bluuebunny/crossref_metadata_2025 huggingface dataset:
Dexmedetomidine
Authors: Ferguson Kris , Stayner R. Scott
Published: May 2024

Dexmedetomidine is unique as it produces “cooperative sedation.” It has axiolytic, sedative and analgesic properties. Dexmedetomidine acts as an alpha2-adrenergic receptor agonist in a similar way to clonidine. It decreases the dose requirement of inhaled and intravenous anesthetics as well as opioids and benzodiazepines. Dexmedetomidine maintains the airway and spontaneous ventilation, thereby enhancing the safety of awake fiberoptic intubation. There is blunting of the sympathetic response to noxious stimuli, making for stable hemodynamics throughout a surgical case. Emergence delirium is minimized compared with other sedatives, and dexmedetomidine has a sparing effect on postoperative opioids. Dexmedetomidine can facilitate a balances anesthetic technique when combined with other sedatives such as benzodiazepines, opioids and propofol. It is not recommended for long term sedation.
Nitroglycerin and Sodium Nitroprusside
Authors: Sprowell Andrew , Sharma Archit
Published: May 2024

Nitrates are widely used as vasodilators for the treatment of ischemic heart disease and heart failure. Nitrates dilate veins, arteries, and coronary arteries by relaxing vascular smooth muscle. Even though they find extensive use in treatment of acute angina symptoms, they are prone to side effects ranging from flushing and headache to hypotension, and hence deserve care during administration as well as knowledge of potential interactions with other drug classes. This chapter discusses the different types of nitrates and their potential utility, as well as the various categories of patients in which these drugs should be restricted or used with caution.
Muscle Relaxants
Authors: Papapetrou Peter , Ferguson Kris
Published: May 2024

Muscle relaxants have been a key component among the armamentarium of anesthetic drugs as they allow for optimal intubating conditions as well as muscle paralysis during surgery. They are classified as either depolarizing or nondepolarizing muscle relaxants. Succinylcholine is currently the only depolarizing muscle relaxant and has a rapid onset, though it carries risk of malignant hyperthermia, hyperkalemia, as well as prolonged paralysis in genetic variants of plasma cholinesterase. Nondepolarizing muscle relaxants have been developed to avoid the side effects of succinylcholine and carry an alternative mechanism of action. They are metabolized via various pathways depending on the drug, and each drug has unique considerations in terms of onset, duration of action, and side effects.
Interaction with Chronic Drug Therapy
Authors: Pinkert Vincent , Rose Sydney E.
Published: May 2024

Medication management is an essential component of patient optimization prior to surgery. Many patients are on complicated regimens of prescription and nonprescription medications. While continuing most medication regimens is tolerated, certain medications put patients at elevated risk for perioperative complications, and should be stopped. Likewise, stopping certain medications places patients at increased risk of acute decompensation, disease progression, and/or withdrawal, and should be continued. Lack of large randomized controlled trials accounts for the variations in recommendations. Nonetheless, there are medications known to interact with anesthetic agents, cause morbidity if abruptly stopped, or have potential perioperative issues. An awareness of these, in addition to a broad understanding of the basic principles of relevant chronic drug-anesthetic interactions, is essential to avoiding dangerous combinations, and keeping patients safe.
Adverse Reactions to Premedication
Authors: Yao Caylynn , Peterson Elisha
Published: May 2024

Adverse reactions to premedication include delirium, postoperative cognitive dysfunction, cardiac and respiratory aberrations, paradoxical reactions, and extrapyramidal symptoms. These adverse reactions to medications can be due in part to intrinsic properties of the medication itself and patient variability. Intrinsic properties of premedications and commonly studied side effects are discussed. Patient variability includes both biological and social factors ranging from genetic predisposition, gender, race and ethnicity, to more modifiable factors including tobacco and alcohol intake. Patient-related factors also comprise polypharmacy, CYP450 hepatic enzyme activity, age, creatinine clearance, body weight and fat distribution, and accompanying disease processes. Each factor influences dose responses and efficacy of premedication.
Drug Abuse
Authors: Sam Sabrina S. , Torres Maria
Published: May 2024

This chapter discusses drug abuse, also known as substance use disorder, which is becoming increasingly prevalent. This requires anesthesia providers to become familiar with perioperative considerations in this patient population. Drug abuse comprises three stages that occur in a cycle: intoxication, withdrawal, and preoccupation. Signs and symptoms of acute intoxication and withdrawal vary depending on the specific substances used in a population with coexisting psychiatric illness. Both behavioral and pharmacological treatments are available for substance use disorders. Treatment goals are immediate and long-term abstinence and recovery. It is important to provide adequate depths of anesthesia and analgesia and also to consider the risk of relapse after re-exposure to these medications. Multimodal analgesia with opioid-sparing techniques and responsible prescribing on discharge are important aspects of perioperative care.
Chronic Steroid Ingestion
Authors: Li Hewenfei , Nguyen Christina T.
Published: May 2024

