Yao & Artusio's Anesthesiology

Name: Yao & Artusio's Anesthesiology | Problem-Oriented Patient Management
Brand: Wolters Kluwer Health
Price: 181.99 EUR
Availability: OnlineOnly

Problem-Oriented Patient Management

Fun-Sun F. Yao Hugh Hemmings Vinod Malhotra Jill Fong(Autor*in)

Wolters Kluwer Health (Verlag)

1. Auflage

Erschienen am 1. Januar 2020

1288 Seiten

E-Book

ePUB mit Adobe-DRM

Systemvoraussetzungen

978-1-9751-2003-0 (ISBN)

181,99 €inkl. 7% MwSt.

Systemvoraussetzungen

für ePUB mit Adobe-DRM

E-Book Einzellizenz

Als Download verfügbar

Beschreibung

Weitere Details

Weitere Ausgaben

Inhalt

Intro
Contributors
Preface
Acknowledgments
SECTION 1 The Respiratory System
1 Asthma and Chronic Obstructive Pulmonary Disease
A. Medical Disease and Differential Diagnosis
A.1. What is the differential diagnosis of dyspnea?
A.2. What is the prevalence of asthma and chronic obstructive pulmonary disease (COPD)?
A.3. What is the etiology of asthma?
A.4. Discuss the pathogenesis of asthma. How is asthma distinguished from COPD?
A.5. What are the triggers of bronchospasm?
A.6. What is the universal finding in ABGs during asthmatic attacks: hypoxemia or CO2 retention?
A.7. Describe the abnormalities seen in spirometry, lung volumes, and lung capacities during an asthmatic attack.
B. Preoperative Evaluation and Preparation
B.1. How would you evaluate the patient preoperatively? What preoperative workup would you order?
B.2. How would you distinguish obstructive lung disease from restrictive lung disease by spirometry?
B.3. Define normal lung volumes and lung capacities. Give normal values for an average adult male.
B.4. What are flow-volume loops? Draw flow-volume loops for a healthy subject and patients with COPD, restrictive lung disease, fixed obstruction of the upper airway, variable extrathoracic obstruction, and variable intrathoracic obstruction.
B.5. Define closing volume (CV) and closing capacity (CC). What is the normal value of CV?
B.6. Why is the functional residual capacity (FRC) important in oxygenation?
B.7. How are FRC and CC affected by age and posture? How are they affected by anesthesia?
B.8. Give the equations for shunt (Qs/Qt) and dead space/tidal volume (Vd/Vt). What are their normal values?
B.9. Interpret the following ABG: pH, 7.36
PCO2, 60 mmHg
PO2, 70 mmHg
and CO2 content, 36 mEq per L.
B.10. What are the common physiologic causes of hypoxemia?
Decreased pulmonary capillary oxygen tension
Increased shunting
Reduced venous oxygen content
B.11. How would you prepare this asthmatic patient with COPD for surgery?
B.12. The patient comes to your perioperative clinic 2 weeks before surgery. He wants to know if his smoking puts him at increased risk during surgery. What do you tell him? Should he quit now?
B.13. You discover that the patient had a recent upper respiratory infection (URI), would you postpone surgery? For how long?
B.14. What medications would you expect the patient to have taken in the past or be taking at the present time?
B.15. The patient was on 20 mg of prednisone per day for 5 days as part of the treatment of an asthma exacerbation 3 months ago. He is currently not on steroids. Should the patient receive stress-dose steroids?
B.16. Should patients with reactive airway disease receive preoperative steroids?
B.17. What is the onset of action of intravenous steroid therapy in asthma?
C. Intraoperative Management
C.1 If the patient had a severe asthmatic attack in the operating room before the induction of anesthesia, would you proceed with the anesthetic or postpone the surgery?
C.2. The patient did not have an asthmatic attack in the operating room and you proceed with induction. How would you induce anesthesia? Would you use a supraglottic airway instead of an endotracheal tube?
C.3. Would you use propofol for induction of anesthesia?
C.4. Would you use thiopental, methohexital, etomidate, or ketamine for induction?
C.5. Would you administer lidocaine for intubation?
C.6. If this is an emergency surgery and rapid sequence induction is indicated, how would you induce anesthesia in this patient?
C.7. Could a regional technique be used for this surgery? Discuss the advantages and disadvantages of neuraxial anesthesia in this patient for this surgery.
C.8. Would you choose an inhalational or an intravenous technique for maintenance of anesthesia?
C.9. What mechanisms produce bronchodilation from volatile anesthetics?
C.10. Which muscle relaxants would you use? Why?
C.11. How will you ventilate the patient? Will you use positive end-expiratory pressure (PEEP)? How can you detect the presence of auto-PEEP on your ventilator?
C.12. What is the differential diagnosis of intraoperative bronchospasm?
C.13. In the middle of surgery, peak inspiratory pressures (PIPs) suddenly increase. How do you manage this?
C.14. How would you give ß 2 -agonists? What is their mechanism of action on asthma?
C.15. If the patient does not respond to the aforementioned treatment and becomes cyanotic, what would you do?
C.16. The asthmatic attack was relieved with your treatment, and the surgery was completed. Following emergence, the patient was found to be hypoventilating. What are the common causes of hypoventilation? What will be your approach to treat hypoventilation?
C.17. Would you consider a deep extubation in this patient?
C.18. If the patient cannot be extubated, what measures can you take to reduce the likelihood of bronchospasm with an endotracheal tube in place?
D. Postoperative Management
D.1. In patients with asthma and COPD, are there special considerations for the use of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative pain control?
D.2. Would you consider using a regional technique for analgesia?
D.3. The patient was breathing well and was extubated. Would you place this patient on supplemental oxygen in the recovery room? How much?
D.4. The patient is hypoventilating in postanesthesia care unit (PACU). Would you initiate noninvasive ventilation (NIV)?
2 Bronchoscopy, Mediastinoscopy, and Thoracoscopy
A. Medical Disease and Differential Diagnosis
A.1. How is the diagnosis of lung cancer made? What is your prediction for the most likely type of malignancy?
A.2. What are the less common manifestations of bronchogenic carcinoma?
A.3. The patient has a long history of cigarette smoking. What is the significance of this finding?
B. Preoperative Evaluation and Preparation
B.1. How would you evaluate the patient prior to surgery?
B.2. What are the pulmonary function guidelines that indicate an increased risk for morbidity and mortality?
B.3. What are the preoperative concerns of induction immunotherapy?
C. Intraoperative Management
C.1. How would you premedicate, monitor, and anesthetize this patient?
C.2. How many types of bronchoscopes are available and what are the intraoperative considerations of each one?
C.3. What are the indications for cervical mediastinoscopy? Are there potential complications?
C.4. The decision was made to proceed with a robotic right middle lobectomy. How would this alter your management?
C.5. What are the indications for single-lung ventilation and how can it be accomplished?
C.6. What are the contraindications to the use of double-lumen endotracheal tubes (DLTs)?
C.7. Would you use a right- or left-sided DLT?
C.8. How do you know that the tube is in the correct position?
C.9. How many types of bronchial blockers are available? What are the advantages and disadvantages of bronchial blockers?
C.10. How will systemic oxygenation be monitored during single-lung ventilation? What is the mechanism of pulse oximetry?
C.11. The patient was placed in the lateral decubitus position. Describe the effects of lateral positioning on pulmonary blood flow and respiration.
Respiratory Effects
C.12. What is hypoxic pulmonary vasoconstriction (HPV)?
C.13. What are the effects of anesthetic agents on HPV and their clinical implications?
C.14. Discuss pulmonary blood flow distribution, shunt flow, and partial pressure of oxygen in the arterial blood (PaO2) (fractional inspired O2 concentration [FIO 2] = 1.0) during single-lung ventilation in the lateral position.
C.15. How could you improve oxygenation during single-lung ventilation?
Ventilated Lung
Collapsed Lung
C.16. A right middle lobectomy was performed. Would you extubate the trachea at the end of the procedure?
D. Postoperative Management
D.1. What are the immediate life-threatening complications that follow lobectomy or pneumonectomy?
D.2. Why is it important to control postoperative pain? How would you achieve this goal?
Epidural, Paravertebral, and Intrathecal Analgesia
Peripheral Nerve Blocks
Systemic Opioids and Adjuvants
Oral and Transdermal Agents
Intrapleural Regional Analgesia
Cryoanalgesia
Transcutaneous Electrical Nerve Stimulation
Shoulder Pain after Lung Resection
3 Aspiration and Postoperative Respiratory Failure
A. Aspiration
A.1. What are the risk factors for perioperative aspiration?
A.2. How does large volume aspiration affect the respiratory system?
A.3. How should you manage the patient after an aspiration event?
A.4. How would you prevent aspiration during emergency surgery?
B. Postoperative Respiratory Failure
B.1. How can you predict which patients will develop postoperative respiratory failure?
B.2. How can intraoperative anesthesia management prevent respiratory failure?
B.3. What is the pathogenesis of postoperative respiratory failure?
B.4. What is the diagnostic approach to postoperative respiratory failure?
C. Indications for Ventilator Support
C.1. What are the indications for noninvasive positive pressure ventilation (NIPPV)?
C.2. What are the indications for emergency endotracheal intubation?
D. The Acute Respiratory Distress Syndrome
D.1. What is the definition and etiology of the acute respiratory distress syndrome (ARDS)?
D.2. Explain the pathophysiology of ARDS.
D.3. What role does ventilator-induced lung injury (VILI) play in ARDS?
E. Management of Mechanical Ventilation
E.1. Which mode of mechanical ventilation will you choose? Describe the features of that mode.
E.2. How should you set the fraction of inspired oxygen (FIO 2 )?
E.3. How should you set the positive end-expiratory pressure (PEEP)?
E.4. What tidal volume and inspiratory pressure target should you set?
F. Management of Refractory Respiratory Failure
F.1. What else can promote additional lung recruitment?
F.2. What rescue strategies can you use for refractory ARDS?
G. Adjunctive Management of Respiratory Failure
G.1. What is the cause and treatment of the hemodynamic instability associated with mechanical ventilation?
G.2. What is the adjunctive medical therapy for ARDS?
H. Liberation of the Patient from Mechanical Ventilation
H.1. Explain the importance of the decision to extubate the patient or continue mechanical ventilation.
H.2. How will you prepare the patient for liberation from the ventilator?
H.3. How will you recognize when the patient is ready for extubation?
4 Lung Transplantation
A. Medical Disease and Differential Diagnosis
A.1. What are the expected manifestations of severe obstructive pulmonary disease in this patient, and why is she a transplant candidate?
A.2. What other end-stage lung diseases can also be treated with transplantation?
A.3. How many lung transplantations have been performed?
A.4. What are the selection criteria for recipients?
A.5. How is the decision made to transplant one or both lungs, and does this influence preoperative management?
A.6. How does a single-lung transplantation (SLT) differ technically from a bilateral-lung transplantation (BLT)?
B. Preoperative Evaluation and Preparation
B.1. What preoperative evaluation is desirable?
B.2. Would you premedicate this patient? If so, how?
B.3. What vascular access is appropriate?
B.4. Is preoperative epidural catheter placement advantageous?
C. Intraoperative Management
C.1. What special equipment is necessary?
C.2. How would you monitor this patient?
C.3. How would you induce anesthesia in this patient?
C.4. How would you ventilate this patient? What kind of endotracheal tube would you use?
C.5. How does the physiology of single-lung ventilation influence the procedure?
C.6. How does single-lung ventilation affect cardiopulmonary function? What are the problems of single-lung ventilation in this patient? How would you treat them?
C.7. What problems are associated with the lateral position?
C.8. Should volatile anesthetics be avoided during single-lung ventilation?
C.9. At what specific points in the procedure are problems anticipated?
C.10. How would you deal with problems related to clamping of the pulmonary artery (PA)?
C.11. What hemodynamic alterations would you expect during graft implantation and reperfusion? How would you correct them?
C.12. When is cardiopulmonary bypass (CPB) necessary for lung transplantation?
C.13. Should fluid administration be restricted, and are blood products commonly required?
C.14. Would you extubate the patient upon conclusion of the procedure?
D. Postoperative Management
D.1. What are the major complications after lung transplantation?
D.2. How is postoperative ventilation managed, and for how long is it required?
D.3. What special precautions should be taken when a lung transplant recipient requires general anesthesia for subsequent nonpulmonary surgery?
D.4. What are the long-term outcomes of lung transplantation?
D.5. Are there surgical alternatives to lung transplantation?
SECTION 2 The Cardiovascular System
5 Ischemic Heart Disease and Coronary Artery Bypass Grafting
A. Medical Disease and Differential Diagnosis
A.1. What is triple-vessel CAD? Name the branches of the coronary arteries.
A.2. What are the indications for CABG?
A.3. What is percutaneous coronary intervention (PCI)? Discuss its indications, contraindications, and results.
A.4. What are the expected results of CABG?
B. Preoperative Evaluation and Preparation
B.1. Which preoperative tests would you order?
B.2. How would you evaluate the patient's left ventricular function?
B.3. Which factors determine myocardial oxygen supply?
B.4. What are the three major determinants of myocardial oxygen consumption? How are they measured clinically?
B.5. Would you continue the ß-blocker (metoprolol) on the day of surgery? Why/why not? What is its half-life? What is the role of ß-adrenergic blockers in treating congestive heart failure (CHF)?
B.6. Would you continue the angiotensin-converting enzyme (ACE) inhibitor on the day of surgery? Why/why not?
B.7. If the patient who is on lisinopril develops hypotension intraoperatively, how would you manage it?
C. Intraoperative Management
C.I. Before Cardiopulmonary Bypass
C.I-1. What is your plan to monitor the patient?
C.I-2. What is the Allen test?
C.I-3. How would you monitor electrocardiogram (ECG)? Why lead V 5? If you do not have precordial leads in your ECG machine, how can you monitor the left ventricle (LV)?
C.I-4. Should you monitor temperature from multiple sites?
C.I-5. Is it necessary to monitor pulmonary artery (PA) pressure for coronary artery operations?
Diagnostic
C.I-6. What are the possible complications of PA catheterization?
Similar to Central Venous Catheter Insertion
From Pulmonary Artery Catheter
C.I-7. What is normal pulmonary artery occlusion pressure (PAOP)?
C.I-8. What are the hemodynamic consequences of myocardial ischemia? How can you detect myocardial ischemia? Is PAOP a sensitive indicator of myocardial ischemia?
C.I-9. Discuss the principles and clinical applications of intraoperative transesophageal two-dimensional echocardiography.
C.I-10. How would you induce anesthesia? Is there any advantage/disadvantage to using propofol versus etomidate as the main induction agent? What kind of neuromuscular blocker (NMB) would you use? Why?
C.I-11. How would you maintain anesthesia? Volatile anesthetics or total intravenous anesthesia (TIVA)?
C.I-12. What are the cardiovascular effects of volatile anesthetics, morphine, and fentanyl?
C.I-13. What should you do during sternotomy?
C.I-14. Would you use prophylactic nitroglycerin during CABG to prevent intraoperative myocardial ischemia or perioperative MI?
C.I-15. If ST-segment depression is seen during surgery, how would you treat it? What is the relation between perioperative myocardial ischemia and postoperative MI?
C.I-16. Discuss autologous transfusion and blood conservation for cardiac surgery.
C.I-17. What antifibrinolytic will you use to reduce blood transfusions?
C.I-18. How do you know that the tip of the PA catheter is in the right ventricle (RV) or the PA?
Pressure Contour
Ventricular Filling
C.II. During Cardiopulmonary Bypass
C.II-1. What anticoagulant would you give before cardiopulmonary bypass (CPB)? How much would you give? What is its mechanism?
C.II-2. What is the half-life of heparin? How is it eliminated?
C.II-3. How do you monitor heparin dosage? What is the activated coagulation time (ACT) test?
C.II-4. What is total CPB? What is partial bypass?
C.II-5. What kinds of pumps are used in CPB? Are they pulsatile or not?
C.II-6. What is the purpose of venting the LV? How can it be done?
C.II-7. How many types of oxygenators are there? What are the advantages of each type?
Direct Gas Interface
Without Gas Interface
C.II-8. What kind of priming solution would you use? How much priming solution would you use? When would you prime with blood? Why?
C.II-9. What are the advantages and disadvantages of hemodilution?
Advantages of Hemodilution
Disadvantages of Hemodilution
C.II-10. How do you monitor the patient during CPB?
Clinical Monitoring
Laboratory Monitoring at Least Once Every Hour
C.II-11. What should your target BP be during CPB?
C.II-12. How would you treat hypotension during CPB?
C.II-13. How would you treat hypertension (a mean arterial pressure [MAP] of over 100 mmHg)?
C.II-14. How do you prepare an IV infusion of sodium nitroprusside, nicardipine, and nitroglycerin? What are the usual doses? Which do you prefer to use?
C.II-15. How much pump flow would you maintain during CPB? During hemodilution? During hypothermia?
C.II-16. How does blood viscosity change during hemodilution and hypothermia?
C.II-17. How is anesthesia provided during CPB?
C.II-18. Would you give muscle relaxants during CPB? How is the action of muscle relaxants affected during CPB?
C.II-19. How do you know the patient is well perfused during CPB?
C.II-20. How much gas flow would you use for the oxygenator? What kind of gas would you use? Why?
C.II-21. What are the disadvantages of hypocapnia during CPB?
C.II-22. How would you preserve the myocardium during CPB?
C.II-23. What is cardioplegia? How much would you use?
C.II-24. The arterial blood gases and electrolytes during CPB are as follows: pH, 7.36
PaCO 2 , 42 mmHg
PaO 2 , 449 mmHg
CO 2 content, 24 mEq per L
sodium (Na), 128 mEq per L
potassium (K), 5.8 mEq per L
glucose, 180 mg/dL
and hematocrit, 20%. The patient's temperature is 27°C (80.6°F). At what temperature are blood gases measured? How would you correct the blood gases according to patient's body temperature? Would you treat the arterial blood gases at 37°C (98.6°F) or at patient's body t
C.II-25. How does the blood sugar level change during CPB? Why? What is optimal glucose control intraoperatively? Does hyperglycemia increase neurologic complications during CPB?
C.II-26. What are the effects of CPB on platelet and coagulation factors?
C.II-27. If the blood level of the venous reservoir is low, what would you replace it with? Blood or balanced salt solution?
C.II-28. How do you estimate the fluid balance during CPB?
C.II-29. For how long a period can the aorta be cross-clamped?
C.II-30. Why does the urine turn pink in some cases of CPB? What is the renal threshold for plasma hemoglobin?
C.II-31. Why does it take longer to rewarm than to cool the patient via the pump oxygenator?
C.II-32. At what temperature can the patient be weaned from CPB?
C.II-33. How would you defibrillate the heart internally during CPB?
C.II-34. If the HR is 40 beats per minute, what should you do?
C.II-35. How would you prepare for termination of CPB?
Laboratory Data
Anesthesia Machine
Monitors
Patient/Pump
Support
C.II-36. How would you decide the need for inotropic support?
C.III. After Cardiopulmonary Bypass
C.III-1. How would you reverse heparin? How much protamine would you use? What are the other drugs used to neutralize heparin?
C.III-2. What is the action mechanism of protamine?
C.III-3. What are the complications of too much protamine?
C.III-4. What is a protamine reaction? How can you prevent this condition? How do you treat it?
C.III-5. What are the indications for intra-aortic balloon pump (IABP)?
Ischemic Heart Disease
Cardiac Surgery
C.III-6. What are the principles of IABP?
C.III-7. What are the complications of IABP?
D. Postoperative Management
D.1. Would you reverse the muscle relaxants? Why?
D.2. When will you wean the patient from the ventilator?
D.3. What criteria would you use in deciding when to wean the patient from the ventilator?
D.4. What are potential postoperative complications?
Cardiovascular
Pulmonary
Renal
Hemorrhage
6 Mechanical Circulatory Support
A. Medical Disease and Differential Diagnosis
A.1. What is an IABP?
A.2. How is an IABP placed and positioned?
A.3. Describe an IABP inflation and deflation timing.
A.4. How does the IABP help improve hemodynamics?
A.5. What are the indications for IABP placement?
A.6. What are the contraindications and potential complications of IABP placement?
A.7. What are the pitfalls of IABP timing?
A.8. What are the main advantages and disadvantages of IABP support?
A.9. What is mechanical circulatory support?
A.10. What is a ventricular assist device (VAD)?
A.11. What are the types of percutaneous/temporary VADs?
A.12. What are the types of permanent VADs?
A.13. How does VAD work?
A.14. When is circulatory support needed?
A.15. What are the physiologic considerations in patients requiring a VAD?
A.16. What are the reasons for suboptimal VAD support?
A.17. What are common complications from VAD?
A.18. How long can VADs remain in the patient?
B. Preoperative Evaluation and Preparation
B.1. What is the focus of the preoperative assessment of an LVAD patient?
C. Intraoperative Management
C.1. Detail the anesthetic management for a patient undergoing LVAD placement.
C.2. How is a VAD patient monitored during a general anesthetic?
C.3. Prescribe an anesthetic for a VAD patient.
C.4. What is ECMO? What are the indications for ECMO? What are the different types of ECMO?
C.5. What are the contraindications of ECMO?
C.6. What are the main complications of ECMO?
C.7. What are the necessary equipment and teams required to place ECMO? What are the pros and cons of different venoatrial ECMO (VA-ECMO) cannula placement?
C.8. How are patients monitored and managed while on ECMO?
C.9. What are the complications of ECMO?
C.10. How frequently is VA-ECMO being used and how effective is it in cardiogenic shock?
D. Postoperative Management
D.1. When and how is a patient weaned off IABP support?
D.2. How is weaning from ECMO accomplished?
7 Valvular Heart Disease
A. Medical Disease and Differential Diagnosis
A.1. What are the major etiologies of AS, AI, mitral stenosis (MS), and MR?
A.2. What are the major changes in the loading conditions of the LV that result from the four different lesions? Why do they occur? What changes result from them?
A.3. What are pressure-volume (P-V) loops? What do the different inflection points represent?
A.4. What are representative P-V loops for the four valvular lesions?
A.5. Draw the pressure/time curves for the LV, left atrium, pulmonary artery, and aorta for a normal patient and for patients with each of the four valvular lesions.
Aortic Stenosis
Aortic Insufficiency
Mitral Stenosis
Mitral Regurgitation
A.6. What are the basic principles of echocardiography? What are M-mode, B-mode, and Doppler color modalities? How do TTE and transesophageal echocardiography (TEE) differ?
A.7. What are the three TEE vantage points for the comprehensive imaging of the LV? How are pressure gradients measured by echocardiography? How do the pressure gradients derived from Doppler echocardiography differ from those obtained in the catheterization laboratory by direct pressure measurement?
A.8. What is the role for three-dimensional (3D) echocardiography in the operating room?
A.9. What are the echocardiographic and cardiac catheterization criteria for the four valvular lesions?
Aortic Stenosis
Aortic Insufficiency
Mitral Stenosis
Mitral Regurgitation
B. Preoperative Evaluation and Preparation
B.1. What are the presenting signs and symptoms of the four valvular lesions listed previously?
Aortic Stenosis
Aortic Insufficiency
Mitral Stenosis
