bluuebunny/crossref_metadata_2025 huggingface dataset:
Independent Living With(out) Privacy
Authors: Ho Anita
Published: March 2023

This chapter highlights various socio-contextual factors that frame people’s practical identity around aging and “independent living,” their available options for health monitoring, and their decisional motivations regarding the use of artificial intelligence (AI) home health monitoring. Section 1 details the perceived need for alternatives to traditional in-person home health monitoring. Section 2 investigates the common claim that AI home health monitoring can promote users’ autonomy and well-being. Section 3 utilizes a relational lens to contextualize AI health monitoring against the backdrop of an aging population, changing family patterns, and inadequate social or system support. It cautions that uncritical promotion of AI health monitoring without systemic improvement in the care environment may paradoxically exacerbate caregiver burden and isolation of those being remotely monitored.
Introduction and Overview
Authors: Galynker Igor
Published: March 2023

This chapter provides an overview of the enduring suicide epidemic in the United States and critically examines the limitations inherent in conventional suicide prevention and risk assessment strategies. To illustrate the challenges, the chapter reviews the current lack of reliable tests for suicide prediction, the problem with relying on patient disclosure of suicidal ideation, and the important distinction between long-term and short-term risk factors for predicting imminent suicide risk. While the field of suicide research has provided a strong empirical basis for understanding who is at risk for suicide, determining when someone may attempt suicide remains an enduring challenge for clinicians and researchers alike. In response to an urgent need to better understand when individuals are at imminent risk for suicide, this chapter introduces a proposed suicide-specific diagnosis, suicide crisis syndrome (SCS), an acute pre-suicidal state that can be identified, treated, and implemented as a clinical tool to save the lives of those in suicidal despair. This chapter also briefly introduces a novel framework, the narrative-crisis model of suicide, which includes SCS as a central feature. The latter half of the chapter examines contemporary practices in suicide risk assessment, including comparisons of clinical judgment and risk stratification systems, and concludes by offering readers suggestions for how to best use this book as a comprehensive roadmap for assessing imminent suicide risk.
Conducting Short-Term Risk Assessment Interviews
Authors: Galynker Igor
Published: March 2023

Chapter 9 describes several ways to integrate the previously discussed constructs (trait vulnerability, stressful life events, suicidal narrative, suicide crisis syndrome, and clinician’s emotional response to suicidal patients) into suicide risk assessment interviews in different clinical settings. The first section of the chapter combines all the core constructs into one comprehensive risk assessment outline. The second section discusses the real-world challenges of suicide risk assessment, emphasizing the limitations of self-disclosed suicidal ideation and intent and highlighting strategies to minimize the suicide risk interview bias. The third section outlines the potential advantages and shortcomings of the existing short-term suicide risk assessment scales. The fourth section describes three risk assessment interview strategies, illustrated by clinically relevant examples. The final section provides a striking clinical case example that underscores the importance of incorporating clinicians’ emotional responses into the suicide risk assessment.
Autonomic Nerve Blocks
Authors: Ethier Steven , Pride Keth
Published: March 2023

Chronic pain disorders present with different etiologies and consequently their signals are carried by different classifications of nerve fibers. Syndromes and disorders that present with sympathetically based pain are therefore treated differently than those with more musculoskeletal based etiologies. Autonomic nerve blockade primarily targeting sympathetic nerve ganglia can be used to provide significant pain relief in certain chronic pain disorders, most notably complex regional pain syndrome. Commonly targeted sympathetic ganglia include the stellate, celiac, and lumbar sympathetic chains. The purpose of this chapter is to provide recommendations on how to best perform these blocks as well as describe their indications, possible complications, and relevant surrounding anatomy.
Peripheral Nerve Blocks (Neck)
Authors: Blaine Scott , Pride Keth
Published: March 2023

To facilitate awake endotracheal intubation, a blockade of the glossopharyngeal, superior laryngeal, and recurrent laryngeal nerves can be utilized. The peripheral blockade of nerves in the neck is most often used to facilitate awake endotracheal intubation for the patient with a difficult airway. Although topicalization with minimal-to-moderate sedation is often sufficient to perform an awake intubation, one should be knowledgeable of all the alternative methods should the need arise. This chapter focuses on the indications, relevant anatomy, and complications of these blocks. Also described is blockade of the cervical plexus, which is useful in facilitating surgery on more superficial neck structures.
Butyrylcholinesterase (Pseudocholinesterase) Deficiency
Authors: Harris Brian , Ferguson Kris
Published: March 2023

Pseudocholinesterase is a plasma enzyme that functions to hydrolyze esters in succinylcholine, mivacurium, and ester-type local anesthetic. Pseudocholinesterase is produced in the liver and exists as an α2-globulin. Pseudocholinesterase deficiency is a rare disorder that can be acquired or inherited. Patients are asymptomatic unless given a medication that requires hydrolysis for termination of action. Pseudocholinesterase deficiency can cause delayed awakening due to prolonged action of succinylcholine. The metabolism of chloroprocaine is significantly prolonged, leading to an extended duration of nerve blockade. Cocaine’s effects can be exaggerated as cocaine is an ester-linked local anesthetic. The dibucaine number can be used to quantify pseudocholinesterase activity. Treatment is typically supportive if pseudocholinesterase deficiency is undiagnosed.
Tranquilizers
Authors: Aiyer Rohit , Money Sarah
Published: March 2023