This chapter discusses the effects of chronic steroid ingestion on the patient and perioperative management. It examines the pathophysiology of steroid use in patients including hypothalamic-pituitary-adrenal axis suppression and the resulting secondary adrenal insufficiency, as well as effects on other organ systems. It focuses on steroid replacement therapy recommendations for the perioperative period, based on differing risk levels for HPAA suppression and proper dosing of glucocorticoids.
Alteration of Gastric Fluid Volume, pH, and Sphincter Tone
Authors: Beplate Sean , Toth Kenneth
Published: May 2024

Understanding aspiration risk is crucial for any anesthesia provider, as pulmonary aspiration is a significant potential source of morbidity and mortality. Thus, efforts must be made to minimize both the chance and severity of an aspiration event. Anesthetic plans for patients at risk for aspiration should include methods of increasing gastric emptying and therefore minimizing gastric volume as well as increasing the pH of gastric contents.
Continuation vs. Discontinuation of Chronic Medications
Authors: Schroell Robert P. , Harter Ronald
Published: May 2024

A large number of patients undergoing surgery take at least one chronic medication, so it is essential for the safe practice of anesthesiology to have a thorough understanding of patients’ medical history and current medications. Some medications are recommended to be continued during surgery due to their protective effects or the risk of withdrawal with discontinuation, while others are recommended to be held. Most cardiac, pulmonary, psychotropic, and chronic pain medications are recommended to be continued in the perioperative period. Agents that impair hemostasis have differing recommendations for their discontinuation. Overall, for the safety of patients, knowing whether to continue or discontinue chronic medications in the perioperative period is imperative.
Nonobstetric Surgery during Pregnancy
Authors: Al Jindi Piotr
Published: May 2024

The pregnant patient should not be denied necessary surgery because delaying such surgery will result in increased morbidity and mortality. Elective surgery should be postponed until after delivery. Anesthetic management of pregnant patients necessitates maternal and fetal considerations. Physiologic and anatomic changes related to pregnancy may require adaptations of surgical and anesthetic techniques. No anesthetic agent has been shown to be teratogenic at clinical concentrations and doses; however, it is prudent to minimize fetal drug exposure. Each case warrants a multidisciplinary approach. It is prudent to maintain oxygenation, hemostasis, and normothermia and avoid hypoxemia to assure the best fetal outcome.
Spinal, Epidural, Caudal, and Combined Spinal/Epidural Anesthesia
Authors: Fadumiye Christopher O. , Cacioppo Brian J.
Published: May 2024

This chapter highlights three different kinds of regional anesthesia—spinal, epidural, and caudal. Specific focus is on how each works, their individual indications and contraindications, and the physiological effects and complications to watch out for. The chapter also explores onset, duration, and action termination for spinal, epidural and caudal anesthesia. The dose, concentration, and volume of local anesthetic administered for spinal, epidural, and caudal have different effects on different individuals, and this chapter examines how possible prior complication plays an important role in the kind and dosage of anesthesia to be administered. 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 spinal, epidural, and caudal anesthesia, making it a handy and quick review for board exam prep.
Assessment/Identification of Difficult Airway
Authors: Chiong Katya H.
Published: May 2024

Proper airway assessment is essential if one is to properly identify a difficult airway. A full history and physical exam should be performed, taking particular note of anatomic components from the airway examination. While there is no one particular anatomic correlate that completely predicts a difficult airway, the collected data can be a useful tool for the anesthesiologist in unmasking potential difficultly and enable proper preparation. The key is proper preparation when a difficult airway is anticipated. This may involve additional airway preparation, including medications and equipment, as well as additional support staff and colleagues for an extra set of skilled hands.
Chronic Environmental Exposure
Authors: Smith Sarah C.
Published: May 2024

Chronic exposure to waste anesthetic gases (WAGs) is an important occupational safety issue for anesthesia practitioners and others working in anesthetizing locations and post-anesthesia recovery units. While the results of epidemiological studies investigating the impact of WAG exposure on perioperative workers are conflicting, chronic exposure to low levels of inhalational anesthetic agents may be associated with oxidative damage, genotoxicity, teratogenicity, and fertility problems. Although completely eliminating the presence of WAGs from perioperative environments is not possible, exposure can be successfully minimized through workplace engineering, appropriate anesthetic management, and other modifications to the work environment.
Bronchospasm
Authors: Eapen Jeffery James , Bang Jason
Published: May 2024

Bronchospasm is a respiratory complication encountered with anesthesia practice. This chapter will provide a review of the condition in terms of pathophysiology and its management in the perioperative period. Bronchospasm is a manifestation of a complication from reactive airway disease (asthma), COPD, anaphylaxis, release of vasoactive substances, or interventions by an anesthesiologist. It is caused by increased activity of smooth muscles surrounding the bronchioles, resulting in airflow obstruction impacting primarily the expiratory phase of the respiratory cycle. Diagnosis is confirmed by physical examinations revealing end expiratory wheezes and increased peak airway pressures during mechanical ventilation. Management includes administering 100% oxygen, use of beta 2 agonists such as albuterol, increasing inspired concentration of bronchodilating inhaled anesthetics, and use of bronchodilating IV agents such as ketamine.
Latex Allergy
Authors: Lacourrege Kelsey E. , Kaye Alan D.
Published: May 2024

