bluuebunny/crossref_metadata_2025 huggingface dataset:
Local anaesthetic agents
Authors: Columb Malachy O.
Published: April 2017

Local anaesthetic agents cause a pharmacologically induced reversible neuropathy characterized by axonal conduction blockade. They act by blocking the sodium ionophore and exhibit membrane stabilizing activity by inhibiting initiation and propagation of action potentials. They are weak bases consisting of three components: a lipophilic aromatic ring, a link, and a hydrophilic amine. The chemical link classifies them as esters or amides. Local anaesthetics diffuse through the axolemma as unionized free-base and block the ionophore in the quaternary ammonium ionized form. The speed of onset of block is therefore dependent on the pKa of the agent and the ambient tissue pH. Esters undergo hydrolysis by plasma esterases and amides are metabolized by hepatic microsomal mixed-function oxidases. Local anaesthetics are bound in the blood to α‎1-acid glycoproteins. Pharmacological potency is dependent on the lipid solubility of the drug as is the potential for systemic toxicity. The blood concentrations required to cause cardiovascular system (CVS) collapse and early central nervous system (CNS) toxicity are used to quantify the CVS:CNS toxicity ratio. Local anaesthetics also have the potential to induce direct neuronal damage. Intravenous lipid emulsion is used for the treatment of systemic toxicity but the scientific evidence is inconsistent. With regard to the pipecoloxylidine local anaesthetics, early evidence indicated that the S- was less toxic than the R-enantiomer. However, clinical research using minimum local analgesic concentration designs suggests that reduced systemic toxicity and motor block sparing is mainly explained by potency rather than enantiomerism.
Clinical trial designs in anaesthesia
Authors: Howell Simon J.
Published: April 2017

A clinical trial is a research study that assigns people or groups to different interventions and compares the impact of these on health outcomes. This chapter examines the design and delivery of clinical trials in anaesthesia and perioperative medicine covering the issues outlined below. The features of a high-quality clinical trial include well-defined inclusion and exclusion criteria, a control group, randomization, and blinding. Outcome measures may be broadly divided into counting the number of people who experience an outcome and taking measurements on people. The outcome measures selected for a clinical trial reflect the purpose of the study and may include ‘true’ clinical measures such as major postoperative complications or surrogate measures such as the results of a biochemical test. Outcome measures may be combined in a composite outcome. Assessment of health-related quality of life using a tool such as the SF-36 questionnaire is an important aspect of many clinical trials in its own right and also informs the economic analyses that may be embedded in a trial. Determining the number for recruits needed for a clinical trial requires both clinical and statistical insight and judgement. The analysis of a clinical trial requires a similarly sophisticated approach that takes into account the objectives of the study and balances the need for appropriate subgroup analyses with the risk of false-positive results. The safe and effective management of a clinical trial requires rigorous organizational discipline and an understanding of the ethical and regulatory structures that govern clinical research.
The roles and responsibilities of the anaesthesiologist
Authors: Knape Hans
Published: April 2017

Anaesthesia, being a relatively young medical specialty, has undergone a process of metamorphosis in the last 60 years. Modern principles of pathophysiology, technical developments, and new pharmacological principles have enhanced the potential of anaesthesia in the operating room, causing several subspecialties to develop. These subspecialties have enabled anaesthesiologists to better serve groups of patients with particular challenges and specific demands. The competences of anaesthesiologists in the pathophysiology of pain, pharmacology, and regional anaesthesia techniques enabled them to take the lead in the development of pain clinics, especially serving the increasing population of patients with chronic pain syndromes, often in close collaboration with experts from other disciplines. A similar development occurred in critical care medicine based on the expertise of anaesthesiologists in ventilatory and circulatory management and also in emergency medicine. With their overview of anaesthesia, intensive care medicine, and emergency medicine, anaesthesiologists are now in a position to lead in the whole perioperative process, not only in the medical management of individual patients but also in the logistic and organizational aspects of care. With further developments in information technology, in telemedicine, and rapid changes in society, with the increased demand of care in times of limited financial resources, a strong appeal will be made to anaesthesiologists to show leadership and cross boundaries. An increased focus on teamwork with surgeons, non-medical professionals, but also with managers and insurance companies in healthcare may open new horizons for the specialty of anaesthesiology and perioperative medicine.
Human factors and simulation in anaesthetic practice
Authors: Glavin Ronnie , Staender Sven , Smith Andrew
Published: April 2017

