bluuebunny/crossref_metadata_2025 huggingface dataset:
Tetanus
Authors: Forrest Patrick
Published: March 2023

Tetanus caused by Clostridium tetani infection is a rare disease still prevalent in the developing world. Toxins from the infection cause damage to the inhibitory synaptic pathways of the central nervous system, resulting in muscle rigidity, spasm, and, in the most severe forms, autonomic instability. Diagnosis is made clinically, and treatment comprises human antitetanus immunoglobulin, antibiotics, and stabilization of the sympathetic and parasympathetic nervous systems through medication classes, including benzodiazepines, opioids, α- and β-adrenergic blockers, and α2-agonists. Anesthetic implications include hemodynamic optimization prior to arrival at the operating room, use of anesthetics that can promote muscle relaxation, and close postoperative observation with possible need for ventilatory support following surgery.
Cerebral Protection
Authors: Kim Roy , Abd-Elsayed Alaa
Published: March 2023

Research has demonstrated that perioperative injury to brain tissue can stimulate active responses in the brain that can persist well after substrate delivery has been restored to baseline levels. Cerebral protection involves understanding the metabolic demands of cerebral tissue to avoid ischemic and/or hypoxic injury. Insults to the brain during surgery and anesthesia can be categorized as global (involving the entire brain) or focal (a defined region of the brain). Such injury can potentially produce devastating results; therefore, it is paramount to prevent or limit ischemic damage by utilizing cerebral protective therapies and strategies throughout the perioperative period. Current available evidence is extrapolated largely from animal studies and limited data from clinical human subjects.
Ventriculostomy
Authors: Kim Roy , Abd-Elsayed Alaa
Published: March 2023

Endoscopic third ventriculostomy (ETV) has become the standard neurosurgical procedure for treating noncommunicating hydrocephalus in both adult and pediatric patients. Although this is a minimally invasive procedure, ETV can rarely lead to serious perioperative complications that both the surgeon and anesthesiologist should be aware of. ETV involves establishing a connection between the third ventricle and prepontine subarachnoid space, allowing the flow of cerebrospinal fluid to bypass the aqueduct. It is faster and simpler than conventional shunt surgery and avoids major brain retraction or dissection. Complications included hemodynamic alterations, bleeding, delayed recovery from anesthesia, cerebrospinal fluid leaks, and electrolyte imbalances. Understanding possible complications and prompt detection can help minimize these risks and ensure optimal outcomes.
Normal Acid-Base Regulation
Authors: Alcibiade Erica , Mechlin Maggie W.
Published: March 2023

Maintaining a normal pH (7.35–7.45) is necessary for normal physiologic function. Beyond a normal range, widespread organ dysfunction ensues. Normal acid-base physiology is critical for numerous physiologic functions, including enzyme activity, chemical reactions, and transport of oxygen throughout the body. Numerous situations in the perioperative period can rapidly alter acid-base status, and general anesthesia can blunt the normal physiologic homeostatic response. Optimal pH is important for enzyme activity, chemical reactions, and transport of oxygen throughout the body. Thus, anesthesia providers must be able to recognize, diagnose, and treat acid and base disorders within the perioperative period. This chapter briefly discusses normal acid-base regulation and compensatory mechanisms that allow optimal physiologic function.
Strong Ionic Difference
Authors: Giordano Christopher , Patel Ravi
Published: March 2023

Physicians and scientists have been using the Henderson-Hasselbach equation to decipher acid-base imbalances since the early 1900s. By using the concentration of arterial CO2 (partial pressure of CO2) and the concentration of bicarbonate [HCO3−], the Henderson-Hasselbach approach helps differentiate between respiratory and metabolic derangements. Subsequently, the concept of anion gap was created to help further differentiate metabolic derangements. However, these traditional models often struggled to explain why acid-base derangements occurred in certain patient populations, such as hypoalbuminemic patients. In 1981, Peter Stewart introduced a novel concept that redefined the independent and dependent variables that affect pH. This new concept, sometimes referred to as the physicochemical approach or the strong ion approach, posits that the three independent variables affecting pH are partial pressure of CO2, total concentration of nonvolatile weak acids, and the strong ion difference. Similar to the traditional approach, Stewart’s approach splits acid-base disturbances into respiratory and metabolic derangements; however, unlike the traditional approach, Stewart’s approach further splits metabolic derangements into strong ion and buffer ion derangements. Perhaps the most controversial aspect of Stewart’s approach is that the concentration of bicarbonate is considered a dependent variable; changes in bicarbonate concentration do not cause pH changes but rather occur in response to pH changes.
Obstructive Lung Disease
Authors: Hierlmeier Bryan J. , Rugnath Anesh
Published: March 2023

Obstructive airway diseases are a commonly tested topic in anesthesia for both the written and oral examinations and are separated into upper airway (obstructive sleep apnea [OSA]), tracheobronchial (foreign body), and parenchymal disorders (mediastinal masses). Obstructive disorders have resistance to airflow which leads to air trapping and in turn increases the residual lung volume and total lung capacity. Obstructive sleep apnea patients typically have daytime somnolence, increased incidence of hypoxia, dysrhythmias, hypertension, myocardial ischemia, and pulmonary hypertension and have increased sensitivity to narcotics with respect to respiratory depression. Foreign body aspiration and mediastinal masses can be an anesthetic dilemma; serous preparation should be completed prior to induction of anesthesia as the consequences can possibly lead to loss of airway and cardiovascular collapse. This chapter concentrates on a few disorders in each major category that are commonly encountered.
Bronchopleural Fistula
Authors: Lepkowsky Adam , Coyne Dane
Published: March 2023