Allergy to natural rubber latex can result in morbidity and mortality. This chapter focuses on the etiology, diagnosis, and management of latex allergy. Exposure to latex allergens through skin contact, such as gloves, has been shown to lead to localized allergic reactions. Powdered latex gloves associated with aerosolization of latex allergens can trigger allergic asthma, rhinitis, ocular symptoms, and anaphylaxis. Patients with spina bifida have heightened susceptibility to latex allergy. At the height of the latex allergy epidemic in 1991, 1 of every 8 patients with spina bifida experienced anaphylaxis perioperatively, with allergy rates as high as 17% among healthcare workers and 70% among spina bifida patients. At present, the rate of allergy development has declined to 1% for the entire population. Patients with a clinical history consistent with latex allergy should be considered high risk even in the absence of serologic confirmation. The use of latex-containing products in healthcare has dwindled significantly in the United States and has led to a decline in incidence of new latex allergies. Prompt recognition and management are critical. Anaphylaxis can occur immediately upon exposure but may take up to 60 minutes to present. Immediate resuscitation with intravenous epinephrine and intravascular fluid should be initiated, with immediate removal of the latex product and replacement with a latex-free alternative.
Selective Serotonin Reuptake Inhibitors (SSRIs)
Authors: Rosenblum David , Elias Hila
Published: May 2024

Selective serotonin reuptake inhibitors (SSRI) and selective noradrenaline reuptake inhibitors (SNRI) are commonly used medications in the treatment of depression, anxiety, and other psychiatric disorders. These drugs are becoming increasingly common and therefore the perioperative clinician needs to know how to recognize, prevent, and treat reactions associated with these medications. Serotonin syndrome is one of the most feared and infamous complications when treating patients who are taking SSRIs. Symptoms can range from mild to life-threatening. They are related to the overactivation of both the central and peripheral serotonin receptors by high serotonin levels, resulting in the serotonin syndrome and its various symptoms. A history of chronic pain or psychiatric comorbidities may alert to the possibility of serotonin syndrome. Other considerations when taking care of patients on these medications include bleeding and sensitivity to epinephrine-containing local anesthetics.
Acupuncture and Hypnosis
Authors: Mazmanyan Hovik , Alexander Bozana
Published: May 2024

Acupuncture and hypnosis are playing an increasingly prominent role in the field of pain management. This chapter discusses and highlights the current understanding of hypnosis and acupuncture in the field of anesthesia and their potential as a useful adjuvant in the current anesthesia toolbox. In the case of acupuncture, memorizing all acupuncture points on the body is not necessary. However, one must understand the full potential of this interconnected system in order to incorporate a few simple and useful techniques in anesthesiology training and to apply them during the perioperative period for patient outcome optimization.
Cardiovascular Consequences of General and Regional Anesthesia
Authors: Herman Jared , Viswanath Omar
Published: May 2024

General anesthesia leads to a reduction in systemic vascular resistance, arterial blood pressure, and cardiac output. Success and failures in the perioperative period rely on a thorough understanding of the cardiovascular physiologic changes associated with administering general and regional anesthesia. Unanticipated spread of local anesthetic during a spinal anesthetic or local anesthetic systemic toxicity can have a devastating impact on the cardiovascular system. Cardiac complications account for 25%–50% of mortality after noncardiac surgery. Understanding cardiac risk and anticipating physiologic changes can allow for successful treatment in the perioperative period and allow for less major cardiac complications following procedures.
Cerebral Blood Flow
Authors: Sharma Surangama , Arora Lovkesh
Published: May 2024

Cerebral blood flow (CBF) is coupled to cerebral metabolism, i.e., when cerebral metabolism (or oxygen consumption) increases, blood flow to that region increases as well. Intracranial pathology may uncouple the relationship, and CBF and cerebral metabolism may become independent of each other. CBF is autoregulated and remains constant over a mean arterial pressure (MAP) range of 65 to 150 mmHg. CBF is also affected by factors like arterial partial pressure of carbon dioxide (PaCO2), arterial partial pressure of oxygen (PaO2), body temperature, and medications, including anesthetics. Understanding the factors affecting CBF, autoregulation, and metabolism is important for safe perioperative patient care.
Increased Intracranial Pressure
Authors: Alkhalili Kenan , Nasr Ned F.
Published: May 2024

Elevated intracranial pressure (ICP) is a potentially devastating complication of neurologic injury. ICP can be elevated in traumatic brain injury, large acute ischemic stroke, intracranial hemorrhage, intracranial neoplasms, and diffuse cerebral disorders such as encephalitis and acute hepatic failure. Management of elevated ICP is, in part, dependent on the underlying cause, and should focus on optimizing perfusion, by minimizing ICP and maximizing cerebral perfusion pressure (CPP). ICP monitoring allows for the judicious use of interventions with a defined target point, thereby avoiding potentially harmful aggressive treatment. Medical management of increased ICP should include sedation, drainage of cerebrospinal fluid (CSF), and osmotherapy with either mannitol or hypertonic saline. This chapter discusses the pathophysiology, monitoring, and treatment modalities of increased ICP.
Spinal Cord Tracts
Authors: Altenhofen Brannon Y. , Schulman Nathan
Published: May 2024

