hypothermia

155 What to Do If You Get a Needlestick Injury

Common Scenarios Associated With Needlestick Injuries

Human Immunodeficiency Virus

Hepatitis B Virus

Hepatitis C Virus

REGIONAL ANESTHESIA

156 Introduction

157 Complications of Regional Anesthesia: Don’t Touch the Needle Before You Know Them

Introduction

Infection

Bleeding

Nerve Damage

Allergic Reactions

Blockade of Other Nerves

Intravascular Injection and Local Anesthetic Toxicity

Supplies and Equipment That Should Be Available When Doing Regional Anesthesia

158 Make Time for a Timeout Before Placing a Block—the Preprocedure Check

Suggested Elements of a Preprocedure Block Checklist

Suggested Script for a Timeout

What Should Happen When the Worst Happens?

159 Chlorhexidine: Killing Bacteria … and Allergic Patients?

Hypersensitivity

Risk Factors

Diagnosis

Management

160 What Is the Correct Brachial Plexus Block to Perform?

Anatomy—The Road Map …

Interscalene Block—Taking the High Road …

Supraclavicular Block—Always Supra, Often Super as Well

Infraclavicular Block–Emerging From the Tunnel

Axillary Block—Taking the Low Road

Those Darn Unblocked Territories

Putting It All Together …

When Should We Avoid or Delay Doing a Block?

161 Getting the Right Ultrasound Image

Picking a Transducer

Ultrasound Controls

Transducer Maneuvers

162 Interscalene Blocks—Preventing the Blues!

Complications

Phrenic Nerve Block

163 The Old-Fashioned “Bier” Block Is Still Relevant—The Trick Is to Not Let the Surgeons Get Ahead of You

Introduction and History

Advantages and Disadvantages

Technique

Agents and Adjuncts

Cautions

Getting Back to Our Case …

164 Remember the Low-Risk/High-Yield Blocks

Superficial Cervical Plexus Block

Femoral Nerve Block

Popliteal Fossa Nerve Block

Ankle Block

165 Preparing to Fail: The Dynamics of a Failed Block

Know Your Anatomy!

What If It Just Doesn’t Work?

Blocks for Postoperative Analgesia

Surgical Blocks

Know Your Dosing

A Note on Catheters

166 Salvage Techniques for Incomplete Upper-Extremity Blocks

Block Failure

Salvage Blocks for the Upper Extremity

Shoulder Surgery

Forearm/Hand Surgery

167 Salvage Blocks for Incomplete Lower Extremity Blocks

Block Failure

Salvage Blocks for the Lower Extremity

Hip Surgery

Knee Surgery

Lower Leg and Foot Surgery

168 More Than a Stick and a Burn: Local Anesthetic Systemic Toxicity

Local Anesthetic Pharmacology

Properties of Commonly Used Local Anesthetics

Risk Factors for LAST

Rate of Systemic Absorption (Fastest to Slowest)

Clinical Presentation of LAST

Signs and Symptoms of Local Anesthetic Toxicity

Prevention of LAST

Treatment and Management of LAST

The Management of LAST

Call for Help and Then Get VOCAL

169 Lipid Rescue—Where Are We Now?

Introduction to LAST

Does This Patient Show Signs of LAST?

Management of LAST

History of Lipid Therapy for LAST

Practical Aspects of Lipid Therapy

How Does Lipid Rescue Work?

Side Effects and Complications

Other Uses for Intralipids

170 A Patient Who Is Planned for Spinal Anesthesia Asks “Can This Paralyze Me?” What Are the Facts and What Do You Say?

Introduction

What Is the Incidence of Injury?

What Are the Potential Causes of Spinal Cord Injury?

Direct Trauma

Compression From Hematoma

Compression From Abscess

Neurotoxic Effects of Neuraxial Drug Delivery

Spinal Cord Ischemia

Predisposing Conditions

So, With All This in Mind, How Do You Answer the Patient’s Question?

