bluuebunny/crossref_metadata_2025 huggingface dataset:
Takayasu’s arteritis
Authors: Kobayashi Yasushi
Published: April 2017

Takayasu’s arteritis is a chronic granulomatous vasculitis of unknown cause characterized by stenosis, occlusion, and aneurysm of large elastic arteries, mainly the aorta and its branches. It mainly affects young women, predominantly in Asian, Middle Eastern, and South American countries.

Clinical presentation—symptoms in the acute stage are nonspecific, such as general fatigue and fever, which can persist for months to years. Symptoms in the chronic stage depend on the anatomical location of the vascular lesions, with typical complaints relating to ischaemia of the brain, eyes, or arms. The commonest finding on physical examination is a weak or absent pulse in one or both brachial, radial, and/or ulnar arteries. Bruits can often be heard over affected arteries. Hypertension and aortic insufficiency are strongly associated with poor prognosis....
Secondary hypertension
Authors: Brown Morris J. , Mir Fraz
Published: April 2017

The term ‘secondary hypertension’ is used to describe patients whose blood pressure is elevated by a single, identifiable cause, with an important subdivision being into reversible and irreversible causes: clinically, it is important to exclude the former, but not necessarily to find the latter.

In the first two decades of life, the prevalence of secondary hypertension is greater than that of essential hypertension; thereafter, a patient is much more likely to have essential hypertension, but investigations for secondary hypertension should still be assiduous in the twenties and thirties because the alternative entails so many years of tablet-taking....
Rheumatoid arthritis
Authors: Nath Maini Ravinder
Published: April 2017

Rheumatoid arthritis (RA) is a common, painful, and disabling disease affecting 0.8 to 1.0% of the adult population worldwide, with a female:male ratio of 3:1.

The predominant feature of the disease is a deforming and destructive polyarthritis, with (less commonly) extra-articular manifestations such as subcutaneous nodule formation, serositis, vasculitis, fibrosing alveolitis, amyloidosis, and Felty’s syndrome. Patients also exhibit systemic features of inflammation, including fatigue, anaemia, weight loss, a raised erythrocyte sedimentation rate (ESR), and elevated concentrations of acute phase proteins....
Peritoneal dialysis
Authors: Davies Simon
Published: April 2017

Abbreviations: CAPD, Continuous ambulatory peritoneal dialysis; APD, automated peritoneal dialysis; CKD Chronic Kidney Disease; AKI, Acute kidney injury; EPS, Encapsulating Peritoneal Sclerosis.

Peritoneal dialysis is achieved by repeated cycles of instillation and drainage of dialysis fluid within the peritoneal cavity, with the two main functions of dialysis—solute and fluid removal—occurring due to the contact between dialysis fluid and the capillary circulation of the parietal and visceral peritoneum across the peritoneal membrane. It can be used to provide renal replacement therapy in acute kidney injury or chronic kidney disease....
Antiglomerular basement membrane disease
Authors: Levy Jeremy , Pusey Charles
Published: April 2017

Antiglomerular basement membrane disease (anti-GBM disease, also known as Goodpasture’s disease) is a rare autoimmune disease caused by pathogenic autoantibodies directed against the noncollagenous, C-terminal domain of the α‎-3 chain of type IV collagen (α‎3(IV)NC1). Immunohistology is characteristic, with linear deposition of IgG (sometimes with IgA or IgM) and complement C3 along the GBMs....
Infection-associated nephropathies
Authors: Neil Turner A
Published: April 2017

Infection may be a primary cause of renal disease (e.g. postinfectious glomerulonephritis) or affect the kidneys on a background of debilitating illnesses and previous medical interventions. Renal disease may arise as a consequence of immune responses to a pathogen, direct invasion by the microorganism, or the effects of infection on the systemic or local circulations....
The renal tubular acidoses
Authors: Sayer John A. , Karet Fiona E.
Published: April 2017

Renal tubular acidosis (RTA) arises when the kidneys either fail to excrete sufficient acid, or are unable to conserve bicarbonate, both circumstances leading to metabolic acidosis of varying severity with altered serum potassium. Proximal and distal types of RTA can be differentiated according to which nephron segment is malfunctioning. The condition may be secondary (e.g. associated with drugs, autoimmune disease, or diabetes mellitus) or inherited, and there may be renal tract calcification and—in chronic cases—metabolic bone disease....
Fluid and electrolyte physiology in anaesthetic practice
Authors: Hahn Robert G.
Published: April 2017