The spinal cord tracts are the ascending and descending neuronal fiber pathways that transmit information to and from the body and the brain. This chapter discusses the ascending pathways, including the spinothalamic tract (pain and temperature), the posterior columns (light touch, vibration, and proprioception), and the spinocerebellar tract (unconscious proprioception). It also discusses the corticospinal tract, which is the major descending motor pathway. The chapter then addresses different spinal cord lesions and explains the reasons for contralateral or ipsilateral deficits (depending on the tracts involved and whether the fibers have crossed over), including disruption of the artery of Adamkiewicz, Brown-Sequard syndrome, posterior cord syndrome, conus medullaris syndrome, and cauda equina syndrome. Finally, it addresses intraoperative neuromonitoring and its role in assessing the functional integrity of the nervous system during surgeries in which these structures are at risk.
Body Temperature Measurement
Authors: Guruswamy Jayakar , Epelman Matthew
Published: May 2024

Intraoperative temperature measurement represents an important but underappreciated aspect of patient care under the purview of the anesthesiologist. Deviations from normal body temperature can have important consequences. Hypothermia is most commonly encountered and is usually caused by loss of heat via radiation within the operating theater. Convection, conduction, and evaporation represent other causes of heat loss. Hyperthermia is less common, but the etiology must be investigated, as it may be a sign of malignant hyperthermia or sepsis, among other causes. Methods to prevent heat loss include application of warm blankets, forced air warming blanket, and adjusting operating room temperature. The patient may shiver in response to cold to increase body temperature, consequently resulting in increased oxygen consumption. Complications of unrecognized and prolonged temperature derangements include decreased wound healing, decreased platelet function, coagulopathy, prolonged action of neuromuscular blockade and anesthetic agent, arrhythmias, hemodynamic instability, significant morbidity, and mortality. A variety of devices exist to aid the anesthesia provider in monitoring temperature, each with its own applications and pitfalls.
Brainstem
Authors: deBoisblanc Charles , Kaye Alan D.
Published: May 2024

The brainstem, responsible for many primitive reflexes, is composed of the midbrain, the pons, and the medulla, each of which performs critical roles in homeostasis. This chapter examines the anatomy and function of each region, as well as reviewing the brainstem’s role in postoperative nausea and emesis. Postoperative nausea and vomiting are, in part, related to the chemoreceptor trigger zone, located within the medullary area postrema; this area and the nucleus tractus solitarius of the medulla constitute the most significant components of the vomiting center. Emetogenic substances activate receptors within the chemoreceptor trigger zone, and this signal is conducted to the nucleus tractus solitarius, which activates the vomiting reflex.
Cerebral Circulation
Authors: Shah Rutvij
Published: May 2024

The brain is supplied by the branches of two internal carotid arteries (ICA) and two vertebral arteries. The terminal branches of ICAs and vertebral arteries form the circle of Willis to provide uninterrupted circulation. Branches of ICAs are the ophthalmic, posterior communicating, anterior choroidal, anterior cerebra,l and middle cerebral arteries. Branches of vertebral arteries are the anterior and posterior spinal arteries, and posterior inferior cerebellar arteries. Both the vertebral arteries merge to make the basilar artery. Acute occlusion of these arteries causes various type of stroke syndromes. Venous drainage of the brain is through superficial and deep cerebral veins. Both superficial and deep cerebral veins drain into various dural venous sinuses to eventually drain to brachiocephalic veins to the right atrium.
Spinal Nerves
Authors: Abdallah Rany T. , Villatoro-Lopez Jasmin
Published: May 2024

The human body contains 12 cranial nerves and 31 pairs of spinal nerves. Spinal nerves carry motor, sensory, and autonomic signals between the spinal cord and the body. They correspond to a segment of the vertebral column: 8 cervical pairs (C1–C8), 12 thoracic pairs (T1–T12), 5 lumbar pairs (L1–L5), 5 sacral pairs (S1–S5), and 1 coccygeal pair. The majority of the upper half of the cervical nerves construct the cervical plexus, specifically from the anterior rami of C1 to C5. The ventral roots C5–T1 form what is known as the brachial plexus, a complex network of nerves that innervate the upper extremities. The thoracic nerves are composed of 12 pairs of spinal nerves in the thoracic spine, each corresponding to a spinal segment. The lumbosacral plexus is simply the lumbar and sacral plexuses that share nerve root overlap. Spinal nerve compression is a condition caused by gradual wear and tear on the joints and discs of the spine, largely known as degenerative arthritis. Other causes may be sudden traumatic blows to the spine that fracture, dislocate, crush, or compress one or more of the vertebrae. However, these conditions may be treated with medications, physical therapy, injections, and in extreme cases with surgery.
Peripheral Nociceptors
Authors: Lennertz Richard
Published: May 2024