Mitral Regurgitation
B.2. What is the New York Heart Association classification of heart failure?
B.3. Discuss the role of premedication for patients with the four different valvular lesions.
B.4. How would you premedicate the patient with severe AS and MR?
C. Intraoperative Management
C.1. Outline the hemodynamic management goals for each of the four valvular lesions. What are the anesthetic goals with respect to heart rate and rhythm, preload, afterload, and contractility?
Aortic Stenosis
Aortic Insufficiency
Mitral Stenosis
Mitral Regurgitation
C.2. What are the hemodynamic goals for this patient with the combination of severe AS and MR?
C.3. How would you monitor this patient with severe AS and MR?
C.4. Should the patient have a pulmonary artery catheter placed before induction?
C.5. Is a pulmonary artery catheter with pacing capabilities indicated?
C.6. What anesthetic technique would you employ? Why?
C.7. What muscle relaxant would you use for this patient?
C.8. What are the usual TEE findings in a patient with AS or MR? How do you grade the severity of AS by TEE? How do you quantify the severity of MR? What is the impact of AS on the severity of MR?
C.9. What special considerations particular to cardiopulmonary bypass (CPB) operations do you have for each of the four lesions? Focus on these concerns with respect to the induction and prebypass, bypass, and postbypass periods.
Aortic Stenosis
Aortic Insufficiency
Mitral Stenosis
Mitral Regurgitation
C.10. The patient cannot be weaned from CPB following an AV replacement and MV replacement. What are the possible causes?
C.11. How would you diagnose right-sided heart failure and pulmonary hypertension? How would you treat it?
C.12. How does an intra-aortic balloon pump (IABP) work to benefit the failing heart?
C.13. What role does the IABP have in this setting?
C.14. What role does TEE play in the placement, timing, and demonstration of efficacy of an IABP?
C.15. How would you properly time the IABP cycle?
C.16. What are the contraindications to the use of an IABP?
C.17. What is the role for ventricular assist devices?
D. Postoperative Management
D.1. In the intensive care unit (ICU) 4 hours later, the patient became hypotensive with a low cardiac output. How could you distinguish between cardiac tamponade and pump failure? How would the TEE images differ?
D.2. Would you extubate this patient early in the ICU? Why?
D.3. What are the advantages and disadvantages of early extubation?
E. Alternative Treatments
E.1. What are the percutaneous options for MV repair?
E.2. How is percutaneous MV repair performed?
E.3. What are the percutaneous options for AV repair and replacement?
E.4. How is percutaneous AV replacement performed?
E.5. What anesthetic techniques and monitors are used?
E.6. What is minimally invasive cardiac valve surgery?
8 Pacemakers, Implantable Cardioverter-Defibrillators, and Cardiac Resynchronization Therapy Devices
A. Medical Disease and Differential Diagnosis
A.1. What are the indications for PPMs?
A.2. What is sick sinus syndrome? What is chronotropic incompetence?
A.3. How would you diagnose first-, second-, and third-degree AV block
bifascicular block (right bundle branch block [RBBB] with left anterior fascicular hemiblock or left posterior fascicular hemiblock)
and trifascicular block?
A.4. Is it necessary to insert a temporary pacemaker before general anesthesia for an asymptomatic patient with bifascicular or trifascicular block?
A.5. What are the three-letter and five-letter identification codes of the North American Society of Pacing and Electrophysiology (NASPE) and British Pacing and Electrophysiology Group (BPEG) generic (NBG) code for pacemaker classification?
A.6. How many modes of pacing are available in modern PPMs? How do they work? What is the difference between DDD pacing and DDI pacing?
A.7. The patient was mechanically hyperventilated during surgery, and her pacemaker gradually increased her heart rate. What feature of the PPM is accounting for this?
A.8. What are the advantages and disadvantages of atrial pacing only? What are the disadvantages of right ventricular pacing only?
A.9. What are the indications for and complications associated with AV sequential PPMs?
A.10. How would you know if the patient's PPM was atrially, ventricularly, or atrioventricularly sequentially pacing?
A.11. What is a biventricular PPM or CRT device? What are the indications for such a device?
A.12. What are the usual lifespans of PPMs and implantable cardioverter-defibrillators (ICDs)?
A.13. What is an ICD? How does it work? What is a subcutaneous ICD?
A.14. What are the indications for ICDs?
A.15. What is the NASPE and BPEG generic defibrillator (NBD) code?
B. Preoperative Evaluation and Preparation
B.1. How would you preoperatively evaluate the patient described earlier?
B.2. How do you determine whether the patient has a cardiac implantable electronic device (CIED) and define what type of CIED?
B.3. How do you determine whether the patient is dependent on the pacing from the CIED?
B.4. How do you know if the implanted PPM or ICD is working?
B.5. What information would you like to obtain from interrogating this device?
B.6. How do you preoperatively prepare the patient for surgery and anesthesia?
B.7. Would you recommend reprogramming this device to asynchronously pace before surgery? What would you recommend regarding the ICD functions of the device?
B.8. The patient requires an abdominal magnetic resonance imaging (MRI) prior to the surgery. What considerations should you make regarding her CIED?
C. Intraoperative Management
C.1. How would you monitor this patient?
C.2. What drugs and equipment would you like to have on hand in the operating room?
C.3. How would you set up the transcutaneous external pacer and defibrillator?
C.4. Had this patient's ICD been implanted the day before surgery, would you consider avoiding certain inhalational gases for anesthesia?
C.5. Electromagnetic interference (EMI) from electrocautery results in significant noise on your cardiac monitor. You recall that EMI also can inhibit pacing function from the PPM. In this pacemaker-dependent patient, how can you determine whether inappropriate inhibition of the PPM is occurring?
C.6. What are the potential responses of pacemakers and ICDs to electrocautery?
C.7. How would you prevent the effects of EMI on the pacemaker or ICD from the electrocautery?
C.8. What are the effects of a magnet on pacemakers and ICDs?
C.9. In the middle of surgery, the patient developed ventricular tachycardia. What would you do?
C.10. What precautions should be taken when a patient with a CIED is undergoing extracorporeal shock wave lithotripsy (ESWL)?
C.11. Is electroconvulsive therapy (ECT) contraindicated in patients with pacemakers or ICDs?
C.12. What precautions should be taken during radiofrequency ablation for a patient with a CIED?
C.13. During surgery, the patient developed frequent premature ventricular complexes and some of these resulted in rapid ventricular pacing (see Fig. 8.8). What is accounting for the pacemaker's behavior?
D. Postoperative Management
D.1. How would you monitor this patient in the postanesthesia care unit?
D.2. How would you confirm that the CIED is functioning properly after surgery?
9 Thoracic and Thoracoabdominal Aortic Aneurysms
A. Pathophysiology and Differential Diagnosis
A.1. What is a thoracic aortic aneurysm (TAA) and TAAA, and how do they typically present?
A.2. How are TAAs and TAAAs classified?
A.3. What is the pathogenesis of aortic aneurysms and what genetic conditions predispose to their formation?
A.4. What are the risk factors for TAA rupture?
A.5. What is the natural history and medical management of thoracic aneurysms?
A.6. What is a thoracic aortic dissection, and how does it typically present?
A.7. How are thoracic aortic dissections classified?
DeBakey Classification
Stanford Classification
Penn Classification
B. Preoperative Evaluation and Preparation
B.1. What are the indications and timing of surgical intervention for TAAs?
B.2. Which patients are candidates for endovascular aortic repair, and what are the advantages to this approach?
B.3. What are the preoperative considerations for the anesthesiologist before TAA repair?
Cardiovascular
Respiratory
Renal
Neurologic
B.4. What is the preoperative management of a patient presenting with an acute aortic dissection (AAD)?
B.5. What is the spinal cord blood supply?
C. Intraoperative Management
C.1. What are the surgical approaches to thoracic aneurysm repair?
Ascending and Arch Aortic Aneurysms
Thoracoabdominal Aneurysms
C.2. How is the open repair performed?
Ascending and Arch Aortic Aneurysms
Thoracoabdominal Aneurysms
C.3. How are endovascular repairs of TAAAs performed?
C.4. What are the surgical approaches to aortic dissections?
Type A Aortic Dissection
Type B Aortic Dissection
C.5. What are the specific considerations for anesthetic management of the patient presenting for open TAAA repair?
C.6. What are the specific considerations for anesthetic management of the patient presenting for endovascular TAAA repair?
C.7. What hemodynamic monitors should be used for the patient undergoing thoracic aneurysm repair?
C.8. What strategies are used for spinal cord protection during a TAAA repair?
Left-Heart Bypass
Intraoperative Neuromonitoring
Cerebrospinal Drainage
Hypothermia
C.9. What strategies are used for mesenteric and renal preservation?
C.10. What is the pathophysiology of aortic clamping and unclamping?
Aortic Clamping
Aortic Unclamping
C.11. Why does a coagulopathy ensue and how is it prevented/treated?
D. Postoperative Anesthetic Management
D.1. What are the postoperative complications after open TAAA repair?
Respiratory Failure
Renal Failure
Spinal Cord Injury
D.2. What are the postoperative complications after endovascular TAAA repair?
Left Upper Extremity Ischemia
Stroke
Spinal Cord Ischemia
Renal Failure
Postimplantation Syndrome
Endograft Collapse
Endoleaks
10 Abdominal Aortic Aneurysm Repair
A. Medical Disease and Differential Diagnosis
A.1. What risk factors are associated with an abdominal aortic aneurysm (AAA)?
A.2. What other diseases are commonly found in patients with aortic aneurysms?
A.3. What is the incidence of morbidity and mortality in these patients if they undergo elective open surgical repair? What is the natural history of the disease without surgical repair?
A.4. What should be done for smaller aortic aneurysms that are found in patients?
A.5. What is the risk of perioperative myocardial infarction (MI) in patients with ischemic heart disease? What can be done to reduce the risk of ischemic events in these patients?
A.6. Does the morbidity and mortality of elective repair of an aortic aneurysm differ significantly from that of an emergency repair?
B. Preoperative Evaluation and Preparation
B.1. Which preoperative laboratory tests would you require for this patient?
B.2. What is the significance of the preoperative ECG? Would you wish to pursue a preoperative cardiac workup? What tests would you request, and what would they tell you?
B.3. Is it necessary to evaluate this patient's pulmonary status?
B.4. Preoperative arterial blood gas (ABG) measurement shows pH, 7.35
PaCO2, 47 mmHg
and PaO2, 68 mmHg on room air. What is the significance of this result?
B.5. How would you measure creatinine clearance in this patient, and what is its value in this case?
B.6. Describe the blood flow to the spinal cord. What is its relevance to surgery involving the abdominal aorta?
B.7. How do you detect spinal cord ischemia?
B.8. What are the various surgical approaches to repair an AAA?
B.9. How does the choice of surgical technique affect the anesthetic management?
B.10. How would you premedicate this patient?
C. Intraoperative Management
C.1. Would you use an arterial line? What are the complications of arterial line placement?
C.2. What various monitors are available for myocardial ischemia? Is a pulmonary artery catheter (PAC) helpful in determining the occurrence of ischemia?
C.3. What additional monitors would you employ?
C.4. Is there a role for somatosensory evoked potential (SSEP) monitoring during aortic clamping?
C.5. How would you anesthetize this patient for an open repair of the aorta? What techniques could be used for an endovascular aortic aneurysm repair? Discuss the various anesthetic techniques that can be employed for this surgery.
C.6. This patient is to be heparinized intraoperatively, and anticoagulation may be continued postoperatively. Is this a contraindication to the preoperative placement of either an epidural or intraspinal catheter? What if the patient is receiving anticoagulants in the preoperative period?
C.7. What are your plans for fluid and blood replacement during surgery?
C.8. What are the hemodynamic changes of aortic cross-clamp placement? What efforts can be made to minimize these changes both before and during cross-clamping? If the patient develops ST-segment depressions with a rising pulmonary capillary wedge pressure (PCWP) during cross-clamp, what maneuvers should be taken?
C.9. Because this case involves an infrarenal aneurysm, is renal blood flow affected with the placement of the cross-clamp? If an endovascular repair is chosen, what are the risks to the kidneys? Are there any treatment maneuvers that can be taken to minimize these risks in either repair?
C.10. What are the hemodynamic consequences of aortic cross-clamp removal? What can be done to minimize the effects of removing the aortic cross-clamp? If the systemic blood pressure remains depressed after removal of the cross-clamp, what is the differential diagnosis? How would you diagnose and correct the problem?
D. Postoperative Management
D.1. What are the parameters used to extubate this patient?
D.2. What are the anticipated changes in postoperative pulmonary function in these patients? How does the surgical technique affect postoperative pulmonary function? Are there any postoperative maneuvers that can improve respiratory parameters?
D.3. How would you control postoperative pain? What are the alternatives in the management of this patient's postoperative pain?
11 Hypertension
A. Medical Disease and Differential Diagnosis
A.1. Define hypertension and categorize its severity.
A.2. What is the prevalence of hypertension?
A.3. What is the general classification of hypertension? Enumerate the causes of each type of hypertension.
Etiology of Hypertension
A.4. What are the clinical patterns of hypertension encountered?
A.5. What is the pathophysiology of essential hypertension?
A.6. What is the pathophysiology of isolated systolic hypertension (ISH) and of pulse pressure hypertension (PPH)?
A.7. What are the end-organ damages caused by long-standing hypertension?
Cardiac Involvement
Eye Involvement
Renal Involvement
Cerebral Involvement
A.8. Are hypertensive patients at an increased risk for perioperative cardiac morbidity?
A.9. Perioperative cerebral and renal complications are mostly associated with which subtype of hypertension?
A.10. Would you employ a controlled hypotensive technique for hypertensive patients? How much would you safely lower the BP?
A.11. What are the BP goals for patients with hypertension and when should antihypertensive drugs be initiated?
A.12. What is the mechanism of action of antihypertensive drugs?
Diuretics
Antiadrenergic Agents
Direct Vasodilators
Dopaminergic Agonists
Calcium Channel Blockers
Angiotensin-Converting Enzyme Inhibitors
Angiotensin II Receptor Blockers
Other Vasodilators
A.13. Does the choice of antihypertensive therapy influence hemodynamic responses to induction, laryngoscopy, and intubation?
A.14. Does chronic angiotensin-converting enzyme (ACE) inhibition influence anesthetic induction?
B. Preoperative Evaluation and Preparation
B.1. How would you evaluate this patient preoperatively?
B.2. Would you postpone the surgery? Why? What BP would you like the patient to achieve before surgery?
B.3. Should all or any of the chronic medications be discontinued before the operation?
B.4. Should hypokalemia be treated before anesthesia? Why?
B.5. Should hypomagnesemia be treated before anesthesia? Why?
B.6. Does an asymptomatic carotid bruit increase the risk in these patients?
B.7. The surgery was postponed for 6 weeks. The patient was on metoprolol, aspirin, atorvastatin, captopril, hydrochlorothiazide, and potassium chloride. His BP was 160/60 mmHg and potassium 4.0 mEq per L. How would you premedicate this patient?
B.8. If the patient is an untreated hypertensive patient with BP 170/70 mmHg, would you treat the patient preoperatively with an antihypertensive agent?
C. Intraoperative Management
C.1. How would you monitor this patient?
C.2. What are the anesthetic goals for hypertensive patients?
C.3. How would you induce anesthesia for the hypertensive patient?
C.4. How does tracheal intubation produce hypertension?
C.5. What happens to the left ventricular ejection fraction during and immediately following intubation?
C.6. What other measures can prevent hypertension and tachycardia at the time of intubation?
C.7. After induction and intubation, the BP decreased to 70/40 mmHg. What would you do?
C.8. What is your choice of agents for maintenance of anesthesia? Why?
C.9. How would you manage fluid therapy for hypertensive patients?
C.10. During the surgery, BP increased to 220/120 mmHg. How would you treat the hypertension?
C.11. What could you do to prevent hypertension during extubation and emergence?
C.12. Would you consider regional anesthesia for this patient?
D. Postoperative Management
D.1. The patient developed hypertension, BP 210/110 mmHg, in the postanesthesia care unit. What would you do?
12 Cardiac Tamponade
A. Medical Disease and Differential Diagnosis
A.1. What is the differential diagnosis of low CO following cardiac surgery?
A.2. Describe the pathophysiology of cardiac tamponade.
A.3. What are the common etiologies of cardiac tamponade?
A.4. What is the difference between acute and delayed cardiac tamponade?
A.5. What is regional cardiac tamponade?
A.6. Describe the ventricular interaction in cardiac tamponade.
A.7. How is coronary blood flow affected in cardiac tamponade?
A.8. What is the Beck triad? Describe the typical signs and symptoms of cardiac tamponade.
A.9. Define pulsus paradoxus and describe its pathophysiology.
A.10. What is Kussmaul sign? Is this finding consistent with tamponade physiology?
A.11. Which medical conditions mimic cardiac tamponade?
B. Preoperative Evaluation and Preparation
B.1. Interpret and explain the pathophysiologic basis for this patient's hemodynamic findings.
B.2. How would you optimize this patient's cardiovascular status prior to definitive diagnosis and treatment?
B.3. What are the radiographic findings in tamponade?
B.4. A limited bedside transthoracic echocardiogram is performed, demonstrating a layer of clotted blood anterior to the right atrium (RA) and ventricle. What echocardiographic findings support the diagnosis of tamponade?
B.5. What additional information should be obtained from a limited echocardiographic study?
B.6. Describe the procedures for treating cardiac tamponade. What are the clinical indications for each approach?
B.7. Having made the diagnosis of tamponade, what additional investigations are required prior to surgery?
B.8. Explain the technical and physiologic principles behind rotational thromboelastometry.
B.9. A rotational thromboelastometry was performed, and a 10-minute analysis reveals the following results (see Fig. 12.9 and Table 12.8). How do you interpret this information?
B.10. Given the ROTEM® findings and high clinical suspicion for occult postsurgical bleeding, what hemostatic products would you arrange to have in the operating room?
B.11. How would you organize and conduct the transport of this patient to the operating room?
C. Intraoperative Management
C.1. What are the cardiovascular effects of commonly used intravenous anesthetic and coinduction agents?
Propofol
Etomidate
Ketamine
Thiopental
Fentanyl
Midazolam
C.2. What is the effect of supine positioning and positive pressure ventilation on the hemodynamics of a patient with tamponade?
C.3. Describe the induction process for cardiac tamponade.
C.4. Following induction and intubation, the systemic blood pressure decreases to 55/30 mmHg. Describe your management.
C.5. What hemodynamic changes are frequently associated with opening the pericardial space?
C.6. Following the removal of approximately 500 mL of dark blood and clots from the mediastinum, the patient's CO remains low. What are your differential diagnoses?
C.7. What is pericardial decompression syndrome (PDS)?
D. Postoperative Management
D.1. A pericardial drain is placed following mediastinal decompression. How should this drainage tube be managed?
D.2. How would you manage hypertension in the intensive care unit?
13 Heart Transplantation and Subsequent Noncardiac Surgery
A. Medical Disease and Differential Diagnosis
A.1. What are the common diagnoses requiring adult heart transplantation?
A.2. What are the indications and relative contraindications for recipient selection?
A.3. What are the criteria for donor heart selection?
A.4. What is the role of donation after cardiac death (DCD) for heart transplantation?
A.5. What are the principles of perioperative donor management?
A.6. What are the risk factors associated with posttransplant mortality?
A.7. What is the difference between the biatrial and bicaval surgical techniques of heart transplant?
A.8. When is a combined heart/lung transplant indicated? What are the important differences?
A.9. What are the medical and surgical alternatives to cardiac transplantation?
A.10. What is the role of ventricular assist devices (VADs) in this type of patient?
A.11. What are the considerations in anesthetizing patients for LVAD insertion?
B. Preoperative Management
B.1. How would you assess this patient preoperatively?
B.2. How would you premedicate this patient? Why?
C. Intraoperative Management
C.1. What anesthetic equipment and monitors would you set up? Why?
C.2. What is the role of transesophageal echocardiography (TEE)?
C.3. Describe the induction and maintenance of anesthesia.
C.4. How would you manage this patient during cardiopulmonary bypass (CPB)?
D. Postoperative Management
D.1. What are the early postoperative complications?
D.2. What are the mechanisms of early right ventricular (RV) failure?
D.3. How would you treat RV failure following heart transplantation?
D.4. How does inhaled nitric oxide (NO) work as a selective pulmonary vasodilator?
D.5. What is the pathophysiology of the denervated heart?
D.6. What are the common cardiac dysrhythmias following heart transplant?
D.7. What are the causes of posttransplant bleeding?
D.8. How would you treat posttransplant bleeding?
D.9. What are the causes of early graft failure?
D.10. How would you manage this patient in the intensive care unit?
E. Subsequent Noncardiac Surgery
E.1. How would you monitor this patient?
E.2. What type of anesthetic is best for the heart-transplanted patient?
E.3. What anesthetic technique would you choose for this patient?
E.4. Do you need to use a muscarinic antagonist with cholinesterase inhibitors to reverse the muscle relaxant in heart-transplanted patients?
E.5. What are the anesthetic implications for heart-transplanted patients?
E.6. What is the significant implication of the denervated heart?
E.7. What is the significance of allograft rejection?
E.8. What is the significance of infection in these patients?
E.9. What are the significant implications of drug interactions?
E.10. What is cardiac allograft vasculopathy (CAV)? Why is this important?
E.11. What is the significant implication of posttransplant hypertension?
E.12. What is the significant implication of renal dysfunction?
E.13. What types of malignancy are found in recipients?
E.14. Is ambulatory surgery appropriate for heart transplant recipients?
14 Ischemic Heart Disease and Noncardiac Surgery
A. Medical Disease and Differential Diagnosis
A.1. What are the preoperative predictors for major adverse cardiac events (MACE) perioperatively?
A.2. What are the determinants of myocardial oxygen demand? How are they measured clinically?
A.3. What factors determine myocardial oxygen supply?
A.4. What is the mechanism of perioperative myocardial ischemia and MI?
A.5. What is the incidence of perioperative reinfarction for noncardiac surgery?
A.6. State the perioperative medical therapy you would employ to reduce the incidence of myocardial ischemia.
ß-Adrenergic Antagonists (Esmolol, Atenolol, Metoprolol, Bisoprolol)
a 2 -Adrenergic Agonist (Clonidine)
Nitrovasodilators (Nitroglycerin, Isosorbide Dinitrate)
