Summary Recent Advances in Anesthesiology (Volume 2) Anesthesia: A Topical Update - Thoracic, Cardiac, Neuro, ICU, and Interesting Cases
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Course
Recent Advances in Anesthesiology
Institution
American Intercontinental University (AIU)
Despite one’s best effort and the efforts of various professional societies, it is often difficult to
keep abreast in all aspects of anesthesia. Over time, every practitioner settles into a daily
practice and keeps current in that area. However, the nature of modern anesthetic practice
require...
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, CONTENTS
PREFACE ................................................................................................................................................ i
ACKNOWLEDGEMENTS ........................................................................................................... i
DEDICATION ......................................................................................................................................... iii
LIST OF CONTRIBUTORS .................................................................................................................. iv
CHAPTER 1 ANESTHETIC CONSIDERATIONS FOR OTOLARYNGOLOGY AND NECK
SURGERY ................................................................................................................................................ 1
Matthew L. Kashima
INTRODUCTION .......................................................................................................................... 1
AIRWAY ......................................................................................................................................... 3
Tracheostomy .......................................................................................................................... 5
Tracheostomy Types ............................................................................................................... 7
LARYNGOLOGY .......................................................................................................................... 9
HEAD AND NECK ......................................................................................................................... 10
NIM TriVantage EMG Endotracheal Tube, Medtronic Xomed Corporation ......................... 11
OTOLOGY ...................................................................................................................................... 13
RHINOLOGY ................................................................................................................................. 14
PEDIATRICS .................................................................................................................................. 14
EPIGLOTTITIS ............................................................................................................................. 15
UPPER AIRWAY FOREIGN BODY ........................................................................................... 16
Nasal Foreign Body Removal ................................................................................................. 18
Pressure Equalization Tube Placement ................................................................................... 18
Tonsillectomy ......................................................................................................................... 18
Deep Neck Infections .............................................................................................................. 19
CONCLUSION ............................................................................................................................... 20
CONSENT FOR PUBLICATION ................................................................................................ 20
CONFLICT OF INTEREST ......................................................................................................... 20
ACKNOWLEDGEMENT ............................................................................................................. 20
REFERENCES ............................................................................................................................... 20
CHAPTER 2 THORACIC ANESTHESIA ......................................................................................... 23
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INTRODUCTION .......................................................................................................................... 23
PREOPERATIVE CONSIDERATIONS IN THE PATIENT WITH LUNG CANCER ........ 24
Histologic Categories of Lung Cancer .................................................................................... 25
Pulmonary Function Testing ................................................................................................... 25
Pulmonary Function Testing Suggestive of Increased Postoperative Morbidity .......... 25
Estimated Postoperative FEV1% = Preoperative FEV1 x (1 – fraction lung tissue
resected/100) ........................................................................................................................... 26
Preoperative Steps to Mitigate Perioperative Risks ................................................................ 27
Preoperative Optimization ............................................................................................ 27
INTRAOPERATIVE MONITORING ......................................................................................... 28
METHODS OF SECURING ONE LUNG VENTILATION ...................................................... 30
Indications for One Lung Ventilation (OLV) ......................................................................... 30
Indications for Lung Isolation (One Lung Ventilation) .......................................................... 30
Endobronchial Double Lumen Tubes ..................................................................................... 31
Standard Fiberoptic Bronchoscopy Images ............................................................................ 33
Univent Tube .......................................................................................................................... 35
Bronchial Blockers .................................................................................................................. 37
, Endobronchial intubation with ETT/MLT .............................................................................. 40
One Lung Ventilation and the Difficult Airway ..................................................................... 40
PHYSIOLOGY OF ONE LUNG VENTILATION ..................................................................... 42
VENTILATORY STRATEGIES DURING ONE LUNG VENTILATION ............................. 45
Managing Hypoxemia ............................................................................................................. 46
Approach to Hypoxemia During One Lung Ventilation (Table 10) ....................................... 47
THORACIC SURGICAL DIAGNOSTIC PROCEDURES ....................................................... 48
(Fiberoptic Bronchoscopy, Rigid Bronchoscopy, and Mediastinoscopy) .............................. 48
ESOPHAGEAL SURGERY .......................................................................................................... 50
VIDEO ASSISTED THORACOSCOPY AND MINIMALLY INVASIVE ROBOTIC
THORACIC SURGERY ................................................................................................................ 52
TRACHEAL RESECTION AND RECONSTRUCTION .......................................................... 53
POSTOPERATIVE CONSIDERATIONS ................................................................................... 55