The maintenance of body fluid homeostasis is an essential task in perioperative care. Body fluid volumes are tightly controlled by the nervous system, by hormones, and by the kidneys. All these systems are affected by anaesthesia and surgery in ways that must be appreciated by the anaesthetist. Administration of infusion fluids is the key tool to prevent major derangements of the body fluid volumes during before, during, and after surgery. By varying its composition, an infusion fluid can be made to selectively expand or shrink a body fluid compartment. The total osmolality determines whether the infused volume distributes over the total body water or over the extracellular fluid volume, or even attracts fluid from intracellular space. Infusion fluid is the first-line tool in the management of the vasodilation that is induced by both general and regional anaesthesia. Fluids are also an essential component in the treatment of haemorrhage, in which a reduction in arterial pressure implies that 20% of the blood volume has been lost. Capillary refill restores the blood volume, but too slowly to prevent haemorrhagic shock. In this situation, prompt intravenous fluid therapy is life-saving. Electrolyte derangements may be induced by disease and/or medication. The most essential ones to consider during anaesthesia are sodium, potassium, calcium, and bicarbonate.
Neuromuscular physiology in anaesthetic practice
Authors: Hopkins Philip M.
Published: April 2017

The pharmacological interventions that constitute general anaesthesia are targeted at producing unconsciousness and an immobile patient even in response to noxious stimuli. Surgical anaesthesia also requires skeletal muscle relaxation, the degree of which depends on the site and nature of the surgical procedure. The anaesthetist therefore needs an advanced level of knowledge and understanding of the function of nerves, synapses, and muscle in order to understand, from first principles, how the drugs they use every day mediate their effects. Nerves and muscle cells are termed excitable cells because the electrical potential across their cell membranes (membrane potential) can be rapidly and profoundly altered because of the presence of specialized ion channels. Some drugs, such as local anaesthetics, act on ion channels involved in nerve conduction while many others act on synaptic transmission, the neurochemical communication between neurons or between a neuron and its effector organ. The neuromuscular junction is a synapse of specific interest to anaesthetists because it is the site of action of neuromuscular blocking drugs. This chapter covers the fundamentals of cellular electrophysiology, structure and function of key ion channels, and the physiology of nerves, synapses, and skeletal muscle.
Pain physiology in anaesthetic practice
Authors: Colvin Lesley A. , Fallon Marie T.
Published: April 2017

The International Association for the Study of Pain defines pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’. A good understanding of the physiology of pain processing is important, with recent advances in basic science, functional neuroimaging, and clinical pain syndromes contributing to our understanding. It is also important to differentiate between nociception, the process of detecting noxious stimuli, and pain perception, which is a much more complex process, integrating biological, psychological, and social factors. The somatosensory nervous system, from peripheral nociceptors, to sensory nerves and spinal cord synapses has many potential sites for modulation, with ascending pathways to the brain, balanced by ‘top-down’ control from higher centres. Under certain circumstances, for example, after tissue injury from trauma or surgery, there will be continued nociceptive input, with resultant changes in the whole somatosensory nervous system that lead to development of chronic pain syndromes. In such cases, even when the original injury has healed, the pathophysiological changes in the nervous system itself lead to ongoing pain, with peripheral or central sensitization, or both. Additionally, in some chronic pain syndromes, for example, chronic widespread pain, it has been postulated that abnormalities in central processing may be the initiating factor, with some evidence for this from neuroimaging studies. Further work is needed to fully understand pain neurobiology in order to advance our management.
The physiology of blood in anaesthetic practice
Authors: El Kenz Hanane , Van der Linden Philippe
Published: April 2017

Following the discovery of the ABO blood groups by Landsteiner in 1901, Albert Hustin described the first transfusion of a whole blood unit in 1914. The modern transfusion era really begins in 1916 with the discovery of sodium citrate as an anticoagulant by the same physician, allowing blood conservation in dedicated packs. Since that time, many advances have been made especially over the past two decades in the storage, the conservation, and the laboratory testing of blood components and in transfusion medicine practice. Transfusion of whole blood has been replaced by blood component therapy, which consists of the administration of packed red blood cells, fresh frozen plasma, or platelets. Although blood transfusion is safer than ever, the risk of complications will never reach zero. The risk of infectious transfusion-transmitted diseases has been markedly reduced by the implementation of extensive infectious disease testing, donor selection, and pathogen-inactivation procedures. In countries with a high human development index, the leading causes of allogeneic blood transfusion-related deaths actually resulted from immunological and septic complications. The first section of this chapter describes the structure, function, and immunological aspects of the different blood components that are routinely transfused today. The second section details the composition of the different blood components, their indications, the pre-transfusion compatibility tests, and the main adverse effects associated with their transfusion.
Mechanisms and determinants of anaesthetic drug action
Authors: Lambert David G.
Published: April 2017