Calcium Channel Blockers (Verapamil, Diltiazem, Nifedipine, Nicardipine)
Aspirin
Statins
A.7. Based on his MI, would you recommend that the surgery be postponed for a certain period of time? If so, why?
A.8. Would you recommend that this elective colectomy be postponed if the patient underwent placement of a right coronary artery, second-generation DES, and is taking aspirin and clopidogrel (Plavix)?
B. Preoperative Evaluation and Preparation
B.1. How would you evaluate the patient's cardiac condition? What laboratory tests would you like to order?
B.2. Would you recommend further cardiac testing or coronary revascularization before surgery?
B.3. How would you classify the cardiac risk according to the type of surgery?
B.4. What is the role of exercise or pharmacologic stress test for this patient?
B.5. Would you discontinue any medication before surgery?
B.6. How would you premedicate this patient?
B.7. Is there a role for a 2 -agonist in premedication?
C. Intraoperative Management
C.1. What are the intraoperative predictors for perioperative MACE?
Intraoperative Predictors
C.2. How would you monitor the patient in the operating room?
C.3. What electrocardiogram (ECG) leads would you monitor? Why lead V 5 ?
C.4. Would you use a pulmonary artery catheter (PAC)?
C.5. Would you use transesophageal echocardiography (TEE) as a monitor?
C.6. Is regional anesthesia better than general anesthesia for patients with cardiac disease?
C.7. How will you induce general anesthesia?
C.8. Would you induce anesthesia with etomidate? Why?
C.9. What is the best choice of anesthetic agents for maintenance of anesthesia? Why?
C.10. You notice a new 3-mm ST-segment depression in lead V 5 . How would you treat it?
C.11. Would you give prophylactic intravenous NTG to prevent myocardial ischemia?
C.12. What is the significance of tight control of the heart rate intraoperatively?
C.13. When would you extubate the trachea in this patient? What could you do to prevent hypertension and tachycardia during extubation and emergence?
D. Postoperative Management
D.1. What are the postoperative predictors of perioperative MACE?
D.2. How would you control postoperative pain?
D.3. Is postoperative anemia associated with adverse cardiac outcome?
D.4. Is postoperative hypothermia associated with postoperative myocardial ischemia?
D.5. How would you make a diagnosis of perioperative MI (PMI)?
D.6. How would you manage the patient with a suspected PMI?
SECTION 3 The Gastrointestinal System
15 Intestinal Obstruction and Enhanced Recovery after Surgery
A. Medical Disease and Differential Diagnosis
A.1. What is the differential diagnosis of the acute abdomen?
A.2. What are the causes of intestinal obstruction of the small bowel and of the large bowel?
A.3. Differentiate between simple and strangulated bowel obstruction.
A.4. Is it important to differentiate whether the bowel obstruction is located in the small bowel or large bowel? Why? How might the distinction be made?
A.5. What are the causes and effects of bowel distention?
A.6. Describe the fluid shifts during small bowel intestinal obstruction.
A.7. Discuss the systemic derangements that occur with intestinal obstruction.
A.8. What is an ileus? Discuss its causes and pathophysiology.
B. Preoperative Evaluation and Preparation
B.1. What is Enhanced Recovery after Surgery (ERAS)? What are the core tenants of these programs?
B.2. Can ERAS be used in this case?
B.3. What components of ERAS are applied in the preoperative phase of the care of colorectal surgery (CRS) patients?
B.4. Is it important to decompress the abdomen before induction of anesthesia? Why?
B.5. Describe the respiratory implications.
B.6. What are the implications of the tense abdominal wall?
B.7. Outline the methods of abdominal decompression.
B.8. Discuss the goals of fluid management.
B.9. What would you use as a guide to fluid volume replacement?
C. Intraoperative Management
C.1. What dangers are present during induction? How are they planned for?
C.2. Does the administration of antacids and/or histamine-2 (H 2 ) blockers before the induction of anesthesia have a significant value in patients with small bowel obstruction?
C.3. In what position would you intubate this patient?
C.4. What is the best muscle relaxant to use for the rapid sequence induction?
C.5. Would you remove or leave the nasogastric tube (NGT) in place before inducing anesthesia?
C.6. Would you use nitrous oxide in this patient?
C.7. Are there any benefits to using a high concentration of inspired oxygen (FIO 2 )?
C.8. What components of ERAS are applied in the intraoperative phase of the care of CRS patients?
C.9. What are the strengths, weaknesses, benefits, and challenges of ERAS?
Strengths
Weakness
Benefits
Challenges
C.10. What are the indications for ERAS?
D. Postoperative Management
D.1. What are the principles of postoperative care in this patient?
D.2. Are there any postoperative respiratory problems associated with factors other than aspiration?
D.3. If the patient did aspirate gastric contents, what are the possible sequelae of this event? What is the treatment?
D.4. What is gram-negative sepsis? Describe the clinical picture and treatment.
D.5. What components of ERAS are applied in the postoperative phase of the care of CRS patients?
16 Liver Transplantation
A. Medical Disease and Differential Diagnosis
A.1. What are the potential graft options for liver transplantation?
A.2. What are the indications and contraindications for liver transplantation?
A.3. What is acute liver failure (ALF)?
A.4. What is the MELD score, and how is it used in liver transplantation evaluation?
A.5. What is portal hypertension? What are the sequelae of portal hypertension?
A.6. Describe the cardiovascular system of patients with end-stage liver disease (ESLD).
A.7. What causes acute kidney injury (AKI) in patients with cirrhosis?
A.8. What causes hyponatremia in patients with cirrhosis?
A.9. Discuss the neurologic manifestations of acute and chronic liver disease.
A.10. Why do patients with ESLD have abnormalities of hemostasis?
A.11. What is the differential diagnosis for hypoxemia in patients with cirrhosis?
A.12. What are the risk factors and treatment guidelines for spontaneous bacterial peritonitis (SBP)?
B. Preoperative Evaluation and Preparation
B.1. What preoperative workup is desirable?
B.2. How is ascites managed preoperatively?
B.3. How is hyponatremia managed preoperatively?
B.4. What is a transjugular intrahepatic portosystemic shunt (TIPS) procedure? What is the role of TIPS in the management of patients with ESLD?
B.5. How are hepatic encephalopathy and elevated intracranial pressure (ICP) treated?
B.6. Should this patient be transfused with fresh frozen plasma prior to surgery?
C. Intraoperative Management
C.1. What monitors would you use? Why?
C.2. What are the considerations for the induction of anesthesia?
C.3. How does liver disease affect intraoperative medication management?
C.4. What happens during the first stage (preanhepatic phase) of the liver transplant operation?
C.5. What happens during the second stage (anhepatic phase) of the liver transplant operation?
C.6. What physiologic disturbances should be anticipated during the second stage (anhepatic phase) of the liver transplant operation?
C.7. What is venovenous bypass? What are the potential advantages and disadvantages of this procedure?
C.8. What surgical techniques anastomose the donor and recipient inferior vena cava (IVC)?
C.9. What are the potential advantages of the "piggyback" (vena cava preservation) technique?
C.10. What hemodynamic changes are expected after removal of vascular clamps? What is postreperfusion syndrome (PRS)?
C.11. How would you treat hyperkalemia?
C.12. Why should you anticipate hypocalcemia?
C.13. What happens during the third stage of the liver transplant operation?
C.14. What causes intraoperative bleeding during each phase of liver transplantation? How is coagulopathy monitored and treated? What are thromboelastography (TEG) and rotational thromboelastography (ROTEM)?
C.15. What are the complications of massive transfusion?
C.16. How are the complications of massive transfusion prevented?
C.17. How is hyperfibrinolysis managed?
C.18. When is intraoperative renal replacement therapy indicated?
C.19. What intraoperative signs suggest that the hepatic graft is working?
D. Postoperative Management
D.1. What are the goals of immediate postoperative care of the liver transplant patient?
D.2. What postoperative findings suggest that the hepatic graft is functioning?
D.3. What coagulation disturbances should be anticipated in the postoperative period?
D.4. Can renal function change after liver transplantation?
D.5. What vascular and biliary complications occur after liver transplantation?
D.6. What immunosuppressive agents will be given after liver transplantation? What are the major side effects?
Acknowledgment
SECTION 4 The Nervous System
17 Brain Tumor and Craniotomy
A. Medical Disease and Differential Diagnosis
A.1. What is the pathology of intracranial tumors?
A.2. What is intracranial pressure (ICP), and what are its determinants?
A.3. How does the presence of a mass alter the ICP in this patient, and what are the clinical manifestations of these alterations?
A.4. What is cerebral blood flow (CBF), and what are its determinants?
A.5. What are the cerebral steal syndromes?
A.6. Are there any issues specific to posterior cranial fossa pathology?
A.7. What is the role of preoperative embolization therapy?
B. Preoperative Evaluation and Preparation
B.1. What are the special considerations in preoperative evaluation of the patient scheduled for posterior fossa craniotomy?
B.2. In a patient who presents with intracranial hypertension, what management might have already been initiated preoperatively, and what are the implications for anesthetic management?
B.3. What are the types of intraoperative neurophysiologic monitoring (IOM) that would likely be used for this procedure, and how will they affect the anesthetic management plan?
B.4. What are the options for patient positioning during posterior fossa surgery?
B.5. What are the principal disadvantages associated with the common posterior fossa craniotomy positions?
B.6. How does the sitting position affect your preoperative assessment and planning?
B.7. How should the patient position ultimately be determined?
B.8. Should this patient receive premedication?
C. Intraoperative Management
C.1. What are the anesthetic goals for craniotomy?
C.2. What monitors should be used during craniotomy?
C.3. Would you monitor for venous air embolism (VAE)? What are the monitoring options?
C.4. What specific risks are associated with induction of anesthesia?
C.5. How would you induce anesthesia?
C.6. What are the effects of anesthetics on cerebral metabolic rate of oxygen (CMRO 2 ), CBF, and ICP? With this in mind, how would you maintain anesthesia?
Volatile Anesthetics
Nitrous Oxide
Intravenous Anesthetics
Opioids
C.7. How would you manage ventilation and maintain arterial carbon dioxide (CO 2 )?
C.8. How would you approach diuretic therapy?
C.9. How would you manage serum glucose?
C.10. How would you approach fluid management?
C.11. Once the bone plate is removed and the dura retracted, the surgeon reports that the brain is still "tight." What would be your response?
C.12. If deliberate hypotension is indicated, how will you achieve it?
C.13. While the surgeon is resecting tumor from near the brainstem, the patient's heart rate suddenly drops to 20 beats per minute. What is your assessment and management?
C.14. Are there any measures you can take to prevent VAE?
C.15. During the procedure, the precordial Doppler becomes loud and turbulent. The end-tidal CO 2 (EtCO 2 ) drops from 31 to 13 mmHg, and the systemic pressure from 121/63 to 64/32 mmHg. What is your assessment and management plan?
C.16. What is your approach to emergence? What if the patient does not regain consciousness?
D. Postoperative Management
D.1. What postoperative complications are of greatest concern? What level of monitoring is required?
D.2. What is your approach to postoperative pain control?
D.3. In the ICU, the patient's neurologic status deteriorates and ICP monitoring is instituted. What are the different methods of monitoring ICP, and what are their limitations?
18 Carotid Artery Disease
A. Medical Disease and Differential Diagnosis
A.1. What are the presenting symptoms of carotid stenosis?
A.2. What is the prevalence of carotid artery disease?
A.3. What is the natural course of carotid artery disease as it relates to stroke?
A.4. What in the patient's history puts them at higher risk for having carotid atherosclerosis?
A.5. Do we screen patients for asymptomatic carotid stenosis?
A.6. What is the risk of stroke and cardiovascular events in asymptomatic carotid atherosclerosis?
A.7. What are the current medical options that the patient has for treating carotid atherosclerosis?
A.8. What are the indications for CEA and carotid artery stenting (CAS) in asymptomatic carotid atherosclerotic disease?
A.9. What are the indications for performing a CEA in symptomatic carotid stenosis?
A.10. Is there any role for CAS in symptomatic patients?
A.11. Discuss the anatomy of the cerebral vasculature, including the carotid artery and the circle of Willis.
A.12. Discuss cerebral blood flow (CBF) in the presence of carotid artery disease.
A.13. Discuss the different surgical approaches to carotid revascularization.
A.14. Discuss the endovascular approaches to carotid stenting.
A.15. What is normal CBF?
A.16. What is critically low CBF as measured by the electroencephalogram (EEG)?
A.17. What is cerebral autoregulation?
A.18. How does PaCO 2 affect CBF?
A.19. What are the principal determinants of CBF?
A.20. What is meant by the term luxury perfusion?
A.21. What is meant by the term intracerebral steal?
B. Preoperative Evaluation and Preparation
B.1. What will you look for in your preoperative evaluation of this patient?
B.2. Is this patient's blood pressure too high for elective surgery?
B.3. What laboratory data are required preoperatively?
B.4. Will you treat this patients' blood glucose?
B.5. Will you premedicate this patient?
C. Intraoperative Management
C.1. How will you monitor this patient?
C.2. How will you know that the patient's cerebral perfusion is adequate during surgery?
C.3. Discuss the differences and relative advantages and disadvantages of unprocessed EEG and processed EEG monitoring.
C.4. How will you measure CBF intraoperatively? What are the relative advantages and disadvantages of each technique?
C.5. Describe the use of stump pressure and its limitations.
C.6. Describe the use of transcranial Doppler (TCD) and its limitations.
C.7. Describe the use of jugular venous oxygen saturation (SjvO 2 ) and its limitations.
C.8. Describe the use of cerebral oximetry and its limitations.
C.9. Discuss somatosensory evoked potentials (SSEPs) as a monitor of CBF during CEA.
C.10. What type of anesthesia will you choose for this patient if she chose to have an endarterectomy?
C.11. What type of anesthesia will you choose for this patient if she chose to have a carotid stent?
C.12. How will you induce and maintain general anesthesia in this patient for CEA?
C.13. How would you proceed if the patient were to receive regional anesthesia?
C.14. Discuss the effects of anesthetics on CBF.
C.15. Discuss the protective effects of anesthetic agents on cerebral function.
C.16. How will you manage this patient's ventilation under general anesthesia?
C.17. How will you manage this patient's blood pressure intraoperatively?
C.18. Discuss reperfusion injury following CEA and CAS.
C.19. What intravenous fluids will you give this patient intraoperatively?
D. Postoperative Management
D.1. The patient does not "wake up" from general anesthesia. Why?
D.2. Postoperatively, the patient's blood pressure is 170/96 mmHg. Will you treat this?
D.3. What immediate postoperative complications might you expect after a CEA?
D.4. What postoperative complications might you expect after a CAS?
D.5. Discuss postoperative neurocognitive dysfunction following uncomplicated carotid intervention.
19 Awake Craniotomy for Mapping and Surgery in the Eloquent Cortex
A. Medical Disease and Differential Diagnosis
A.1. What is the eloquent cortex?
A.2. What is the underlying pathology?
A.3. What determines intracranial pressure (ICP)?
A.4. How does a space-occupying mass alter ICP?
A.5. What is autoregulation, and why is it important?
A.6. How is cerebral blood flow (CBF) regulated?
A.7. What drug therapies may be associated with this pathology?
B. Preoperative Evaluation and Preparation
B.1. Why is the craniotomy performed awake?
B.2. What neurologic symptoms of the patient are important?
B.3. What is the status of their other comorbid conditions?
B.4. Are there anesthetic implications from current treatment drugs?
B.5. What laboratory data are required?
B.6. What radiology data should be reviewed?
B.7. How do you prepare the patient for an awake craniotomy?
B.8. Should this patient receive premedications?
B.9. What precautions should be made for airway management?
C. Intraoperative Management
C.1. How should this patient be monitored?
C.2. Does this patient require invasive monitoring?
C.3. Can current drug therapy alter eloquent cortex mapping?
C.4. Why use hypertonic fluids during a craniotomy?
C.5. What intravenous fluids (IVFs) are recommended?
C.6. Would a lumbar drain for cerebrospinal fluid (CSF) removal benefit this patient?
C.7. Venous air embolism (VAE): Is it a concern in this case?
C.8. How is the eloquent cortex mapped?
C.9. How are intraoperative seizures treated?
C.10. How will you conduct this anesthetic?
D. Postoperative Management
D.1. What are the major concerns following craniotomy?
Acknowledgments
20 Head Injury
A. Pathophysiology and Differential Diagnosis
A.1. What types of intracranial injuries are most likely to have occurred in this patient?
A.2. What is the difference between primary and secondary injury? What factors contribute to secondary injury?
A.3. What are the benefits and risks of administering mannitol?
Benefits
Risks
A.4. What is the effect of hyperglycemia on neurologic outcome following head trauma?
A.5. What alterations in sodium and potassium balance can occur in patients with head injury?
A.6. In addition to sodium and potassium, what other electrolyte abnormalities can be present after head trauma?
A.7. What are the neuroprotective effects of administering magnesium (Mg)?
A.8. What role do gender and female sex hormones have in the pathophysiology of traumatic brain injury (TBI)?
A.9. What is the role of decompressive craniectomy (DC) as a treatment option for ICP control after head injury?
A.10. Do genetic factors play a role in the outcome after head injury?
B. Preoperative Evaluation and Preparation
B.1. What is the GCS? What is the significance of a GCS of 7T in this patient?
B.2. In addition to the GCS, what other assessments can be done to evaluate neurologic function?
B.3. What is the role of CT scanning in the initial evaluation of the patient with head injury? What are the management options in patients whose neurologic condition is deteriorating before obtaining a CT scan?
B.4. What is the role of ICP monitoring in the management of head injury?
B.5. How can you clear this patient's cervical spine?
B.6. What are the advantages of early endotracheal intubation in this patient?
B.7. What is your plan for airway management in this patient? How would it change if the patient were combative? How would it change if the patient had facial fractures with significant swelling of the head and neck?
B.8. What are the effects of succinylcholine on ICP? What is the significance of the effect, if any?
B.9. What coagulation abnormalities are present after TBI? What modalities can be used to provide hemostasis and reduce intracranial hematoma expansion?
C. Intraoperative Management
C.1. What is appropriate hemodynamic monitoring during CT scanning and during craniotomy for evacuation of a subdural hematoma?
C.2. Should hyperventilation be used in this patient?
C.3. What are the implications of arterial hypertension in patients with head injury? How should BP be managed?
C.4. What should be done about intravenous (IV) fluid replacement? Should corticosteroids be given empirically?
C.5. Should hypertonic saline (HTS) be administered to this patient? How is HTS administered?
C.6. The patient underwent a craniectomy for evacuation of a frontal intracerebral hematoma. Should some anesthetic agents be avoided in this situation? Which ones? What agents might be preferred in this situation?
C.7. Should hypothermia be employed in this patient?
D. Postoperative Neurointensive Care Management
D.1. What are the postoperative ventilation concerns in this patient?
D.2. What specific measure should be used to control the patient's ICP? What type of monitoring devices can be used to measure ICP?
D.3. What is neurogenic pulmonary edema? Would you avoid positive end-expiratory pressure (PEEP) in a patient with increased ICP?
D.4. What is the role of antiseizure prophylaxis in the perioperative management of head trauma?
D.5. How can cerebral oxygenation monitoring be used in the clinical management of TBI?
D.6. What methods can be used in the neurointensive care unit to prevent hyperthermia?
21 Cerebral Aneurysm
A. Medical Disease and Differential Diagnosis
A.1. What are the incidence, prevalence, and causes of subarachnoid hemorrhage (SAH), and what are the risk factors associated with rupture of intracranial aneurysms?
A.2. What are common sizes and locations of intracranial aneurysms?
A.3. What is the pathophysiology of aneurysmal rupture and SAH?
A.4. What are symptoms and signs of SAH?
A.5. How does one assess the severity of SAH?
A.6. What are the cardiovascular effects of SAH?
A.7. How is the diagnosis of SAH made?
A.8. What is the risk for rebleeding for a patient with SAH?
B. Preoperative Evaluation and Preparation
B.1. What are some concerns in going to the interventional neuroradiology suite in the midst of an angiogram to be followed immediately with coiling of an aneurysm?
B.2. What type of anesthesia is required for coiling of an aneurysm?
B.3. Should one proceed with induction of general anesthesia under these circumstances?
B.4. What types of emergencies can occur during coiling of an aneurysm, and how should they be managed?
B.5. What other modalities of endovascular therapy are available?
B.6. A craniotomy is planned for the following day to clip the middle cerebral artery aneurysm. Should surgery be postponed because of the patient's elevated troponin and CPK-MB fractions?
B.7. Would you premedicate this patient before craniotomy?
C. Intraoperative Management
C.1. What are the goals of the induction and maintenance of anesthesia for this patient?
C.2. Is placement of an arterial catheter necessary for induction of anesthesia in this patient in the interventional neuroradiology suite?
C.3. How would you assess fluid status in this patient?
C.4. Would monitoring central venous pressure (CVP) be useful for craniotomy and aneurysm clipping in this patient?
C.5. What other forms of monitoring would you consider?
C.6. What are your specific concerns during induction of anesthesia in this patient?
C.7. How would you accomplish a smooth and safe induction and intubation in this patient?
C.8. Would you perform a rapid sequence induction and tracheal intubation for this patient?
C.9. What are the effects of hypoxemia and hypercapnia, such as would be seen with loss of the airway on induction, on cerebral blood flow (CBF)?
C.10. What is optimal fluid management for aneurysm clipping? Would you use a dextrose-containing solution?
C.11. After the bone plate was removed and as the dura was being opened, the surgeon complained that the brain was "tight." What could you do to achieve better brain relaxation and facilitate surgical exposure?
C.12. How might transmural pressure be decreased to allow for aneurysm clip placement?
C.13. What is the purpose of controlled hypotension, and how is it achieved?
C.14. What are some of the drawbacks of controlled hypotension?
C.15. What methods of cerebral protection might you use during this operation?
C.16. Would you induce mild hypothermia as a means of cerebral protection?
C.17. What are the indications for deep hypothermic circulatory arrest?
C.18. What steps should be taken in the case of intraoperative rupture of an intracranial aneurysm?
C.19. How would you plan the emergence from an anesthetic for aneurysm clipping?
D. Postoperative Management
D.1. Would you extubate the patient postoperatively?