A bronchopleural fistula is an abnormal communication between the bronchial tree and the pleural space that can be caused by a number of surgical and nonsurgical etiologies. They are most commonly seen postpneumonectomy due to failed bronchial stump closure. Bronchopleural fistulas present with an air leak in the chest tube along with sudden onset dyspnea, cough, and increase of air-fluid levels on chest radiograph. The patient may also have fever and leukocytosis if empyema is present. Bronchopleural fistulas can lead to life-threatening pneumothorax. Diagnosis is usually made clinically and is then confirmed with either a bronchoscopy or a computed tomographic scan. One-lung ventilation is used to provide positive pressure ventilation to the healthy lung without loss of minute ventilation while reducing the risk of contamination from the affected lung. The safest approach is awake fiber-optic intubation with the patient breathing spontaneously to avoid a pneumothorax from positive pressure ventilation. Confirmation of lung isolation is necessary before positive pressure ventilation is applied to prevent a possible pneumothorax from inadequate isolation. Extubation should be attempted as early as possible to avoid barotrauma to the surgical stump.
Complications and Side Effects of Mechanical Ventilation
Authors: Mahboobi Sohail K. , Sohail Mahad
Published: March 2023

Mechanical ventilation is routinely used not only in critical care units but also on regular floors. Caring for a patient on a ventilator requires knowledge and understanding of the ventilator, its functioning, indications for placing a patient on the ventilator, choice of optimum ventilator mode, and sedation. In spite of the life-saving nature of mechanical ventilation, it is not free of complications and side effects. In fact, prolonged mechanical ventilation affects almost every organ system of the body, including the cardiorespiratory, gastrointestinal, renal, brain, hematologic, and immune systems. Successful outcome depends on prevention of possible complications, and adequate knowledge and planning are required to achieve this goal. This chapter summarizes the complications related to mechanical ventilation systematically.
Preconditioning
Authors: Helou Mada , Nazemian Ryan
Published: March 2023

The concept that brief manipulation(s) could protect an organ or tissue from subsequent ischemic injury was first put forth by Bob Jennings of Duke University. In the ensuing 35 years, ischemic preconditioning has been shown in preclinical studies to protect all commonly transplanted organs from myriad pathophysiologic insults; however, the translation of this phenomenon into clinical practice has not been smooth. Nonetheless, under controlled scenarios where there is a high probability of an ischemic event, various human preconditioning trials have demonstrated benefit with respect to improved organ function and reduced morbidity and mortality. Volatile anesthetics (VAs) have been shown to directly precondition or indirectly enhance ischemic preconditioning of a variety of different organs. The importance of preconditioning and its implications during general anesthesia and specifically during surgery are still controversial.
Off-Pump Coronary Artery Bypass (OPCAB)
Authors: Krebs Ryan , Sanders Joseph
Published: March 2023

Off-pump coronary artery bypass graft surgery (OPCAB) is an alternative to standard coronary artery bypass graft (CABG) surgery. This procedure is performed similarly to CABG and involves one or more coronary arteries bypassed via a midline sternotomy approach. OPCAB has the advantage of avoiding the complications of cardiopulmonary bypass (CPB), such as coagulopathy, the inflammatory response, and manipulation of the aorta. Compared to the use of CPB, the lack of optimal surgical conditions and increased hemodynamic instability with OPCAB are challenges the surgeon and anesthesiologist will face. The anesthesiologist must be prepared to handle patient hemodynamic instability during OPCAB, which is different from full hemodynamic support provided during CPB.
Percutaneous Valve Repair/Replacement
Authors: Mohammed Asif Neil , Potchileev Iordan
Published: March 2023

Percutaneous valve replacement and repair have become a rapidly emerging treatment modality in the field of cardiology and cardiothoracic surgery due to the less invasive nature and the ability to prolong the lives of patients with significant comorbidities. When percutaneous techniques were introduced, most patients were treated under general anesthesia. However, studies and experience demonstrated over time that moderate sedation led to improved outcomes in the majority of patients. Methods to repair the valve include balloon valvuloplasty, edge-to-edge repair, annuloplasty, or complete valve replacement. Physical approaches can be performed via transfemoral, subclavian, axillary, radial, transcarotid, or, less commonly, transapical routes. Hemodynamic goals vary according to the type of valvular lesion being repaired, but the anesthesiologist should strive to maintain sinus rhythm, preload and afterload, and contractility of the heart through inotropic support.
Anesthetic Management of Kidney Transplantation
Authors: Helou Mada , Nazemian Ryan
Published: March 2023