Conditions Associated with Need for Mechanical Ventilation After Thoracic Surgery ........ 55
PAIN MANAGEMENT ................................................................................................................. 56
Implications for Lack of Adequate Analgesia After Thoracic Surgery .................................. 57
Approaches to Postoperative Analgesia .................................................................................. 57
COMPLICATIONS OF THORACIC SURGERY ...................................................................... 58
Airway Concerns .................................................................................................................... 58
Pulmonary Complications ....................................................................................................... 58
Cardiac Complications ............................................................................................................ 60
Hemorrhage ............................................................................................................................. 60
Neurologic Injuries ................................................................................................................. 60
Positioning Injuries Associated with Thoracic Surgery .......................................................... 61
CONCLUSION ............................................................................................................................... 61
CONSENT FOR PUBLICATION ................................................................................................ 62
CONFLICT OF INTEREST ......................................................................................................... 62
ACKNOWLEDGEMENT ............................................................................................................. 62
REFERENCES ............................................................................................................................... 62
CHAPTER 3 CARDIAC ANESTHESIA ............................................................................................ 70
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INTRODUCTION .......................................................................................................................... 70
PRELOAD, AFTERLOAD AND CONTRACTILITY ............................................................... 73
PRELOAD .............................................................................................................................. 73
AFTERLOAD ......................................................................................................................... 73
CONTRACTILITY ........................................................................................................................ 73
Interaction Between Preload, Afterload and Contractility ...................................................... 74
PRESSURE WORK, VOLUME WORK AND THEIR ROLE IN CARDIAC VALVULAR
DISEASE ......................................................................................................................................... 77
Physiologic Response to Pressure Loading ............................................................................ 77
Physiologic Response to Volume Loading Conditions .......................................................... 78
Ramifications of Pressure Load vs. Volume Load For Anesthesiologist ............................... 80
ANESTHETIC CONSIDERATIONS FOR SPECIFIC LESIONS ........................................... 81
AORTIC STENOSIS (AoS) ................................................................................................... 81
MITRAL STENOSIS .............................................................................................................. 82
AORTIC INSUFFICIENCY (AoI) ......................................................................................... 83
MITRAL REGURGITATION (MR) ...................................................................................... 84
HYPERTROPHIC CARDIOMYOPATHY/HYPERTROPHIC OBSTRUC- TIVE
CARDIOMYOPATHY (HCM/HOCM) ....................................................................................... 85
HEART VALVES AND ANTICOAGULATION ........................................................................ 86
, PACEMAKERS .............................................................................................................................. 88
INOTROPIC SUPPORT – PHARMACOLOGIC ...................................................................... 90
Two agents Under Development Include Levosimendan and Istaroxime. ............................. 91
VASOPRESSORS .................................................................................................................. 91
INOTROPIC SUPPORT – MECHANICAL ............................................................................... 92
SYSTOLIC AND DIASTOLIC HEART FAILURE ................................................................... 93
SYSTOLIC HEART FAILURE ............................................................................................. 93
DIASTOLIC HEART FAILURE .................................................................................................. 94
Clinical Approach ................................................................................................................... 96
VENTRICULAR ASSIST DEVICES ........................................................................................... 97
Caring for the Patient with VAD ............................................................................................ 100
Intraoperative Care ....................................................................................................... 100
CONCLUSION ............................................................................................................................... 101
CONSENT FOR PUBLICATION ................................................................................................ 102
CONFLICT OF INTEREST ......................................................................................................... 102
ACKNOWLEDGEMENT ............................................................................................................. 102
REFERENCES ............................................................................................................................... 102
ADDITIONAL MATERIAL USED FOR THIS WORK ............................................................ 102
CHAPTER 4 NEUROANESTHESIA ................................................................................................. 104
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INTRODUCTION .......................................................................................................................... 104
Secondary Insults to Brain ...................................................................................................... 107
PREOPERATIVE CONSIDERATIONS ..................................................................................... 107
Herniation Syndromes (Fig. 4) ............................................................................................... 109
Preoperative Medications ........................................................................................................ 111
Laboratory ............................................................................................................................... 111
Communication with Surgeon ................................................................................................ 112
