,Recent Advances in Anesthesiology
(Volume 2)
Anesthesia: A Topical Update - Thoracic, Cardiac,
Neuro, ICU, and Interesting Cases
Edited by
Amballur D. John
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins
University School of Medicine Baltimore, MD, USA
,Recent Advances in Anesthesiology
Volume # 2
Anesthesia: A Topical Update – Thoracic, Cardiac, Neuro, ICU, and Interesting Cases
Editor: Amballur D. John
ISSN (Online): 2589-9392
ISSN (Print): 2589-9384
ISBN (Online): 978-1-68108-723-8
ISBN (Print): 978-1-68108-724-5
© 2018, Bentham eBooks imprint.
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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