Kidney transplantation is the treatment of choice for end-stage renal disease (ESRD). With recent advancements in the field of transplantation, especially with an expanded donor pool and postoperative care, kidney transplants are now viewed as relatively straightforward surgeries. More than 23,000 kidney transplants were done in the United States in 2019, yet there still remains major unmet need for more organs. As of June 20, 2020, there were more than 93,000 patients on the waiting list to receive a kidney transplant. Thus, optimum anesthetic management is an integral part of patient and graft survival. The majority of transplanted kidneys are procured from deceased donors following death by neurological criteria (DNC). Therefore, due to the unpredictable and emergent nature of the surgery, in addition to routine preoperative evaluation, unique considerations need to be addressed. This chapter reviews the major considerations for pre-, intra-, and postoperative care of kidney transplantation.
Urologic Surgery
Authors: Dalton Allison K.
Published: March 2023

Patients presenting for urological surgery represent a spectrum of genitourinary disease states. Common presenting diagnoses include hematuria, urinary obstruction, and benign and malignant tumors. Urologic procedures run a continuum of risk from simple cystoscopy to open cystectomy. While open procedures are associated with increased morbidity and mortality, minimally invasive procedures utilizing robotic assistance create distinct issues for anesthetic management. Each individual urologic procedure presents its own challenges to the anesthesiologist: concern for intraoperative blood loss, electrolyte derangements, risk of nerve injury, and altered respiratory and cardiovascular physiology. In addition, due to common risk factors for malignancy, patients presenting for urologic surgery may have significant medical comorbidities, which will require meticulous preoperative planning, intraoperative execution, and postoperative monitoring.
Anticoagulants and Antagonists
Authors: Devangam Suhas , Lemmink Gretchen A.
Published: March 2023

The realm of pharmacological anticoagulation has changed rapidly in the past two decades, expanding from the narrow field of aspirin (ASA), heparinoids, and vitamin K antagonists to the myriad classes of anticoagulants available in the modern era. Patients may present for surgery on any combination of the aforementioned drugs. Conversely, they may be taking one of the newer classes of antiplatelet agents (often in combination with ASA), direct oral anticoagulants, or even a parenteral direct thrombin inhibitor. Anesthesiologists will encounter all of these drugs during their career in a variety of clinical settings from elective surgery to unplanned procedures and life-threatening emergencies. An astute perioperative physician must understand the numerous indications for anticoagulation as well as the pharmacokinetics of these agents, how to monitor their anticoagulant activity, and how best to reverse each specific drug in an emergency. This chapter discusses the most common anticoagulants and antithrombotics used in clinical practice today and antagonist agents that are used to counteract them.
Coagulopathy in Trauma Patients
Authors: Ford Timothy , Abd-Elsayed Alaa
Published: March 2023

Despite advances in trauma care, trauma remains a leading cause of disability and death globally due to uncontrolled hemorrhage. This is because one-quarter to one-third of trauma patients develop a biochemically evident coagulopathy. Coagulopathy arising in trauma patients is complex and multifactorial, with overlapping etiologies disrupting the balance of hemostatic and fibrinolytic processes. Contributing etiologies include acidosis, hypothermia, dilutional resuscitation, disseminated intravascular coagulation, platelet dysfunction, and trauma-induced coagulopathy. The last is due to a combination of tissue injury and shock resulting in molecular and physiologic perturbations. Ultimately, this complex coagulopathy in trauma patients manifests as uncontrolled hemorrhage, organ failure, thromboembolic complications, and death.
Transfusion Indications and Reactions
Authors: Scott Courtney L. , Boydston Elaine A.
Published: March 2023

Understanding both the indications for blood product transfusion and the potential complications is crucial to the knowledge base of an anesthesiologist. In the setting of anemia, the available evidence generally supports transfusion of packed red blood cells (pRBCs) when a patient’s hemoglobin level is between 7 and 10 g/dL depending on the patient’s comorbid conditions, the potential for ongoing blood loss, and signs or symptoms of organ ischemia. Transfusion of fresh frozen plasma and/or platelets is generally indicated in the setting of bleeding attributable to an inherited or acquired deficiency in these factors. Similarly, cryoprecipitate is indicated for bleeding due to hypofibrinogenemia or dysfibrogenemias. Transfusion-related complications vary in severity on the spectrum from symptomatically mild to severe and fatal. The most common complications are relatively benign and include febrile nonhemolytic transfusion reactions (0.5%–1% of all transfusions) and urticarial reactions. More severe reactions are fortunately less common and include anaphylactic reactions (most commonly due to a recipient with immunoglobulin [Ig] A deficiency who receives a blood transfusion containing IgA) and acute hemolytic transfusion reactions (due to transfusion of ABO-incompatible blood most commonly due to clerical error). The risk of transmission of bloodborne pathogens has decreased due to improved testing of the donor blood supply; however, bacterial contamination, especially of platelets (due to their storage at room temperature, which is optimal for bacterial growth), may still occur. Transfusion-related acute lung injury (TRALI) is an illness like acute respiratory distress syndrome (ARDS) appearing within 6 hours of receiving a blood transfusion and is the most common cause of death attributable to blood transfusion. Metabolic derangements, including acidemia, hyperkalemia, and hypocalcemia, are more commonly associated with transfusion of large volumes of blood products.
Thyroid Gland
Authors: Romanov Evgenev , Noguera Edward
Published: March 2023