Human factors is the study of how interactions between organizations, tasks, and the individual worker impact human behaviour and affect systems performance. The importance of human factors in anaesthesia and critical care has been increasingly recognized, leading to its inclusion in the European-wide standards for patient safety in anaesthesiology within the Helsinki Declaration for Patient Safety in Anaesthesiology. ‘Person’ factors include permanent characteristics such as an individual’s personality and temporary influences such as physical condition, stress, morale, and workload. ‘Task’ factors include task complexity, preparation and checking, timing, equipment, and working environment. ‘Organization’ factors include communication, leadership, staffing levels, and organizational (safety) culture. While some of these features rely on the technical domain of anaesthetic/critical care practice, most are in the domain of ‘non-technical’ skills. This chapter reviews a number of these influences in detail and describes how non-technical aspects of practice can be encouraged and promoted. Simulation has been used as an educational tool in healthcare for some years, often with anaesthetists closely involved in establishing and running simulation centres and programmes. However, recent changes in medical education, coupled with public demands for increased patient safety, have brought simulation to the fore. This chapter reviews the classification of simulation systems and outlines the use of scenario-based and in situ simulation, before examining the evidence for its effectiveness. The authors emphasize that simulation provides a means for achieving an educational aim rather than being a technological end in its own right.
Teaching in anaesthesia
Authors: Lam W. Hiu , Sneyd J. Robert
Published: April 2017

Anaesthesia education is uniquely placed to allow safe and supervised workplace teaching and training delivered in a personalized, contextual one-to-one basis. Trainers and trainees need to manage their expectations in training, enabling flexible and opportunistic capturing of these learning episodes, as well as structured learning. Structured planning of individualized training is imperative to facilitate learning in trainees with different learning styles. Role modelling of trainers in the workplace is an essential component of both clinical and professional teaching. Critical reflection and high-quality trainee feedback enhances this experiential learning. A robust framework of education governance is fundamental in maintaining a high standard of training; this includes trainer accreditation, recognizing the importance of trainer development, and an appropriate infrastructure to support training and education in the clinical workplace.
Intraoperative monitoring
Authors: Magee Patrick , Tooley Mark
Published: April 2017

Chapter 25 introduced some basic generic principles applicable to many measurement and monitoring techniques. Chapter 43 introduces those principles not covered in Chapter 25 and discusses in detail the clinical applications and limitations of the many monitoring techniques available to the modern clinical anaesthetist. It starts with non-invasive blood pressure measurement, including clinical and automated techniques. This is followed by techniques of direct blood pressure measurement, noting that transducers and calibration have been discussed in Chapter 25. This is followed by electrocardiography. There then follows a section on the different methods of measuring cardiac output, including the pulmonary artery catheter, the application of ultrasound in echocardiography, pulse contour analysis (LiDCO™ and PiCCO™), and transthoracic electrical impedance. Pulse oximetry is then discussed in some detail. Depth of anaesthesia monitoring is then described, starting with the electroencephalogram and its application in BIS™ monitors, the use of evoked potentials, and entropy. There then follow sections on gas pressure measurement in cylinders and in breathing systems, followed by gas volume and flow measurement, including the rotameter, spirometry, and the pneumotachograph, and the measurement of lung dead space and functional residual capacity using body plethysmography and dilution techniques. The final section is on respiratory gas analysis, starting with light refractometry as the standard against which other techniques are compared, infrared spectroscopy, mass spectrometry, and Raman spectroscopy (the principles of these techniques having been introduced in Chapter 25), piezoelectric and paramagnetic analysers, polarography and fuel cells, and blood gas analysis.
Hazards in anaesthetic practice: general considerations, injury, and drugs.
Authors: Merry Alan F. , Mitchell Simon J. , Hardman Jonathan G.
Published: April 2017