171 Spinals in the Lateral Position

Basic Positioning

Understanding the Anatomy

172 Consider the Paramedian Approach for Spinal Anesthesia in the Hip Fracture Patient

173 When Is a Whisper a Cry for Help? When the Patient Has a High Block

Inadvertent Intrathecal Injection

Intravascular Injection

Ultrasound Guidance and Regional Anesthesia

Prevention and Treatment

174 Issues Related to Discharging the Postspinal Patient

Spinal Anesthesia

Complications

Discharge From the PACU

175 Epidural or Truncal Block? Sorting It Out

176 Dang It! Wet Tap

The Differential Diagnosis: Is This a PDPH?

Why Is a “Simple Headache” so Important?

What Causes This Type of Headache?

I Caused a Dural Puncture—Now Who’s Going to Get a Headache?

What Do I Do After an Unintentional Dural Puncture?

Oh No! This Is a PDPH. What Do I Do NOW?

How Do You Perform an Epidural Blood Patch?

177 Consider Continuous Paravertebral Block as Your Primary Analgesic Technique

Considerations

Options

Anatomy of the Paravertebral Space

Technique of CPBV

Multimodal Analgesia: Making the Most of Your Nerve Block

178 Pneumothorax After Paravertebral, Supraclavicular, or Interscalene Block

Avoiding Iatrogenic Pneumothorax

Diagnosing Pneumothorax

Treatment

179 Epidural Anesthesia for Mastectomy

180 What Is the Right Level for Postoperative Epidural Catheter Insertions Based on Type of Surgery?

Location, Location, Location

Before Is Likely Better

Know What You Are Covering—Operative or Postoperative

Landmarks for Placement and Assessment

181 Know the Complications of Epidural Corticosteroid Injections

Neurologic Injury

Infections

Systemic Effects

Arachnoiditis

182 If You Are New to Neuraxial and Peripheral Nerve Block Infusions—a View From Both Academia and Private Practice

Why a Continuous Infusion?

Indications

Contraindications

Neuraxial Infusion of What?

Common Neuraxial Infusion Concentrations

A Peripheral Nerve Block Infusion of What?

Do I Make the Solution Myself?

What Can Go Wrong?

Troubleshooting Continuous Infusions

In Summary

183 What to Do With a Prolonged Block

Talk to the Patient!

Review the Chart

Is It a Nerve Injury?

What Do I Tell the Patient?

184 Regional Anesthesia in the ICU—What Should We Use and When Should We Use It?

Introduction

Specific Considerations of Regional Anesthesia in the ICU

Analgesia and Delirium

Opiates and Cancer

Regional Anesthesia/Analgesia and Sympathetic Tone

Regional Anesthesia/Analgesia and Mechanical Ventilation

Regional Anesthesia/Analgesia in the Septic/Bacteremic Patient

Regional Anesthesia/Analgesia in the Immunocompromised Patient

Regional Anesthesia/Analgesia in the Critically Ill Patient With Impaired Homeostasis

Specific Peripheral Nerve Blocks in the ICU

PEDIATRIC ANESTHESIA

185 Introduction

186 Assent, Consent, and Refusal: Informed Consent and Decision-Making for Adult and Pediatric Patients

Informed Consent

Decision-Making Capacity and Competency

When a Patient Lacks DMC

The Role of the Surrogate

The Consent Process for Minors

Assent, Consent, and Refusal for Pediatric Patients

Resolution and Assistance

187 NPO Guidelines Made Easy—Always Maintain a Firm Hold on Current Principles, Best Practices, and Your Own Common Sense

188 Aspiration and Food Injury—Or When Not to Extubate Deep

Risk Factors

Gastric Volume and pH

Opioids

Nausea and Vomiting

Trauma

Precautions

Time

Cricoid Pressure

Pharmacotherapy

IV Placement Prior to Induction

189 Don’t Underestimate the Power of Distraction During Separation and Induction of Anesthesia in Kids

No Midazolam?