Anesthesiologists should be familiar with thyroid gland anatomy, pathophysiology, and clinical management of thyroid disorders. The thyroid gland is in the neck in front of the thyroid cartilage. It consists of two lobes connected by the isthmus. The thyroid gland secretes thyroid hormones that play a major role in the regulation of metabolism, development, growth, and brain development. Each lobule is filled with microscopic follicles that are the functional units of the thyroid gland. For instance, thyroid storm, although rare, carries high perioperative mortality. There are multiple airway considerations in patients with a thyroid mass. Furthermore, patients who are not euthyroid can have different clinical responses to anesthetic agents.
Carcinoid Syndrome
Authors: Sam Sabrina S. , Ragheb-Mueller Nawal E.
Published: March 2023

Carcinoid syndrome is a paraneoplastic syndrome secondary to vasoactive substances secreted by carcinoid tumors. The most common vasoactive substances secreted by carcinoid tumors are serotonin, histamine, and kinins. The trademark triad consists of flushing, diarrhea, and bronchospasm. Right-sided heart disease is a serious complication. Diagnosis is confirmed by discovery of serotonin metabolites in the urine. Treatment with octreotide, a somatostatin analogue, is the mainstay of treatment for controlling symptoms related to serotonin. Definitive therapy is possible in some cases with surgery. Avoidance of surgical and anesthetic triggers that lead to the release of vasoactive substances is essential. Chemoprophylaxis is provided with octreotide.
Guillain-Barré Syndrome
Authors: O’Farrell Justin L. , Eckmann Maxim S.
Published: March 2023

Guillain-Barré syndrome is an acute immune-mediated paralytic neuropathy secondary to prior infection. There are multiple variants of Guillain-Barré syndrome that describe the mechanism by which the neurodegeneration occurs. The most common presenting symptoms include areflexia in addition to caudad-to-cephalad progressive muscle weakness. The diagnosis of Guillain-Barré syndrome is made by clinical evaluation of symptoms and laboratory studies. While disease-modifying treatment involves plasmapheresis or intravenous immunoglobulin (IVIG), the majority of care is supportive due to severe dysfunction of the respiratory, cardiopulmonary, and autonomic nervous systems. Patients require close monitoring due to the rapid progression of muscle weakness, which often occurs in the intensive care unit. Complete recovery of Guillain-Barré syndrome may occur over a period of up to 4 weeks; however severe cases may lead to permanent paralysis.
Hyperkalemic Periodic Paralysis
Authors: Simmons Brett , Matteson David
Published: March 2023

The review chapter on hyperkalemic periodic paralysis (HyperPP) examines the genetics, epidemiology, and pathophysiology of this hereditary neuromuscular disorder. It compares the disorder to another related skeletal muscle channelopathy, hypokalemic periodic paralysis. The role of the NaV1.4 sodium channel and the relationship between sodium and potassium homeostasis at the skeletal muscle cell membrane are reviewed. The clinical presentation, red flags, prevention, and treatment considerations, including the roles of acetazolamide, intravenous calcium, and glucose-rich foods, are summarized. The chapter highlights the most common and relevant triggers of HyperPP episodes. Finally, a discussion of the preoperative, intraoperative, and postoperative anesthetic considerations emphasizes the importance of avoiding high potassium levels, carbohydrate depletion, and other common triggers when caring for patients with HyperPP.
Hypokalemic Periodic Paralysis
Authors: Simmons Brett , Matteson David
Published: March 2023

The review chapter on hypokalemic periodic paralysis (HypoPP) examines the epidemiology, genetic basis, and pathophysiology of this rare hereditary channelopathy. It discusses diagnostic considerations, prevention, and treatment options, including the role of acetazolamide. Comparisons are made between type 1 HypoPP, which is caused by a defective dihydropyridine-sensitive calcium channel, and type 2 HypoPP, which results from a defective skeletal muscle sodium channel. The general presentation and prevention of the disorder are reviewed and contrasted with another disorder of potassium homeostasis producing muscle weakness, known as hyperkalemic periodic paralysis. Finally, a discussion of the preoperative, intraoperative, and postoperative anesthetic considerations highlights the importance of avoiding low potassium levels and common triggers when caring for patients with HypoPP.
Anesthetic Actions Different From Adults
Authors: Fadumiye Christopher O.
Published: March 2023

Anesthetic actions and clinical practices vary vastly from the adult population to the pediatric population. This chapter places emphasis on various practices and actions that differ in the nonadult population. Understanding the physiologic and pharmacological principles among neonates, infants, and children and how they compare to adults are primary focuses of this chapter. Specific focus is on how to approach anesthetic actions from a system-wise approach, a perioperative and anesthetic consideration approach, and potential medical and surgical considerations pertinent only to the pediatric population. The target audience is anesthesia residents in the United States and around the world. The chapter’s overall intention is to provide a quick, broad overview of anesthetic actions different from the adult population making, it a handy and quick review for board examination prep.
Thermal Regulation
Authors: Bennett David , Ohliger Shelley
Published: March 2023