This chapter is broken into two main sections: a general description of the principles of ligand receptor interaction and a discussion of the main groups of ‘targets’; and explanation of some common pharmacological interactions in anaesthesia, critical care, and pain management. Agonists bind to and activate receptors while antagonists bind to receptors and block the effects of agonists. Antagonists can be competitive (most common) or non-competitive/irreversible. The main classes of drug target are enzymes, carriers, ion channels, and receptors with examples of anaesthetic relevance interacting with all classes. There are many examples in anaesthesia where multiple interacting drugs are co-administered—polypharmacology. To give an example: neuromuscular blockade. Rocuronium is a non-depolarizing neuromuscular blocker acting as a competitive antagonist at the nicotinic acetylcholine receptor. Rocuronium competes with endogenous acetylcholine to shift the concentration–response curve for contraction to the right. The degree of contractility is less for a given concentration of acetylcholine (agonist) in the presence of rocuronium. Using the same principle, the rightward shift can be compensated by increasing the amount of acetylcholine (as long as the amount of rocuronium presented to the receptor as an antagonist remains unchanged, its action can be overcome by increased agonist). Acetylcholine at the effect site is increased by acetylcholinesterase inhibition with neostigmine. One of the side-effects of neostigmine is that it acts as an indirect parasympathomimetic. In the cardiovascular system this would lead to muscarinic receptor-mediated bradycardia; these effects are routinely reversed by the competitive muscarinic antagonist glycopyrrolate.
Analgesics in anaesthetic practice
Authors: Williams John , Bonnet Francis
Published: April 2017

Each year, approximately 230 million major surgical procedures are undertaken worldwide, with over three-quarters of the patients complaining of pain postoperatively and 10% complaining of severe pain. Pain is not, however, just an unpleasant sensory consequence of surgery, but can also have significant physiological implications impacting negatively on well-being and postoperative outcome. Postoperative pain may also result in changes within the central nervous system, leading to the development of chronic pain states lasting in excess of 3–6 months. Adequate analgesia has proven to be effective when employed in the perioperative period at combating many of these adverse effects. An understanding of the basic physiological and pharmacological mechanisms responsible for producing, transmitting, and sustaining pain has allowed for a variety of effective analgesic agents to be fashioned and used clinically to treat pain. Morphine, the archetypal opioid analgesic, is the most familiar of these agents with a long history of use and evidence of effectiveness; morphine possesses a number-needed-to-treat (NNT) to reduce pain by 50% of around 3 when given in doses of between 10 and 15 mg. Non-steroidal agents and paracetamol are similarly effective in the immediate postoperative period with NNTs of between 2 and 4. More recently, a number of analgesic adjuncts such as gabapentin, pregabalin, ketamine, clonidine, and nefopam have found favour for the treatment of acute postoperative pain. None of these agents, however, are without side-effects, ensuring that the search for effective analgesic agents continues to be a vibrant area of research with new analgesic agents continuing to be developed.
Cardiovascular drugs in anaesthetic practice
Authors: Schwarte Lothar A. , Loer Stephan A. , Götz Wietasch J. K. , Scheeren Thomas W. L.
Published: April 2017

Anaesthetists should be familiar with currently available cardiovascular drugs used to maintain cardiovascular stability and achieve haemodynamic goals in surgical patients. The first part of this chapter summarizes antihypertensive agents, and the second part discusses positive inotropic drugs and vasopressors, which can be used perioperatively. Selection of vasoactive agents should be guided by the therapeutic goal (e.g. decreasing or increasing blood pressure or blood flow) and the underlying pathophysiology. Choice of catecholamines in a given situation should be based on the desired effects, that is, goals that can be monitored. Generally speaking, it is easier to affect blood pressure than cardiac output, and how to optimize regional and microcirculatory blood flow remains uncertain. Regardless of the chosen intervention, its haemodynamic effects should be closely monitored and always evaluated against the clinical effects. Recent developments include the definition of haemodynamic goals (goal-directed therapy) and clinical end-points, which seem to decrease morbidity and mortality, regardless of the goals defined and interventions used. With regard to mortality, use of inotropic agents has been associated with adverse outcomes, whereas the use of vasodilators has not. Inotropes in combination with vasodilators have the highest mortality.
Intravenous fluids in anaesthetic practice
Authors: Hahn Robert G.
Published: April 2017