Tranquilizers over the years have provided physicians a means to help control patients’ anxiety, agitation, and aggression. The major groups of tranquilizers are antipsychotics, specifically butyrophenones, and benzodiazepines. The butyrophenones, such as haloperidol, block dopamine D2 receptors, which clinically results in a reduction in agitation and psychosis. This can be a very effective medication for the treatment of acute delirium, particularly in an inpatient hospital setting. Benzodiazepines are also widely prescribed by clinicians, particularly due to their multipurpose uses, which include alleviation of tension, anxiety, muscle tensions, and spasticity. This class of medications interacts with γ-aminobutyric acid (GABA) A receptor, which opens the channel and allows for chloride ions to travel into the cell, resultingin hyperpolarization. Clinically, benzodiazepines can be grouped based on several factors, such as lipid solubility, half-life, and receptor binding affinity.
Neurological Disorders
Authors: Jowza Maryam , James Dominika
Published: March 2023

Neurological diseases are a heterogeneous group of disorders with varying etiologies. Neurologic conditions affecting the brain can be related to trauma, tumor, vascular malformations, congenital anomalies, or degenerative diseases. Congenital neurological conditions are often hereditary and may affect brain structure and physiology (tuberous sclerosis, neurofibromatosis). Degenerative neurological conditions often are associated with aging and involve central nervous system (CNS) malfunction at both anatomic and molecular levels (Parkinson disease, Alzheimer disease). Presence of these underlying disease processes should be taken under consideration to ensure appropriate anesthetic management. This chapter focuses on specific congenital and degenerative neurologic disorders and explores their anesthetic implications.
Epilepsy
Authors: Jowza Maryam , James Dominika
Published: March 2023

Seizures are among the most common neurological disorders encountered by anesthesiologists. Prevention and treatment of perioperative seizure is of utmost importance during neurosurgical procedures as uncontrolled seizures increase brain tissue metabolic demand and lead to poor operative outcomes. Perioperative use of antiepileptic drugs (AEDs) effectively decreases risk of intraoperative seizure events. AEDs, although very effective, are associated with many adverse effects and can interact with anesthetic agents. Phenytoin, phenobarbital, and carbamazepine induce hepatic microsomal enzymes (CYP3A4, CYP2C19), which can lead to accelerated metabolism of benzodiazepines, certain opioids, and resistance to neuromuscular blockers (NMBDs). Conversely, valproic acid inhibits certain enzymes (CYP2D6), leading to a decrease in methadone elimination. Sedative effects of AEDs impact anesthetic management by enhancing effects of anesthetic volatiles and sedatives. Intraoperative seizures should be treated immediately with securing the airway, performing ventilation, and ensuring hemodynamic stability, followed by intravenous administration of fast-acting benzodiazepines and phenytoin/fosphenytoin. For anesthesia induction, one should consider agents with antiepileptic properties, such as propofol, thiopental, or phenobarbital, but avoid ketamine and methohexital. Regarding the nondepolarizing muscle relaxants, atracurium and cisatracurium should be avoided as their metabolite laudanosine may have central nervous system–activating, epileptogenic properties. Anesthesia may be maintained with desflurane or isoflurane due to anticonvulsant properties. If possible, one should avoid long-acting neuromuscular blockers in an effort to monitor for seizure recurrence. AEDs should be continued throughout the entire perioperative period.
Therapeutic Barbiturate Coma
Authors: Rahman Syed A.
Published: March 2023

Pharmacological neuroprotection in patients with cerebral injury has been an area of interest for decades. Therapeutic barbiturate coma is initiated for neuroprotective benefit in focal cerebral ischemia and treatment of intractable intracranial hypertension and refractory status epilepticus. Brain protection is believed to be from depression of cerebral metabolic rate and cerebral blood flow, antiseizure effects, hypnotic properties, and inverse steal. Barbiturates and propofol are the drugs frequently used for this purpose. However, the doses and dosing regimens employed to achieve barbiturate coma often result in significant and severe side effects, like hemodynamic instability, cardiac arrhythmias, and difficulty in assessing neurological status. Therefore, close monitoring for adverse effects and judicious use of therapeutic coma in clinical circumstances with clear potential benefit is imperative.
Positioning and Anesthesia in Sitting Position
Authors: Mahboobi Sohail K. , Rothkrug Alexander
Published: March 2023