D.2. What would be the differential diagnosis if the patient did not return to her preoperative neurologic condition?
D.3. On postoperative day 2, the patient became disoriented and developed hemiplegia. A CT scan was obtained, which shows no new intracranial bleeding. What other diagnostic studies should be performed?
D.4. What is cerebral vasospasm, and what causes it?
D.5. What are pathophysiologic changes seen in cerebral vasospasm?
D.6. How is the diagnosis of cerebral vasospasm made?
D.7. What steps can be taken to prevent cerebral vasospasm?
D.8. What treatments can be undertaken once a diagnosis of cerebral vasospasm is made?
D.9. What are other neurologic complications following SAH and aneurysm clipping?
D.10. What other organ systems may manifest problems postoperatively in aneurysm clipping patients?
SECTION 5 The Endocrine System
22 Pheochromocytoma
A. Medical Disease and Differential Diagnosis
A.1. What are some common differential diagnoses for arterial hypertension?
A.2. What is a pheochromocytoma?
A.3. Describe the anatomy of the adrenal gland.
A.4. What substances does the adrenal medulla secrete?
A.5. What are the mechanisms of action of epinephrine and norepinephrine?
A.6. What is the pathway for synthesis and breakdown of catecholamines?
A.7. What does the adrenal cortex secrete?
A.8. What are the metabolic actions of the glucocorticoids and the mineralocorticoids?
A.9. What are the clinical features associated with a pheochromocytoma?
A.10. What is the prevalence of pheochromocytomas and paragangliomas?
B. Preoperative Evaluation and Preparation
B.1. How can you diagnose and localize the tumor preoperatively?
B.2. How do you pharmacologically prepare the patient with a pheochromocytoma for surgery?
B.3. What other aspects of preoperative management are important?
C. Intraoperative Management
C.1. What drugs should be avoided during the operation?
C.2. How would you monitor this patient?
C.3. Describe the anesthetic management of the patient with pheochromocytoma.
C.4. What drugs are used to control the effects of catecholamine stimulation during surgery?
C.5. What are some management concerns after the tumor is removed?
C.6. What are some of the concerns with laparoscopic adrenalectomy?
D. Postoperative Management
D.1. What is the significance of postoperative hypotension? How is it treated?
D.2. What other problems can arise in the postoperative period?
23 Diabetes Mellitus
A. Medical Disease and Differential Diagnosis
A.1. What is the epidemiology of DM in the general population?
A.2. What are the factors in the etiology of the disease?
A.3. How is DM classified?
A.4. What are the complications of DM?
A.5. How are the different forms of this illness treated?
A.6. How is control of the disease adequately monitored?
A.7. What are some of the factors that alter insulin requirements?
A.8. What are the principles of management of diabetic ketoacidosis (DKA)?
A.9. What is a hyperglycemic hyperosmolar state?
B. Preoperative Evaluation and Preparation
B.1. How should this patient be evaluated?
B.2. How would the stiff joint syndrome affect her airway management?
B.3. What are the signs and implications of autonomic neuropathy in the diabetic patient?
B.4. How should this patient be prepared for anesthesia and surgery?
B.5. For elective surgery, how are insulin and glucose requirements managed on the day of surgery?
B.6. How should this patient be premedicated?
C. Intraoperative Management
C.1. What are the effects of anesthesia and surgery on insulin and glucose metabolism?
C.2. What anesthetic techniques should be considered?
C.3. How should this patient be monitored?
C.4. How is hyperglycemia treated intraoperatively?
C.5. How is hypoglycemic shock recognized and treated intraoperatively?
D. Postoperative Management
D.1. How is diabetes controlled in this patient postoperatively?
D.2. Does diabetes increase perioperative risk?
D.3. What are the common postoperative complications to be expected in a diabetic patient?
D.4. Is it necessary to achieve tight perioperative control of glucose?
SECTION 6 The Genitourinary System
24 Transurethral Resection of the Prostate and Geriatric Anesthesia
A. Medical Disease and Differential Diagnosis
A.1. What comorbidities are common in patients undergoing TURP?
A.2. What are the normal physiologic consequences of aging for the various organ systems?
A.3. How should drug dosages be adjusted for elderly patients? Should any particular medications be avoided?
A.4. Does a history of prior MI increase the patient's risk of perioperative reinfarction or stent thrombosis?
A.5. In patients with a history of recent MI, would you recommend that the surgery be postponed for a certain period?
B. Preoperative Evaluation and Preparation
B.1. How would you evaluate the patient's cardiac condition? Does he need additional testing?
B.2. Would you discontinue any antihypertensives or any medications for angina?
B.3. For a patient with a cardiac implantable electronic device (CIED), what information should you know? What precautions should be taken?
B.4. What types of coronary stents are available? What is their perioperative relevance?
B.5. What is the conventional recommendation for dual antiplatelet therapy (DAPT) in a patient with previous percutaneous coronary intervention (PCI) undergoing elective noncardiac surgery?
B.6. What risk is associated with continuing perioperative antiplatelet therapy? What risk is there with stopping it?
B.7. How should patients with coronary stents undergoing noncardiac surgery be managed?
C. Intraoperative Management
C.1. What monitors would you use for this patient?
C.2. Is there a preferred anesthetic technique for patients undergoing TURP, and why?
C.3. Does regional anesthesia result in a lower incidence of perioperative mortality than general anesthesia?
C.4. What intravenous fluid would you use during TURP?
C.5. Forty minutes after a sensory level of T10 was established with intrathecal anesthesia, and monopolar TURP (M-TURP) resection was initiated with the use of glycine as the bladder irrigating solution, the patient becomes agitated and complains of nausea. Further sedation along with an antiemetic is administered. However, shortly thereafter, the patient becomes very restless, blood pressure rises, and heart rate decreases. The patient becomes cyanotic and obtunded, blood pressure precipitousl
C.6. What are the important characteristics of irrigation solutions used during TURP?
C.7. What is the effect on body temperature of continuous bladder irrigation during TURP?
C.8. What is the definition of TURP syndrome? What are the signs and symptoms of the syndrome?
Cardiopulmonary
Hematologic and Renal
Central Nervous System
C.9. How does the patient absorb irrigation solution during TURP?
C.10. What factors increase the incidence of TURP syndrome?
C.11. What is the effect on cardiopulmonary, renal, and central nervous system (CNS) functions of excessive absorption of irrigation solution during TURP?
C.12. What causes CNS dysfunction in patients who have undergone M-TURP?
C.13. How does acute hyponatremia affect the cardiovascular system?
C.14. What prophylactic measures may reduce the incidence of TURP syndrome?
C.15. What therapeutic measures are recommended for patients with TURP syndrome?
C.16. Is hypertonic saline administration necessary to correct hyponatremia? Explain. What are the risks of rapidly correcting hyponatremia?
C.17. What are the toxic effects of glycine? Is there an antidote to glycine toxicity? What are the metabolic by-products of glycine?
C.18. What are the symptoms and clinical course of TURP-induced hyperammonemia?
C.19. What are the clinical characteristics, causes, and prognosis of TURP-related blindness?
C.20. What are the causes of excessive bleeding during TURP?
C.21. What are the causes, signs, symptoms, and treatment of bladder perforation during TURP?
C.22. What are the causes of hypotension during TURP?
D. Postoperative Management
D.1. What is the source of postoperative bacteremia in patients who have undergone TURP? What factors increase the incidence of bacteremia?
D.2. What are the signs of post-TURP septicemia? What preventive measures are generally recommended?
D.3. Is postoperative hypothermia a risk factor for myocardial ischemia?
D.4. What is postoperative cognitive dysfunction (POCD)? How does this differ from delirium, and what is the time course to resolution?
D.5. What are the mechanisms and risk factors for POCD? How would you mitigate the risk of POCD? Does anesthesia type influence development of POCD?
E. Comparing M-TURP, B-TURP, and L-TURP
E.1. What differentiates M-TURP from B-TURP?
E.2. Are decreased morbidity and mortality associated more closely with M-TURP or with B-TURP?
E.3. What differentiates the technologies for L-TURP?
25 Kidney Transplant
A. Medical Disease and Differential Diagnosis
A.1. What are the causes of chronic renal disease that can progress to renal failure?
A.2. How is chronic kidney disease (CKD) diagnosed?
A.3. What are the indications for dialysis?
A.4. What are the common clinical manifestations of ESRD?
A.5. What electrolyte imbalances occur in patients with impaired renal function, and how are they treated?
A.6. How is metabolic acidosis managed in chronic renal failure?
A.7. Are patients with renal disease at increased risk of cardiovascular disease?
A.8. When is the best time to receive a kidney transplant?
A.9. How are immunosuppressive drugs managed in kidney transplant recipients?
A.10. How are kidneys allocated to recipients on the waiting list in the United States?
A.11. What is donation after cardiac death (DCD)?
A.12. What is a living donor transplant program?
A.13. What is a paired donor exchange transplant program?
A.14. What are some barriers to receiving a kidney transplant?
A.15. What surgical techniques are available for donor nephrectomy (DN)?
A.16. How is a donor kidney preserved?
A.17. Describe the operative procedure of kidney transplantation.
B. Preoperative Evaluation and Preparation
B.1. What preoperative workup would you order for a recipient?
B.2. How does the presence of obesity affect the outcome of a transplanted kidney?
B.3. How are routine medications and immunosuppressive medications managed in the perioperative period?
C. Intraoperative Management
C.1. Are a central venous pressure (CVP) monitoring line, an arterial line, and a pulmonary artery catheter required for the transplant procedure?
C.2. What type of intravenous fluid should be used during surgery?
C.3. How would you conduct the anesthesia induction?
C.4. Is succinylcholine contraindicated in renal failure patients?
C.5. How are the nondepolarizing muscle relaxants affected by renal failure?
C.6. How would you maintain anesthesia during the case?
C.7. What are the effects of inhalation anesthetics on renal blood flow (RBF), glomerular filtration (GFR), and urine output?
C.8. What are the potential nephrotoxic effects of inhalation anesthetics? What are the nephrotoxic metabolites of inhalation anesthetics?
C.9. How does renal failure affect the pharmacology of opioids?
D. Postoperative Management
D.1. How is the diagnosis of transplant rejection made?
D.2. What are immunosuppressive agents, and how do they affect anesthetic care?
26 Robotic-Assisted Laparoscopic Surgery
A. Medical Disease and Differential Diagnosis
A.1. What is the incidence of carcinoma of the prostate?
A.2. How is prostate cancer diagnosed?
A.3. How is prostate cancer treated?
A.4. Define laparoscopy.
A.5. Describe the development of robotic-assisted laparoscopy.
A.6. What are the advantages and disadvantages of minimally invasive surgery over open surgery?
A.7. What are the contraindications to laparoscopic or robotic-assisted laparoscopic surgery? Is pregnancy a contraindication to robotic surgery?
A.8. What other specialties commonly perform robotic surgery?
A.9. Why is carbon dioxide (CO 2 ) the gas of choice for robotic laparoscopy? What are its disadvantages?
A.10. How much endogenous CO 2 is produced at basal level and at maximal exercise?
A.11. How much CO 2 is stored in the body? Where is it stored? Of what significance is this to laparoscopy?
A.12. Describe the diffusion and solubility properties of CO 2 and their significance in laparoscopy.
A.13. Is CO 2 soluble in water or plasma? Is it soluble in blood? Why?
B. Preoperative Evaluation and Preparation
B.1. What do you want to know about this patient's history and physical condition that may affect whether or not you clear him for robotic surgery?
B.2. What factors increase this patient's risk of pulmonary complications?
B.3. What laboratory tests should be performed preoperatively?
B.4. What specific information should the patient be given about robotic surgery before obtaining informed consent?
B.5. What additional procedures should be done before surgery?
B.6. What are the three major forces that uniquely alter the patient's physiology during robotic laparoscopy?
C. Intraoperative Management
C.1. What is the anesthetic technique of choice for robotic-assisted laparoscopy? Why?
C.2. Can a laryngeal mask airway (LMA) be used?
C.3. What anesthetic agents or adjuvant drugs are recommended for laparoscopy? Are any anesthetic agents contraindicated?
C.4. Should nitrous oxide (N 2 O) be used during laparoscopy? What are the pros and cons? Does N 2 O cause bowel distention during laparoscopy? Does N 2 O cause nausea and vomiting after laparoscopy?
C.5. Can laparoscopy be performed under local or regional anesthesia?
C.6. What monitors and devices would you apply to the patient? Why?
C.7. How is the patient to be positioned? What special precautions are required for robotic laparoscopy?
C.8. How will you ventilate the patient? What are the respiratory and circulatory effects of the Trendelenburg position during laparoscopy?
Respiratory
Circulatory
C.9. What techniques are available for initial access to the peritoneal cavity? What anesthetic problems can arise during insufflation?
C.10. What intravenous (IV) solution and how much fluid volume do you plan to infuse?
C.11. Under what circumstances should laparoscopy be converted to laparotomy?
C.12. What is the arterial to end-tidal CO 2 gradient (PaCO 2 -EtCO 2 ) in the normal awake patient? What is the cause of the gradient? Does the gradient change during laparoscopy? Why?
C.13. Is an arterial line necessary? Why? Does end-tidal CO 2 tension accurately reflect arterial CO 2 tension? Under what circumstances may the EtCO 2 exceed the PaCO 2 ? Why?
C.14. What are the possible causes of hypercarbia?
C.15. What factors play a role in the unusually rapid and marked elevation of CO 2 that is sometimes seen in laparoscopy?
C.16. How rapidly does the PaCO 2 rise in the apneic patient (endogenous CO 2 )? How rapidly does the PaCO 2 rise if 5% CO 2 gas is inhaled (exogenous)? How rapidly can the CO 2 rise during laparoscopy? What factors explain the differences?
C.17. What is the net effect of pneumoperitoneum, hypercarbia, and steep Trendelenburg on the cardiovascular system?
C.18. What is the net effect of pneumoperitoneum, hypercarbia, and steep Trendelenburg on the respiratory system?
C.19. What is the net effect of pneumoperitoneum, hypercarbia, and steep Trendelenburg on the central nervous system?
C.20. What are the neuroendocrine changes that occur during laparoscopy?
C.21. What is the net effect of pneumoperitoneum, hypercarbia, and steep Trendelenburg on the renal system?
C.22. What is the net effect of pneumoperitoneum, hypercarbia, and steep Trendelenburg on the bowel and gastrointestinal system?
C.23. How would you recognize a CO 2 embolism during laparoscopy? How does this differ from an air embolism? Why should N 2 O be discontinued during suspected embolization? Will N 2 O increase the size of CO 2 emboli?
C.24. What is the mechanism of increase in shunting resulting from embolization?
C.25. How is a gas embolism (CO 2 or air) treated?
C.26. What are the causes of pneumothorax or pneumomediastinum during laparoscopy? How would you diagnose it? How would you treat it?
C.27. How would you decide when to extubate?
D. Postoperative Management
D.1. What are some of the unique complications of laparoscopy?
Injuries from Instruments
Complications of Pneumoperitoneum
Systemic Effects of CO 2 Absorption
Trendelenburg Position
Late Complications
D.2. In the postanesthesia care unit (PACU), our patient complains of numbness and weakness of the lower extremities after 6 hours of anesthesia for robotic prostatectomy. What tests will you order? When would you remove the Foley catheter and arterial line? Under what circumstances would you order a chest x-ray film?
D.3. What is the incidence of postoperative nausea and vomiting?
SECTION 7 The Reproductive System
27 Placenta Previa/Placenta Accreta Spectrum
A. Medical Disease and Differential Diagnosis
A.1. What are the leading causes of maternal mortality, and what role does anesthesia play in this mortality?
A.2. What is the differential diagnosis for an antepartum hemorrhage?
A.3. How would you diagnose the etiology of antepartum bleeding after midpregnancy?
A.4. What is the incidence of placenta previa, and what are the associated conditions?
A.5. What are the different types of placenta previa?
A.6. What is the usual obstetric management for placenta previa?
A.7. What is vasa previa? How is it diagnosed and managed?
A.8. What are the risk factors for the development of a placental abruption?
A.9. How is placental abruption diagnosed and managed?
A.10. What complications are associated with placental abruption?
A.11. Who is at risk for uterine rupture, and how is uterine rupture diagnosed?
A.12. What is the treatment for uterine rupture?
A.13. Is this patient at risk for postpartum bleeding?
A.14. What is the placenta accreta spectrum (PAS)?
A.15. How is the PAS diagnosed?
A.16. How is the PAS managed obstetrically?
A.17. What tests and/or interventions can improve neonatal outcome of a preterm birth?
B. Preoperative Evaluation and Preparation
B.1. How does pregnancy change respiratory function, and what impact does this have on anesthetic care?
B.2. What are the maternal cardiovascular changes of pregnancy?
B.3. What are the maternal gastrointestinal changes of pregnancy?
B.4. What hematologic changes occur during pregnancy?
B.5. What laboratory data do you need before taking this patient to the operating room?
B.6. What preoperative medications would you administer to this patient?
C. Intraoperative Management
C.1. What monitors would you use for this patient?
C.2. What anesthetic could be used in this patient?
C.3. What are the absolute and relative contraindications for neuraxial anesthesia?
C.4. How is postpartum hemorrhage (PPH) defined, and what are the etiologies of this bleeding?
C.5. After delivery of the fetus, the placenta is removed with some difficulty in one small area and generalized oozing from the placental implantation site is noted. What is the most likely cause of this patient's bleeding?
C.6. After delivery of the placenta in a cesarean section, what maneuvers and drugs can enhance myometrial contractility and therefore decrease blood loss?
C.7. When should this patient receive tranexamic acid (TXA)?
C.8. If this patient had ongoing bleeding intraoperatively, what guidelines help determine when red blood cell (RBC) transfusions should be given?
C.9. What laboratory tests should be ordered during the resuscitation of this patient?
C.10. If this patient had a massive blood loss, what blood replacement therapy would be indicated?
C.11. What is the role of recombinant activated factor VII (rFVIIa) in the hemorrhaging obstetric patient?
C.12. What is the role of type O Rh-negative (universal donor) uncrossmatched blood in emergency transfusions, and how does this change your future management?
C.13. What complications can occur from the transfusion of blood products?
C.14. What is the role of autologous transfusion in obstetric patients?
C.15. Significant intraoperative blood loss required the transfusion of 8 units of type-specific, crossmatched packed RBCs (pRBCs). This patient had generalized oozing in the surgical field and hematuria. What is your differential diagnosis?
C.16. What is disseminated intravascular coagulation (DIC)?
C.17. Define amniotic fluid embolism (AFE) syndrome and discuss treatment.
D. Postoperative Management
D.1. If the patient received epidural anesthesia and subsequently developed DIC, when should the epidural catheter be removed?
D.2. You have successfully treated the patient's massive hemorrhage. Her laboratory values have returned to normal. The patient, however, is still hypotensive despite appropriate intravascular volume replacement and support with vasopressors. What is your concern in this case?
28 Hypertensive Disorders of Pregnancy
A. Medical Disease and Differential Diagnosis
A.1. What is the classification of hypertension disorders in pregnancy as defined by the American College of Obstetricians and Gynecologists?
A.2. What is preeclampsia?
A.3. What is preeclampsia with severe features?
A.4. What is eclampsia?
A.5. What is HELLP syndrome?
A.6. What are the risk factors for developing preeclampsia?
A.7. What is the mortality associated with preeclampsia?
A.8. Discuss the pathogenesis of preeclampsia.
Immunologic Factors
Genetic Factors
Endothelial Factors
Platelet Factors
Calcium
Coagulation Factors
Fatty Acid Metabolism
Markers of Angiogenesis
A.9. Discuss the pathologic alterations of preeclampsia.
Cardiovascular Changes
Hemodynamic Changes
Hematologic Changes
Renal Changes
Endocrine Changes
Respiratory Changes
Hepatic Changes
Neurologic Changes
Uteroplacental Perfusion
A.10. What are some of the complications associated with preeclampsia?
B. Preoperative Evaluation and Preparation
B.1. What initial laboratory studies are recommended for patients with preeclampsia?
B.2. Discuss bleeding time and platelet count evaluation during preoperative assessment of a patient with preeclampsia requesting epidural analgesia/anesthesia for labor and delivery.
B.3. What types of monitoring are important for patients with preeclampsia? When is a central venous pressure (CVP) monitor indicated?
B.4. Discuss the obstetric management of preeclampsia with severe features.
B.5. What are the antihypertensive agents of choice for preeclampsia?
B.6. What drug therapy is the treatment of choice for seizure prophylaxis?
B.7. Discuss the mechanism of action of magnesium sulfate.
B.8. What are the fetal effects of magnesium sulfate therapy?
B.9. Discuss the treatment of magnesium sulfate toxicity.
B.10. What conditions mandate immediate delivery, regardless of the gestational age?
B.11. Discuss the management of eclampsia.
C. Intraoperative Management
C.1. What is your choice of labor analgesia for patients with preeclampsia?
C.2. What is the advantage of prehydration prior to initiation of neuraxial analgesia?
C.3. What sensory level of analgesia is required for labor and delivery?
C.4. Discuss the commonly used local anesthetics for labor analgesia.
C.5. Is the addition of epinephrine to local anesthetics advisable in preeclamptic patients?
C.6. What is the treatment for the abnormal fetal heart rate pattern seen with maternal hypotension after neuraxial analgesia is instituted?
C.7. What would you do after an accidental dural puncture? How do you treat postdural puncture headache?
C.8. How would you manage total spinal anesthesia?
C.9. Should methylergonovine be given to preeclamptic patients?
C.10. When and how would you give spinal anesthesia?
C.11. Discuss a general anesthesia technique for the patient with preeclampsia presenting for cesarean delivery.
C.12. What agents can you use to prevent hypertension during the induction of general anesthesia for cesarean delivery?
D. Postoperative Management
D.1. Discuss the postpartum management of preeclamptic patients.
D.2. Can nonsteroidal anti-inflammatory drugs (NSAIDs) be used to treat postpartum pain in preeclamptic patients?
29 Breech Presentation, Fetal Distress, and Mitral Stenosis
A. Medical Disease and Differential Diagnosis
A.1. How are fetal lie, presentation, and position defined and determined?
A.2. What is the approximate frequency of the various lies and presentations at or near term?
A.3. What are the different types of breech presentation, and what is their incidence?
A.4. What is the cause of breech presentation?
A.5. What are the delivery problems associated with breech presentation?
A.6. What is the usual obstetrical management for patients with breech presentation?
A.7. What is the incidence of heart disease in pregnancy and the mortality rate associated with maternal cardiac disease?