Infusion fluids may be regarded as drugs in the perioperative setting. The therapeutic effects of crystalloid solutions are strongly related to the administered volume, while fluids of the colloid type may also improve microcirculation and have anti-inflammatory properties. The anaesthetist should be able to handle all available infusion fluids and be aware of their benefits, limitations, and risks. Fluid administration programmes for surgery are traditionally based on a balance method in which perceived and measured losses are continuously replaced. Two outcome-guided approaches—restrictive and goal-directed fluid therapy—have been added in recent years. The latter places all patients on the top of the Frank–Starling curve by titrating repeated bolus infusions of colloid fluid while observing the stroke volume response. Areas where special consideration should be given to fluid therapy include burn injury, children, day surgery, endoscopic surgery, neurosurgery, induction of spinal and epidural anaesthesia, and in septic and trauma-related shock. As volume is the key component of infusion fluids, kinetic analysis of their disposition is based on their dilution effect on components already present in the blood, usually haemoglobin.
Measurement and monitoring in anaesthesia
Authors: Magee Patrick , Tooley Mark
Published: April 2017

This chapter introduces some basic physical principles that contribute to the function of various monitors used in anaesthetic practice. Topics include biological signal processing, operational amplifiers, including single-ended amplifiers, and the benefit of patient-isolated differential amplifiers; it includes filtering, digital processing, and electrodes. The generic principles of transducers are introduced, including resistive, capacitive, and inductance strain gauges used in transducers, photoelectric, piezoelectric, and chemical transducers, calibration of transducers, and the significance of resonance and damping in measurement systems. Since both are widely used in monitoring systems, there is an introduction to spectroscopy and magnetism.
Presentation and handling of data, descriptive and inferential statistics
Authors: Alexander Peter D. G. , Columb Malachy O.
Published: April 2017

The need for any doctor to comprehend, assimilate, analyse, and form an opinion on data cannot be overestimated. This chapter examines the presentation and handling of such data and its subsequent statistical analysis. It covers the organization and description of data, measures of central tendency such as mean, median, and mode, measures of dispersion (standard deviation), and the problems of missing data. Theoretical distributions, such as the Gaussian distribution, are examined and the possibility of data transformation discussed. Inferential statistics are used as a means of comparing groups, and the rationale and use of parametric and non-parametric tests and confidence intervals is outlined. The analysis of categorical variables using the chi-squared test and assessing the value of diagnostic tests using sensitivity, specificity, positive and negative predictive values, and a likelihood ratio are discussed. Measures of association are covered, namely linear regression, as is time-to-event analysis using the Kaplan–Meier method. Finally, the chapter discusses the statistical analysis used when comparing clinical measurements—the Bland and Altman method. Illustrative examples, relevant to the practice of anaesthesia, are used throughout and it is hoped that this will provide the reader with an outline of the methodologies employed and encourage further reading where necessary.
Evidence-based medicine in anaesthesia
Authors: Møller Ann Merete
Published: April 2017

Evidence-based medicine (EBM) is defined as ‘The judicious use of the best current evidence in making decisions about the care of individual patients’. Evidence-based medicine (EBM) is meant to integrate clinical expertise with the best available research evidence and patient values. The purpose of EBM is to assist clinicians in making the best decisions. Practising EBM includes asking an answerable, well-defined clinical question, searching for information, critically appraising information retrieved, extracting data, synthesizing data, and making conclusions about the overall effect. The clinical question includes information of the following elements: the population, the intervention, and the clinically relevant outcomes in focus. The clinical question is a tool to make the focus of the question clearer, and an aid to build the following search strategy. A comprehensive and reproducible literature search is essential for conducting a high-quality and up-to-date search. The search should include all relevant clinical databases. Papers retrieved after the search must be critically appraised and evaluated for the risk of bias. Evidence-based methods are used in the production of systematic reviews, and the development of clinical guidelines. Whether a meta-analysis should be performed depends on the quality and nature of the extracted data. Practising EBM may be challenged by a lack of well-performed trials, various types of bias (including publication bias), and heterogeneity between existing trials. Several tools have been constructed to help the process; examples are the CONSORT statement, the PRISMA statement, and the AGREE instrument.
Informatics and technology for anaesthesia
Authors: Madden Anthony P.
Published: April 2017

Health informatics is concerned with the structure, acquisition, and use of health information. Its origins can be traced back to the publication of Bills of Mortality by the parishes of London in the sixteenth century. Interest in health information accelerated during the late nineteenth century with the development of an internationally recognized classification of the causes of death. Further work on the classification of diseases and causes of death has resulted in the ICD-10, while SNOMED CT provides an international thesaurus of medical terms suitable for use in computerized medical record systems. In 1932, Tovell and Dunn described the systematic collection of data about anaesthetics with the aim of identifying areas for improvement. The improvement of healthcare is the main driver for the implementation of electronic patient record systems in hospitals. A natural corollary is the implementation of computerized anaesthetic information management systems. Computerized record systems can automatically store the output of physiological monitors and reduce errors with active and passive decision support. Although the recording and processing of health information in the twenty-first century almost always involves the use of computers, this can give rise to problems with security and inter-operability. Computer technology also has other uses in modern anaesthetic practice. The modelling of physiological processes and the use of simulators in the training of anaesthetists are good examples.
Safety and quality assurance in anaesthesia
Authors: Staender Sven , Smith Andrew
Published: April 2017