Nociceptors are specialized nerve fibers that respond to intense, noxious stimuli. They are classified by their degree of myelination and responses to mechanical, heat, and cold stimuli. The expression of various ion channels determines their sensitivity to mechanical, thermal and chemical stimuli. Nociceptors respond to stimuli when these ion channels depolarize the plasma membrane and initiate an action potential. Some subtypes of voltage-gated sodium channels are highly expressed by nociceptors. In particular, mutations in NaV1.7 have been linked to human diseases such as erythomelalgia and congenital insensitivity to pain. Inflammatory mediators sensitize nociceptors, and nociceptors themselves release neurohumoral peptides that modulate inflammation. These changes may increase the response elicited by painful stimuli or lead to spontaneous activity. These inflammatory changes contribute to acute postoperative pain.
Static, Dynamic Compliance and Airway Resistance
Authors: Shapiro Ezra , Crimi Ettore
Published: May 2024

Physiologic work of breathing includes the inspiratory work to overcome both elastic and frictional forces. Elastic recoil is the natural tendency of the lungs to collapse and can be expressed in terms of elastance. Compliance, the reciprocal of elastance, is defined as the change in volume per unit change in pressure. The total compliance of the respiratory system is the sum of lung and chest wall compliance. Static compliance is the compliance measured under static (zero flow) condition, while dynamic compliance is measured with air flow. Atelectasis, pulmonary edema, acute respiratory distress syndrome, and pleural effusions decrease lung compliance, while pulmonary emphysema is associated with increased lung compliance. Frictional forces, also defined as non-elastic resistance, include the resistance to air flow of the conductive airways and the viscous tissue resistance of the lung and chest wall. Bronchospasm, mucus plugging, and airway foreign bodies increase airway resistance.
Pleural Pressure Gradient, Laplace’s Law, Surfactant, Hysteresis, and Flow-Volume Loops
Authors: Pham Ba Hoang Nguyen , Bang Jason
Published: May 2024

Normal respiration is dependent on the main 3 pressure gradients: transrespiratory pressure, transpulmonary pressure, and transthoracic pressure. While they are the driving forces for inspiration and expiration, and play an important role in keeping the lungs and the alveoli inflated, without surfactant, the alveoli would collapse from the surface tension forces as depicted by Laplace’s law. It states that pressure is directly proportional to the surface tension and inversely proportional to the radius of the alveolus. Surface tension is also main the reason for the presence of hysteresis in the lung compliance curves. In order to help with the diagnosis of certain airway obstruction, as well as lung restrictive diseases that affect the lung compliance, the flow-volume loop can be employed.
Distribution of Ventilation
Authors: Morales Monnica , Jamroz Tatiana
Published: May 2024

This chapter reviews pressure differentials in the respiratory cycle, providing information on how this relates to compliance of the lung and the distribution of inspired gases in the alveoli. Pleural pressure gradients, distribution of ventilation, compliance, and functional residual capacity (FRC) are reviewed. There is also a brief discussion on how this relates to both the spontaneously breathing awake patient and positioning in the anesthetized patient. Pleural pressure differences, termed pleural pressure gradients, exist in the lung due to a variety of reasons. These include gravity, density of the lung tissue, compression from surrounding structures and the shape of the lung in the thorax favoring compression of tissues at the base; therefore, ventilation is also distributed differently.
Diffusion and Pulmonary Diffusion Capacity
Authors: Moldysz Anna , Sharma Archit
Published: May 2024

One of the major roles of the lungs is to facilitate gas exchange from the circulatory system and the external environment. Gas exchange occurs in the lungs between alveolar air and blood of the pulmonary capillaries. A test of the diffusing capacity of the lungs for carbon monoxide (DLCO, also known as transfer factor for carbon monoxide or TLCO), is a valuable test of lung function, specifically before undergoing an operation. This can be helpful in predicting patients at higher risk for postoperative complications following lung volume reduction surgery (LVRS) and overall postoperative pulmonary morbidity.
Beta (β) Agonists
Authors: Markatos Sheridan , Manders Larry
Published: May 2024

Beta receptors are part of the sympathetic nervous system and are stimulated by the catecholamines epinephrine and norepinephrine. There are three types β1, β2, and β3 receptors. This chapter focuses on β2 receptors and their agonists. Bronchodilation occurs when β2 receptors are stimulated by epinephrine, and less so norepinephrine. Ultimately, activation prevents contraction of the smooth muscles in the airway, dilating the airway, and decreasing airway resistance. There are two classes of beta agonists: short and long. This chapter reviews beta receptors, beta agonists, and utilization in the perioperative setting.
Perioperative Use of Alcohol
Authors: Cieslinski Lindsey
Published: May 2024

As an anesthesiologist, it is imperative to identify alcohol misuse in the perioperative period. It is estimated that anywhere between 10% and 20% of surgical patients meet criteria for alcohol dependence or abuse. When patients are not as forthcoming about their total alcohol consumption, the clinical picture combined with objective findings can aid in diagnosis and perioperative management. Compared to individuals who drink infrequently, those who heavily consume alcohol, whether in the acute setting or chronically, are predisposed to multiple perioperative complications. Patients who regularly consume high volumes of alcohol have an increased tolerance to many sedative drugs and are at increased risk of hepatic disease which can impact the choice of anesthetic agents. Common perioperative complications include infection, sepsis, bleeding, delayed wound healing, liver dysfunction, and cardiac dysfunction. Chronic alcoholism leads to a variety of electrolyte abnormalities, mostly due to poor nutritional intake and malabsorption. This chapter discusses the pathophysiology of alcoholism predisposing these patients to perioperative complications, along with the anesthetic considerations and management strategies.
Cocaine Pharmacology
Authors: Cieslinski Lindsey
Published: May 2024