Positioning is an important aspect of any surgical procedure. Anesthetized patients cannot reliably express discomfort; thus, the burden of ensuring safe positioning falls on the provider. Assigning roles to staff is important to efficiently and smoothly achieve proper positioning for any case. Potential harm that may befall a patient as a result of poor positioning includes but is not limited to pressure injuries, peripheral nerve injuries, and complications related to unfavorable hemodynamics. The American Society of Anesthesiologists Closed Claims Project identifies perioperative nerve injury as the second most common injury (16%). Nerve injuries may be a result of stretching, compression, ischemia, or metabolic derangements. General anesthesia has been shown not to be a risk factor for peripheral nerve injury as compared to cases under regional anesthesia and/or varying levels of sedation. Risk factors that contribute to nerve injuries include advanced age, history of peripheral neuropathy, and diabetes. Eye injuries (<0.1% of all anesthetics) range from mild discomfort to permanent vision loss. For instance, the prone position risks excessive pressure placed on the eyes. If that pressure exceeds arterial pressure, a patient may experience retinal ischemia. If the eyes are left open, corneal drying can occur in 10 minutes. Corneal abrasions, the most common eye injury, are usually secondary to foreign objects, such as masks and drapes, causing direct trauma. This chapter discusses the different positions seen in surgery and special considerations for each one.
Monitored Anesthesia Care and Sedation
Authors: Eden Nikki , Rajan Shobana
Published: March 2023

Any anesthesia service provided exclusively by a qualified anesthesia provider for a specific procedure defines monitored anesthesia care (MAC), regardless of level of sedation achieved. MAC dictates that an anesthesiologist will provide a preoperative assessment, intraoperative management, and postoperative follow-up care for every patient. In contrast, conscious sedation can be performed by certified non–anesthesia providers during specific procedures; however, the anesthesiologist and non–anesthesia provider must both perform the procedure and monitor the patient under sedation. Having an anesthesiologist who is strictly focused on the anesthetic permits the highest level of patient safety and care throughout the entire procedure.
Divisions of Bronchoscopic Anatomy
Authors: Gunst Matthew , Giordano Christopher
Published: March 2023

The lower airway anatomy should be as familiar to the anesthesiologist as the upper airway anatomy as both are pivotal to adequately and efficiently instrument the airway. Alterations in bronchial segments and their anatomic differences can affect anesthetic delivery, airway management, management of patients with chronic pulmonary conditions, and alterations in pulmonary mechanics following lung surgery. Recognizing the changing structures in the respiratory tree as it pertains to entering different segments will equip physicians in ideally instrumenting the airway as well as maximizing ventilation and perfusion exchange. This chapter focuses on conductive airway anatomy, which is vital for anesthesiologists managing thoracic and non-thoracic surgical and critical care patients.
Temperature Effect on Blood Gases
Authors: Mahboobi Sohail K. , Mahmood Faraz
Published: March 2023

The solubility of gases increases in blood with decreasing temperature and consequently a decrease in partial pressures. In certain clinical conditions, a patient’s body temperature is lower than normal (e.g., ventilated patients in critical care units and floors, after cardiac arrest when return of spontaneous circulation has been achieved, and during surgery, particularly on bypass in cardiac surgical procedures). The management of acid-base balance in the hypothermic state is a topic of discussion as with decreasing temperature, PaO2 and PaCO2 also decrease, causing a lower PaCO2 and a rise in pH and an alkalotic picture at that temperature if nothing is added to the blood. When the blood gases are sent to the laboratory, the sample is warmed to 37°C and measurements performed are then corrected to the patient’s actual current body temperature. The two major schools of thought are alpha-stat and pH-stat management of blood gases in hypothermic patients. In alpha-stat, if at 37°C blood gases are in normal range, then nothing is required with an assumption that a decrease in pH on both sides of the cell membrane is in the same direction that keeps electrical neutrality in normal functioning range without causing disruption of cell function. In pH-stat, the aim is to keep blood gas values in normal range at the patient’s actual temperature by adding CO2 to raise PaCO2 and decrease pH to a normal level. Both methods have benefits and drawbacks, and no one method is considered superior to the other.
Lung Volume
Authors: Helwege Sarah , Sharma Archit
Published: March 2023

Formally evaluating the pulmonary function testing of patients is not a standard of care; however, in patients with life-impacting or long-standing pulmonary disease, pulmonary function testing the different volumes and capacities can be quite beneficial to the anesthesia provider. For most patients, a detailed history and physical examination is sufficient for managing patients with common pulmonary diseases. Even though preoperative testing of volumes and capacities does not give an exact picture of postoperative pulmonary performance, understanding the dynamics and sequelae associated with deficiencies in pulmonary function is vital as it lends guidance on ventilatory settings, medication administration, and postoperative care.
Nonpulmonary Surgery, Including Mediastinoscopy and Bronchoscopy
Authors: Fadumiye Christopher O.
Published: March 2023

This chapter focuses on nonpulmonary surgeries of the thoracic cavity, with the exception of pulmonary surgeries like thoracotomy and surgical resections of the lungs. Its emphasis is on mediastinal surgeries and bronchoscopy under general anesthesia. Specific focus is on how to approach these procedures from a perioperative perspective; the chapter also discuss adverse effects and complications. The chapter further explores ultrasound use in bronchoscopy, lung lavage with bronchoscopy, and the various anesthetic options available for these procedures, either in the operating room or in an outpatient or minor procedural area. 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 nonpulmonary surgery and bronchoscopy, making it a handy and quick review for board examination preparation.
Management of Respiratory Failure
Authors: Boysen Phil , Newman Patrick
Published: March 2023