Quality assurance has its roots in industry and therefore is strongly influenced by concepts from business, hence the reference to the definition of the term ‘quality’ according to the International Standard Organization (ISO), for example. In order to better understand the various concepts of quality assurance, this chapter clarifies concepts such as ‘effectiveness’, ‘efficiency’, ‘patient-centredness’, and ‘equity’. Of major importance in clinical medicine are guidelines, standards, recommendations, and their grade of evidence. Guidelines in particular have the advantage of facilitation of the practice of evidence-based medicine in that they can provide a practically orientated summary of the relevant research literature. Other important tools for quality assurance include ‘plan–do–study–act’ (PDSA) cycles, process mapping, monitoring of outcome indicators, auditing, and peer review. Patient safety is another rather young discipline in academic medicine. Triggered by the landmark publication of To Err is Human by the US Institute of Medicine (IOM) in 1999, patient safety gained widespread attention in healthcare. Anaesthesiology as a typical safety discipline was among the first to adopt safety measures such as ‘incident reporting’ or ‘human factors training’ years before the IOM report. Safety is closely related to outcome and therefore mortality, morbidity, as well as adverse events in general have to be considered. In order to improve, safety lessons can be learned from the so-called high-reliability organizations and transferred into clinical practice.
Research in anaesthesia
Authors: Minto Gary , Sneyd J. Robert
Published: April 2017

Clinicians need critical appraisal skills to weigh up the quality of the literature and to decide whether it has implications for their practice. Every belief in medicine is a construct created from the limited information available and carries a degree of uncertainty. A centralized approach to research identifies the highest priority areas of uncertainty so as to bring about the most improvement for the largest number of patients. This patient-centred model classifies studies into basic science, translational, and clinical research. Adequately powered mega-trials are required to bridge the translational gap between efficacy (does a treatment work?) and effectiveness (does a treatment work when applied in ordinary clinical practice?). There is a paucity of these in perioperative medicine.
Outcomes of anaesthesia
Authors: Ash Simon A. , Buggy Donal J.
Published: April 2017

Prevailing attitudes and conviction maintain that anaesthetic management, while ensuring safety, analgesia, and comfort perioperatively, has little influence on long-term patient outcomes. Gradually accumulating evidence is challenging this conventional wisdom, suggesting that choice of anaesthetic technique and perioperative management may, on the contrary, exert previously unrecognized long-term influences. This chapter seeks to review topical aspects of anaesthesia management which may influence postoperative patient outcomes. These include cardiovascular and pulmonary outcomes, surgical site infection, blood transfusion, perioperative glycaemic control, cancer recurrence, the development of chronic persistent pain, and postoperative cognitive dysfunction.
Management of anaesthesia
Authors: Moppett Iain
Published: April 2017

Successful management of anaesthesia requires expertise in the triad of knowledge, technical skills, and non-technical skills. The decision-making and techniques chosen should all be focused on patient safety, followed by patient comfort and efficiency. There is increasing evidence that anaesthesia management has an influence on patient outcome beyond the first couple of postoperative days. This chapter provides an overview of some of the key aspects of management of anaesthesia: the importance of proper preparation at all stages; the evidence—or lack thereof—for choices between techniques and drugs; and the key role of effective communication by the anaesthetist.
The airway in anaesthetic practice
Authors: Frerk Christopher , Asai Takashi
Published: April 2017

This chapter provides a comprehensive review of current airway management set against its historical context and likely future developments in the field. Developments in equipment design are discussed against the background of a short review of the anatomy and physiology relevant to clinical airway management. An exploration of airway devices examines progress in design from the first facemasks and early hands-free delivery systems, through to current second-generation supraglottic airways and the future of providing improved protection against aspiration. Continuing advances in tracheal tube and cuff design are set alongside developments in techniques and equipment for laryngoscopy and possibilities for supplementing capnography in confirmation of correct tube placement within the trachea. The use of newer drugs to facilitate control of airway reflexes is also discussed. The importance of using optimal evidence-based techniques in airway management is highlighted in the reduction of complications. This covers preoperative evaluation of the airway, planning a strategy, induction of anaesthesia, and establishing a clear airway through to safe termination of anaesthesia, emergence, tracheal extubation, and recovery. Techniques for dealing with complications if they arise are described. Drawing on lessons from the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society ‘Major complications of airway management in the United Kingdom’ (NAP4) and the general literature, emphasis is placed on high-risk areas of airway management and areas where the existing knowledge base is not covered in depth in other texts.
Conscious sedation
Authors: Knape Johannes (Hans) T. A.
Published: April 2017