A.8. How is peripartum cardiomyopathy defined?
A.9. What classifications help predict an individual pregnant woman's cardiac risk?
A.10. What are the cardiovascular changes of pregnancy?
A.11. What changes normally occur in heart sounds during pregnancy?
A.12. What are the normal electrocardiographic and echocardiographic changes seen during pregnancy?
A.13. What causes rheumatic heart disease?
A.14. What are the physiologic consequences of mitral stenosis?
A.15. What are the auscultatory findings associated with mitral stenosis?
A.16. What may be seen on the electrocardiogram (ECG) in patients with mitral stenosis?
A.17. What are the echocardiographic findings associated with mitral stenosis?
A.18. What is the effect of the physiologic changes of pregnancy on patients with mitral stenosis?
A.19. If mitral stenosis is first recognized during pregnancy and symptoms develop, how would you treat the patient?
A.20. What are the determinants of fetal oxygenation?
A.21. What are the determinants of uterine blood flow?
B. Preoperative Evaluation and Preparation
B.1. How is fetal well-being assessed during labor?
B.2. How are FHR and maternal contractions monitored?
B.3. What is the normal FHR with beat-to-beat variability?
B.4. What are FHR decelerations?
B.5. How accurate is FHR monitoring in predicting fetal well-being?
B.6. In a fetus with minimal FHR variability, what other modalities can be used to assess fetal well-being?
B.7. What is the significance of meconium-stained amniotic fluid?
B.8. What is meconium aspiration syndrome?
B.9. What are the usual noninvasive tests used to evaluate the pregnant cardiac patient?
B.10. What preoperative medications, if any, would you give this patient?
C. Intraoperative Management
C.1. What monitors would you use in this functional New York Heart Association (NYHA) class II patient during her cesarean section?
C.2. When would you use invasive monitoring in a pregnant patient with cardiac disease?
C.3. What are the hemodynamic goals of intraoperative management of the pregnant patient with mitral stenosis?
C.4. What anesthetic technique would you use for this emergency cesarean section?
C.5. How would you manage local anesthetic systemic toxicity (LAST) in this patient?
C.6. If cardiac arrest were to occur prior to delivery, how would you proceed?
C.7. What technique could you use for general anesthesia in this patient?
C.8. If you are unexpectedly unable to intubate this patient, how would you manage the airway?
C.9. Would this patient benefit from the use of ß-blockers?
C.10. What is the effect of the inhalation agents on uterine contractility?
C.11. What is the Apgar scoring system?
C.12. What is the significance of Apgar scores?
C.13. At birth, what should be done to minimize an infant's risk of meconium aspiration syndrome?
C.14. If the Apgar score of the newborn is 3 at 1 minute, how would you treat the newborn?
C.15. Blood gases are sent immediately after delivery. What are the normal values for umbilical vein and artery blood gases?
D. Postoperative Management
D.1. Immediately after the baby is delivered, the mother's oxygen saturation decreases. What is the differential diagnosis?
D.2. Additional bleeding occurs in the postanesthesia care unit, and the obstetrician diagnoses retained placenta. What, if any, antibiotics are indicated to prevent endometritis after manual extraction of retained placenta?
30 Appendectomy for a Pregnant Patient 648
A. Medical Disease and Differential Diagnosis
A.1. What is the differential diagnosis for acute abdomen in the pregnant patient?
Medical Conditions
Obstetric Conditions
Gynecologic Conditions
Surgical Conditions
A.2. How would you make the clinical diagnosis of acute appendicitis?
A.3. What is the incidence of surgery during pregnancy? What is the incidence of appendicitis during pregnancy?
A.4. What is the incidence of gangrenous appendix/peritonitis during pregnancy, and is this incidence higher in pregnant than in nonpregnant women?
A.5. What are the main concerns associated with nonobstetric surgery in the pregnant patient?
A.6. What are the factors influencing teratogenicity from anesthetic agents in humans?
A.7. Are there any specific concerns regarding neurotoxicity and cognitive development in the developing fetus?
A.8. What factors influence fetal oxygenation, and how would you prevent intrauterine fetal asphyxia?
A.9. What is the incidence of trauma during pregnancy, and what are the risks to the mother and the fetus secondary to trauma?
A.10. What are other common surgeries performed during pregnancy?
B. Preoperative Evaluation and Preparation
B.1. Preoperatively, what would you discuss with this patient? Are any additional medical consultations warranted?
B.2. Is there a difference in the goal of anesthesia for delivery and for nonobstetric surgery in a pregnant patient?
B.3. How would you premedicate this patient?
C. Intraoperative Management
C.1. What factors would alter your anesthetic technique from that used for a nonpregnant patient?
Cardiovascular System
Respiratory System
Gastrointestinal System
Central Nervous System
Airway, Skin, and Mucous Membranes
C.2. If you choose epidural anesthesia, describe your technique and dosage.
C.3. If the patient needs supplemental analgesia, what would be your choice?
C.4. What vasopressor would you choose to improve uteroplacental perfusion?
C.5. When this patient arrived in the operating room, she desired a general anesthetic. Describe your technique.
C.6. Does any controversy exist surrounding the use of nitrous oxide?
C.7. Does any controversy exist surrounding operating room personnel, anesthetic exposure, and pregnancy outcomes?
C.8. What is the impact of nonobstetric surgery on maternal mortality, birth defects, and fetal loss? What factors influence it?
C.9. Should intraoperative fetal heart rate (FHR) monitoring be used? What would you expect to see on the electronic fetal monitor during anesthesia?
C.10. How would your anesthetic management differ if the patient were having upper extremity surgery?
C.11. The surgeon schedules the procedure to be performed laparoscopically. Does this pose any additional problems?
D. Postoperative Management
D.1. When would you extubate this patient?
D.2. Postoperatively, what monitors would you use?
D.3. What other postoperative precautions would you take? What is the incidence of preterm delivery following nonobstetric surgery during pregnancy?
D.4. The next day, the patient went into premature labor and now needs a cesarean section for prematurity and breech presentation. She requires another general anesthetic. In what way would your technique differ from your previous anesthetic technique?
SECTION 8 The Hematologic System
31 Hemophilia and Disorders of Coagulation
A. Medical Disease and Differential Diagnosis
A.1. Describe the various laboratory tests that evaluate the coagulation cascade and the specific components measured by each.
A.2. What is the difference between platelet adhesion, activation, and aggregation at sites of vascular injury?
A.3. Describe the physiologic events that occur following endothelial interruption in the blood vessel.
A.4. What factors prevent the extension of a clot beyond the site of injury?
A.5. Describe the factors involved in the extrinsic, intrinsic, and common coagulation cascade.
A.6. Describe the typical presentation history and pathophysiology associated with von Willebrand disease (vWD).
A.7. Explain the pathophysiology, frequency, and treatment of significant rare disorders of coagulation (factor VII [FVII], factor XII [FXII], and fibrinogen).
A.8. Differentiate between hemophilia A, B, and C.
A.9. What are the differences in factor replacement therapy between patients with hemophilia A and hemophilia B?
A.10. What is acquired hemophilia?
A.11. Which plasma protein is important in maintaining normal levels of factor VIII (FVIII)?
A.12. How are patients with severe hemophilia managed in the outpatient setting?
A.13. Describe the levels of FVIII necessary to maintain hemostasis in patients with spontaneous or surgical bleeding.
B. Preoperative Evaluation and Preparation
B.1. What steps would you take to normalize this patient's coagulation status before surgery?
B.2. What is meant by 1 unit of FVIII clotting activity, and how much does 1 unit of FVIII clotting activity per kilogram of body weight increase FVIII concentrations?
Approach 1
Approach 2
Plasma Volume Calculation
B.3. Would you administer FVIII using a bolus or infusion technique?
B.4. Can hemophiliac patients fail to mount an appropriate coagulation response following FVIII infusion?
B.5. If a patient with hemophilia does not respond to a bolus injection of FVIII, can an infusion technique be effective?
B.6. How much FVIII activity is present in plasma? What are the risks associated with plasma administration?
B.7. What are the indications for the administration of plasma?
B.8. What is cryoprecipitate, and how is it prepared? How much FVIII activity is present in cryoprecipitate? When is cryoprecipitate indicated?
B.9. Describe the advantages and disadvantages of the products that are available for repletion of FVIII activity.
B.10. What is the role of desmopressin (D-amino D-arginine vasopressin [DDAVP]) for hemostatic management in this patient?
B.11. What is the role of antifibrinolytic therapy in the perioperative period for the patient with hemophilia? What are examples of antifibrinolytics used in the treatment of hemophilia?
B.12. What are the options for operative treatment of patients with acquired hemophilia? Describe the mechanism of action and dosing considerations for each of these therapies.
C. Intraoperative Management
C.1. Is it safe to administer an intramuscular injection to this patient before surgery?
C.2. Would an axillary block be appropriate for this patient?
C.3. If general anesthesia is used, would it be safe to intubate the patient's trachea?
C.4. Would you use any special precautions for this patient who is positive for HIV?
C.5. What special considerations should be taken in choosing anesthetic drugs for this patient?
C.6. During an operative procedure, if the surgeon indicates that significant blood loss is occurring, would you transfuse this patient with packed red blood cells (RBCs) or whole blood?
C.7. During the transfusion of the first unit of whole blood, the patient's temperature rose from 36.8°C to 37.9°C (98.2°F to 100.2°F). What immediate steps should be taken by the anesthesiologist at this time?
C.8. Does giving blood intraoperatively increase the potential for the development of FVIII inhibitors?
C.9. Can FVIII be safely administered to patients who have developed circulating inhibitors?
C.10. The surgeon has requested the use of a tourniquet to minimize surgical bleeding. What are the physiologic and hemodynamic responses to tourniquet use?
C.11. Is it appropriate to suction the endotracheal tube and oropharynx of this patient before extubation?
D. Postoperative Management
D.1. What special consideration should be given to postoperative pain management for this patient?
D.2. What steps should be taken to enhance the coagulation status of this patient in the postoperative period while at home?
D.3. Can this patient be treated with FVIII supplements using home infusion?
Acknowledgment
32 Sickle Cell Disease
A. Medical Disease and Differential Diagnosis
A.1. What was the most likely underlying medical condition in this patient? How would you confirm the diagnosis of sickle cell anemia (SCA)?
A.2. What is sickle cell disease (SCD)?
A.3. What is sickle cell trait (SCT)?
A.4. What are some of the other common hemoglobinopathies and what are their clinical features?
A.5. What are the clinical features of SCD?
A.6. Describe the different types of sickle cell crises.
A.7. Discuss the pathophysiologic effects of SCD.
A.8. What is acute chest syndrome?
B. Preoperative Evaluation and Preparation
B.1. What preoperative evaluation and testing would you perform on this patient prior to anesthesia? Would you ask for a hematology consult, and what question(s) would you ask?
B.2. What preoperative instructions would you give this patient prior to being admitted to the hospital? How would you prepare this patient for general anesthesia and regional anesthesia?
B.3. Discuss the indications for perioperative exchange transfusion in this patient.
B.4. What are the indications for blood transfusion in SCD?
Acute conditions
Chronic conditions
C. Intraoperative Management
C.1. Discuss the anesthetic management for this patient. Discuss both regional and general anesthesia considerations.
C.2. Discuss how the comorbidities associated with SCD can affect your anesthetic management.
C.3. What precautions should one take to prevent sickling in this patient?
C.4. Discuss what issues or concerns should be brought up by the team during the debrief at the conclusion of the case. What would you sign-out to the postanesthesia care unit (PACU) staff?
D. Postoperative Management
D.1. Discuss the postoperative management of this patient. What opioid sparing techniques can you use and discuss a multimodal analgesic plan?
D.2. What complications might occur in this patient in the immediate postoperative period?
D.3. What is the treatment of sickle cell crisis?
D.4. What is the role of hyperbaric oxygen therapy in treatment of sickle cell crisis?
SECTION 9 Eye, Ear, Nose, and Throat
33 Airway Trauma
A. Medical Disease and Differential Diagnosis
A.1. What variables mitigate injury from motorcycle collisions?
A.2. What other significant trauma may be present?
A.3. How is the initial assessment of a trauma patient organized?
A.4. How would you evaluate airway and breathing?
A.5. How would you evaluate the circulation?
A.6. How would you evaluate mental status and neurologic condition?
A.7. What diagnostic tests are indicated for this patient based on the mechanism of injury?
A.8. What are the zones of the neck, and what is their clinical significance?
A.9. What immediate treatment is necessary before diagnostic studies?
A.10. When and where should the impaling object be removed?
B. Preoperative Evaluation and Preparation
B.1. What laboratory tests would you want?
B.2. What x-ray studies are most important to the anesthesiologist?
B.3. Is an electrocardiogram (ECG) necessary?
B.4. Should this patient be intubated before going for computed tomography (CT) scanning?
B.5. When and where should this patient's airway be managed?
B.6. Are any prophylactic medications indicated?
C. Intraoperative Management
C.1. What monitors would you use? Is invasive monitoring necessary before definitive airway control?
C.2. What is the surgical approach to a zone I neck injury?
C.3. Is the patient likely to require tube thoracostomy? Should this be placed before managing the airway?
C.4. What are the options for managing this patient's airway?
C.5. What are the risks of rapid sequence induction in this patient?
C.6. What anesthetic agents would you use for a rapid sequence induction?
C.7. How can you minimize the risk of exacerbating cervical spine trauma?
C.8. How can you minimize the risks of aspiration?
C.9. How would you anesthetize the airway for an awake intubation?
C.10. What are the risks of awake fiberoptic intubation?
C.11. If the patient cannot be ventilated, what options are available?
C.12. Would a laryngeal mask airway (LMA) or other pharyngeal airway be of assistance?
C.13. What surgical airway options are available in this case?
C.14. What maintenance anesthetics are indicated or contraindicated in this patient?
C.15. What complications will the surgical plan introduce?
D. Postoperative Management
D.1. What are the criteria for extubation?
D.2. What techniques may be used during extubation?
D.3. How does alcohol abuse affect postoperative management?
D.4. What pain medication should be used?
34 Open-Eye Injury and Cataract Surgery
A. Medical Disease and Differential Diagnosis
A.1. Why is this patient a particular challenge to the anesthesiologist?
A.2. What are the determinants of intraocular pressure (IOP) under normal circumstances? What is the normal range? What was the expected IOP in this patient's injured eye?
A.3. How is aqueous humor formed and eliminated?
A.4. How is IOP affected by arterial PCO 2 , systemic blood pressure, coughing and vomiting, deep inspiration, and hypoxemia?
A.5. What is the role of the central nervous system (CNS) on IOP?
A.6. What is glaucoma?
A.7. Is atropine contraindicated in patients with glaucoma?
A.8. How do carbonic anhydrase inhibitors work to decrease IOP? By what mechanism may osmotic agents decrease IOP?
A.9. Are carbonic anhydrase inhibitors or osmotic diuretics indicated in open-globe injuries?
A.10. Are topically applied ophthalmic medications absorbed systemically? How can this absorption be reduced? Which eyedrops may have effects that are of concern to the anesthesiologist?
Atropine
Scopolamine
Cyclopentolate (Cyclogyl)
Tropicamide (Mydriacyl)
Phenylephrine Hydrochloride (Neo-Synephrine)
Epinephrine
Timolol Maleate (Timoptic)
Betaxolol Hydrochloride (Betoptic)
Acetylcholine
Echothiophate Iodide (Phospholine Iodide)
Cocaine
B. Preoperative Evaluation and Preparation
B.1. Is an open-globe injury always a surgical emergency?
B.2. What preoperative evaluation would you require?
B.3. The patient ate shortly before the accident. Would you attempt to pass a nasogastric tube or to administer emetics to empty the stomach?
B.4. Could this case be done with topical anesthesia or a retrobulbar block?
B.5. How would you premedicate this patient?
C. Intraoperative Management
C.1. What are some factors that may increase the risk of vitreous herniation during induction and maintenance of anesthesia?
C.2. Will you intubate this patient? Would you consider a laryngeal mask airway? How does intubation affect IOP? How can this effect be minimized?
C.3. Would you consider an awake intubation?
C.4. Is succinylcholine contraindicated in open-globe injuries? How does succinylcholine affect IOP?
C.5. Does pretreatment with nondepolarizing muscle relaxants prevent the succinylcholine-induced elevation in IOP?
C.6. How do nondepolarizing muscle relaxants affect IOP?
C.7. How will you perform a rapid sequence induction and intubation without using succinylcholine?
C.8. What are the effects of ketamine on the eye?
C.9. Would you consider the use of etomidate as an induction agent? What about propofol?
C.10. How do inhalation agents affect IOP and by what mechanism?
C.11. During the procedure, the patient's pulse suddenly dropped to 40 beats per minute. What do you think was happening? What is the oculocardiac reflex (OCR)?
C.12. What are the afferent and efferent pathways of the OCR?
C.13. What factors contribute to the incidence of the OCR?
C.14. How do you diagnose and treat the OCR?
C.15. Is atropine useful for the OCR?
C.16. Can a retrobulbar block prevent the OCR? Is it appropriate in this patient?
D. Postoperative Management
D.1. Would you reverse the neuromuscular blockade in this patient?
D.2. Do reversal doses of atropine affect IOP?
D.3. What would you do before extubating this patient?
D.4. When would you extubate this patient?
D.5. The patient awakened in the recovery room and complained of pain and tearing in the opposite eye. The conjunctiva was inflamed. What was the likely cause?
D.6. Will taping the eyes shut or applying ointment prevent corneal abrasions? Are there any contributing factors?
D.7. What should you do when you suspect your patient might have a corneal abrasion?
D.7. A month after the surgical repair, the patient complained of impaired vision in the operative eye. He was examined and found to have a detached retina. As part of the surgical treatment, the ophthalmologist injected a gas bubble into the patient's posterior chamber. Why is this important to an anesthesiologist?
E. Anesthesia for Cataract Surgery
E.1. What is a cataract?
E.2. What are the causes and risk factors of cataract formation?
E.3. How would you conduct the preoperative medical evaluation for a patient having cataract surgery?
E.4. What is the cardiac risk for this patient? If this patient is on anticoagulation and/or antiplatelet medications, should he stop or continue these medications?
E.5. What are the anesthetic options for cataract surgery?
E.6. What is the postoperative course after cataract surgery?
35 Laser Treatment for Laryngeal Lesions
A. Medical Disease and Differential Diagnosis
A.1. What is the cause of RRP?
A.2. What is the usual presentation of RRP?
A.3. How do you diagnose RRP?
A.4. What are the available treatment options for RRP?
A.5. What are common adverse effects of a-interferon therapy?
A.6. What is the differential diagnosis of hoarseness in this child?
B. Preoperative Evaluation and Preparation
B.1. What are the key points of the preanesthetic history and physical examination in this patient?
B.2. What preoperative laboratory tests are necessary?
B.3. How should this child be premedicated before coming to the operating room?
B.4. What are the special anesthetic considerations prior to inducing anesthesia in this patient?
C. Intraoperative Management
C.1. What is a laser, and how does it work?
C.2. What are the characteristics of laser radiation?
C.3. Discuss some advantages associated with the use of lasers for laryngeal surgery.
C.4. What are some disadvantages of lasers compared with microdebriders?
C.5. How would you protect the external surface of a conventional endotracheal tube (ETT) for use during laser microlaryngoscopy?
C.6. What special ETTs are available for laser surgery?
C.7. How would you manage an airway fire?
C.8. What is the Venturi effect?
C.9. What is Venturi jet ventilation?
C.10. How would you institute and maintain manual jet ventilation?
C.11. How is anesthesia maintained during jet ventilation?
C.12. What are the complications of jet ventilation?
C.13. Are there contraindications for the use of jet ventilation?
C.14. Discuss airway management options during laryngeal papilloma resection.
C.15. How would you plan to monitor this patient?
C.16. How would you induce anesthesia for an intermittent apnea technique?
D. Postoperative Management
D.1. What are the common postoperative complications?
SECTION 10 Pediatrics
36 Tracheoesophageal Fistula
A. Pathophysiology and Differential Diagnosis
A.1. What is the diagnosis? What are the clinical features of this disease?
A.2. What is the pathophysiology of this disease?
A.3. Describe the normal development of the trachea and esophagus.
A.4. How are tracheoesophageal fistula (TEF) and esophageal atresia (EA) inherited?
A.5. How are the different types of TEF/EA classified?
A.6. What other problems may this child have, and when should these be investigated?
A.7. What should the parents be told regarding perioperative risk? Risk of recurrence?
B. Preoperative Evaluation and Preparation
B.1. What laboratory workup should be obtained before surgery?
B.2. Describe management in the NICU before surgery.
B.3. How is severe lung disease managed before repair?
B.4. Should this patient be intubated preoperatively for airway protection?
C. Intraoperative Management
C.1. What invasive lines and monitoring are appropriate before induction? After induction?
C.2. Discuss fluid and temperature management for this baby.
C.3. What are the options regarding induction and intubation?
C.4. What is the role of rigid and fiberoptic bronchoscopy in this patient prior to incision?
C.5. Describe the steps of an open repair of EA/TEF.
C.6. What are common intraoperative problems, and how can they be managed?
C.7. If the surgeon decides to proceed thoracoscopically, how will you perform your anesthetic? Is one-lung ventilation required? What are some complications unique to thoracoscopy in the newborn?
D. Postoperative Management
D.1. When should the baby be extubated?
D.2. What options are available for postoperative analgesia?
D.3. What are early and late complications of TEF repair?
37 Congenital Diaphragmatic Hernia
A. Medical Disease and Differential Diagnosis
A.1. What differential diagnoses are compatible with these signs and symptoms?
A.2. Describe the incidence and classification of congenital diaphragmatic hernia (CDH).
A.3. What are the causes of hypoxemia in patients with CDH?
A.4. How do you assess the severity of pulmonary hypoplasia?
A.5. How do you make a diagnosis of right-to-left shunting through the patent ductus arteriosus?
A.6. What other congenital anomalies are usually associated with CDH?
B. Preoperative Evaluation and Preparation
B.1. How would you interpret the following arterial blood gas analyses: pH, 7.20
PaCO 2 , 55 mmHg
PaO 2 , 35 mmHg
and CO 2 content, 19 mEq per L? How would you correct them?