Neonates rely primarily on nonshivering thermogenesis via brown adipose tissue to generate heat as they lack many of the mechanisms with which adults regulate their temperature, such as behavioral modifications and shivering. Nonshivering thermogenesis is inhibited by many of the drugs used in anesthesia, and given the unique anatomy of neonates, which includes increased body surface area to volume and reduced subcutaneous fat stores, as compared to the adult, hypothermia is a serious perioperative concern. Hypothermia is associated with respiratory depression, bradycardia, metabolic acidosis, coagulopathy, and decreased wound healing. Hyperthermia is most commonly iatrogenic in origin and is associated with tachycardia, dehydration, and lethargy.
Bronchopulmonary Dysplasia
Authors: Klein Jonathan W.
Published: March 2023

Bronchopulmonary dysplasia (BPD) is a profound lung condition affecting premature infants. Historically, this chronic lung disease was noted in premature infants who required prolonged oxygen therapy and mechanical ventilation. These patients that required high levels of oxygen and/or mechanical ventilation displayed high lung resistance due to fibrosis of the lung and airway inflammation from cytokine involvement. Severe BPD is regarded as “an infant’s need for supplemental oxygen requirement at 28 days of life and a greater than 30% oxygen and/or positive pressure at 36 weeks of corrected gestational age (CGA) in an infant born at less than 32 weeks of gestational age.” Mechanical ventilation strategies have emerged not only to manage severe BPD but also to aid in the prevention of this chronic lung condition.
Cyanotic Defects
Authors: Sinton Jamie W.
Published: March 2023

Cyanotic congenital heart disease (CCHD) is often complex, with multiple lesions present in a single heart. CCHD accounts for 1300 per million live births with congenital heart disease. This review covers the physiology of chronic cyanosis and adaptations and the common cyanotic heart diseases: hypoplastic left heart syndrome (HLHS), d-transposition of great arteries (d-TGA), and tetralogy of Fallot (TOF). Medical and surgical treatments as well as the usual palliative course are reviewed. Additionally, the spectrum of disease in TOF is classified. Late complications of these diseases are mentioned ; they are reviewed in the chapter on chronic congenital heart disease.
Major Vascular Malformations
Authors: Kloesel Benjamin , Horvath Balazs
Published: March 2023

Major vascular malformations encompass a wide variety of conditions. While some involve the peripheral vasculature, this chapter focuses on the group that affects central blood vessels. Within the group of congenital major vascular malformations, the chapter discusses (1) coarctation of the aorta, where the aortic isthmus is narrowed and impairs blood flow to the lower body; (2) patent ductus arteriosus, which describes the persistence of a fetal structure that allows blood to bypass the pulmonary circulation in utero, and its persistence after birth causes diastolic runoff into the pulmonary arteries, thereby jeopardizing lower body perfusion; and (3) vascular rings, a group of aortic arch abnormalities that can result in tracheal and esophageal compression.
Pyloric Stenosis
Authors: Batakji Mariam , Diaz Christina D.
Published: March 2023

Pyloric stenosis is a medical neonatal emergency that requires stabilization and eventual surgical intervention within the first few weeks of life. It is a result of idiopathic thickening of the pyloric musculature, leading to a gastric outlet obstruction syndrome. Infants present with projectile vomiting and various degrees of dehydration and metabolic derangements. Vomiting leads to hypochloremia hypokalemic metabolic alkalosis because of the depletion of gastric contents, which contains sodium, potassium, and hydrochloric acid. It is relatively common, with an incidence of 2 to 4 per 1000 live births, with a male predominance. It is crucial that before proceeding to the operating room, infants are resuscitated appropriately, and their electrolyte derangements have normalized. These infants are at high risk for aspiration because of the incomplete gastric emptying, therefore prompting the importance of preinduction suctioning of the stomach and consideration of a rapid sequence induction. The use of intravenous opioids should be avoided because of an increased risk of apnea and delayed awakening due to the persistent pH derangement in the cerebrospinal fluid. Extubation occurs at the end of the procedure when infants are fully awake with intact airway reflexes. Premature neonates less than 44–60 weeks of gestation should receive appropriate monitoring for postoperative apnea. Oral feeds are usually resumed 4 to 6 hours after surgery.
Omphalocele and Gastroschisis
Authors: Karroum Rami Edward
Published: March 2023

Omphalocele and gastroschisis are two distinct congenital anatomical defects of the abdominal wall. They are usually diagnosed in the antenatal period by fetal ultrasound. They are both considered surgical emergencies and need to have surgical repair soon after birth. Surgical repair of the defect is the only available treatment. Omphalocele is usually associated with other congenital anomalies, while gastroschisis may be associated with prematurity and low birth weight. Anesthetic considerations are similar for both defects, and they are often discussed together. The main objective of anesthesia is to preserve perfusion for the herniated viscera while maintaining normothermia, euvolemia, and acid-base/electrolyte balance.
Pneumo-, Hemo-, and Chylothoraces
Authors: Gyorfi Michael J. , Abd-Elsayed Alaa
Published: March 2023