So …. Back to Basics!

Introduction to Distraction Techniques

190 Parental Presence on Induction—It’s Your Call and How to Do It

191 The Child With a URI

192 Accept That You Will Have to Meet the Clinical Challenges of Obesity and Obstructive Sleep Apnea in Your Pediatric Patient Cohort

Definitions and Comorbidities

BMI

Coronary Artery Disease (CAD)

Diabetes Mellitus, Type 2 (DM)

Mental Health

Metabolic Syndrome

Nonalcoholic Fatty Liver Disease (NAFLD)

Obstructive Sleep Apnea (OSA)

Orthopedic Comorbidities

Pseudotumor Cerebri

A Focus on OSA

Diagnosis

Treatment

Perioperative Concerns for Obese Children With and Without OSA

Cardiovascular

Respiratory

Endocrine

Preoperative Considerations

Intraoperative Considerations

Postoperative Concerns

193 Neuromuscular Disease in Kids Can Be Very Challenging Because You Don’t Always Have a Definitive Diagnosis—Here’s How to Approach the Clinical Situations

Muscular Dystrophies

Myotonic Dystrophy

Congenital Myopathies

Mitochondrial Disease

Malignant Hyperthermia

194 Pediatric Patients With Epilepsy: Considerations for Patients on a Ketogenic Diet and for Cortical Mapping

Ketogenic Diet

Cortical Stimulation Mapping

195 Neonates Deserve Perioperative Analgesia, Too

Evaluation of Pain

Know Your High-Risk Populations

Planning Postoperative Analgesia

Drug Therapy for Acute Pain

Patient-Controlled Analgesia for Children

Regional Anesthesia for Postoperative Pain

196 Anesthetic Considerations in Patients With Fontan Physiology Who Present for Noncardiac Surgery

Introduction

Physiology

Evaluation

Intraoperative Management

Complications

197 Anesthesia for Kids and Neurotoxicity: You Are Going to Be Asked, So Don’t Be Surprised and Don’t Act Uninformed

What Is the Big Deal?

Experimental Literature

What About Humans?

What Now?