Cocaine came into Western medicine as the first local anesthetic, unique due to its combined properties of local anesthesia with intense vasoconstriction. Today in modern medicine, cocaine can be used as a topical intranasal anesthetic agent for sinus surgery or, less commonly, for awake intubation in a 4% solution. It is an illicit drug originating from the leaves of the erthryoxylon coca plant that is both harmful and dangerous to the human body due to its toxic abilities and highly addictive properties. This effect can carry over to the perioperative period, creating a potentially challenging anesthetic scenario due to the numerous physiologic effects of cocaine. In addition to local anesthetic effects, cocaine has both peripheral and centrally acting sympathomimetic actions. This chapter discusses the pharmacologic and physiologic effects of cocaine while considering the anesthetic implications.
Systolic and Diastolic Function
Authors: Al-Attar Neal , Manders Larry
Published: May 2024

Systolic and diastolic function of the heart is complex relation of pressure, volume, and contractility over a period of time. The preload or venous return to the heart, as well as the afterload, greatly changes the ability of the heart to pump. This chapter briefly discusses the governing force on the heart in terms of systolic and diastolic function in addition to identifying some alterations that may occur during the delivery of anesthesia.
Vessel Function
Authors: Yousef John , Manders Larry
Published: May 2024

Five types of vessels exist in the body to carry oxygenated blood to the tissues and take deoxygenated blood away from them. These are the arteries, arterioles, capillaries, venules, and veins. The exchange between cellular waste and nutrition takes place at the level of the capillaries. Substances such as water, oxygen, carbon dioxide, and glucose are supplied and removed. This chapter briefly discusses the anatomical composition of the different vessel types and their function. Furthermore, it highlights changes among vessel groups during general anesthesia.
Systemic, Pulmonary Vascular Resistance and Viscosity
Authors: Huarte Maria , Chhabada Surendrasingh
Published: May 2024

Systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR) are the resistances that the left and right sides of the heart must overcome to generate flow through the circulatory system. Each of the systemic and pulmonary circuits has its unique characteristics and regulation, but since they are connected in series, flow must be equal to sustain life. The systemic circulation is characterized by high pressure and resistance, while the pulmonary one has low pressure and resistance. Since under normal conditions systemic and pulmonary pressures are maintained relatively constant, flow is highly dependent on resistance. The Hagen-Poiseuille equation underlines the impact of the vessel radius and blood viscosity on SVR and PVR (and ultimately on blood flow). It is important for the anesthesiologist to understand how different factors impact the hemodynamics of both the systemic and pulmonary circulations when caring for an increasingly complex patient population.
Regional Blood Flow and Its Regulation
Authors: Walia Anureet , Sharma Archit
Published: May 2024

Control of blood flow to tissues is vital to maintaining adequate but not excessive nutrient supply and removal of waste products. The anatomy and physiology of the endothelium and vascular smooth muscle allow tissues to regulate blood flow to match supply to demand in the face of a wide range of systemic changes. Different organ systems follow different control mechanisms to increase or decrease the amount of blood flowing through them. This chapter discusses the key aspects of this process, including structural features, mechanisms of autoregulation, and the fundamental roles of the endothelium and vascular smooth muscle.
Blood Filters and Pumps
Authors: Prem Anand , Anand Suwarna
Published: May 2024

Blood transfusion therapy is an integral part of the anesthetic management of patients in the setting of intraoperative acute blood loss and hemodynamic instability. While transfusion of blood products can be lifesaving, it is an intervention that has potential risks to the patient as well. Over the last several decades, the infectious risks of blood product transfusions have been significantly reduced by appropriate screening of donors and blood products. Hemolytic transfusion reactions have been reduced by more stringent guidelines to ensure the “right product gets to the right person.” The practice of leucocyte reduction of blood components has reduced the risks of febrile nonhemolytic transfusion reactions, transmission of cytomegalovirus, and platelet refractoriness, largely eliminating the need for leucocyte filters. However, it is universally recognized that microaggregates of fibrin clots and cellular debris that form when blood is stored need to be filtered out prior to administering blood products to patients. Blood transfusion sets currently available are routinely equipped with 170–200 micron filters, and the use of these filters during transfusion of all blood products except for hematopoietic precursor cells is considered “standard of care” throughout the developed world. A variety of pumps are available to help regulate the speed of infusion of blood products without inducing hemolysis, and some of these are equipped with the ability to warm the products to offset the risk of arrythmias and coagulopathy, particularly during massive blood transfusion protocols.
Anesthetic Considerations for Reactions to Transfusions
Authors: Rose John
Published: May 2024