The pleural space holds a negative pressure thanks to the elasticity of the lungs. Different pathologies result from injuries to the lung, with the pleural space losing its pressure gradient or being filled with something other than air. A pneumothorax, hemothorax, and chylothorax may all result from traumatic lung injuries and chronic lung conditions and ultimately result in decreased vital capacity, hypoventilation, and possibly decreased cardiac output. General anesthesia is a risk factor for countless conditions, and a pneumothorax is no exception. Although an intraoperative pneumothorax is rare, the incidence is approximately 0.5%. Management involves supplemental oxygenation and ultimately chest tube placement or surgical intervention.
Upper Respiratory Infections (Colds, Epiglottitis, Laryngotracheobronchitis), Bronchopulmonary Dysplasia, Cystic Fibrosis
Authors: Salik Irim , Kelley Ashley
Published: March 2023

Upper respiratory tract infections are the most common acute illnesses evaluated in an outpatient setting. They can range from the common cold, generally mild and self-limited, to more severe, potentially life-threatening, infections, including croup and epiglottitis. This chapter reviews the etiologies, common comorbidities, clinical interventions for treatment, and anesthetic implications of common upper respiratory tract infections as well as bronchopulmonary dysplasia and cystic fibrosis. The common cold is a viral infection of the upper respiratory tract that causes a substantial social and economic burden. Epiglottitis most commonly has a bacterial etiology and leads to a life-threatening inflammation of structures above the glottis. Croup is a pediatric respiratory tract illness that represents the most common cause of inspiratory stridor, barking cough, and hoarseness in febrile children. Bronchopulmonary dysplasia is a form of chronic lung disease that develops in preterm neonates commonly treated with positive pressure ventilation and oxygen therapy. Cystic fibrosis is a multisystemic disease of the exocrine glands that results in chronic respiratory infections, with end-stage lung disease as the leading cause of death. Anesthesiologists should be well versed in the perioperative considerations and implications for each of these disease processes.
Skeletal Abnormalities in Children
Authors: Montone Gina , Adams Jonathan
Published: March 2023

Abnormal development of bone or cartilage in children causes many alterations in anatomy and physiology. With over 400 distinct syndromes and subtypes, it is notable that there is an incidence of 15.7 per 100,000 live births of disproportionate shortening of limbs or trunks. Down syndrome is the most common genetic disorder, with other disorders, such as achondroplasia, Klippel-Feil syndrome, Marfan syndrome, osteogenesis imperfecta, and Morquio syndrome, also being relatively common. These syndromes can present anesthetic challenges, such as difficulty with intubation, proper positioning, and management of cardiopulmonary comorbidities. These issues should be anticipated when determining an anesthetic plan for these children.
Trisomy 21 (Down Syndrome) and VATER Association
Authors: Batakji Mariam , Diaz Christina D.
Published: March 2023

A syndrome is an association of phenotypical traits that occur together due to a specific genetic abnormality. Diagnosis of genetic disorders is usually done through karyotyping, chromosomal microarray (CMA), or fluorescence in situ hybridization (FISH). Due to medical advancements in the management of these children and their increased life span, more of these children are presenting for anesthesia for diagnostic and therapeutic procedures. Therefore, it is important to understand the specifics of each syndrome and the anesthetic considerations and challenges in order to provide a safe anesthetic. Trisomy 21 is the most common chromosomal disorder in live-born infants and occurs in one in 700–800 infants. Trisomy 21 (Down syndrome) affects almost all organ systems and poses specific anesthetic challenges. This chapter summarizes the clinical manifestations of Down syndrome and the different anesthetic considerations and challenges that might be faced during preoperative, intraoperative, and postoperative periods.
Pediatric Anesthesia Outside the Operating Room
Authors: Masters Hannah , Diaz Christina D.
Published: March 2023

The chapter on pediatric anesthesia outside the operating room (OOR) examines the unique procedures and anesthetic considerations for providing safe patient care outside of the traditional OR environments, where pediatric anesthesia providers are increasingly more involved in diagnostic and therapeutic procedures. Anesthesia services can be required for diagnostic imaging and interventions, including computed tomography (CT), magnetic resonance imaging (MRI), interventional radiology, nuclear medicine, and radiation therapy. Each OOR location has its own unique considerations related to the needs of the team, procedure, and patient. Proceduralist considerations include patient positioning and the need for breath holds. Procedure-related considerations include the use of intravenous contrast, radiation exposure, MRI contraindications and compatibility, as well as patient monitoring challenges from a distance. Patient factors include appropriate preoperative assessment of comorbidities and fasting (nothing by mouth [NPO] status.
Oxytocic Drugs
Authors: Al-Jindi Piotr , Shah Nimit K.
Published: March 2023

It is estimated that postpartum hemorrhage affects 10% of deliveries. Oxytocic drugs are used to increase uterine tone and for the prevention of postpartum hemorrhage and its treatment. They are divided into three groups: oxytocin, prostaglandins, and methylergonovine. Oxytocin can be used in prevention and treatment, and it is considered the first-line treatment for postpartum hemorrhage. It can be given intravenously and intramuscularly. The most common side effect is hypotension. Second-line drugs include Carboprost (IM, intrauterine), which is contraindicated in asthma due to its ability to induce bronchospasm; Misoprostol (per rectum, sublingually) is safe in asthma; and methylergonovine (IM), which is contraindicated in hypertension.
Fetal Disposition of Drugs
Authors: Heidari Afshin , Aquino Ben
Published: March 2023