198 Double Down on Pediatric Airway Equipment

199 Optimizing Bag Mask Ventilation and Direct Laryngoscopy in Children

Key Anatomic Differences Between Children and Adults

Optimizing Bag Mask Ventilation and Mask Fit

Ventilation

Airway Adjuncts

Optimizing Direct Laryngoscopy

Equipment

Positioning

Laryngoscopy

200 Why You Should Expect Hypoxemia During Induction and Emergence of the Pediatric Patient and What to Do About It

Physiology and Anatomy

What Can Go Wrong

How to Avoid These Problems

What to Do When Hypoxemia Occurs

201 Why Air Bubbles and Air Emboli Can Be So Serious in Pediatric Patients and How to Safeguard Your Patients

202 Pediatric Fluid Management

203 Keeping Babies Warm in the Perioperative Period Is Important, Challenging, and at Times Dangerous!

204 Pediatric Arterial Access—And the Beat Goes On

Site Selection

Complications of Arterial Access in Pediatric Patient

205 Pediatric Regional Anesthesia—The Karma of Caudals

Indications

Contraindications

Risk-Benefit Ratio and Parental Consent

Anatomy

Technique

Complications

206 Avoiding the One-Hour Wake Up or How to Save the Sanity of the Parents and Your Own Reputation at the Same Time

207 When Not to Extubate Deep! And if the Patient Is Already Coughing or Swallowing, It’s Too Late Anyway

Advantages

Disadvantages

How to Successfully Perform a Deep Extubation

Contraindications to Deep Extubation

208 Emergence Delirium—Don’t Overcall It, Don’t Undercall It, and Don’t Let It Happen

Diagnosis

Causes

MRI

Treatment

Prevention

209 Too Much, Too Little, Just Right: Avoiding Opioid Withdrawal in Pediatric Patients on Chronic Opioids

Signs and Symptoms of Withdrawal

Basics of the Opioid Wean

Benzodiazepine Dependence

210 Careful and Conservative Clinical Judgment Is Required Before Discharging a Pediatric Patient to Home

211 Chronic Pediatric Pain: There’s Always More Than Enough Pain for Everybody Involved and It’s Not About the Blocks!

Managing Postoperative Pain in Children With Chronic Pain

Preventing Opioid Withdrawal

Avoiding Inadequate Postoperative Pain Management

Avoiding the “Block Is the Cure” Trap

Pediatric Chronic Pain and Peripheral Nerve Blocks

Evaluating a Chronic Pain Patient

Chronic Pain History

Chronic Pain Examination

Management of Chronic Pain in Pediatric Patients

212 “But, It’s Just an Herb!” Avoiding Problems Resulting From Nontraditional Pain Medications in the Pediatric Population

Chronic Pain and Herbal Therapy

Chronic Headaches

Chronic Functional Abdominal Pain

Musculoskeletal Pain

A Quick Note on Herbal Contaminants

Do Herbals Really Cause Adverse Events or Is It All Theoretical?

What About Neuraxial Blocks and Herbal Medications?

Common Pitfalls With Herbal Medications

213 Okay, There Are Herbals, but What About Those “Other Herbals?”

Anesthetic Considerations of Marijuana

214 Pitfalls in Pediatric Sedation

Patient and Procedure

Risks and Preparation

Goals and Plan for Procedural Sedation

Postsedation Discharge Criteria

215 Pitfalls of Pediatric Anesthesia for International Service Missions

Pediatric Anesthesia for International Voluntary Services

Choose Your Adventure Wisely

Know Your Team Members

Find the Right Patients

Equipment Pitfalls

Don’t Forget the Monitors

Use Spontaneous Ventilation

Regional Anesthesia Is Your Friend

Remember a Postoperative Care Plan

216 Pediatric Cardiac Arrest Under Anesthesia—Predicting and Preventing the Most Devastating Event of All

Predictors of Anesthesia-Related Cardiac Arrest in Children

ASA Physical Status

Emergency Surgery

Age

Cardiac Disease

Annual Caseload

Changing Profile of Anesthesia-Related Cardiac Arrest in Children

Causes of Cardiac Arrest

Demographics of Cardiac Arrest

Strategies to Prevent Cardiac Arrest in Anesthetized Children

Specific Measures

General Measures

Conclusion

NEUROANESTHESIA

217 Introduction

218 The Neurophysiology You Learned in Medical School Is Always Relevant—Get a Grip on It and Don’t Let Go

219 Cerebral Aneurysm Versus “Routine” Craniotomy—The Anesthetic Goals Are Not the Same

220 Perioperative Visual Loss Is One of the Most Feared and Devastating Complications of Spine Surgery

221 Being Maximally Prepared for Minimally Invasive Pituitary Surgery

222 Evoked Potentials: Don’t Approach the Surgeon or Neurophysiologist Until You Know These Principles

223 Awake Craniotomy

Introduction

Preoperative Considerations

Intraoperative Management

Intraoperative Complications

Postoperative Care

224 Anesthesia for the Pregnant Patient With Neurosurgical Disorder: These Cases Actually Do Happen in Real Life ….. and on the Oral Boards

Introduction

Physiologic Changes During Pregnancy

Timing and Method of Delivery

Neurosurgical Conditions Requiring Neurosurgical Interventions During Pregnancy

Traumatic Brain Injury (TBI)