After a thorough introduction to conscious sedation, including the reasons for the increase in demand for assistance for moderate (conscious)-to-deep sedation in medicine over recent decades, this chapter covers some key definitions, before moving on to morbidity, mortality, and safety. The chapter then discusses how to prepare the patient for sedation, including the issue of whether the patient should have fasted prior to sedation and the screening of patients for sedation. It looks at the necessary qualifications and responsibilities of a sedation practitioner, and the monitoring of patients undergoing moderate-to-deep sedation: this includes monitoring of the ventilation via pulse oximetry, monitoring the efficacy of spontaneous ventilation via capnography, monitoring of the circulation, ECG monitoring, and monitoring the depth of sedation. Routine oxygen administration is also discussed, as are emergency interventions and resuscitation, and recovery and discharge of the patient following moderate-to-deep sedation. The chapter finishes with a discussion of the techniques and drugs used in sedation, and specific considerations surrounding sedation in children.
Anaesthesia for cardiac surgery
Authors: Schirmer Uwe , Koster Andreas
Published: April 2017

Cardiac anaesthesia continues to develop as a specialized discipline within the wide field of clinical anaesthesia. A comprehensive knowledge of cardiovascular physiology and its improved monitoring with modern invasive and non-invasive devices is the basis for the pharmacological treatment of complex cardiovascular disorders. Excellent skills in intraoperative transoesophageal echocardiography have become essential. Rapid developments in cardiopulmonary bypass techniques and surgical devices have resulted in the speedy introduction of new surgical techniques which anaesthesia has to embrace. The developments in the field of (left) ventricular assist devices are expansive. By changing the paradigm of the indication of implantation from ‘bridging to heart transplantation’ to ‘destination therapy’, particularly in the large group of elderly patients with end-stage heart failure, these complex operations are no longer restricted to the small group of heart centres performing heart transplantation. This chapter provides a comprehensive review of modern cardiac anaesthesia in the contemporary world of quickly evolving cardiac surgery. The basics of anaesthesia management for the ‘cardiac’ patient are described and principles of extracorporeal circulation as well as diagnostic and treatment strategies of disturbances of the haemostatic system are highlighted. Pharmacological strategies to treat left- and right-heart failure and strategies for temporary mechanical support are outlined. Further areas of focus are the anaesthetic implications of modern less or minimally invasive procedures such as off-pump coronary artery bypass grafting and minimally invasive valve implantation/surgery and anaesthesia for implantation of ventricular assist devices and heart transplantation.
Anaesthesia for vascular surgery
Authors: Thompson Jonathan P.
Published: April 2017

Vascular surgical patients are at higher risk of cardiovascular morbidity and mortality than other surgical patients, and perioperative care remains challenging. However, vascular surgical practice is changing, with the expanding use of endovascular techniques to treat patients with vascular disease, improvements in medical therapy, and the evolution of evidence-based approaches to preoperative assessment. Preoperative assessment should concentrate on identifying and optimizing potentially correctable medical conditions, in particular cardiovascular disease. Successful outcomes depend on good anaesthetic techniques with emphasis on meticulous attention to detail and maintaining cardiovascular function and stability. Good communication with surgical and radiological colleagues is also vital. Anaesthesia for major vascular surgery also requires expertise in managing major haemorrhage, the use of invasive monitoring and cardioactive drugs, and regional anaesthesia. Knowledge and skills in the use of specific techniques for monitoring and protection against organ dysfunction are required. Endovascular surgery may be performed in dedicated operating suites or within the radiology department so the anaesthetist needs to be aware of considerations for anaesthesia in an isolated environment. This chapter details the management of patients presenting for the commonest major vascular procedures. All aspects of perioperative care for patients with abdominal and thoracic aortic aneurysms, occlusive aortic and peripheral vascular disease, and carotid stenosis are discussed. Anaesthesia for open surgery, endovascular and hybrid procedures, and elective and emergency procedures are included. The benefits of regional and general anaesthetic techniques are considered, where appropriate. The chapter also incorporates the anaesthetic management for less common procedures to treat carotid body tumours, thoracic outlet syndrome, and for thoracoscopic sympathectomy.
Obstetric anaesthesia and analgesia
Authors: Biro Peter , Velde Marc Van de
Published: April 2017