MONITORING ............................................................................................................................... 112
Noninvasive Monitoring ......................................................................................................... 112
Invasive Monitoring ................................................................................................................ 112
Neuromonitoring ..................................................................................................................... 113
Intracranial Pressure Monitoring (ICP) .................................................................................. 114
Fluid and Blood ....................................................................................................................... 114
INDUCTION OF ANESTHESIA .................................................................................................. 114
Position and Padding ............................................................................................................... 115
MAINTENANCE OF ANESTHESIA .......................................................................................... 115
Measures to Decrease the ICP ................................................................................................ 117
INTRAOPERATIVE COMPLICATIONS IN NEUROSURGERY .......................................... 117
Unintended Wake-up During Neurosurgery ........................................................................... 117
Emergence (Early versus Late Emergence) ............................................................................ 118
Indication for Late Emergence ................................................................................................ 118
Criteria Met for Early Emergence ........................................................................................... 119
Differential Diagnosis of Delayed Emergence ....................................................................... 119
Reversal of Anesthesia and Extubation .................................................................................. 119
Transfer to Neurosurgical ICU or Post Anesthesia Care Unit ................................................ 119
IMPORTANT ISSUES WITH DIFFERENT NEUROSURGICAL PROCEDURES ............. 120
Traumatic Brain Injury (TBI) ................................................................................................. 120
Recommendations from Guidelines for Management of Severe Traumatic Brain Injury
(TBI) ....................................................................................................................................... 120
Management of Elevated ICP ................................................................................................. 120
,CENTRAL NERVOUS SYSTEM TUMORS .............................................................................. 121
WHO Grading of CNS Tumors (Table 4) ............................................................................... 121
Supratentorial Tumors ............................................................................................................ 122
Infratentorial Tumors .............................................................................................................. 122
Intracranial Aneurysm and Cerebral Arteriovenous Malformation (AVM) ........................... 123
Surgical intervention ............................................................................................................... 124
Prevention of Rebleed After SAH .................................................................................. 124
Clinical Signs of Vasospasm ......................................................................................... 125
Predictors of Mortality After Subarachnoid Hemorrhage ............................................ 125
Anesthesia for AVM Repair ................................................................................................... 126
Aneurysm Coiling ................................................................................................................... 126
ISCHEMIC CEREBROVASCULAR DISEASE ......................................................................... 127
Carotid Endarterectomy (CEA) .............................................................................................. 127
Carotid Angioplasty and Stenting (CAS) ............................................................................... 128
Contraindications to CEA ............................................................................................. 128
Indications for CAS ....................................................................................................... 128
Contraindications for CAS ............................................................................................ 128
NEURO ENDOCRINE TUMORS ................................................................................................ 129
Epilepsy, Surgical Intervention ............................................................................................... 129
Spinal Cord Tumors ................................................................................................................ 129
ARNOLD CHIARI MALFORMATION ..................................................................................... 130
Types ....................................................................................................................................... 130
Treatment ................................................................................................................................ 130
CERVICAL SPINE FUSION, SCOLIOSIS AND MULTILEVEL LAMINECTOMIES,
INSTRUMENTATION AND FUSION ........................................................................................ 131
Neuromonitoring ..................................................................................................................... 131
VENTRICULOPERITONEAL SHUNT AND ENDOSCOPIC VENTRICULOSTOMY ...... 131
Hydrocephalus – Two types .................................................................................................... 131
POSTOPERATIVE COMPLICATIONS .................................................................................... 132
Signs That Should Trigger Immediate Response .................................................................... 132
Delayed Emergence from Anesthesia ..................................................................................... 132
Major Predictors of Delayed Emergence: ............................................................................... 132
Postoperative Paralysis and Nerve Injury ............................................................................... 133
Pressure Injury, Skin Lesions, and Corneal Abrasion ............................................................ 133
Upper Airway Complications ................................................................................................. 133
Hypertension ........................................................................................................................... 133
Postoperative Seizure: ............................................................................................................. 134
Arrhythmias ............................................................................................................................ 134
Postoperative Pain ................................................................................................................... 135
Postoperative Nausea and Vomiting ....................................................................................... 135
POSTOPERATIVE COMPLICATIONS ASSOCIATED WITH SPECIFIC