Respiratory failure is the loss of the body’s ability to maintain appropriate oxygen delivery to the blood and removal of carbon dioxide from the blood. Respiratory failure can be classified as hypoxemic, hypercarbic, or mixed. The timeline is also used to describe it: acute, chronic, and acute on chronic. Significant morbidity and mortality occur due to respiratory failure, which is a common reason for hospital and intensive care unit (ICU) admission. As such, timely and effective management, both in the ICU and the operating room (OR), is extremely important. This chapter takes a look at management of respiratory failure and anesthetic considerations for patients in respiratory failure.
Lung Transplantation
Authors: Amiri Yamah , Kurian Dinesh J.
Published: March 2023

Patients with end-stage lung disease can be candidates for lung transplant therapy and get prioritized based on lung allocation score (LAS). It is critical to evaluate preoperative factors related to patient lung disease, including studies evaluating right and left heart function and V/Q (ventilation-perfusion) scan. The complexity of the procedure requires adequate equipment, including a double-lumen endotracheal tube, difficult airway adjuncts, arterial line, central line, large-bore intravenous lines, transesophageal echocardiography, and a second ventilator. Uniquely, hemodynamic instability can necessitate the use of inotropes to support right ventricular function and careful fluid resuscitation to minimize pulmonary edema. Native and donor lungs require different ventilation strategies. Furthermore, coordination with the pulmonary transplant team requires planning for immunosuppression medication and timing, along with antibiotic therapy. Anesthetic planning for a transplanted lung requires consideration of complications related to transplant, including infection, immunosuppression, ventilation strategies, aspiration risk from gastroesophageal reflux disease (GERD) or decreased esophageal sphincter tone, kidney function, and appropriate blood product use.
Ischemic Heart Disease
Authors: Parga Daniel Ramirez , Jamroz Tatiana
Published: March 2023

Ischemic heart disease occurs when the blood supply does not meet the oxygen demand of the heart. There are several reasons for this mismatch. The most common is atherosclerotic disease, wherein endovascular endothelium damage and plaque rupture with thrombus formation cause the imbalance. Common symptoms include chest pain, sweating, and shortness of breath. Diagnosis is usually clinical, with laboratory and imaging confirmation. Acute coronary syndrome is an emergency that should be treated as soon as possible to prevent serious complications and to improve patients’ outcomes. Therapy could be pharmacological or interventional (reperfusion and revascularization). Myocardial injury, even though it is a prerequisite for the diagnosis of myocardial infarction, is also recognized as an entity itself. It is defined by an elevated cardiac troponin value and is frequently encountered clinically. It is associated with an adverse prognosis. An elevated cardiac troponin value reflects injury to myocardial cells from a variety of underlying pathophysiological mechanisms, ischemic and nonischemic alike. Myocardial injury after noncardiac surgery (MINS) is troponin elevation apparently from cardiac ischemia. It occurs postoperatively, usually silently, and is independently associated with risk of death and cardiovascular complications over the initial postoperative year.
Postobstructive Pulmonary Edema
Authors: Kloesel Benjamin , Horvath Balazs
Published: March 2023

Postobstructive pulmonary edema (POPE) can occur in the perioperative period. A variety of causes, including upper airway obstruction due to oropharyngeal anatomical and functional variations, oversedation, laryngospasm, and occlusion of the endotracheal tube, may result in supraglottic or glottic obstruction. Respiratory efforts against an obstructed airway can generate negative pleural pressures significantly below the physiological level. The large pressure gradient increases venous return to the heart and facilitates fluid movement from the alveolar capillary network into the alveoli. The ensuing pulmonary edema causes dyspnea, hypoxemia, and cough. POPE is frequently self-limited with a good prognosis but, depending on the severity, may require treatment ranging from supplemental oxygen to mechanical ventilation and potentially even extracorporeal life support.
Pulmonary Hypertension
Authors: Barrack Frank , Noorda Bryan
Published: March 2023

Providing effective care of patients with pulmonary hypertension requires a thorough understanding of the etiology and severity of the disease. Persons with pulmonary hypertension can experience a range of symptoms, from shortness of breath, chest pains, fatigue, to syncope. These effects on the body stem from increased right heart strain and eventually right heart failure in advanced disease. Pulmonary hypertension is divisible into five groups with different mechanisms. Differentiation of pulmonary hypertension by group has important implications in the treatment of the disease for a specific patient, although some principles of management are applicable for all types. Important considerations to keep in mind for preoperative, intraoperative, and postoperative care of patients with pulmonary hypertension are also discussed.
Mechanical Circulatory Assist Devices
Authors: Leonardi James , Cormican Daniel
Published: March 2023