Blood products can be a life-saving intervention in the perioperative period, but it is important to transfuse judiciously. Febrile, allergic, and hemolytic transfusion reactions each have a specific mechanism of action, clinical manifestation, and treatment requirement. The presentation of these reactions ranges from the relatively benign, such as afebrile and urticarial reactions, to more severe presentations, like anaphylactic and hemolytic reactions. Mild reactions may only require the provider to monitor the patient throughout their transfusion, while severe reactions can necessitate more aggressive interventions. This chapter examines the pathological mechanisms, common patient presentations, and treatment modalities for these reactions. Preoperative, intraoperative, and postoperative management is also reviewed.
Parathyroid Anatomy and Physiology
Authors: Prejean Rosemary , Kaye Alan D.
Published: May 2024

Parathyroid anatomy and physiology have enormous clinical implications. A concise review of general parathyroid anatomy, focusing on pertinent landmarks for identification, and specific details of physiological function of parathyroid hormone (PTH) are presented in this chapter. Details of interactions between PTH, calcitonin from the thyroid gland, and dietary vitamin D that maintain calcium homeostasis in the body are discussed. Control of PTH release from the parathyroid glands by concentrations of calcium, phosphate, and magnesium in the blood are presented, with specific discussion on actions of PTH at the kidney and bone leading to an overall increase in serum calcium, decrease in serum phosphate, and activation of vitamin D. Appreciation of parathyroid anatomy and physiology is the basis for best practice management of surgical removal of the parathyroid glands or in pathophysiological states that alter parathyroid-related homeostasis, in particular calcium, phosphate, and magnesium levels.
Carbohydrates
Authors: Torres Felipe Vasconcelos , Montagner Rossi Raquel
Published: May 2024

This chapter discusses the highlights of carbohydrate metabolism. Glucose plays a central role in energy generation by cells. Glucose molecules can be stored as glycogen by the body, or can be oxidized for the formation of nucleotides (pentose phosphate pathway) or for energy (glycolytic pathway). Glycolysis is the oxidation of the glucose molecule into pyruvate, and it can occur under aerobic or anaerobic conditions. When oxygen is available (aerobic metabolism), pyruvate becomes acetyl-CoA and enters the TCA cycle. This is followed by oxidative phosphorylation inside mitochondria, which leads to the generation of substantial amounts of energy. When oxygen availability is reduced (e.g., in anemia, hypovolemic shock, cardiogenic shock, obstructive shock, or strenuous exercise), cells rely on anaerobic glycolysis for energy and excess pyruvate is converted to lactate. Some tissues (e.g., liver and heart) can utilize lactate found in the bloodstream for energy.
Effects of Stress
Authors: Spence Allyson L. , Cornett Elyse M.
Published: May 2024

Stressors activate the “fight or flight” response, a protective mechanism of the body to adapt to and prepare for challenging situations. Overall, prolonged stress can lead to and/or worsen endocrine disorders and can produce a reduction in neuroprotective hormones. Overactivation of the hypothalamic-pituitary-adrenal (HPA) axis can cause fatigue, decreased cognitive abilities, and an increased risk of developing metabolic and psychiatric diseases, and increased immune response. This up-regulation of the immune system increases these individuals’ susceptibilities to developing inflammatory diseases, such as acute stress disorder. The perioperative period is associated with acute stress that can exacerbate symptoms of pain, anxiety, the surgical stress response, and the potential of anesthetic agents to produce neurotoxicity. Anesthesiologists should make conscious efforts to reduce this acute perioperative stress, and thus improve patient outcomes.
Perioperative Management of Insulin
Authors: Kim Jonathan I. , Schulman Nathan
Published: May 2024

Perioperative insulin management for the diabetic patient is critical to ensure optimal patient outcomes. It is particularly important for the anesthesiologist to understand given the fact that 9% of the US population has diabetes. This chapter discusses the importance of avoiding both hypoglycemia and hyperglycemia throughout the perioperative process. It addresses the preoperative planning for diabetic patients. It also discusses intraoperative strategies for insulin management, depending on the patient’s level of insulin dependence and the type and length of surgery they undergo. And finally, it discusses postoperative management.
Lipids
Authors: James Dominika Lipowska , Ghanavatian Shirin
Published: May 2024

Lipids are a structurally very diverse group of hydrophobic molecules broadly divided into fats, oils, and steroids. Lipids are essential to many biochemical processes, as well as the structural integrity of living organisms. Lipids form the building blocks of cellular membranes, serve as an energy source, and are involved in immune function and cellular communication in the form of hormones and steroids. Steroids are a varied group of molecules contributing to an organism’s proper growth and sexual development, metabolic function, and immune defense. Cholesterol is a precursor of sex steroids, cortisol, and aldosterone, as well as vitamin D. Cholesterol is also a substrate for bile salt production. Cholesterol, being a hydrophobic molecule, requires lipoproteins for transport in plasma. Elevation in cholesterol and triglycerides, called hypercholesterolemia and hyperlipidemia respectively, has been associated with increased risk for cardiovascular disease.
Ethics
Authors: Hanna Joseph Salama , Saad Ramsey
Published: May 2024