Intracranial Tumors

Intracranial Hemorrhage

Back Surgery

Anesthetic Considerations of the Pregnant Patient During Neurosurgery

Preoperative Anesthetic Considerations

Intraoperative Anesthetic Considerations

Postoperative Anesthetic Care

225 Don’t Forget There’s No Such Thing as a Brain Transplant: Preventing Perioperative Stroke

Recognizing At-Risk Patients

Preoperative and Intraoperative Management

General Anesthesia and Regional Techniques

Hemorrhage and Intraoperative Anemia

Hyperglycemia

Intraoperative Hypotension

Postoperative Assessment and Treatment of Stroke

226 Anesthesia for Emergent Neurointerventional Procedures: “Neurology Just Called, They Have a Stroke Patient for Thrombectomy Down in Neuroradiology, Start Time is 2 AM”

Introduction

General

General Considerations for All Neurointerventional Procedures

Emergent Neurointerventional Procedures

Acute Ischemic Stroke

Cerebral Aneurysm Coiling Following Subarachnoid Hemorrhage

Endovascular Management of Cerebral Vasospasm

Conclusion

227 Encephalopathy and Intracranial Hypertension in the Acute Liver Failure Patient Are Not the Same Thing!

West Haven Criteria for Encephalopathy

Pathophysiology of Raised ICP in ALF

Intracranial Pressure Monitoring

General Measures

Specific Measures

CARDIAC ANESTHESIA

228 Introduction

229 Cardiac Surgical Coagulopathy—You’ll Need the Blood Bank and a Genie in a Bottle

230 A Is for Aortic, C Is for Cannulation, B Is for … Be Careful!

Femoral Artery Cannulation

Axillary Artery Cannulation

Innominate Artery Cannulation

Line Placement and Pressure Monitoring

231 Transesophageal Echocardiography in the Cardiac Surgery Suite—Strategies to Stay Out of Trouble

232 Myocardial Protection Strategies During Cardiopulmonary Bypass—Do Everything You Can but Realize That Some Ischemic Damage Is Inevitable

Why Do We Need to Protect the Heart?

How Do We Protect the Heart? Cardioplegia!

How Often Is the Cardioplegia Given?

How Warm or How Cold Is the Cardioplegia Solution?

Should the Cardioplegia Be Mostly Crystalloid or Blood?

What Is the Deal With Hyperpolarizing Versus Depolarizing Cardioplegia Solutions?

Does Transesophageal Echocardiography Play a Role in Cardioplegia Delivery?

Is There Anything Else We Can Do to Protect the Heart?

233 The Heartbreak of Left-Sided Valvular Dysfunction

Need-to-Know Information for Aortic Valve Disease

Aortic Stenosis

Hemodynamic Goals for Aortic Stenosis—“Slow, Sinus, and Tight”

Aortic Insufficiency

Hemodynamic Goals for Aortic Insufficiency—“Fast, Full, and Forward”

Need-to-Know Information for Mitral Valve Disease

Mitral Stenosis

Hemodynamic Goals for Mitral Stenosis

Mitral Regurgitation

Hemodynamic Goals for Mitral Regurgitation

234 Anesthesia for the Descending Thoracic Aorta—Initiate Damage Control Measures

Monitoring for DTA Procedures

DTA Surgery and Organ Ischemia/Protection

DTA Anatomical Considerations

DTA Analgesia

235 Buckle Your Seat Belt: Taking Care of the Patient With Ascending Aortic Dissection

236 Rolling in the Deep Hypothermic Circulatory Arrest

Mechanisms of Benefits of DHCA

Direct Application of Ice to the Head

Pharmacologic Adjuncts

Blood Gas Management

Selective Cerebral Perfusion

Temperature Management During Rewarming

Monitoring Cerebral Protection During DHCA

Additional Monitoring

237 Anesthesia for Left Ventricular Assist Device Surgery: Essentials to Bear in Mind

Introduction to Ventricular Assist Devices

Preoperative Concerns

Invasive Monitoring

Careful Induction and Maintenance

Other Management Issues

Pre-CPB TEE Evaluation

During CPB

Separation From Bypass

Post-CPB TEE Evaluation

Right Heart Support

Extubation Timing

238 Off-Pump Coronary Artery Grafting Is Like Working on an Engine (While It Is Still Running)

Background

Who Best Qualifies for OPCAB?