Ventricular assist devices (VADs) are technologies used to provide mechanical support to failing ventricles in order to improve cardiac output to ensure adequate tissue perfusion. VADs are used as a bridge to transplant, bridge to recovery, or destination therapy for failure of the right ventricle, left ventricle, or both ventricles and may be used as either temporary or long-term treatments. They can utilized as temporizing measure to stabilize blood pressure for patients in acute, severe cardiogenic shock associated with respiratory failure refractory to ventilator management. Each VAD device is associated with nuances that must be considered in order to provide optimal therapeutic benefit and reduce risk of harm; the reader is referred to the chapters within this text that are specific to each device for additional information. An overview of the aforementioned devices in presented in the chapter.
Extracorporeal Membrane Oxygenation (ECMO)
Authors: Morkos Michael , Cormican Daniel
Published: March 2023

Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary bypass used as a last resort effort following unsuccessful medical management in patients with severe, but reversible, cardiopulmonary pathology. Physicians should be well versed in the different modes of support available and appropriate patient selection for each mode. Outcomes are optimized when the configuration is tailored to each individual’s needs and comorbidities. Specific indications and contraindications exist for each approach to ECMO as well as multiple options for cannulation that may alter hemodynamic monitoring. Many complications often arise during ECMO that must be addressed in a timely manner to reduce morbidity and mortality.
Parenteral Nutrition
Authors: Fayed Mohamed , Valliani Arif
Published: March 2023

Parenteral nutrition refers to the provision of nutrition via the parenteral route. Nutrition should provide calories, protein, electrolytes, vitamins, minerals, trace elements, and fluids. Adequate nutritional support is essential for the management of critically ill patients. This chapter reviews the daily nutritional requirements and the timing of parenteral nutrition. It also summarizes the effects of malnutrition and of overfeeding in the critically ill patient. It also discusses immune-enhancing nutrition and provides a quick overview of refeeding syndrome and its management. This chapter and the enteral nutrition chapter complement each other in providing the basic principles of nutrition in critically ill patients.
Postoperative Hepatic Dysfunction
Authors: Nielson Peter , Kaufman Michael
Published: March 2023

While the causes of postoperative hepatic dysfunction are numerous, a systematic approach involves an evaluation based on analysis of intraoperative events as well as a pattern of laboratory value abnormalities. Elevated enzymes (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) should raise suspicion for direct damage to the liver, usually through a low-flow state or via drug or immunologic damage. Bilirubinemia will likely be from disruption of the pathway of bile excretion or from an increase of heme breakdown products. Halogenated anesthetic-induced hepatitis, while a theoretical cause of postoperative liver dysfunction, might be considered a diagnosis of exclusion until other causes are investigated in the modern era.
Liver Transplant Surgery
Authors: Mattimore John , Kaufman Michael
Published: March 2023

Liver transplantation surgery is a life-saving treatment for people with end-stage liver disease, often with very short life expectancies. Liver transplantation has become the mainstay treatment for most causes of hepatic failure, with 8250 cases performed in the United States in 2018, and graft 1-year survival rates reaching greater than 91%. Liver transplant surgery presents the anesthesiologist with very complex hemodynamic challenges requiring constant vigilance, a plethora of advanced monitoring devices, and close collaboration with surgical colleagues. This chapter covers the recipient selection process; the stages of a transplantation surgery with specific concerns of the anesthesiologist at each stage, including the intraoperative electrolyte and hemodynamic changes; and the evaluation of postoperative graft function.
Perioperative Oliguria and Anuria
Authors: Earls Brent , Sivanesan Eellan
Published: March 2023

Perioperative oliguria and anuria are common clinical signs associated with reduced kidney function and acute kidney injury (AKI). AKI in the perioperative period is a common complication associated with increased morbidity and mortality. A standard definition and staging system for AKI has been developed that is based on urine output and serum creatinine. Future classification schemes may seek to incorporate the use of novel biomarkers to detect kidney damage before or without traditional serum markers like creatinine. During the intraoperative period, urine output may be reduced in the absence of kidney injury or the presence of kidney injury, with or without fluid responsiveness. Several risk factors for AKI are important to assess in surgical patients. These include comorbidities such as chronic kidney disease and chronic heart failure. Increased risk of in-hospital AKI has also been associated with medications such as diuretics, contrast agents, and nephrotoxic drugs, which are commonly used throughout the perioperative period. Intraoperatively, episodes of hypotension should be avoided when possible since even short periods of hypotension are associated with an increased risk of AKI. Emergency surgery, procedures in the critically ill, and even open surgical techniques have also been associated with higher rates of AKI. The Kidney Disease: Improving Global Outcomes guidelines from 2012 suggested implementing preventive strategies in high-risk patients. Prevention includes hemodynamic goal-directed therapy, restoration of circulating volume, functional hemodynamic monitoring, and avoidance of nephrotoxic agents and hyperglycemia.
Dialysis and Hemofiltration
Authors: Gyorfi Michael J. , Abd-Elsayed Alaa
Published: March 2023

Renal replacement therapy (RRT) is designed to replace nonendocrine kidney function. This is important for patients with acute/chronic renal failure, electrolyte/uremic abnormalities, fluid management, and occasionally for some forms of poisoning. Techniques include hemodialysis, hemofiltration, and peritoneal dialysis. All modalities exchange solute and remove fluid from the blood using dialysis and filtration across permeable membranes. Dialysis is an important aspect to factor into pre-, intra-, and postoperative plans. Factors such as drug elimination, electrolyte abnormalities, fluid management, and bleeding risk must be considered for dialysis-dependent patients.
Assessment of Fluid Responsiveness and Goal-Directed Therapies
Authors: Sohn Jacqueline , McNamara Connor
Published: March 2023