The pregnant woman is a unique and challenging patient for the anaesthetist. When analgesia or anaesthesia is administered, the anaesthetic effects on the fetus or neonate, or both, should be carefully considered. Additionally, pregnancy induces significant maternal physiological changes, which may be influenced by and have an impact on routine anaesthetic management. Hence, anaesthetists are forced to adapt conventional anaesthetic techniques. This chapter reviews the physiological changes associated with pregnancy and describes the anaesthetic care of these patients during vaginal and operative delivery and for non-obstetric interventions during pregnancy.
Anaesthesia for day-stay surgery
Authors: Jakobsson Jan
Published: April 2017

Day-stay surgery is becoming increasingly common the world over. There are several benefits of avoiding in-hospital care. Early ambulation reduces the risk for thromboembolic events, facilitates wound healing, and avoiding admission reduces the risk for hospital-related infection. Additionally, the risk of neurocognitive side-effects can be avoided by returning the elderly patient to their home environment. Day-stay anaesthesia calls for adequate and structured preoperative assessment and patient evaluation, and the potential risk associated with surgery and anaesthesia should be assessed on an individual basis. Need for preoperative testing should be based on functional status of the patient and preoperative medical history but even the surgical procedure should be taken into account. Preoperative fasting should be in accordance with modern guidelines, refraining from food for 6 hours and fluids for 2 hours prior to induction in low-risk patients. Preventive analgesia and prophylaxis of postoperative nausea and vomiting (PONV) should be administered preoperatively. Local anaesthesia should be administered prior to incision, constituting part of multimodal analgesia. The multimodal analgesia strategy should also include paracetamol and a non-steroidal anti-inflammatory drug in order to reduce the noxious stimulus from the surgical field. Third-generation inhaled anaesthetics or a propofol-based maintenance are both feasible alternatives. Titrating depth of anaesthesia by using an EEG-based depth of anaesthesia monitor may facilitate the recovery process. The laryngeal mask airway has become commonly used and has several advantages. Ultrasound-guided peripheral blocks may facilitate the early postoperative course by reducing pain and avoiding the use of opiates. Perineural catheters may be an option for prolongation of the block following painful orthopaedic procedures but a strict protocol and follow-up must be secured. Not only pain but even nausea and vomiting should be prevented, and therefore risk stratification, for example by the Apfel score, and PONV prophylaxis in accordance with the risk score is strongly recommended. Early ambulation should be encouraged postoperatively. Safe discharge should include an escort who also remains at home during the first postoperative night. Analgesics should be provided and be readily available for self-care when the patient comes home. Pain medication should include an opioid; however, the benefit versus risk must be assessed on an individual basis. Patients should also be instructed about a rescue return-to-hospital plan. Quality of care should include follow-up and analysis of clinical practice, and institution of methods to improve quality should be enforced for the benefit of the ambulatory surgical patient.
Procedural sedation in children
Authors: Sury Michael
Published: April 2017

Sedation is a state of reduced consciousness in which the patient should be rousable. The main concern is that sedation can become too deep, unintentionally, and the patient can be harmed. The practitioner must therefore be trained to cope with all the common side-effects of sedation. Sedation techniques depend on the intended procedure. Four common scenarios are covered in this chapter: painless imaging, painful procedures, endoscopy, and dental procedures. Each of these has specific demands and they are discussed in detail. The anaesthetist should choose short-acting potent drugs to provide effective sedation or anaesthesia. Non-anaesthetists should, unless specifically trained, limit their techniques to those which are truly sedation and have a wide margin of safety. Unfortunately, such drugs are usually less potent and the techniques have a failure rate. In the absence of anaesthetists, high-quality services need to minimize the risk of failure and develop effective sedation techniques by trained staff.
Acute paediatric pain management
Authors: Hansen Tom G.
Published: April 2017

Paediatric pain management has made great strides in the past few decades in the understanding of developmental neurobiology, developmental pharmacology, the use of analgesics in children, the use of regional techniques in children, and of the psychological needs of children in pain. The consequences of a painful experience on the young nervous system are so significant that long-term effects can occur, resulting in behavioural changes and a lowered pain threshold for months after a painful event. Accurate assessment of pain in different age groups and the effective treatment of postoperative pain are constantly being refined, with newer drugs being used alone and in combination with other drugs, and continue to be explored. Systemic opioids, paracetamol, non-steroidal anti-inflammatories, and regional anaesthesia alone or combined with additives are currently used to provide effective postoperative analgesia. These modalities are often best utilized when combined as a multimodal approach to treat acute pain in the perioperative setting. The safe and effective management of pain in children includes the prevention, recognition, and assessment of pain; early and individualized treatment; and evaluation of the efficacy of treatment. This chapter discusses selected topics in paediatric acute pain management, with more specific emphasis placed on pharmacology and regional anaesthesia in the treatment of acute postoperative pain management.
Musculoskeletal disorders and anaesthesia
Authors: Hopkins Philip M.
Published: April 2017