OPCAB Is Associated With Outcomes That Are Better or Worse or Equivocal Depending on the Specific Outcome in Question

Better Outcomes Associated With OPCAB

Worse Outcomes Associated With OPCAB

Equivocal Outcomes Associated with OPCAB

Surgical Technique

Don’t Lose Sight of the Basics of Anesthetic Management for OPCAB Cases

Monitoring

Lines and Access

Anesthetics

Anticoagulation

Hypotension Associated With Retraction and Compression of Heart

Management of Intraoperative Ischemia

Extubation

239 What to Do and What Not to Do for Your Patients With Hypertrophic Obstructive Cardiomyopathy

240 Cardiac Transplant—Gotta Get This One Right

Important OHT Patient Preoperative Items

Immunosuppression for OHT

Managing the ICD

Timing OHT Anesthesia Induction

Monitoring for OHT

Right Ventricular Failure Risk in OHT

Coagulopathy in OHT

Waking Up the OHT Patient

241 The Right Heart Should Never Play Second Fiddle to the Left Heart—What to Do When the Right Heart Just Really Ain’t Right at All

Right Heart Anatomy

Right Heart Dysfunction

Treating Right Heart Dysfunction

Tricuspid Valve Regurgitation

Tricuspid Valve Stenosis

OBSTETRIC ANESTHESIA

242 Introduction

243 Be Prepared for the Presence of a Doula in Both the Labor and Delivery Rooms

244 Guests on the Labor Deck and in the Delivery Room—How to Manage It and Keep Your Professional Demeanor

Helpful Hints for Managing Guests

For the Labor and Delivery Rooms

For the OR

In General

245 Alternatives to Epidural Analgesia for Labor Pain—What to Consider, What You Might Be Asked

Remifentanil PCA

Nitrous Oxide

Acupuncture

246 Epidural Labor Analgesia: Does It Prolong Labor?

247 We Were Taught Once a C-section, Always a C-Section … What to Do When Your Hospital Now Wants to Provide Trial of Labor After Cesarean (TOLAC) Services

248 Should We Place a Spinal for a Version? Anesthesia for External Cephalic Version

249 Management of an Accidental Dural Puncture in the Laboring Patient “When the Hanging Drop Becomes a Flowing River …”

250 “We Have an Urgent C-Section!” The Pitfalls of Intrapartum Monitoring of the Fetus

Introduction

Basics of Fetal Heart Rate Monitoring

Baseline

Variability

Accelerations

Decelerations

Pitfalls With FHR Monitoring

Inter-observer Variability

Effects of Treatment on the Fetal Heart Rate

Conclusion

251 Stat C-Section—The 30-Minute Rule and Beyond

252 Postpartum Hemorrhage: Don’t Forget That Having a Baby Is Major Surgery

Uterine Atony

Lacerations

Other Causes of Postpartum Hemorrhage

General Response to Bleeding

253 From Glad to Sad (Part 1): Pain Control After Cesarean Section

IV Opioids

Nonsteroidal Anti-Inflammatory Drugs

Acetaminophen

Postoperative Epidural: Patient-Controlled Epidural Analgesia

Preservative-Free Morphine (AstraMorph, Duramorph)

Local Anesthetic Infiltration and TAP Blocks

Analgesia and Breastfeeding

254 From Glad to Sad (Part 2): Postpartum Neuropathy of the Lower Extremity

255 Obstetric Anesthesia/Analgesia Can Work in a Small Hospital: The Key Principles Are Commitment, Flexibility, and Planning