An accurate assessment of intravascular volume status and its management is challenging, and there have been many debates over the topic through the years. The clinical assessment of a patient’s intravascular volume is very challenging and controversial. However, the maintenance of euvolemia is critical to electrolyte homeostasis and oxygen delivery to the tissues. This chapter reviews physiological background and various modalities on assessment of fluid responsiveness. The modalities include central venous pressure (CVP), pulmonary artery occlusion pressure (PAOP), esophageal Doppler, pulse pressure variation, and pulse contour analysis. This chapter further discusses goal-directed therapies and the controversies surrounding fluid management strategies.
Hemoglobinopathies and Porphyrias
Authors: Haynes Elizabeth , Hussain Nasir
Published: March 2023

Hemoglobinopathies are genetic blood disorders that include α- and β-thalassemia as well as diseases that cause abnormal hemoglobin structure. Porphyrias also encompass a group of metabolic disorders that interfere with the body’s normal hemoglobin production by altering heme synthesis. A series of blood tests is used to confirm the diagnosis of a hemoglobinopathy. Porphyrias are often difficult to diagnose because of their varied presentations and nonspecific symptoms. The medical therapies for both focus less on curative treatments and aim to provide symptomatic management and prevention of crises. In both disease states, acute attacks can be triggered by many factors during the perioperative period. A thorough preoperative evaluation should be performed to evaluate disease severity and the need for additional testing. Possible triggers for acute attacks should be identified and avoided. Postoperative monitoring is needed as these patients are at an increased risk of having an acute crisis as well as postsurgical complications.
Transfusion Ratios
Authors: Lee Albert , Schulman Nathan
Published: March 2023

This chapter discusses optimum transfusion ratios in the setting of massive transfusion, a critical topic given that blood product transfusions remain one of the most common procedures in hospitals. Component transfusion therapy has been adapted to various transfusion protocols and policies based largely on anecdotal and observational data given the lack of robust, randomized clinical trials (RCTs). This chapter reviews and briefly summarizes the current evidence, including the PROMMTT (Prospective, Observational, Multicenter, Major Trauma Transfusion) and PROPPR trials, meta-analyses, and one of the few RCTs available to date. The available data would favor the utilization of a structured, component-based transfusion strategy in patients with massive transfusion requirements with transfusion ratios of fresh frozen plasma to red blood cells at least greater than/or equal to 1:2. Blood product transfusion inherently carries risks, including those specific to massive product administration. This chapter also briefly reviews citrate, supernatant potassium, transfusion hypothermia, transfusion-associated circulatory overload (TACO), and transfusion-associated lung injury (TRALI) as risks to consider when utilizing a massive transfusion strategy, regardless of ultimate component ratio.
Hypopituitary Disease
Authors: Nalbandyan Ruzanna , Ragheb-Mueller Nawal E.
Published: March 2023

Hypopituitarism refers to decreased secretion of one or more pituitary hormones, which can result from diseases of the pituitary gland or pathology arising in the hypothalamus. The clinical manifestations depend on which pituitary hormone is deficient. Patients may present with nonspecific symptoms or with severe symptoms related to a deficiency in a particular hormone. Preoperative evaluation should include a complete history, physical examination, appropriate laboratory and endocrine evaluation, and include a complete thyroid panel, serum cortisol, corticotropin (formerly adrenocorticotropin, ACTH) growth hormone, insulinlike growth factor 1, follicle-stimulating hormone, luteinizing hormone, prolactin, and testosterone levels. Intraoperative management of patients includes maintenance hormone replacement therapy, continuous hemodynamic monitoring, and monitoring of intraoperative electrolyte and metabolic abnormalities. Emergency conditions such as Addisonian crisis, myxedema coma, and central diabetes insipidus require prompt recognition and treatment. Postoperative management necessitates adequate postoperative analgesia as well as appropriate fluid and electrolyte monitoring.
Multiple Sclerosis
Authors: O’Farrell Justin L. , Eckmann Maxim S.
Published: March 2023

Multiple sclerosis is an immune-mediated inflammatory disease causing demyelination of axons in the central nervous system. The location of demyelination and plaque development correlates with clinical symptoms observed in patients with multiple sclerosis. Classic presenting symptoms include nystagmus, dysarthria, and intention tremors. Patients with multiple sclerosis may present with different patterns of disease progression and acute exacerbations. The diagnosis is mainly clinical and can be supported with magnetic resonance imaging. Managing comorbid symptoms and acute exacerbations is critical along with long-term disease-modifying therapy. There are no curative therapies for multiple sclerosis. Patients will require close monitoring throughout the periods of acute disease exacerbation. Due to variability in disease presentation, critical preoperative assessment of patients with multiple sclerosis is needed to avoid the use of medications that may complicate perioperative management.
Myasthenia Gravis
Authors: Morkos Michael , Cormican Daniel
Published: March 2023