Fetal Disposition of Drugs looks at maternally administered medications and their effects on fetal well-being and development. Due to immature metabolism and potentially teratogenic consequences during organogenesis, fetal disposition of medications is critically important. The first trimester of pregnancy is especially important due to the organogenesis that takes place during this period; drugs given during this time are important. The chapter also looks at medications that are commonly given in the perinatal period and the effects they can have on fetal well-being. Placental characteristics and fetal physiology also play roles in the fetal disposition of drugs, and these are examined as well.
Respiratory Disorders
Authors: O’Conor Devin , Chung Kevin W.
Published: March 2023

Respiratory failure represents a significant source of morbidity in the pregnant population. While a variety of etiologies exists, this group presents a unique challenge to the anesthesiologist. In patients who have airway hyperresponsiveness, tracheal intubation can be a potential trigger for bronchospasm in the perioperative period. β2-Agonists are a mainstay of therapy for bronchospasm treatment, although these medications carry the risk of decreasing uterine tone. By administering β2-agonists locally via aerosolization, their systemic effects can be minimized. Neuraxial anesthesia is often the gold standard for parturients with respiratory disease as it allows the provider to provide adequate analgesia and surgical conditions while minimizing airway manipulation. When neuraxial techniques are not an option, the decision of how to proceed must take into account the risk of aspiration, airway reactivity, uterine tone, and hormonal and physiologic changes during pregnancy.
Renal Changes in Pregnancy
Authors: Shah Jarna
Published: March 2023

Pregnancy is associated with multiple changes in renal physiology and function. Physiologic renal dysfunction can adversely affect the health of the fetus and mother. These impact anesthetic and peripartum management of the parturient. Maternal hormone shifts, including elevated progesterone levels, affect glomerular filtration rates, creatinine clearance, and kidney blood flow. Normal pregnancies demonstrate upregulation in the renin-angiotensin-aldosterone system, an increase in circulating volume, and glomerular hyperfiltration and decreases in oncotic pressures, among many other changes. Normal laboratory values in an adult nonpregnant patient are not considered to be normal in the parturient. If abnormalities are detected, these laboratory tests should be monitored closely in the peripartum period.
Aspiration of Gastric Contents
Authors: Ahmed Muhammad Fayyaz , Kamel Ihab
Published: March 2023

The risk for aspiration pneumonia is increased during pregnancy. The reported incidence of aspiration pneumonia has significantly dropped in recent years due to liberal use of neuraxial anesthesia. Aspiration of a significant volume of particulate acidic gastric contents can lead to higher morbidity and mortality. Factors determining the morbidity and mortality associated with aspiration include the type and volume of aspirate, the therapy administered, the physical status of the patient, and the criteria used for making the diagnosis. Aspiration pneumonia is best managed by prevention using pharmacological agents and rapid sequence induction. If aspiration occurs, prompt recognition of the complication and following current management recommendations may limit the extent of lung injury.
Cord Prolapse
Authors: Ahmed Muhammad Fayyaz , Kamel Ihab
Published: March 2023

Umbilical cord prolapse is an obstetric emergency. The prolapse occurs when the cord slips ahead (overt umbilical cord prolapse) or alongside (occult umbilical cord prolapse) the presenting part of the fetus and protrudes into the cervical canal or beyond. Compression of the prolapsed cord leads to occlusion of the umbilical vein and vasospasm of the umbilical artery, which compromises fetal oxygenation. The discussion includes common risk factors, prevention, pathophysiology, clinical presentation of cord prolapses, prevention, and management to improve neonatal outcome. The anesthetic technique that provides the shortest induction time is the best choice. Although regional anesthesia can be used, general anesthesia is usually chosen for an emergent delivery.
Neonatal Resuscitation
Authors: Salik Irim , Doherty Tara
Published: March 2023

The ability to provide appropriate life-saving resuscitation techniques in the first minute of life can play a crucial role in an infant’s overall survival and well-being. A small fraction of neonates will require respiratory assistance, and even fewer will necessitate cardiac intervention. Proper clinical assessment as well as the application of evidence-based guidelines are integral to proper management of newborn infants. A few examples of preexisting risk factors such as prematurity, maternal disease, meconium aspiration, and asphyxia can predispose to the birth of nonvigorous infants. Although the vast majority of infants will respond to gentle stimuli, others will necessitate ventilatory support, chest compressions, or medication administration, including epinephrine. Appropriate thermoregulation is also critical to reduce infant morbidity and mortality. Preparedness for neonatal resuscitation requires assessment of perinatal risk, assembly of experienced personnel to initiate intervention, access to appropriate supplies and equipment, and standardization of behavioral skills that enable effective communication and teamwork.
Umbilical Cord Blood Gas
Authors: Tarwade Pritee , Acho Christine
Published: March 2023