This chapter reviews the main concepts of HIPAA, advance directive, and discussions involving the possibility of DNR suspension during surgical procedures. HIPAA in its core includes specific regulations designed to protect the privacy of an individual’s health records. Advance directive is the way healthcare providers can learn about the patient’s wishes regarding his or her medical care in a situation in which the patient cannot speak for him- or herself. Discussion, as well as clear documentation of the code status before any surgical or interventional procedure, is very important and should take place before proceeding. Plan for intra- and postoperative code status should be clearly outlined and documented.
Core Competencies
Authors: Hanna Joseph Salama , Saad Ramsey
Published: May 2024

The Six Core Competencies, adopted by ABMS and ACGME in 1999, are recognized as integral to quality patient care. Most medical boards integrate learning and assessment of the six competencies throughout their process for Initial Certification in a manner that best serves the needs of patients cared for by diplomates, and that is relevant to the practice of their respective specialties and to the specific type of practice of a candidate. The six competencies are practice-based learning and improvement, patient care and procedure skills, systems-based practice, medical knowledge, interpersonal and communication skills, in addition to professionalism. This chapter presents a brief description of these competencies.
Approach to Anesthesiology Exams
Authors: Cole Dooley F. , Ching Adrian
Published: May 2024

During anesthesiology residency, trainees work countless hours gaining exposure to a wide variety of clinical specialties, and there is a significant amount of content to master. To judge progress toward this knowledge goal and competency as a consultant anesthesiologist, the trainee will sit for at least six exams, three in-training, one BASIC, one ADVANCED, and one APPLIED exam. The goal of this chapter is to provide background and basic information on the tests, discusses the differences between learning material and studying for standardized exams, as well as helpful information for how to study for these exams. Information is also included to help when the candidate must guess between answers.
How Technology, Social Media, and Current Events Profoundly Affect Adolescents
Authors: Goldstein M.D. Mark A. , Chandler Goldstein Myrna
Published: May 2024

How Technology, Social Media, and Current Events Profoundly Affect Adolescents examines 18 contemporary issues and their impact on the biological, psychological, and social domains in adolescents. Using research and clinical studies in each chapter, it reviews biological issues that include sleep, obesity, and stress. The mental health section contains chapters on anxiety, depression, eating disorders, substance use, and suicidality/self-harm. In the section on social issues, cyberbullying, problematic internet use, racism/discrimination, LGBTQ, transgender and gender dysphoria, poverty, divorce, and bereavement and mortality are studied. An analysis of current events including the COVID pandemic and war completes the book. There are multiple recurring themes including the importance of positive role modeling by parents, teachers, and clinicians; the harms and benefits from new technologies including social media; and the complex interrelationships that an issue has with the other issues reviewed. In addition, the impact on adolescents’ biopsychosocial domains from the perspective of the social determinants of health is reviewed. Each chapter also has a section on prevention and treatment. This book is written for a broad audience including primary care physicians, psychiatrists, psychologists, social workers, sociologists, trainees in these fields, as well as parents, teachers, and administrators.
Stress
Authors: Goldstein Mark A. , Goldstein Myrna Chandler
Published: May 2024

Stress is ubiquitous to all of us. While a person’s reaction to acute stress may be lifesaving, the response to chronic stress may negatively impact health. Chronic stress for adolescents may include psychological abuse, personal or parental physical or mental illness, and physical or emotional neglect. Stressful experiences are a major cause of anxiety disorders in adolescents, and early stress from adverse childhood events increases the risk that adolescents will develop depression. Poverty is also an early life stressor. With social media, adolescents may experience digital stress, which is caused by negative interactions in emails, texts, chat rooms, and various types of forums. The death of a parent, especially during adolescence, can be a devastating stressor for teens. Exercise and mindfulness may be helpful in reducing stress for adolescents.
Anxiety
Authors: Goldstein Mark A. , Goldstein Myrna Chandler
Published: May 2024

Even though everyone experiences some anxiety, researchers have yet to determine why certain teens develop an anxiety disorder. There are known biological, psychological, and social factors that interact to trigger an anxiety disorder. Genetic factors play an important role in determining which adolescents will have a problem with anxiety. It is generally believed that there is no single gene that directs the onset of anxiety; rather, it may be the cumulative effect of many genes. In addition, children of anxious parents are at increased risk for developing an anxiety disorder. Moreover, there appears to be a positive association between social media use and anxiety in adolescents. Violence in any form including school shootings can produce an acute stress reaction that includes anxiety. In the long term, some witnesses to such violence may develop posttraumatic stress disorder.
Suicidality and Self-Harm
Authors: Goldstein Mark A. , Goldstein Myrna Chandler
Published: May 2024

Suicide is the third leading cause of death in youth ages 15 to 19 years in the United States; most adolescents who die from suicide have a mental health disorder including depression, oppositional defiant or conduct disorder, attention-deficit/hyperactivity disorder, or bipolar disease. Adolescents continue to spend a significant amount of time on social media, an activity that has been correlated with depression and suicide-related outcomes, while they are spending less time on nonscreen activities including sports and exercise. Discrimination, racism, and minority sexual orientation have been identified as risk factors. Parents, teachers, coaches, clergy, and others should carefully observe adolescents for signs of suicidality; routine screening should be performed on a periodic basis by a clinician. Early referral for treatment is critical.