Myasthenia gravis is the result of autoimmune antibodies targeted against acetylcholine receptors on postsynaptic membranes of the neuromuscular junction. The majority of patients will describe drooping of the eyelids and blurred vision as their initial symptoms with worsening weakness associated with continued muscle use. Typically treated with pyridostigmine, other options such as intravenous immunoglobulin and plasmapheresis, exist for severe symptoms associated with myasthenic syndrome. The anesthetic plan must be thoughtfully considered, taking into account premedication, induction agents, and neuromuscular blocking drugs administered. Most importantly, extubation must be done in a well-planned manner to ensure adequate neuromuscular function to allow appropriate ventilation.
Postherpetic Neuralgia
Authors: Abd-Elsayed Alaa , Mauer Kim
Published: March 2023

This is a brief abstract of postherpetic neuralgia. Post-herpetic neuralgia can be a troubling diagnosis, but it is also known as a classic example of a neuropathic pain condition and is well studied. It provides a clear example of how a peripheral nerve change can lead to dysfunction of the central nervous system. Postherpetic neuralgia is the most common complication of shingles, which is characterized by its classical dermatomal rash. The pain is a classical neuropathic, burning pain The etiology of postherpetic neuralgia and common treatments are discussed; also, demographic and prevalence information is given about postherpetic neuralgia. Some investigational uses of therapies for postherpetic neuralgia are mentioned (these investigational uses need additional studies).
Apparatus and Breathing Circuits
Authors: Sinton Jamie W.
Published: March 2023

Breathing circuit apparatus choice for infants and children is often pragmatic. It relies on ability to maintain heat and humidity while minimizing work of breathing required to sustain normocarbia. This chapter discuss breathing circuits as they apply to neonatal and pediatric patients. Circle systems conserve heat and humidity at the potential expense of volume loss to the circuit and errant delivery of dangerous tidal volumes. Meanwhile, the Jackson-Rees circuit minimizes work of breathing during spontaneous respiration but predisposes to airway desiccation and heat loss. Finally, infant t-piece resuscitators effectively minimize dead space but carry the risk of breath stacking and inaccuracy of tidal volume delivery.
Induction Techniques
Authors: Shaik Sadiq S. , Boyette Lydia C.
Published: March 2023

Anesthetic induction in pediatric patients can safely be performed using multiple modalities but requires a multifaceted review and discussion with the patient and the patient’s parents or legal guardians. Intravenous (IV), intramuscular (IM), rectal, and inhaled anesthetics are all options for pediatric anesthetic induction; however, the technique chosen should be based on review of patients’ medical, surgical, and anesthetic histories; physical examination findings; and the planned procedure. The thorough review of patients’ histories and discussions with their families will not only facilitate rapport between the anesthesiologist and the aforementioned parties, but also provide information that may aid in early identification and treatment of complications associated with induction.
Drug Toxicities Preferentially Occurring in Children
Authors: Yao Caylynn , Peterson Elisha
Published: March 2023

Drug Toxicities Preferentially Occurring in Children reviews medication toxicities of relevance to an anesthesiologist concerning neonates, infants, and children. Toxicities can manifest in the setting of immature organ function in neonates, genetic variability of cytochrome p450 enzymes or due to medication-induced mitochondrial dysfunction. Identifying toxicities in a preverbal/limited verbal patient population is an added challenges that often results in late symptom identification. This chapter outlines the considerations in the pharmacokinetics and pharmacodynamics of young patient populations that render them vulnerable to toxicity in certain analgesics and hypnotics. Codeine and amide local anesthetics are discussed in greater detail. Reyes syndrome and propofol infusion syndrome (PRIS) are covered. The mechanisms underlying PRIS and the role of aspirin in Reyes syndrome have yet to be clarified.
Regional Anesthesia
Authors: Hoffmann Cassandra , Frazee Tiffany
Published: March 2023

Many differences exist between pediatric and adult regional anesthesia, including differing neurocognitive states, anatomy, physiology, and pharmacodynamics. In pediatric patients, regional procedures are performed under general anesthesia; many children cannot tolerate the placement of an awake block. Infant spine anatomy involves a low-lying conus medullaris and an increased volume of cerebral spinal fluid per kilogram with rapid turnover. These differences affect both block placement and duration. Physiologically, infants and children undergoing neuraxial procedures tolerate sympathetic blockade, and blood pressure remains preserved. Pharmacodynamics are affected by decreased levels of α1-glycoprotein, which result in decreased protein binding of local anesthetics and can increase toxicity risk. Despite these challenging differences, pediatric regional anesthesia can result in improved postoperative analgesia, decreased intraoperative anesthetic requirements, and decreased opioid requirements.
Fluid Therapy and Blood Replacement
Authors: Bilga Iana , Tzonkov Anna
Published: March 2023