Umbilical cord blood gas along with the Apgar score is a useful tool to assess fetal well-being. Both umbilical artery and venous blood samples should be obtained, especially in case of fetal distress, to differentiate placental insufficiency from cord abnormalities. There is a strong correlation between umbilical cord gas abnormalities and fetal morbidity and mortality, but no proven predictive value has been found. Choice of anesthesia for labor analgesia and cesarean section and its effect on umbilical cord gas has been extensively studied but failed to show any consistent correlation. Factors that are deemed predictive of decreasing umbilical arterial pH are maternal body mass index (BMI), noncephalic presentation, spinal start to delivery interval, uterine incision to delivery, and maximum reduction in blood pressure from baseline.
Intrauterine Surgery
Authors: Shah Jarna
Published: March 2023

Many fetal abnormalities can be treated in the antepartum period. However, often with certain underlying conditions, intervention is required prior to delivery. Techniques utilized include minimally invasive surgery, open fetal surgery, and ex utero intrapartum treatment (EXIT) procedures. Fetal surgery prior to delivery, otherwise known as maternal-fetal surgery, is a very specialized intervention. It is considered only for select fetal conditions or when delivery prior to surgical correction would be associated with high morbidity or mortality rates. This procedure is offered at a select number of large academic centers, and these patients require complex care, with management including both maternal and fetal considerations.
Liposuction
Authors: Cole Alexandra N. , Sharma Balram
Published: March 2023

Liposuction is a popular cosmetic surgery technique used for expedient weight loss. The development of tumescent lidocaine has allowed for extensive liposuction with large volumes of aspiration and has quickly become the technique of choice. It is a cosmetic surgery procedure where metal cannulas are inserted through small incisions into the subcutaneous adipose tissue and large aspiration volumes are suctioned into a canister using negative pressure. Careful preoperative evaluation is necessary due to the toxicity of lidocaine and volume shifts associated with large-volume techniques. The maximum dose of lidocaine has been shown to be 35–55 mg/kg and reaches peak plasma level 10–14 hours after injection. The most common complication of liposuction is pulmonary embolism (thromboembolism or fat embolism).
Orthopedic Anesthesia
Authors: Thomas Alberto , Bang Jason
Published: March 2023

Tourniquet cuff pressure is recommended to be done with the lowest amount of pressure possible. Current methods, such as limb occlusion pressures (LOP), are utilized to minimize the required pressure. Although tourniquet time and pressure continue to be controversial, the recommended time of cuff inflation is 90–120 minutes, and if the anticipated time will last longer, the cuff should be deflated for 10 minutes every 1-hour interval. Air embolism in orthopedic procedures may occur when a pressure gradient is in favor of entry through a blood vessel that is open. This complication should be considered in any procedure where the surgical field is above the level of the heart. Fat embolism syndrome relates to fat embolization and bone marrow debris that, when released, may produce a vascular blockage. Another important complication to consider is compartment syndrome. Coexisting diseases such as rheumatoid arthritis will have disorders such as atlantoaxial subluxation and temporomandibular joint involvement. The use of regional anesthesia in orthopedic surgery has shown its advantages over general anesthesia. Among the most important advantages are postoperative pain management and reductions in perioperative complications, such as venous thromboembolism, myocardial infarction, respiratory depression, and bleeding complications.
Multiple Organ Dysfunction Syndrome
Authors: Shehata Peter , Sakr Esa Wael Ali
Published: March 2023

Multiple organ dysfunction syndrome (MODS) is a spectrum of physiologic maladaptation in separate organs that leads to significant morbidity and mortality in intensive care unit patients. This dysfunction is rooted in the dysregulated immune response and imbalance of the pro-inflammatory and anti-inflammatory responses to a degree that homeostatic mechanisms fail to self-regulate. As a result, multiorgan failure and significant organ injury occurs. MODS is defined and quantified by assessment of injury to six vital organ systems: cardiovascular, respiratory, hepatic, renal, hematologic, and neurologic systems. Some studies have defined a numerical scaling system to quantify the degree of organ dysfunction and relative outcome measures associated. To date, the best therapy is supportive care and avoidance of further injury. It is quite evident to us that the single most effective intervention is one of primary prevention, whereby we try to prevent the failure of organs as they show manifestations of early involvement.
Infection Control
Authors: Jury David , Noguera Edward
Published: March 2023

Nosocomial infections complicate patient management and increase hospital mortality. Hospital-related infections are, to a great degree, preventable. Healthcare providers are considered vectors of some hospital-related infections because of suboptimal hand hygiene habits. In addition, healthcare providers are potentially exposed to contagious infections that can be acquired due to poor compliance with infection prevention strategies. Standard precautions for infection prevention include hand hygiene, basic personal protective equipment (PPE), and safe injection practices and should be used with all patients. Situational awareness, optimization of infection precautions, standards compliance, and continuous quality improvement are of fundamental importance to protect the well-being of healthcare workers and patients.
Ethics, Practice Management, Professionalism, and Medicolegal Issues
Authors: Siddiqui Shahla
Published: March 2023

Aspects of ethical care, patient information confidentiality as well as patient safety are important aspects of professionalism and licensure, which are related in all aspects of patient care. Professionalism is one of the most important core competencies and is codified in the recent milestones advocated in the residency and fellowship training programs. The role of licensing bodies is to forge and ensure the trust between physicians and society is preserved by maintaining the highest standards of medical and professional conduct. Medical licensure is linked to the continued maintenance of the code of ethical and professional behaviors. These issues are discussed in this chapter and relevant guidelines are alluded to.