B.2. What immediate treatment should be given to improve the newborn's respiratory status preoperatively?
B.3. Should CDH be repaired urgently once the diagnosis is made and confirmed?
B.4. What are the effects of nitric oxide (NO) on pulmonary and systemic circulation?
B.5. What is the current role of extracorporeal membrane oxygenation (ECMO) in the management of CDH?
C. Intraoperative Management
C.1. What monitors would you use for this neonate during surgery?
Respiratory
Cardiovascular
Thermoregulatory
C.2. How would you induce and maintain anesthesia?
C.3. Would you use nitrous oxide for anesthesia? Why?
C.4. How would you ventilate the patient?
C.5. Is the infant with CDH more at risk from hypothermia?
C.6. The surgeon returned the intrathoracic stomach and intestine to the peritoneal cavity and the ipsilateral lung was found to be hypoplastic and collapsed. The resident anesthesiologist tried to expand the collapsed lung manually with positive airway pressure. Five minutes after the abdomen was closed, the blood pressure suddenly dropped from 70/40 to 30/20 mmHg, the heart rate from 150 to 80 beats per minute, and the pulse oximeter from 95% down to 60% saturation. What would you immediately
C.7. Discuss fluid therapy in this patient.
C.8. At the conclusion of surgery, would you extubate the patient in the operating room?
D. Postoperative Management
D.1. What is the mortality rate in patients with CDH? What postoperative problems would you expect in this patient?
38 Tetralogy of Fallot
A. Medical Disease and Differential Diagnosis
A.1. What is TOF?
Tetralogy of Fallot with Pulmonary Stenosis
Tetralogy of Fallot with Pulmonary Atresia
Tetralogy of Fallot with Absent Pulmonary Valve
A.2. What is the pathophysiology of TOF/PS?
A.3. What is shunting, and how is Q P :Q S calculated?
A.4. What is the pathophysiology of TOF with pulmonary atresia?
A.5. How is SaO 2 determined in single ventricle physiology?
A.6. What is a "pink Tet"?
A.7. What are hypercyanotic spells? How are they treated?
A.8. What palliative surgical procedures are available for treating patients with TOF/PS?
A.9. What palliative catheter-based procedures are available for patients with TOF?
A.10. What definitive surgical procedures are available for treating patients with TOF/PS?
A.11. What palliative and definitive surgical procedures are available for patients with TOF with pulmonary atresia?
A.12. What are the long-term outcomes of patients with TOF?
B. Preoperative Evaluation and Preparation
B.1. What preoperative history and physical examination information do you want?
B.2. Which other abnormalities need to be considered in this patient?
B.3. What premedication will you give to a child with congenital heart disease?
C. Intraoperative Management
C.1. How will you induce anesthesia in this patient if intravenous (IV) access cannot be obtained?
C.2. Why would end-tidal carbon dioxide (EtCO 2 ) monitoring be of particular use in a patient with TOF/PS?
C.3. What is near-infrared spectroscopy (NIRS) and what does it measure?
C.4. What are the important management issues during creation of a palliative shunt?
C.5. What is the effect of inhalation anesthetics on airway reflexes, myocardial contractility, systemic vascular resistance (SVR), and pulmonary vascular resistance (PVR) in children?
C.6. What are the pre-cardiopulmonary bypass (pre-CPB) anesthetic goals for a patient undergoing definitive surgical correction of TOF/PS?
C.7. What interventions will reliably reduce PVR?
C.8. How does heparin administration and activated coagulation time (ACT) monitoring for CPB differ in children as compared with adults?
C.9. How is heparin reversed?
C.10. What is the incidence of protamine reactions in children?
C.11. What is the role of transesophageal echocardiography (TEE) in this patient?
C.12. What effect would a residual ventricular septal defect (VSD) have in this patient following separation from CPB?
D. Postoperative Management
D.1. How should postoperative ventilation be managed in this patient following placement of a transannular patch for TOF/PS?
D.2. Following complete repair of TOF/PS in an infant, what SaO 2 is acceptable?
D.3. Following placement of a modified Blalock-Taussig shunt (MBTS) for TOF/PS in an infant, what SaO 2 is acceptable?
D.4. What is junctional ectopic tachycardia (JET)?
39 Transposition of the Great Arteries
A. Medical Disease and Differential Diagnosis
A.1. What defines the cardiac situs?
A.2. What is transposition of the great arteries (D-TGA)?
A.3. What additional cardiac lesions are associated with D-TGA?
A.4. What is the natural history of D-TGA?
A.5. What is the pathophysiology of D-TGA?
A.6. What determines the oxygen saturation in patients with D-TGA?
A.7. Why did this infant have reverse differential cyanosis?
A.8. What are the preoperative issues pertaining to the coronary arteries in D-TGA?
A.9. What are the clinical subsets of D-TGA?
A.10. What is the differential diagnosis of D-TGA and how is the diagnosis made?
A.11. What preoperative interventions can help stabilize a patient with D-TGA?
Intact Ventricular Septum
Ventricular Septal Defect
Ventricular Septal Defect and Left Ventricular Outflow Tract Obstruction
Pulmonary Artery Hypertension
A.12. What are the surgical options for repair? Why is one chosen over the others?
Arterial Anatomic Repair: Arterial Switch (Jatene) Operation
Intra-atrial Physiologic Repairs: Mustard and Senning Procedures
Rastelli, LeCompte, and Nikaidoh Procedures
B. Preoperative Evaluation and Preparation
B.1. What information is important to prepare for this case?
B.2. What are the anesthetic goals before cardiopulmonary bypass (CPB)?
B.3. What is the plan for glucose management in this patient?
C. Intraoperative Management
C.1. How would you monitor this infant?
C.2. What would be the best method of induction for this patient?
C.3. Is CPB in infants and children different from adults?
C.4. What is modified ultrafiltration (MUF)?
C.5. Briefly describe the surgical techniques of the Mustard/Senning, ASO, and Rastelli procedures.
Intra-atrial Physiologic Repairs: Mustard and Senning Procedures
Arterial Anatomic Repair: Arterial Switch (Jatene) Operation
Rastelli Procedure
C.6. What is hypothermia, and how is it classified? What is low-flow cardiopulmonary bypass (LFCPB)? What is deep hypothermic circulatory arrest (DHCA)?
C.7. Why is hypothermia beneficial to the brain during LFCPB and DHCA?
C.8. Explain the difference between a-stat and pH-stat blood gas management.
C.9. What are the immediate post-CPB issues following ASO?
D. Postoperative Management
D.1. How is myocardial ischemia addressed in the intensive care unit (ICU) following the ASO?
D.2. What immediate postoperative problems would be anticipated following the Rastelli procedure?
D.3. What intermediate and long-term surgical problems are seen after ASO?
D.4. What are the long-term outcomes after ASO?
D.5. What are the long-term outcomes after Rastelli repair for patients with D-TGA with left ventricular outflow tract (LVOT) obstruction?
D.6. What is long-term neurologic outcome like after ASO?
40 Pyloric Stenosis
A. Medical Disease and Differential Diagnosis
A.1. What is the diagnosis in this patient?
A.2. What is the differential diagnosis of pyloric stenosis?
A.3. What are the metabolic problems in this newborn secondary to his disease?
A.4. What are the adverse effects of metabolic alkalosis?
A.5. How would you treat this infant?
Supportive Therapy
Fluids
Electrolytes
Prevention of Aspiration
Diagnostic Tests
Surgery
A.6. How would you determine fluid replacement in a newborn, and what fluids would you use?
Maintenance Fluids
Electrolytes
Correction of Deficits
Replacement of Losses
A.7. How would you correct the metabolic alkalosis in this patient?
A.8. What causes a cardiac murmur?
B. Preoperative Evaluation and Preparation
B.1. How would you evaluate this patient preoperatively?
History
Physical Examination
Laboratory Findings
B.2. How would you evaluate a heart murmur?
B.3. How would you differentiate between functional versus organic murmur?
B.4. What are the types of VSD? What type of shunt do they cause?
B.5. What are the risks of surgery and anesthesia in a patient with VSD?
B.6. How would you prepare this patient rapidly for emergency surgery? Is surgical intervention an acute emergency in this case?
B.7. How would you prepare this patient for anesthesia?
C. Intraoperative Management
C.1. What induction-intubation sequence would you use?
C.2. What are the anatomic characteristics of the airway in the newborn and how do they differ from those in the adult?
C.3. How do you determine the size of an endotracheal tube in a pediatric patient?
C.4. What anesthesia system would you use and why?
C.5. What are the advantages and the disadvantages of commonly employed nonrebreathing systems?
C.6. How would you monitor this patient intraoperatively?
C.7. How does the pulse oximeter function?
C.8. What factors affect the measurement of oxygen saturation by the pulse oximeter?
D. Postoperative Management
D.1. What are the complications that can occur in the postanesthesia recovery period?
D.2. How would you treat postextubation "croup" in this infant?
41 Inflammatory Airway Disease in Childhood: Laryngotracheobronchitis
A. Medical Disease and Differential Diagnosis
A.1. What portion of the airway is affected in the croup syndrome and why?
A.2. What is stridor?
A.3. How does stridor correlate with anatomic location?
A.4. Define croup. What is the clinical presentation of laryngotracheitis?
A.5. What is the differential diagnosis of acute upper airway obstruction in children?
A.6. What is bacterial tracheitis?
A.7. What congenital problems can mimic features of croup?
A.8. How is the severity of croup assessed?
A.9. What is the medical management of croup? Does this have implications for the anesthesiologist?
A.10. What is epiglottitis? What are its common causes? What is the incidence?
A.11. What are the clinical manifestations of epiglottitis?
A.12. How is the diagnosis of epiglottitis made?
A.13. What is postextubation croup? How is it managed?
A.14. What are the nonacute causes of partial airway obstruction in children?
Extrinsic Pathologies
Intrinsic Pathologies
B. Preoperative Evaluation and Preparation
B.1. Is intubation always required in children with epiglottitis?
B.2. Why is general anesthesia administered to a child with epiglottitis?
B.3. How would you prepare the patient for anesthesia?
C. Intraoperative Management
C.1. How is the airway of the child with epiglottitis best secured?
C.2. How would you induce anesthesia?
C.3. Should a child with epiglottitis undergo a rapid sequence induction?
C.4. Is awake intubation a practical alternative to secure the patient's airway?
C.5. What would you do if the airway cannot be secured with intubation?
C.6. Should this patient have a nasotracheal or orotracheal tube placed?
C.7. Shortly after intubation, frothy secretions were obtained on suctioning the endotracheal tube. What is the reason for this? How can this be treated?
D. Postoperative Management
D.1. How long should this patient remain intubated? What criteria determine extubation time?
D.2. How would you make this patient comfortable during the course of intubation?
D.3. What outcome can one expect for the child with acute epiglottitis?
42 Cleft Palate
A. Medical Disease and Differential Diagnosis
A.1. Describe the anatomic concept of a cleft palate and a cleft lip.
A.2. What is the cause of a cleft lip or a cleft palate?
A.3. What is the incidence of a cleft lip and a cleft palate?
A.4. Discuss the pathophysiology of a cleft lip and palate in the neonate and the older child (e.g., age &5 years).
A.5. What other conditions are associated with a cleft lip and a cleft palate?
A.6. What is Pierre Robin syndrome?
A.7. What is Treacher Collins syndrome?
A.8. What kind of specialized team care would these patients need?
A.9. Discuss indications and timing of closure of cleft lip and palate.
A.10. What is velopharyngeal incompetence, and how can it be diagnosed?
A.11. What is the relation of tonsillectomy and adenoidectomy to velopharyngeal incompetence?
B. Preoperative Evaluation and Preparation
B.1. What information do you need before closure of a cleft lip and palate?
B.2. What preoperative orders are needed?
C. Intraoperative Management
C.1. What monitors will you need for cheiloplasty and palatoplasty?
C.2. Discuss the induction and the anesthetic management for cleft lip and palate.
C.3. What positioning is recommended for cleft palate repair surgery?
C.4. What are the reported complications of this type of surgery and anesthesia?
C.5. Briefly describe the surgical techniques used to repair cleft defects.
C.6. How does a pharyngeal flap affect anesthetic management or any subsequent anesthetic administered to this patient?
C.7. What is an Abbe flap? What are its anesthetic implications?
C.8. What is the crucial problem of anesthesia for cleft palate? What are the unique considerations of this surgical repair?
C.9. What is laryngospasm? How would you make a diagnosis of laryngospasm?
C.10. How would you manage the patient with laryngospasm?
D. Postoperative Management
D.1. What complications of cleft lip and cleft palate surgery may be seen in the recovery room?
D.2. How do you protect the airway postoperatively?
D.3. How would you control postoperative pain in patients following a cleft lip and cleft palate repair?
43 Congenital Heart Disease with a Cervical Mass in Infancy
A. Medical Disease and Differential Diagnosis
A.1. What is 22q11 deletion syndrome?
A.2. What are the associated cardiovascular defects in 22q11 deletion syndrome?
A.3. What are the metabolic and endocrine abnormalities in patients with 22q11 deletion syndrome and the attendant manifestations?
A.4. What are the immunologic findings in 22q11 deletion syndrome?
A.5. What is the differential diagnosis of cervical masses in infancy?
A.6. What is a cystic hygroma? What are the complications? What is the treatment?
A.7. What is the IAA anomaly?
A.8. What is the pathophysiology of the IAA syndrome?
A.9. How is ductal patency maintained?
A.10. What are the side effects of prostaglandin infusion?
A.11. What is the hyperoxia test?
B. Preoperative Evaluation and Preparation
B.1. What preoperative studies should be obtained to evaluate the neck mass?
B.2. How would you categorize the difficult airway in children?
B.3. What features of the difficult airway can be noted on physical examination?
B.4. How would you preoperatively optimize the ability to secure the airway in the operating room?
B.5. What laboratory studies are necessary before surgery?
B.6. What are the causes of heart failure (HF) in the infant? How would you assess this infant in your preoperative evaluation for signs of HF?
B.7. How would you optimize the preoperative treatment of HF?
B.8. How would you premedicate this infant?
B.9. When is premedication useful in infants and children?
B.10. Before the planned surgery, the infant is scheduled for a magnetic resonance imaging (MRI) scan. You are asked to ensure that the baby remains immobile for 20 minutes to perform the scan adequately. How would you accomplish this?
C. Intraoperative Management
C.1. What anesthesia equipment, circuit, and monitors would you use?
C.2. Describe techniques other than direct laryngoscopy that would be useful for securing the airway in this baby.
Infant Video Laryngoscope
Intubation through a Laryngeal Mask Airway
Retrograde Cricothyroid Wire
Blind Nasal Intubation
Nasal Intubation with Laryngoscope and Magill Forceps
Fiberoptic Intubation
C.3. How would you monitor blood loss in this patient?
C.4. What anesthetic technique should be used in a patient who may experience severe loss of blood intraoperatively?
C.5. How would you induce and maintain anesthesia in this neonate?
C.6. Intraoperatively, the surgeon must dissect the tumor in the anterior mediastinum and needs to have a quiet surgical field. How would you accomplish this in the infant?
D. Postoperative Management
D.1. How would you manage this patient postoperatively?
44 Patent Ductus Arteriosus and Prematurity
A. Medical Disease and Differential Diagnosis
A.1. How would you classify prematurity? What are the common problems associated with prematurity?
A.2. What are the survival rates of preterm infants?
A.3. What are the incidence and survival rates of respiratory distress syndrome (RDS)? Discuss its pathophysiology.
A.4. What is bronchopulmonary dysplasia (BPD)? How would you treat it?
A.5. What are apnea spells? What are the possible causes of apneic spells?
A.6. Discuss the incidence and pathophysiology of PDA in preterm infants.
A.7. How would you make a diagnosis of PDA? Describe its treatment.
A.8. Would you give digitalis to treat congestive heart failure in preterm infants? Why?
A.9. How does indomethacin close the ductus? What are the adverse effects of indomethacin?
A.10. When is surgical closure indicated? What are the complications associated with surgical ligation?
A.11. What is retinopathy of prematurity (ROP) (retrolental fibroplasia [RLF])? Discuss its etiology, pathophysiology, prognosis, prevention, and treatment.
A.12. Define neutral and critical temperatures. What are these values in the preterm neonate, in the term neonate, and in the adult? Discuss temperature regulation in the neonate.
B. Preoperative Evaluation and Preparation
B.1. How would you evaluate this patient preoperatively?
B.2. What are the normal values of arterial blood gases and pH in neonates and infants?
B.3. Interpret the arterial blood gases: pH, 7.30
PaCO2, 60 mmHg
PaO 2, 49 mmHg
HCO 3-, 20 mEq per L on 50% oxygen
and 6 cm H2O of positive end-expiratory pressure (PEEP). How would you improve them?
B.4. What are the normal values of arterial blood pressure, heart rate, and respiratory rate for preterm infants?
B.5. What are the normal values of WBC, red blood cells (RBCs), hemoglobin, glucose, electrolytes, calcium, blood urea nitrogen, and creatinine for preterm infants?
B.6. Would you transfuse blood to this patient preoperatively?
B.7. How would you interpret the urinalysis: specific gravity, 1.005
sugar, 1+
and protein, 1+?
B.8. Would you correct a serum calcium level of 6.0 mg per dL? What other information would you like to have? Which contains more calcium, 10 mL of 10% calcium chloride or 10 mL of 10% calcium gluconate? Could you hyperventilate this child safely?
B.9. How would you premedicate this patient?
C. Intraoperative Management
C.1. Where should the procedure take place? In the neonatal intensive care unit (NICU) or the operating room?
C.2. What monitors would you use for this child during surgery?
C.3. How does the oxygen analyzer work?
C.4. What is the Doppler effect? How does the Doppler transducer measure blood pressure?
C.5. What is the mechanism of pulse oximetry? Why is it important to monitor arterial oxygen saturation? What levels of arterial oxygen saturation would you like to keep during surgery?
C.6. How would you maintain the patient's body temperature?
C.7. How do the anesthetic requirements of the preterm infant differ from those of the adult?
C.8. What size endotracheal tube would you have used if the patient had not been intubated?
C.9. How would you have induced anesthesia if the patient had not been intubated?
C.10. How would you maintain anesthesia?
C.11. How would you ventilate the patient? What tidal volume, respiratory rates, and FIO 2 would you set for the infant?
C.12. Discuss blood and fluid therapy in this preterm infant.
C.13. During dissection of the ductus arteriosus, the arterial oxygen saturation dropped from 92% to 80% and the heart rate decreased from 140 beats per minute to 80 beats per minute. What were the causes? How would you correct this situation?
D. Postoperative Management
D.1. Would you reverse the muscle relaxants and extubate the patient at the end of surgery?
D.2. How can one minimize the risk of transporting the patient to the NICU after surgery?
D.3. The patient's condition deteriorated postoperatively in the intensive care unit (ICU). Physical examination revealed persistent cardiac murmur. What was the possible diagnosis?
45 Post-tonsillectomy Hemorrhage
A. Medical Disease and Differential Diagnosis
A.1. Approximately how many pediatric tonsillectomies are performed in the United States each year? What are the indications for tonsillectomy?
A.2. What is the differential diagnosis for this patient?
A.3. What is the treatment for a patient with von Willebrand disease?
A.4. Describe the vascular anatomy of the tonsils. What is the incidence of post-tonsillectomy hemorrhage?
A.5. What are the risk factors for post-tonsillectomy hemorrhage? Does age matter?
A.6. Describe the morbidity and mortality of post-tonsillectomy hemorrhage.
B. Preoperative Evaluation and Preparation
B.1. What is your approach to assessing this patient?
B.2. What will you set up in the operating room for this patient? How will your preparation be different from a routine general anesthetic set up?
B.3. Should you plan to use vasopressors?
B.4. The patient seems anxious. Will you administer a sedative to calm the patient down?
B.5. How do you plan on interpreting this patient's laboratory results?
B.6. What are your expectations of the surgeon, specifically as it relates to induction of anesthesia?
C. Intraoperative Management
C.1. What is your plan for induction of anesthesia? During the initial procedure, this patient underwent an uneventful inhalational induction, with postinduction intravenous (IV) placement. Would you perform an inhalational induction again? Why or why not?
C.2. What is your plan for management of blood in the oropharynx?
C.3. What is your plan for airway management?
C.4. Laryngoscopy and intubation prove challenging due to blood in the airway. What options do you have now?
C.5. What is your plan for maintenance of the anesthetic? What other medications might you want to give?
C.6. Assuming the surgical intervention is successful, what is your plan for emergence and extubation?
D. Postoperative Management
D.1. Is postoperative management in the pediatric intensive care unit (PICU) indicated?
D.2. What would you require for safe transport from the operating room to the PICU?
D.3. Discuss potential postoperative complications for this patient.
D.4. What discharge instructions should be given post-tonsillectomy?
SECTION 11 Pain Management and Neuraxial Blocks
46 Brachial Plexus Block
A. Medical Disease and Differential Diagnosis
A.1. What are the presenting problems in this patient?
A.2. What additional medical history would you want to obtain?
A.3. What implications does the use of atenolol have on the patient's coexisting medical condition?
A.4. Why is immobilization of the arm important following humeral fracture?
A.5. What nerve is at particular risk for injury from humeral fracture?
B. Preoperative Evaluation and Preparation
B.1. What testing would be helpful to elucidate the cause of this patient's fainting spells?
B.2. What premedication would you order?
B.3. What are the respiratory effects of benzodiazepines?
C. Intraoperative Management
C.1. What anesthetic technique would you use?
C.2. Describe the relevant anatomy of the brachial plexus.
C.3. What relevant anatomic structures in the neck and below the neck can be injured or injected accidentally during brachial plexus block?
C.4. What regional technique would you choose to block the brachial plexus in this patient?
C.5. What are the advantages and disadvantages of the following blocks?
Interscalene Block
Supraclavicular Block
Infraclavicular Block
Axillary Block
C.6. Describe the landmarks and procedures for nerve stimulator and ultrasound-guided interscalene block.
C.7. Describe the landmarks and procedures for supraclavicular block.
C.8. Describe the landmarks and procedures for infraclavicular block.
C.9. Describe the landmarks and procedures for axillary block.
C.10. The patient requests to have the brachial plexus block performed after you administer general anesthesia. Would you agree to this request?
C.11. What relevant respiratory complications or side effects are you concerned about in this patient?
C.12. What is the incidence of hemidiaphragmatic paresis following interscalene brachial plexus block? Can this complication be avoided by decreasing the volume or concentration of local anesthetic injected or by using ultrasound-guided supraclavicular block?
C.13. Describe the pulmonary function changes that occur after interscalene brachial plexus block.
C.14. What would you do if the patient complained of dyspnea after you performed an interscalene or supraclavicular block?