256 Resuscitation of the Pregnant Cardiopulmonary Arrest Patient: Not Just Standard ACLS

Immediate Resuscitation Response

Modifications From BLS/ACLS

No Modifications

Emergency Perimortem Cesarean Delivery

Team Management

257 The Pregnant Anesthesia Provider (Part 1)—Managing the Occupational Exposures

Blood-Borne Pathogens

Inhalational Anesthetic Agents

Radiation

Methyl Methacrylate

Conclusions

258 The Pregnant Anesthesia Provider (and New Adoptive Parent)—Part 2

Family Medical Leave Act

Other Legal Protections

HUMAN FACTORS

259 Introduction

260 Understanding the Human Factor

Decision Making

Technology Design and Cognitive Ergonomics

Communication

Environmental Design

Complex Systems

261 Minimize Errors in Anesthesia: Lessons Learned From Aviation

Application of Aviation-Adopted Crew Resource Management to Anesthesia Practice

Communication

Leadership

Conflict

Vigilance

262 Eliminate Communication Errors by Using a Spelling Alphabet and Spoken Digits

263 Don’t Ignore Your Intuition

264 Ethics in Anesthesiology Practice

Principles

Ethics and Anesthesiology

Summary

265 Know When to Stop—Anesthesia Providers Have Got to Know Their Limitations

266 Before You Press Play, Let’s Talk About Music in the OR

267 Never Rush Through a Signout

268 Don’t Ignore the Folklore—It Can Be a Powerful Ally in Your Clinical Practice

269 Don’t Underestimate the Role of Spirituality in Patients’ Perceptions of Disease and Healing, and Remember to Uphold the Right to Self-Determination

Importance to Patients

The Power of Prayer: Private Versus Intercessory Prayer

Autonomy, Self-Determination, and Legal Considerations

What Can We Do?

270 What’s in a Name?

271 We Are Not the Only People Who Care About the Patients

From the Preoperative Evaluation Center Nurse-Practitioners

From the OR Nurses

FROM the PACU Nurses

272 Working in the OR—Sometimes the Staff Gets Sick or Injured, Too

Workplace Injuries

Working Sick

Heads and Hearts

Syncopal Episodes

Expect the Unexpected

Conclusions

273 The Physician as Patient—What I Learned During the Last Five Times I Went to the OR on the Stretcher Instead of Pushing It

274 A Primer on Simulation in Anesthesiology— Definitions and Concepts

275 What Makes a Great Anesthesia Resident?

The Attending Viewpoint—What Makes a Great Anesthesia Resident?

The Resident Viewpoint—What Makes a Great Anesthesia Resident?

LEGAL

276 Introduction

277 A Brief on the Legal Process

Before the Lawsuit

The “Med Mal” Lawsuit—Who’s Who

The Lawsuit

Discovery

Trial

Alternatives to Lawsuit

Mediation

Arbitration

278 How “Not” to End Up in a Closed Claims File—Lessons Learned From the ASA Closed Claims Project

Overview of the ASA Closed Claims Project

Consent

Preoperative Evaluation

Changing of the Guard or “Handoffs” With Poor Communication

Documentation (or Lack Thereof)

Altering the Medical Record

Poor Followup/Communication After an Adverse Outcome

What to Do

What Not to Do

Maligning by Other Healthcare Providers

279 The Anesthesia Closed Claims Project— What’s Trending Now?

What’s New in the Database?

Specific Injuries and Outcomes

280 A Careful and Complete Anesthesia Record Is the Best Defense Against a Lawsuit

Components of the Anesthetic Record

The Anesthesia Record: Friend or Foe

Potential Pitfalls in Completion of the Anesthesia Record

Electronic Anesthesia Records

Additional Uses of the Anesthesia Record

281 Documentation Disputes in the Medical Record—How to Avoid a Chart War and How to Survive One

Don’t Start It!