This chapter covers the anaesthetic implications of the polyarthropathies, connective tissue diseases, and primary myopathies. There are generic considerations for management of patients with joint and muscle disease but many of these conditions have multisystem involvement, the nature of which varies between the individual members of each class. Anaesthetic management of the polyarthropathies requires knowledge of the adverse effects of disease-modifying drugs and new biological treatments. Advances in genetic diagnosis of inherited myopathies aid the identification of potential hazards of anaesthesia in these challenging patients.
Central nervous system pathologies and anaesthesia
Authors: Gill Steven J. , Nathanson Michael H.
Published: April 2017

Anaesthesia induces changes in many organ systems within the body, though clearly none more so than the central nervous system. The physiology of the normal central nervous system is complex and the addition of chronic pathology and polypharmacy creates a significant challenge for the anaesthetist. This chapter demonstrates a common approach for the anaesthetist and specific considerations for a wide range of neurological conditions. Detailed preoperative assessment is essential to gain understanding of the current symptomatology and neurological deficit, including at times restrictions on movement and position. Some conditions may pose challenges relating to communication, capacity, and consent. As part of the consent process, patients may worry that an anaesthetic may aggravate or worsen their neurological disease. There is little evidence to support this understandable concern; however, the risks and benefits must be considered on an individual patient basis. The conduct of anaesthesia may involve a preference for general or regional anaesthesia and requires careful consideration of the pharmacological and physiological impact on the patient and their disease. Interactions between regular medications and anaesthetic drugs are common. Chronically denervated muscle may induce hyperkalaemia after administration of succinylcholine. Other patients may have an altered response to non-depolarizing agents, such as those suffering from myasthenia gravis. The most common neurological condition encountered is epilepsy. This requires consideration of the patient’s antiepileptic drugs, often relating to hepatic enzyme induction or less commonly inhibition and competition for protein binding, and the effect of the anaesthetic technique and drugs on the patient’s seizure risk. Postoperative care may need to take place in a high dependency unit, especially in those with limited preoperative reserve or markers of frailty, and where the gastrointestinal tract has been compromised, alternative routes of drug delivery need to be considered. Overall, patients with chronic neurological conditions require careful assessment and preparation, a considered technique with attention to detail, and often higher levels of care during their immediate postoperative period.
Pre-surgical optimization of the high-risk patient
Authors: Clarkin Andrew J. , Webster Nigel R.
Published: April 2017

There is a small group of patients undergoing surgery who comprise the majority of perioperative deaths. Morbidity and mortality resulting from tissue hypoxia in the perioperative period can be predicted and prevented by identification of the at-risk group and targeted interventions. Management of these patients requires an understanding of oxygen delivery, the use of cardiac output monitoring to guide fluid and inotrope administration to attain a predefined goal of supranormal oxygen delivery, and the attainment of physiological goals. There are both patient outcome and economic benefits to this management strategy which support the individualized goal-directed therapy approach to managing high-risk patients.
Feasibility of Hip Fracture Surgery Using a No Transfusion Protocol in Elderly Patients: A Propensity Score-Matched Cohort Study
Authors: Yoon Byung-Ho , Ko Young Seung , Jang Suk-Hwan , Ha Jeong Ku
Published: April 2017

Objectives:

To determine whether hip fracture surgery (HFS) without transfusion affects postoperative mortality and complications in elderly patients.

Design:

Retrospective comparative study.

Patients:

Three hundred fourteen patients ≥65 years of age who underwent HFS between May 2003 and December 2014. Patients were divided into 2 groups: those who consented to blood transfusion if needed and those who did not. One-to-one propensity score matching generated 50 matched pairs of patients.

Intervention:

Patients underwent HFS with or without blood transfusion. In the no transfusion group, simultaneous administration of erythropoietin and iron was used as an alternative.

Main Outcome Measurements:

The primary outcome was postoperative mortality (90-day, 1-year, overall). The secondary outcomes were hemoglobin change and the incidence of postoperative complications.

Results:

HFS using a no transfusion protocol was not associated with increased mortality at any time point. Mean hemoglobin levels were significantly different between the 2 groups on postoperative day 1 (11.0 ± 1.3 vs. 10.5 ± 1.6, P = 0.002) but levels completely recovered within 2 weeks in both groups. There was also no difference in postoperative complication rates between the 2 groups, and overall hospital stays and charges were similar.

Conclusions:

An HFS protocol without blood transfusion was not associated with increased mortality or complications in elderly patients.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.