C.15. The surgeon prefers to perform the surgical procedure in the sitting position. What are the advantages and disadvantages of this position compared to the lateral position in this patient?
C.16. Which nerves are most commonly missed with axillary brachial plexus block? With interscalene block? With all brachial plexus blocks?
C.17. What is the expected duration of brachial plexus block with 30 mL of 1.5% mepivacaine with 5 µg per mL epinephrine?
C.18. What is the maximum safe dose of local anesthetic for brachial plexus block?
D. Postoperative Management
D.1. What regimen would you suggest for postoperative pain management?
D.2. In the postanesthesia care unit, the patient complains of dyspnea. How would you evaluate and manage this?
D.3. On the third postoperative day after removal of the brachial plexus catheter, the patient complains of persistent numbness and paresthesia in the ulnar nerve distribution. What would you tell the patient? How would you manage neurologic dysfunction after brachial plexus block that persists for 1 week?
47 Nerve Blocks of the Lower Extremity
A. Preoperative Evaluation
A.1. What is the Glasgow Coma Scale and its significance in this patient?
A.2. Should surgery be allowed to proceed in this patient who has a subdural bleed?
A.3. Does the patient's atrial fibrillation need to be addressed prior to surgery, and if so, how?
B. Preoperative Preparation
B.1. What is dabigatran (Pradaxa)? How is its effect measured? How far in advance of elective surgery should it be stopped? Can its effect be reversed?
B.2. What concerns do you have regarding neuraxial anesthesia in this patient who has a subdural hematoma?
B.3. What concerns do you have regarding neuraxial anesthesia in this patient who has prior back surgery?
B.4. The surgeon is willing to wait a few days prior to surgery while the swelling around the injury decreases. When would you feel comfortable proceeding with surgery in this patient?
C. Intraoperative Management
C.1. What two nerve plexuses need to be blocked in this case? What nerve roots contribute to each plexus? Name the major nerves that come from each plexus.
C.2. What is the innervation to the medial and lateral aspects of the ankle? What nerves need to be blocked for his surgery?
C.3. What nerves are blocked with an ankle block? Would you do an ankle block in this case?
C.4. Explain the posterior landmark technique to blocking the lumbar plexus. What motor response would be elicited with a nerve stimulator? At what stimulation level would you feel safe injecting the patient? Why not at a lower level of stimulation? Can ultrasound guidance be utilized for this injection?
C.5. What is a fascia iliaca block (three-in-one block)?
C.6. Describe the different ultrasound approaches to blocking the saphenous nerve above the knee.
C.7. What benefits might a saphenous nerve block above the knee provide compared to a femoral nerve block?
C.8. How would pain from a midthigh tourniquet dictate which peripheral nerve blocks to use in this patient? Describe the landmark technique of sciatic nerve block in the gluteal region. What is seen while performing an ultrasound technique to block the sciatic nerve?
C.9. Why does a popliteal nerve block have a high failure rate if performed too proximate to the popliteal fossa when using a landmark/nerve stimulator technique? Describe how this can be avoided when using ultrasound-based popliteal block.
C.10. What is the IPACK block? In what situations would this block be useful?
D. Postoperative Pain Management
D.1. Describe compartment syndrome and how that risk would influence your postoperative plan for peripheral regional analgesia.
D.2. How would the addition of dexamethasone to your local anesthetic influence the duration of the blocks placed in the OR?
D.3. What is liposomal bupivacaine?
D.4. What benefit would a peripheral nerve catheter provide over a long-acting local anesthetic? Are there any downsides?
D.5. You were able to perform a continuous spinal epidural (CSE) at L3-L4 and used 0.125% bupivacaine via epidural route for postoperative pain control. The patient reports that he is comfortable regarding both his back pain and his ankle pain. What benefit would continuing the patient's methadone confer in this case?
D.6. How can regional analgesia aid in fast-track postoperative care?
48 Complex Regional Pain Syndromes
A. Medical Disease and Differential Diagnosis
A.1. What is the differential diagnosis of pain in this patient?
A.2. What is complex regional pain syndrome (CRPS)?
A.3. What are the two types of CRPS?
A.4. What are the diagnostic criteria for CRPS? What is the incidence of this disease?
A.5. Define allodynia, hyperalgesia, hyperesthesia, and dysesthesia.
A.6. What are the stages of CRPS?
Stage I
Stage II
Stage III
A.7. What are the possible etiologies of CRPS?
A.8. Explain the pathophysiology of the development of CRPS.
A.9. Define sympathetically maintained pain (SMP) and sympathetically independent pain (SIP).
A.10. How does CRPS differ from neuralgia?
A.11. What is central pain? How will you differentiate central pain from CRPS?
A.12. Is the social history of this patient relevant to the development of chronic pain syndrome?
B. Pain Management
B.1. How will you work up CRPS types I and II?
B.2. Describe the sympathetic nerve supply to the arm?
B.3. Where is the stellate ganglion located?
B.4. What are the anatomic landmarks used in the stellate ganglion block?
B.5. What are the clinical signs of stellate ganglion block?
B.6. What is Horner syndrome?
B.7. After a stellate ganglion block, this patient reports no significant change in the degree of pain despite developing Horner syndrome. Is the pain psychogenic in this patient?
B.8. What types of nerve fibers are interrupted in stellate ganglion block?
B.9. What is a differential block?
B.10. What are the two major classes of local anesthetics? Describe the major differences in their clinical pharmacology.
B.11. What factors determine the onset, potency, and duration of a local anesthetic block?
B.12. How does the addition of epinephrine to commercially available premixed solutions affect the efficacy of local anesthetics?
B.13. How will you treat this patient?
B.14. What is the pharmacologic management of CRPS?
B.15. What is the role of intravenous regional block (Bier method) in diagnosis and treatment of CRPS?
B.16. Compare and contrast the mechanism of actions of ketamine and methadone.
B.17. What roles does ketamine infusion play in the treatment of CRPS? Is there a guideline for ketamine infusion in treating CRPS?
B.18. What is neuromodulation? What is the role of spinal cord stimulation (SCS) in treating CRPS?
B.19. What is the role of surgical sympathectomy?
B.20. What role does intrathecal (IT) therapy play in managing CRPS?
B.21. If opioids are prescribed as treatment for CRPS patients, what is the Centers for Disease Control and Prevention (CDC) guideline of chronic opioid therapy?
C. Complications
C.1 What are the complications of stellate ganglion block?
C.2 What is the systemic toxicity of local anesthetics?
Central Nervous System Effects
Cardiovascular Effects
C.3 How do you treat the systemic toxicity of local anesthetic drugs?
C.4 What are the possible complications of SCS?
C.5. What are the possible complications of IT therapy?
49 Cancer Pain
A. Medical Disease and Differential Diagnosis
A.1. What is the definition of pain?
A.2. How significant is the problem of pain in patients with cancer?
A.3. What are the components of cancer pain?
A.4. How does the pain contribute to the suffering of patients with cancer?
A.5. How do psychological factors affect pain in patients with cancer?
A.6. What are the causes of pain in patients with cancer?
A.7. How do you classify pin in patients with cancer?
A.8. What are the characteristics of pancreatic cancer pain?
A.9. How do you assess pain in patients with cancer?
A.10. What is the differential diagnosis of abdominal pain?
B. Pharmacologic Treatment of Pain
B.1. What is the World Health Organization stepladder approach for cancer pain management?
B.2. What class of drugs does morphine sulfate belongs to?
B.3. What is the difference between morphine and synthetic opioids?
B.4. How does mixed opioid agonist/antagonist differ from opioid agonist?
B.5. Describe the role of methadone in the management of cancer pain.
B.6. What are the advantages and disadvantages of methadone?
B.7. What is the mechanism of action of opioids?
B.8. What are the side effects of opioid therapy?
B.9. Define tolerance and physical dependence.
B.10. How would you treat the side effects of opioid therapy?
B.11. What is tramadol? Is it an opioid?
B.12. When would you consider adjuvant analgesics as part of the treatment plan?
B.13. The patient and his family are worried about addiction. How would you approach this problem?
B.14. Describe different routes of opioid administration.
B.15. Describe advantages and complications of patient-controlled analgesia (PCA). What is minimum effective analgesic concentration (MEAC)?
B.16. What is meperidine? How is it different from other opioids?
B.17. What is rotation of opioids? When would you consider rotation of opioids?
C. Invasive Therapy
C.1. Describe the role of peripheral nerve blocks in cancer pain management.
C.2. Describe the role of celiac plexus block in cancer pain management.
C.3. What are the complications of celiac plexus block?
C.4. Would you consider neuraxial opioid infusion in this patient? Discuss complications of this procedure.
C.5. Which medications can be used intrathecally? What is ziconotide?
C.6. What is a Personal Therapy Manager (PTM), and what role does it play in neuraxial pain relief?
C.7. Would you consider neuraxial neurolysis in this patient to manage his pain? Discuss advantages and disadvantages of these blocks.
C.8. Which neuroablative procedures can be considered in the terminal stage of pancreatic cancer?
C.9. Describe the role of radiation therapy in cancer pain.
D. Nonpharmacologic Management
D.1. What are the various nonpharmacologic techniques of cancer pain management?
D.2. What physical modalities have been successfully tried in cancer pain management?
D.3. Describe the role of neuromodulation in cancer pain management.
D.4. What psychological techniques have been promoted for comfort care and pain relief?
D.5. What are distraction and reframing techniques? What is the role of hypnosis in cancer pain?
50 Low Back Pain and Sciatica
A. Medical Disease and Differential Diagnosis
A.1. How great an issue is low back pain in the general population?
A.2. What is the prevalence of low back pain?
A.3. What is the societal cost of low back pain?
A.4. What causes low back pain?
A.5. What are the risk factors for low back pain?
A.6. What are the potential sources of pain in the spine?
A.7. What is the anatomy of the intervertebral discs? What is the mechanism of pain from herniated discs?
A.8. What is the anatomy of the spinal facets? How do the facet joints cause pain?
A.9. What are the important findings through history and physical examination?
A.10. What are the appropriate diagnostic studies for low back pain?
A.11. What is the differential diagnosis of low back pain?
A.12. What are the causes of persistent back pain after multiple spine surgeries?
B. Management of Low Back Pain and Sciatica
B.1. What are the noninterventional treatments available?
B.2. What traditional interventional treatments are available and how should they be used?
B.3. What are some of the recent safety improvements recommended for lumbar epidural steroid injection?
B.4. What are some of other approaches in minimally invasive interventions?
B.5. What are the concerns about magnetic resonance imaging (MRI) safety in patients with a spinal cord stimulator (SCS)?
B.6. When should surgery be considered?
B.7. What surgical options are available for the treatment of disc disease?
51 Perioperative Pain Management
A. Perioperative Pain Management for Thoracotomy
A.1. What would be your advice to the patient about the planned thoracotomy and postoperative pain relief?
A.2. How will you decide about the choice of anesthetic technique?
A.3. What is chronic postsurgical pain (CPSP)? Does video-assisted thoracic surgery reduce the risk of chronic pain after thoracotomy?
A.4. What would be your perioperative analgesic strategy?
A.5. Does the choice of analgesic technique influence postoperative outcome?
A.6. Does it matter if the epidural catheter is at the thoracic or lumbar level?
A.7. Does the choice of drugs influence the efficacy or safety of thoracic epidural analgesia (TEA)?
A.8. What are the usual doses and concentrations of the anesthetic combinations commonly employed in epidural analgesia?
A.9. If accidental dural puncture occurs during placement of the epidural needle, what steps should be taken?
A.10. What are the alternatives to TEA?
A.11. What is the usual clinical regimen for intravenous patient-controlled analgesia (IV-PCA) and is special patient monitoring required during its use?
A.12. What are the side effects and complications of epidural technique?
A.13. What recommendations for placement and removal of epidural catheter will you make if this patient is on antiplatelet or anticoagulant therapy or thromboprophylaxis is planned?
Prophylactic Unfractionated Heparin
Therapeutic Intravenous Unfractionated Heparin
Preoperative Low Molecular Weight Heparin (Enoxaparin)
Postoperative Low Molecular Weight Heparin
Oral Anticoagulants
Newer Agents
B. Chronic Opioid Therapy and Perioperative Pain Management
B.1. How does chronic opioid therapy influence postoperative pain management?
B.2. What are the causes for increased postoperative pain and opioid consumption in patients chronically using opioids?
B.3. What are the main differences between a chronic opioid-consuming patient and a patient who abuses or is addicted to opioids?
B.4. What issues need to be considered in the opioid-tolerant patient who is scheduled for surgery?
B.5. What would be your strategy regarding preoperative information and choice of anesthesia technique?
B.6. What are the choices for perioperative pain management in opioid-tolerant patients?
B.7. What issues need to be considered before discharging an opioid-tolerant patient?
C. Perioperative Pain Management for Ambulatory Surgery
C.1. What would be your preoperative considerations and advice to the patient?
C.2. What are the consequences of inadequate pain management after ambulatory surgery?
C.3. What is the role of premedication or preoperative analgesic?
C.4. Does the choice of anesthetic technique influence postoperative pain?
C.5. Are nonsteroidal anti-inflammatory drugs (NSAIDs) effective? If so, does the choice of drug matter?
C.6. What is the role of surgical technique in influencing postoperative pain after a laparoscopic cholecystectomy?
C.7. What would be your strategy for pain control after discharge home?
D. The Role of an Acute Pain Service (APS)
D.1. What is the extent of the problem, and which patients are at greatest risk of undertreatment?
D.2. What are the consequences of inadequate postoperative pain relief?
D.3. What is the role of an APS in improving postoperative pain management?
D.4. Does an APS improve postoperative outcome?
52 Acupuncture
A. Acupuncture as a Complementary Medical Therapy
A.1. What is acupuncture?
A.2. How is acupuncture practiced? (Video 52.1)
A.3. What are the mechanisms of acupuncture analgesia?
A.4. What were the conclusions of the National Institutes of Health Consensus Conference about acupuncture?
A.5. Can acupuncture be a novel nonopioid alternative pain therapy?
B. Acupuncture for the Treatment of Chronic Conditions
B.1. What are the rationales in integrating acupuncture for the treatment of postoperative nausea and vomiting?
B.2. Can acupuncture be used for the treatment of chemotherapy-induced nausea and vomiting?
B.3. How effective is acupuncture for the management of chronic headache?
B.4. Can acupuncture be used for the treatment of chronic neck and back pain?
B.5. Can acupuncture be used for the treatment of osteoarthritis?
B.6. What role can acupuncture play in the care of patients with cancer?
B.7. Can acupuncture/acupressure be used to decrease anxiety?
B.8. What is ear acupuncture/acupressure? Can it be useful for alleviating anxiety and pain? (Video 52.2)
C. Complications
C.1. What are the possible complications of acupuncture treatment?
SECTION 12 Miscellaneous
53 Myasthenia Gravis
A. Medical Disease and Differential Diagnosis
A.1. What is MG?
A.2. What is the etiology and pathophysiology of MG?
A.3. Describe the clinical classification of MG.
A.4. How is the diagnosis of MG made?
A.5. What should be considered in the differential diagnosis?
A.6. How does myasthenic syndrome (Lambert-Eaton syndrome) differ from MG?
A.7. What treatments are available for a patient with MG?
Medical Therapy
Surgical Therapy
B. Preoperative Evaluation and Preparation
B.1. Describe the preoperative evaluation of this patient.
B.2. What preoperative laboratory data are required?
B.3. How should the patient's medications be managed preoperatively?
C. Intraoperative Management
C.1. What are your considerations in the choice of anesthetic technique?
C.2. How should this patient be monitored intraoperatively?
C.3. What anesthetic regimen would you choose for this patient?
C.4. Can neuromuscular blocking drugs be used safely in a patient with MG?
C.5. Should the MG patient who is in remission (i.e., symptom free without treatment) be managed differently?
D. Postoperative Management
D.1. What factors will help you predict this patient's need for continued intubation or other postoperative ventilatory support?
D.2. How will you determine if this patient's trachea can be safely extubated?
D.3. How will you manage postoperative analgesia?
D.4. How will you define and manage postextubation ventilatory failure in this patient?
54 Malignant Hyperthermia
A. Medical Disease and Differential Diagnosis
A.1. What was the problem of concern in this case?
A.2. What is malignant hyperthermia (MH)?
A.3. What are the clinical features of a susceptible patient?
A.4. Does the history of previous uneventful sevoflurane anesthesia reasonably exclude the patient's susceptibility to MH?
A.5. What are the clinical features of the syndrome?
Hyperkalemic Cardiac Arrest
A.6. What are the laboratory findings during an acute crisis of MH?
A.7. What is the incidence of this syndrome?
A.8. What is the mode of inheritance of the disease? Does MH "skip" generations?
A.9. What genetic disorder results in MH susceptibility?
A.10. What is the pathophysiology of the syndrome?
A.11. What laboratory tests can further substantiate the susceptibility of the patient to MH?
Molecular Genetic Testing for MH Susceptibility
A.12. What is neuroleptic malignant syndrome (NMS)?
B. Preoperative Evaluation and Preparation
B.1. How would you prepare this patient for anesthesia and surgery?
B.2. Is dantrolene prophylaxis indicated?
B.3. What laboratory tests would you obtain before surgery?
B.4. Is outpatient surgery appropriate for this patient?
B.5. In anticipation of general anesthesia, what preparations would you make?
C. Intraoperative Management
C.1. What anesthetic techniques and agents would you employ?
C.2. Should body (core) temperature be monitored during general anesthesia lasting more than a short time?
C.3. What anesthetic agents are contraindicated?
C.4. If the surgeon wants to use local anesthesia for a procedure, what agents will you recommend?
C.5. What is the significance of masseter muscle spasm occurring after succinylcholine administration?
C.6. Twenty minutes into the procedure with sevoflurane anesthesia, the patient developed increasing tachycardia with ventricular premature beats and mottled skin. What emergency measures would you take?
C.7. What modalities would you monitor closely during management of the crisis?
C.8. What steps should be taken to avoid major morbidity from MH?
C.9. How does the new formulation of dantrolene (Ryanodex) compare with the existing formulation of dantrolene (Dantrium or Revonto)?
D. Postoperative Management
D.1. What complications may follow this syndrome?
D.2. What would be your follow-up in this case?
D.3. What would you advise the patient and the family?
D.4. What precautions should an MH-susceptible patient take outside of the operating room (OR)?
55 Postoperative Residual Neuromuscular Weakness and Prolonged Apnea
A. Medical Diseases and Differential Diagnosis
A.1. What is the differential diagnosis for postoperative hypoventilation?
A.2. How is residual neuromuscular blockade (NMB) diagnosed?
A.3. What is the order of recovery of voluntary muscle groups from nondepolarizing muscle relaxants?
A.4. What is the mechanism of action of succinylcholine, and how is it metabolized? What are the side effects of succinylcholine?
A.5. If succinylcholine were the only muscle relaxant used during the case and the patient did not exhibit a response to train-of-four (TOF) stimulation, what is the likely diagnosis? How would you confirm it?
A.6. What are acetylcholinesterase and serum cholinesterase? What is the clinical significance of heterozygosity for atypical pseudocholinesterase (PChE)?
A.7. What is the incidence of atypical cholinesterase activity?
A.8. What are some factors that can lower PChE levels?
B. Intraoperative Management
B.1. How is the choice among muscle relaxants made?
B.2. What factors can alter sensitivity to nondepolarizing neuromuscular blockers?
B.3. What are the characteristics of nondepolarizing block?
B.4. What is a TOF stimulus?
B.5. Why is the TOF ratio of clinical importance?
B.6. How do we define adequate recovery of neuromuscular function?
B.7. Are there useful and/or trustworthy clinical tests of neuromuscular recovery?
B.8. How accurate are subjective estimates of the TOF ratio, and what purpose do peripheral nerve stimulator (PNS) monitors serve?
B.9. What is double burst stimulation (DBS)?
B.10. What is the posttetanic count (PTC)?
B.11. How can the TOF ratio be measured quantitatively?
B.12. What are the limitations of acetylcholinesterase antagonists?
B.13. Is there anything wrong with administering neostigmine when the TOFC is less than 3?
B.14. Is reversal of blockade always necessary?
B.15. Is there any way to rapidly antagonize a profound nondepolarizing block?
C. Postoperative Management
C.1. What is the incidence of residual NMB in the PACU?
C.2. Does undetected postoperative residual neuromuscular block (PORB) have clinical consequences?
56 Burns
A. Medical Disease and Differential Diagnosis
A.1. How do you classify the burn injury?
A.2. How do you express the extent of the burn injury?
A.3. Should the "rule of nines" be used in children?
A.4. What functions does the skin perform?
A.5. What pathophysiologic changes accompany major thermal injury?
A.6. What is the prognosis for this patient? What major factors affect his prognosis?
A.7. What are the common causes of death in burn patients?
A.8. Does this patient have a smoke inhalation burn? How do you make the diagnosis?
A.9. What is carbon monoxide poisoning? How do you diagnose and treat carbon monoxide poisoning?
A.10. What resuscitative measure would you institute immediately in this patient with 40% burns?
A.11. What fluid formula would you use?
Parkland Formula
A.12. What cardiovascular changes typify the burn injury?
A.13. What changes occur in hepatic function? What are the anesthetic implications of such changes?
A.14. What are Curling ulcers? How can they be prevented?
A.15. What complications are associated with electrical burns?
B. Preoperative Evaluation and Preparation
B.1. What preoperative preparations would you order? What are particular concerns in this patient?
B.2. What are the various operative and management options available for severely burned patients?
B.3. What are the advantages and disadvantages of early tangential excision split-thickness skin grafting (TE/STSG)?
B.4. What is this patient's mean arterial blood pressure? How do you calculate it?
B.5. Are you concerned about this patient's blood pressure? What treatment would you institute?
B.6. This patient was ventilated with respirator settings of tidal volume, 800 mL
respiratory rate, 20 breaths per minute
fraction of inspired oxygen (FIO 2 ), 60%
and positive end-expiratory pressure, 10 cm H 2 O. Arterial blood gas analyses showed the following: pH, 7.24
PO 2 , 56 mmHg
PCO 2 , 60 mmHg
and oxygen saturation, 80%. How would you interpret these arterial blood gas analysis results? What are the possible causes of high PCO 2 and low PO 2 ?
B.7. How do you calculate oxygen content and oxygen delivery? What factors govern the oxygen delivery to the tissues?