Neonates, infants, and young children are more susceptible to overhydration and dehydration in the perioperative period than adults. There a lot of controversies related to fluid management in modern anesthesia. Fluid therapy in pediatric patients is focused on four main targets: replacement of preoperative deficit, maintenance fluids, and ongoing intraoperative losses. The selection of fluid in pediatric patients depends on age and settings. Decisions regarding blood transfusion must be based not purely on estimated blood loss but also patient’s blood volume, preoperative hematocrit, underlying medical conditions, nature of the surgical procedure, and risks versus benefits of transfusion. Knowledge of physiology and demand of pediatric patients is the key to the best fluid management and blood product therapy.
Neonatal Physiology
Authors: Dua Nupur , Fromer Ilana R.
Published: March 2023

To safely care for newborns in the operating room, anesthesiologists need a thorough understanding of the neonatal physiology at different gestational ages and anticipate how immature organs might respond to surgery and anesthetic agents. There are differences in neonatal, pediatric, and adult physiology. The neonates have transitional circulation during the first few weeks of life, and various factors need to be considered to avoid reversion to fetal circulation. There are major differences in the neonatal and adult airway that require modification in the choice of equipment and intubation technique. It is important to know that the respiration is less efficient in neonates, and they are more prone to hypoxia. Most of the major organs, such as kidneys, liver, and heart, are immature at birth and develop at different rates as the neonate grows. Similarly, metabolism and fluid distribution are very different from adults. This involves consideration with the use of anesthetic agents and management in the operating room. Neonates are especially vulnerable to intraoperative hypothermia. Preoperative evaluation is arguably the most important part of anesthetic care. The purpose of this chapter is to allow anesthesia providers to administer safe care to newborns based on an understanding of developmental physiology.
Pulmonary Hypertension
Authors: Kloesel Benjamin , Horvath Balazs
Published: March 2023

Pulmonary hypertension is defined by a resting mean pulmonary artery pressure equal or greater than 25 mm Hg. In the perioperative setting, children diagnosed with pulmonary hypertension are at 20-fold higher risk for cardiac arrest and death. It is associated with significant morbidity and mortality and requires a carefully planned and executed approach to deliver a safe anesthetic. A feared complication in children with pulmonary hypertension is the development of a pulmonary hypertensive crisis. This emergency, which can potentially result in cardiopulmonary arrest, requires prompt intervention aimed at reducing pulmonary vascular resistance and interrupting the vicious cycle that ultimately results in right ventricular failure.
Chronic Congenital Heart Disease
Authors: Sinton Jamie W.
Published: March 2023

Presently there are many more adults than children living with congenital heart disease (CHD). The adult with CHD will likely have had at least one previous intracardiac repair and transitioned care from a pediatric cardiologist to a general or adult congenital cardiologist. Therefore, expert care of this population relies on knowledge of previous anatomy, repair, present anatomy, and long-term complications. A high index of suspicion must be maintained for subtle historical or physical examination features that suggest progression or complication of disease or subacute bacterial endocarditis. Compliance with instruction, medication, and cardiology follow-up should help to optimize each patient prior to elective surgery and anesthesia.
Tracheoesophageal Fistula
Authors: Wasson Cassandra , Diaz Christina D.
Published: March 2023

Tracheoesophageal fistula (TEF) is a congenital fistula between the trachea and esophagus. Prenatal ultrasound suggests a diagnosis of TEF by findings of polyhydramnios and a small or absent fetal stomach bubble. There are five subtypes of TEF, which are determined by the location of the fistula and presence or absence of esophageal atresia, the most common being type C. Additional congenital anomalies occur in 50% of patients with TEF. Many of these congenital anomalies are part of the VACTERL (vertebral defects, anal atresia, cardiac anomalies, TEF, renal agenesis and dysplasia, and limb anomalies) sequence. A 12-lead electrocardiogram (ECG) and echo should be obtained to diagnose associated congenital heart disease. Treatment for TEF is by surgical repair (cervical dissection, thoracotomy, or thoracoscopy) or endoscopic procedures. TEF repair is generally an urgent operation to minimize aspiration pneumonia and begin enteral nutrition. The preferred endotracheal tube for intubation is a microcuff endotracheal tube. Historically, TEF was 100% fatal. However, survival rates are now as high as 95%. Postoperative analgesia options include an opioid infusion, epidural catheter, caudal catheter, subcutaneous wound catheter, and local infiltration. Regional anesthesia can facilitate earlier extubation by reducing the risk of apnea with opioid analgesia.
Respiratory Distress Syndrome
Authors: Sinton Jamie W.
Published: March 2023

Respiratory distress syndrome (RDS) is a condition of the newborn in which lack of pulmonary surfactant predisposes to atelectasis, intrapulmonary shunting, hypoxemia, and hypoventilation. These problems lead to reopening or failed closure of the patent ductus arteriosus, bronchopulmonary dysplasia (BPD), and pulmonary hypertension. RDS is commonly found in premature infants as their surfactant production is inadequate or has yet to occur or infants of diabetic mothers whose lungs are often immature for their gestational age. In addition to anesthetic considerations for newborns, those with RDS will benefit from a lower oxygen saturation target; avoidance of cold, dry respiratory gas; and maintenance of continuous positive airway pressure throughout the perioperative period.