If You Find Yourself in a Dispute in the Medical Record

282 Reading in the Operating Room: Is It Worth the Risk?

283 Going to the Operating Room With a Do-Not-Resuscitate Patient

Introduction

The DNR Order

DNR in the Perioperative Setting

Alternate Policies for DNR Orders in the OR

Guidelines Related to DNR Orders in the Perioperative Setting

Approach to the Perioperative Patient With a DNR Order (“Required Reconsideration”)

Conclusion

284 Refusal to Do a Case on Moral or Ethical Grounds: More Practical Navigation Through Choppy Waters

285 Dental Injuries—Document Carefully and Do Not Overpromise

286 Apologizing to Patients After an Adverse Event Is the Ethical Thing to Do and Just Might Keep You Out of Court

What Is a Medical Apology?

Barriers to Apology

Advantages of Protecting an Apology

PROFESSIONAL PRACTICE

287 Introduction

288 Marketing 101: Know Your Customers and What They Need!

Identify Your Customer(s)!

Ante-Up Qualifications

Your Group—Initial Job Search, Making Partner, Being a Good Citizen

Your Hospital or Facility

Your Surgeons

Your Patients

289 Improving OR Throughput: Don’t Say “No”

First Case On-Time Starts

Turnover Time

Parallel Processes

Reducing Overtime

290 Cost Analysis: You Always Want to Be at the Table

Cost Definitions

Costs Are Not Charges

Definitions of Costs

Perspective—Be at the Table

Cost Analysis: Cost-Minimization Versus Cost-Benefit

291 Strategic Planning: Failing to Prepare Is Preparing to Fail

Individual Strategic Objectives

S–W–O–T Analysis

Mission Statement

Vision

Guiding Principles

Strategic Planning Process

292 Business Plan 101: Where You Want to Go and How You Are Going to Get There

Classical Business Plan Elements

Executive Summary

Company Description

Market Analysis

Organization and Management

Financial Projections

293 Avoid Being Labeled “Simply a Gas-Passer”: An Overview of the Perioperative Surgical Home

What Is the Perioperative Surgical Home?

Components of the PSH

Principles of the PSH

Why Anesthesiologists?

Who Benefits From the PSH?

Implementation Challenges

294 The Curriculum Vitae: Know Your Audience

295 Your Career: Interviewing

Preparing for a New Job: The Network and Your Curriculum Vitae

Preparing for the Interview

Interview Day—Your Best Effort

The Interview

The Followup

Final Note

296 Your Career: Understanding the Basics of Ownership Jobs

Introduction

Different Types of Partnership Tracks

The Buy-In

Buy-In Example

Buy-In Negotiations

Becoming an Equity Partner

The Buy-Out

297 Your Career: Employee Jobs

Single-Specialty and Multispecialty Groups

Hospital-Owned Practice

Healthcare Maintenance Organizations

Anesthesia Practice Management Companies

Summary

298 Your Career: Understanding the Basics of Locum Tenens Jobs

Starting the Process

299 Your Career—Understanding Solo Practice and the Basics of Medical Practice Finance and Legal Organization

Case Distribution

Call Distribution

Anesthesiologist Relationships

Control Versus Responsibility

Finances/Accounting/Legal

Legal Structure

300 Your Career: Make Sure You Understand the Compliance Plan

Billing and Collection Services

301 Your Career—Know the Risk-Management Strategies of the Practice

Adaptability to Change

Liabilities

Outstanding Litigation

302 Avoiding Bad Employment Contracts: Due Diligence, Termination, and Restrictive Covenants

Due Diligence

Term

Termination

Without Cause

With Cause

Disability

Death

Restrictive Covenants

303 Avoiding Bad Employment Contracts: Duties, Compensation, and Benefits

Duties

Compensation

Benefits

304 MACRA—Robbing Peter to Pay Val (ue)

CONCLUSION

305 Sage Advice to Close This Book: Anesthesiology and the Aphorisms of B. Franklin, Printer

Index

 

An aparitie	1 Oct. 2019
Autor	Catherine Marcucci , Brian T. Gierl , Jeffrey R. Kirsch MD
Dimensiuni	15.24 x 3.3 x 22.86 cm
Editura	LWW
Format	Paperback
ISBN	9781451195194
Limba	Engleza
Nr pag	1152