NEUROSURGICAL PROCEDURES .......................................................................................... 135
Carotid Endarterectomy .......................................................................................................... 135
Posterior Fossa Craniotomies ................................................................................................. 135
Pituitary Tumor Resection ...................................................................................................... 135
Spinal Surgeries ...................................................................................................................... 136
AWAKE CRANIOTOMY [5 - 7] .................................................................................................. 136
Indication for Doing an Awake Craniotomy .......................................................................... 136
Anesthetic Goals ..................................................................................................................... 136
Benefits of an Awake Craniotomy .......................................................................................... 137
Contraindications .................................................................................................................... 137
, Preoperative Preparation and Evaluations .............................................................................. 137
Positioning and Padding ......................................................................................................... 138
Expanded Role of the Anesthesiologist .................................................................................. 138
Anesthetic Management .......................................................................................................... 138
Premedication ......................................................................................................................... 139
Monitoring .............................................................................................................................. 139
Intraoperative .......................................................................................................................... 139
INDUCTION AND MAINTENANCE OF ANESTHESIA ........................................................ 140
Craniotomy ............................................................................................................................. 140
Scalp Block ............................................................................................................................. 140
Land Marks for an Effective Scalp Block (Fig. 5) .................................................................. 141
Local Anesthetic for the Block ............................................................................................... 143
Electrophysiological Monitoring and Functional Mapping .................................................... 143
Resection of Tumor ................................................................................................................. 144
Non-Pharmacologic Measures ................................................................................................ 144
Intraoperative Complications .................................................................................................. 144
Anesthetic Agents Used – Pros and Cons ............................................................................... 145
Future Development ................................................................................................................ 146
CONCLUSION ............................................................................................................................... 146
CONSENT FOR PUBLICATION ................................................................................................ 146
CONFLICT OF INTEREST ......................................................................................................... 146
ACKNOWLEDGEMENT ............................................................................................................. 146
REFERENCES ............................................................................................................................... 147
CHAPTER 5 MICU ISSUES ................................................................................................................ 148
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INTRODUCTION .......................................................................................................................... 148
Acute Respiratory Distress Syndrome (ARDS) ...................................................................... 148
Management of ARDS ............................................................................................................ 149
SHOCK ............................................................................................................................................ 150
SEVERE SEPSIS AND SEPTIC SHOCK ................................................................................... 152
Gastrointestinal Bleeding ........................................................................................................ 153
Hypertensive Emergency ........................................................................................................ 155
ACUTE KIDNEY INJURY ........................................................................................................... 157
TOXIDROMES AND EXPOSURES ............................................................................................ 159
Cocaine Intoxication ............................................................................................................... 159
Alcohol Withdrawal ................................................................................................................ 160
Toxic Alcohols ........................................................................................................................ 161
DELIRIUM ..................................................................................................................................... 162
CONCLUSION ............................................................................................................................... 162
CONSENT FOR PUBLICATION ................................................................................................ 163
CONFLICT OF INTEREST ......................................................................................................... 163
ACKNOWLEDGEMENT ............................................................................................................. 163
REFERENCES ............................................................................................................................... 163
CHAPTER 6 SICU UPDATE ............................................................................................................... 170
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INTRODUCTION .......................................................................................................................... 170
MODES OF MECHANICAL VENTILATION .......................................................................... 171
Introduction ............................................................................................................................. 171
Volume-Controlled Ventilation .............................................................................................. 171
PRESSURE-CONTROLLED VENTILATION .......................................................................... 172
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