C. Intraoperative Management
C.1. What monitors would you use in the operating room?
C.2. What information can be obtained from an arterial line and a pulmonary artery catheter? How are these calculations performed?
C.3. If the patient had not been intubated, how would you proceed with the anesthetic induction?
C.4. Why is awake intubation considered the safest?
C.5. What anesthetic agents would you use? Discuss inhalation versus intravenous agents.
C.6. Why are you concerned about the patient's body temperature? What is normothermia for a burned patient?
C.7. How is temperature best maintained?
C.8. What derangements occur with hypothermia?
C.9. What muscle relaxant would you use?
C.10. Why is succinylcholine contraindicated in burned patients? For how long should it be avoided?
C.11. What other adverse effects are associated with succinylcholine?
C.12. How are the doses of nondepolarizing muscle relaxants affected by burn injury?
C.13. How are the muscle relaxants such as succinylcholine, atracurium, cisatracurium, vecuronium, pancuronium, rocuronium, and curare metabolized and eliminated? Which of them has significant histamine release?
D. Postoperative Management
D.1. How would you monitor this patient during transport?
D.2. What is meant by diffusion hypoxia? How do you prevent it?
D.3. Why do patients often shiver in the recovery room on emergence from anesthesia?
D.4. Discuss the causes of oliguria in the recovery room.
57 Trauma
A. Medical Disease and Differential Diagnosis
A.1. How is trauma classified?
A.2. What are the injuries associated with thoracic trauma?
A.3. What are the injuries associated with cardiac trauma?
A.4. What is the pathophysiology of acute pericardial tamponade?
A.5. What are the anesthetic implications for treating cardiac tamponade?
A.6. How is the initial assessment and management of the trauma patient performed?
A.7. What constitutes a primary survey, and what is its objective?
A.8. What constitutes a secondary survey, and what is its objective?
A.9. What is the definition of massive hemothorax? What are the signs and symptoms of a hemothorax?
A.10. What are the indications for a thoracotomy to treat a hemothorax?
A.11. How are pneumothoraces categorized?
A.12. What is an occult pneumothorax?
A.13. If the patient has a widened mediastinum on chest radiograph, what are your concerns?
A.14. What are the most commonly injured organs in blunt abdominal trauma?
A.15. What is a focused abdominal sonography for trauma (FAST) examination?
A.16. What is diagnostic peritoneal lavage (DPL)?
A.17. Why was DPL not performed for this patient?
A.18. Define shock.
A.19. What are the four types of shock?
A.20. List the signs and symptoms of shock.
A.21. What is the pathophysiology of hypovolemic shock?
Cardiovascular Derangement
Acid-Base Disturbance
A.22. How would you classify hemorrhage?
A.23. What is the initial treatment of hemorrhagic shock?
A.24. Would you choose crystalloid, colloid, or blood products to treat hemorrhagic shock?
A.25. Is there a place for dextran or hetastarch (Hespan) in treating hypovolemic shock?
B. Preoperative Evaluation and Preparation
B.1. What premedication would you order?
B.2. What preoperative testing would you order?
C. Intraoperative Management
C.1. How would you monitor this patient?
C.2. How would you induce anesthesia?
C.3. What technique could you use if single-lung ventilation was indicated?
C.4. What agents would you choose to maintain anesthesia?
C.5. What muscle relaxant would you choose?
C.6. What can be done to decrease the incidence of intraoperative awareness?
C.7. Five minutes after intubation, the peak airway pressure increased from 20 to 40 cm H 2 O. What are the possible causes?
C.8. How would you make a diagnosis of tension pneumothorax?
C.9. What is the treatment of tension pneumothorax?
C.10. The patient's blood loss was continuing, and the hematocrit was 18%. What type of blood would you give if the type and crossmatch are not completed?
C.11. What precautions should be taken if more than 2 units of low titer type O uncrossmatched whole blood are given?
C.12. What are the complications associated with any blood transfusion?
Transfusion Reactions
Transmission of Disease
Microembolization
What is considered a massive transfusion (MT)? What is the Assessment of Blood Consumption (ABC) score?
C.14. What are the complications associated with an MT?
C.15. Can the shift of the oxygen-hemoglobin dissociation curve be quantified?
C.16. How is hypothermia defined?
C.17. What are the adverse effects of hypothermia?
C.18. What is the treatment of hypothermia?
C.19. What are the effects of blood transfusion on the immune system?
C.20. What are the guidelines for transfusion of blood products?
Red Blood Cell Transfusion Criteria
Platelet Transfusion Criteria
Fresh Frozen Plasma Transfusion Criteria
Cryoprecipitate Transfusion Criteria
What are the guidelines for the ratio of plasma/platelet transfusion to packed red blood cells in an MT?
C.22. If a patient were a member of the Jehovah's Witness religious sect, would you give a blood transfusion?
C.23. If a child is a Jehovah's Witness and suffered from hemorrhagic shock, what would you do?
C.24. What are the concentrated factors and hemostatic agents available for bleeding patients?
Recombinant Activated Factor VII (rFVIIa, NovoSeven)
Four-Factor Prothrombin Complex Concentrate
Fibrinogen Concentrates
Tranexamic Acid
What is thromboelastography (TEG) and thromboelastometry? How can they guide transfusion?
Rotation Thromboelastometry
Thromboelastography
D. Postoperative Management
D.1. What is acute respiratory distress syndrome (ARDS)? What is acute lung injury?
D.2. How is ARDS treated?
D.3. In the recovery room, you are called to see this patient because of oliguria. How would you evaluate and treat this patient?
Prerenal
Renal
Postrenal
D.4. If this patient had a crush injury and low urine output, what other concerns might you have? What if the patient has dark or "tea-colored" urine?
58 Scoliosis
A. Medical Disease and Differential Diagnosis
A.1. What is scoliosis?
A.2. What is the most common type of scoliosis?
A.3. What are the other types of scoliosis?
Idiopathic
Neuromuscular
Myopathic
Congenital
Neurofibromatosis
Mesenchymal Disorders
Trauma
A.4. How is the severity of scoliosis assessed, and why is the severity important?
A.5. What are the nonoperative treatment options of scoliosis?
A.6. What abnormalities in pulmonary function tests (PFTs) are most commonly seen in scoliosis? What is the cause of these abnormalities?
A.7. What is the most common arterial blood gas abnormality seen in scoliosis? What are possible causes for this abnormality?
A.8. What abnormalities of ventilatory drive may be associated with scoliosis?
A.9. How may the cardiovascular system be affected in patients with scoliosis?
A.10. What is the relationship between scoliosis and malignant hyperthermia?
B. Preoperative Evaluation and Preparation
B.1. What should the anesthesiologist know about the nature of the spinal curve?
B.2. What aspects of the history are most important?
B.3. What aspects of the physical examination are most important?
B.4. Why is a preoperative neurologic assessment important?
B.5. What tests would you order preoperatively?
B.6. What is an enhanced recovery after surgery (ERAS) pathway? How has it been applied to the recovery for pediatric patients undergoing posterior spinal instrumentation and fusion?
B.7. How will the surgical procedure influence the anesthetic management?
C. Intraoperative Management
C.1. What monitoring would you use?
C.2. What is the incidence of neurologic complications in scoliosis surgery, and which patients are at highest risk?
C.3. What monitoring techniques are used to minimize neurologic complication?
C.4. What are somatosensory evoked potentials (SSEPs), and how are they used?
C.5. How reliable are SSEPs for predicting spinal injury?
C.6. What are motor evoked potentials (MEPs), and how are they used?
C.7. How is spinal cord monitoring affected by anesthetic agents? What other factors affect spinal cord monitoring?
C.8. What is the optimal anesthetic technique for scoliosis surgery?
C.9. What should be done if the SSEPs or MEPs become abnormal during surgery?
C.10. How is the "wake-up" test performed? What complications can occur during this test?
C.11. Four hours into the surgical procedure, the surgeon reports some bubbling in the thoracic portion of the wound. Shortly thereafter, end-tidal carbon dioxide decreases abruptly from 35 to 18 mmHg, heart rate increases from 80 to 120 beats per minute, blood pressure begins to fall, and arterial saturation decreases to 90%. On auscultation through esophageal stethoscope, you hear a loud gurgling murmur. What is your diagnosis?
C.12. How common is significant air embolism during scoliosis surgery?
C.13. What should be done if an air embolus is suspected?
C.14. What complications occur related to positioning the patient?
C.15. What is transfusion-related acute lung injury (TRALI)? How do you distinguish it from transfusion-associated circulatory overload (TACO)?
C.16. What techniques can be used to minimize transfusion requirements?
D. Postoperative Management
D.1. When would you extubate the patient?
D.2. What should be done to optimize pulmonary status?
D.3. What laboratory tests should be ordered postoperatively?
D.4. What fluid therapy would you use postoperatively?
D.5. What complications may occur following scoliosis surgery?
D.6. Upon arrival to the recovery room, you notice that the urine appears to be tea colored. What is your diagnosis, and how should this be managed?
D.7. How would you manage this patient's pain, nausea, and vomiting postoperatively?
59 Hypoxia and Equipment Failure
A. Medical Disease and Differential Diagnosis
A.1. What is hypoxia, and what is hypoxemia?
A.2. Is the partial pressure of oxygen in arterial blood (PaO 2 ) related to age?
A.3. Was this patient hypoxemic?
A.4. What is a pulse oximeter, and what is a hemoximeter?
A.5. How does a pulse oximeter work?
A.6. How is a two-wavelength pulse oximeter calibrated by the manufacturer?
A.7. What may affect the accuracy of a two-wavelength pulse oximeter?
A.8. How do the dyshemoglobins, methemoglobin (metHb), and carboxyhemoglobin (HbCO) affect SpO 2 readings?
A.9. What is a capnometer, and what is capnography? Of what value are they in patient monitoring?
A.10. What is meant by the term end-tidal carbon dioxide (EtCO 2 )?
A.11. What is the appearance of a normal capnogram, and what is its significance?
A.12. What are mainstream and sidestream capnometers?
A.13. Show some common capnograms and provide a differential diagnosis of each event.
A.14. What is the arterial-alveolar difference in carbon dioxide (CO 2 )?
A.15. What are some of the important safety features of the contemporary anesthesia workstation?
Features Intended to Prevent Human Error
Features to Correct for Use Error
Monitoring Systems
Alarm Systems
A.16. What are the common sites for gas leakage?
A.17. How is the anesthesia machine checked for leaks?
B. Preoperative Evaluation and Preparation
B.1. What should be included in the equipment checkout in preparation for anesthesia?
Emergency ventilation equipment
High-pressure system
Low-pressure systems
Scavenging system
Breathing system
Manual and automatic ventilation systems
Monitors
Final position
B.2. What emergency equipment should be easily available to the anesthesiologist?
B.3. How should this patient be premedicated?
C. Intraoperative Management
C.1. How should this patient be monitored?
Oxygenation
Ventilation
Circulation
Body temperature
C.2. Following uncomplicated induction of anesthesia and endotracheal intubation, the procedure begins. Upon insufflation of the abdomen with CO 2 , the SpO 2 decreases to 78%. What acute diagnostic and therapeutic interventions would you perform?
C.3. The endotracheal tube was withdrawn 2 cm. Squeezing the reservoir bag in the circle breathing system failed to generate positive pressure in the circuit. What are the common sites for gas leaks in the circle breathing system?
C.4. The patient was taken out of Trendelenburg position. Direct laryngoscopy revealed the endotracheal tube to be supraglottic. Additionally, green secretions were noted to be pooled in the posterior pharynx. What should be done next?
D. Postoperative Management
D.1. What criteria would you use for tracheal extubation?
D.2. What are the causes of postoperative hypoxemia?
D.3. What is the difference between shunt, ventilation/perfusion mismatch, and dead space?
D.4. Postoperatively, the patient developed hypoxia and pulmonary edema. What is the differential diagnosis of pulmonary edema? What is the most likely cause of pulmonary edema in this patient?
D.5. How should the ventilator be set if mechanical ventilation is required postoperatively?
D.6. If this patient had acute respiratory distress syndrome (ARDS) secondary to aspiration, besides low-tidal volume ventilation, what other changes in routine therapy should be considered?
D.7. What therapies routinely administered by the anesthesiologist may cause acute lung injury?
D.8. What methods of oxygen administration may be used postoperatively?
60 Electroconvulsive Therapy
A. Medical Disease and Differential Diagnosis
A.1. What are the indications for ECT?
A.2. Are there any contraindications to ECT?
A.3. What is the mechanism of action of ECT?
B. Preoperative Evaluation and Preparation
B.1. How would you assess the cardiac status of this patient?
B.2. How should his anticoagulation be managed during ECT?
B.3. What implications do his history of sleep apnea have on management of ECT?
B.4. How does his history of TIA and carotid endarterectomy impact your preoperative evaluation?
B.5. Is ECT contraindicated in a patient with a permanent pacemaker or implantable cardioverter-defibrillator?
B.6. Are there any psychiatric medications he is taking that would impact your anesthetic care?
C. Intraoperative Management
C.1. Describe the hemodynamic and cardiac response to ECT in a typical patient.
C.2. Is an arterial line warranted in this patient?
C.3. By what means would you attempt to maximize hemodynamic stability?
C.4. Describe the cerebral hemodynamic effects of ECT.
C.5. How would you proceed with an anesthetic induction for this procedure?
C.6. How do you intend to manage his airway during each treatment?
D. Postoperative Management
D.1. The patient is extremely agitated upon emergence. Discuss the risk factors for postictal agitation (PIA) as well as the therapeutic options.
D.2. After three consecutive uneventful inpatient treatments, the psychiatrist asks if the patient may undergo ECT as an outpatient. Would you agree to this plan?
61 Ambulatory Surgery
A. Medical Disease and Differential Diagnosis
A.1. Is this patient morbidly obese?
A.2. What medical conditions may be associated with obesity and morbid obesity?
A.3. Is there a link to a decline in memory and thinking with anesthesia and surgery?
B. Preoperative Evaluation and Preparation
B.1. What advantages does outpatient surgery offer?
B.2. What are the goals of the preoperative evaluation of the surgical outpatient?
B.3. In order to thoroughly screen for disease, should one put all outpatients through a full battery of laboratory testing?
B.4. What preoperative laboratory testing is necessary for surgical outpatients?
B.5. Which outpatients should receive a preoperative chest roentgenogram?
B.6. In which patients is an electrocardiogram (ECG) necessary before outpatient anesthesia and surgery?
B.7. Would age or physical status influence the decision to perform outpatient surgery?
B.8. What patients are considered inappropriate for ambulatory surgery?
B.9. What questions are critically important to ask this patient when obtaining her history?
B.10. What instructions should the patient be given with regard to continuing or discontinuing lisinopril in the perioperative period?
B.11. What is an enhanced recovery after surgery (ERAS) protocol, and how would you apply it in the outpatient setting?
B.12. How would you premedicate this patient?
B.13. Should every outpatient receive prophylaxis against aspiration pneumonitis?
B.14. Is an overnight fast justified for all outpatients?
C. Intraoperative Management
C.1. What are the important considerations in choosing an anesthetic technique for outpatient surgery?
C.2. How would you monitor this patient?
C.3. What is the bispectral index (BIS) monitor, and what information does it convey?
C.4. What benefits might be derived from using a BIS monitor?
C.5. Is BIS monitoring applicable to children?
C.6. What are the major limitations of BIS monitoring?
C.7. What does a BIS reading of 56 mean?
C.8. What anesthetic agents would you use to induce and maintain general anesthesia in this patient?
C.9. Under what circumstances might spinal anesthesia be appropriate for outpatient surgery?
D. Postoperative Management
D.1. What are the common causes of nausea and vomiting in outpatients?
D.2. How would you pharmacologically prevent PONV in the susceptible ambulatory patient?
D.3. How is postoperative pain treated?
D.4. What criteria would you use to establish that a patient can be safely discharged after ambulatory surgery?
D.5. How would you decide when to discharge a patient after regional anesthesia?
D.6. What instructions should be given to an ambulatory surgical patients upon discharge?
62 Magnetic Resonance Imaging
A. Medical Disease and Differential Diagnosis
A.1. What is MRI, and how does it work?
A.2. What are some advantages of MRI?
A.3. What are some disadvantages associated with MRI? What are some safety concerns?
A.4. How do you manage patients with implanted devices?
A.5. What are the biologic effects of clinical MRI?
A.6. What are the anesthetic considerations for this procedure?
A.7. What is intraoperative MRI (iMRI)? What is real-time MRI, and in what setting can this be used?
B. Preoperative Evaluation and Preparation
B.1. What type of patients may require sedation or general anesthesia for MRI?
B.2. Do all children require sedation for MRI?
B.3. What preoperative laboratory testing would you require for this patient?
B.4. How would you premedicate this patient? What are some options that can be used to premedicate other patients for MRI?
C. Intraoperative Management
C.1. What are some of the anesthetic options for this patient?
C.2. How is an MRI conducted?
C.3. How would you monitor this patient?
C.4. What special considerations apply to monitoring equipment used during MRI?
C.5. How would you induce and maintain general anesthesia in this patient?
C.6. What are ways to maintain the airway during an MRI scan?
C.7. During the scan, you notice loss of end-tidal carbon dioxide. You immediately go into the scanner, remove the patient from the MRI scanner and initiate bag ventilation. However, you are still unable to ventilate the patient, and asystole follows. What do you do next?
C.8. What is the risk to the patient of gadolinium administration in the presence of acute renal insufficiency?
D. Postoperative Management
D.1. How will you recover the patient from anesthesia?
63 Morbid Obesity, Obstructive Sleep Apnea, and Bariatric Anesthesia
A. Medical Disease and Differential Diagnosis
A.1. What problems exist with this patient? The patient asks you if he is high risk. What is the evidence? Is surgical therapy a safe and viable alternative for this patient?
A.2. Define the terms overweight, obesity, MO, super obesity (SO), super-SO (SSO), normal weight, ideal body weight (IBW), and lean body weight (LBW). What is the impact of obesity on society?
A.3. What is OSA? What are the risk factors for OSA?
A.4. How is OSA diagnosed? What is a sleep study, or PSG? How are results obtained from a PSG used to grade the severity of OSA? What are the subtypes of OSA? Are there genetic disorders with a predisposition to OSA? What is the role of OSA screening tests in the preoperative setting?
A.5. How does OSA differ in the pediatric population in clinical presentation and pathogenesis?
A.6. What is the Pickwickian syndrome (PS)? What is obesity hypoventilation syndrome (OHS)? Describe the pathogenesis of severe OSA.
A.7. What is the association between obesity and OSA? What is the etiology of OSA in severe obesity?
A.8. What are the anesthetic implications of OSA?
A.9. What type of metabolic problems would you expect to find in morbidly obese patients? What are the roles of leptin and ghrelin in obesity?
A.10. Describe the changes that occur in the following respiratory parameters in morbidly obese patients:
A.11. What changes occur in PaO 2 and PaCO 2 in morbidly obese patients?
A.12. What changes occur in intrapulmonary shunt (QS/QT) and dead space (V D/V T) in MO? Describe the Shunt equation and the physiologic dead space, or Bohr equation.
A.13. What changes occur in the cardiovascular system of the obese patient? Discuss cardiac output, blood volume, blood pressure, and pulmonary arterial pressure.
A.14. Are there any other disease entities commonly associated with obesity? What is their relationship?
A.15. What anatomic changes that affect the airway are associated with MO and OSA?
A.16. What derangements of the gastrointestinal system are associated with MO?
B. Preoperative Evaluation and Preparation
B.1. How would this patient be optimized for surgery preoperatively? Would you use preoperative screening questionnaires to diagnose OSA? Summarize the workup for this patient.
B.2. One of the recent developments in bariatric surgery is that many patients are receiving prebariatric screening procedures performed in the endoscopy suite. Describe the anesthetic considerations.
B.3. Summarize the evidence-based workup, risk, chance of various adverse outcome, and expected length of stay for this patient.
B.4. What is the role of enhanced recovery after surgery (ERAS) in bariatric surgery? How does the public find a quality bariatric surgery team and surgical facility? What is the role of robotics in bariatric surgery?
B.5. Would you premedicate the patient?
B.6. Describe the mechanism of action of each premedication in the ENERGY protocol.
B.7. How would you adjust doses of anesthetics in the morbidly obese?
C. Intraoperative Management
C.1. How would you monitor this patient?
C.2. The American Society of Anesthesiologists' (ASA) Difficult Airway Algorithm (DAA) provides a guideline for management of the difficult airway. How do the comorbidities of MO and OSA modify implementation of the algorithm?
C.3. Why is it important to preoxygenate the obese patient? How would you do it? Compare the effectiveness of the four-maximum-breath and 3-minute techniques. What is the importance of continuous positive airway pressure (CPAP) during the induction of general anesthesia? Describe use of the nasal CPAP mask in the induction of general anesthesia.
C.4. There are many new airway devices on the marketplace. Which of these devices have been particularly successful on the morbidly obese or OSA patient?
C.5. How would you induce anesthesia? Describe the intubation technique.
C.6. How would you maintain general anesthesia? What agents would you choose? How would you prepare for emergence?
C.7. Which muscle relaxants would you use?
C.8. Is postoperative pain severe after bariatric surgery? What are the pain generators? What is the role of regional anesthesia to decrease opioid requirements for bariatric surgery? What are the advantages and disadvantages of regional anesthesia? What are some of the newer techniques available?
C.9. What is the pathophysiology of pneumoperitoneum (PNP)? What is the effect on the cardiopulmonary system? How does it change perioperative care? What are the optimal ventilator strategies for morbidly obese patients undergoing bariatric surgery?
C.10. What are the devices that anesthesiologists place in the upper gastrointestinal canal during laparoscopic bariatric surgery? Are there risks associated with placement and management of these devices?
C.11. When will you extubate this patient? Describe weight-based extubation criteria.
C.12. What is apneic oxygenation?
C.13. What is diffusion hypoxia (DH)? How do you prevent it?
D. Postoperative Management
D.1. What are the early postoperative complications of bariatric surgical procedures?
D.2. What are the late complications of bariatric surgical procedures?
D.3. What is the effect of position on respiratory function in the obese patient?
D.4. How would you prevent postoperative atelectasis?
D.5. How long would you prescribe supplementary oxygen postoperatively?
D.6. How would you control postoperative pain?
Index

Systemvoraussetzungen

Als PDF speichern Als Link merken