The hazards of anaesthesia should be considered in the context of the hazard of surgery and of the pathology for which the surgery is being undertaken. Anaesthesia has become progressively safer since the successful demonstration of ether anaesthesia in Boston, Massachusetts, United States in 1846 and the first reported death under anaesthesia in 1847. The best estimation of the rate of anaesthesia-related mortality comes from the anaesthesia mortality review committees in Australia and New Zealand, where data have been collected under essentially consistent definitions since 1960, and reports are amalgamated under the auspices of the Australian and New Zealand College of Surgeons. An internationally accepted definition of anaesthetic mortality is overdue. Extending the time for inclusion of deaths from 24 h to 30 days or longer substantially increases estimated rates of mortality. Attribution of cause of death may be problematic. Even quite small degrees of myocardial injury in patients undergoing non-cardiac surgery increase the risk of subsequent mortality, and in older patients, 30-day all-cause mortality following inpatient surgery may be surprisingly high. Patients should be given a single estimate of the combined risk of surgery and anaesthesia, rather than placing undue emphasis on the risk from anaesthesia alone. Hazards may arise from equipment or from drugs either directly or through error. Error often underlies harmful events in anaesthesia and may be made more likely by fatigue or circadian factors, but violations are also important. Training in expert skills and knowledge, and in human factors, teamwork, and communication is key to improving safety.
General principles of regional anaesthesia
Authors: Berrill Andrew , Gupta Pawan
Published: April 2017

Regional anaesthesia is now extremely safe in experienced hands. The vast majority of upper and lower limb procedures can now be performed with either a peripheral regional block alone or in combination with a general anaesthetic. Neuraxial blocks can provide reliable postoperative pain relief for operations on the trunk and lower limbs. There is no consensus on the maximum safe dose of local anaesthetics. It is important therefore to use a minimum optimal dose of a local anaesthetic for any nerve block to reduce the risk of toxicity and to improve the success rate. Adjuncts, such as clonidine and dexamethasone, can prolong the duration of the block. Advances in nerve localization methods and block needles have further improved the safety of nerve blocks. There is increasing evidence to show that ultrasound is superior to peripheral nerve stimulation for identifying nerves. Ultrasound also helps in real-time visualization of the spread of the local anaesthetic. Consent, sedation, and support from non-anaesthetic staff play a key role in the success of regional anaesthesia, especially in awake patients. Although serious complications from nerve blocks are uncommon, direct nerve injury is perhaps the most serious complication. Fortunately, these symptoms in the overwhelming majority resolve within a year. This chapter covers the history, factors affecting local anaesthetics, role of adjuncts, nerve localization techniques, and complications of regional anaesthesia. Finally, some suggestions to improve the success and safety of peripheral nerve blocks are discussed.
Regional anaesthesia of the lower limb
Authors: Gupta Pawan , Vats Anurag
Published: April 2017

Lower limb nerve blocks gained popularity with the introduction of better nerve localization techniques such as peripheral nerve stimulation and ultrasound. A combination of lower limb peripheral nerve blocks can provide anaesthesia and analgesia of the entire lower limb. Lower limb blocks, as compared to central neuraxial blocks, do not affect blood pressure, can be used in sick patients, provide longer-lasting analgesia, avoid the risk of epidural haematoma or urinary retention, provide better patient satisfaction, and have acceptable success rates in experienced hands. Detailed knowledge of the relevant anatomy is essential before performing any nerve blocks in the lower limb as the nerve plexuses and the peripheral nerves are deep and obscured by bony structures and large muscles. The lumbosacral plexus provides sensory and motor innervation to the superficial tissues, muscles, and bones of the lower limb. This chapter covers different approaches and techniques for lower limb blocks, that is, the lumbar plexus, femoral nerve, fascia iliaca, saphenous nerve, sciatic nerve, popliteal nerve, ankle block, forefoot block, and the intra-articular infusion of local anaesthetics. Both peripheral nerve stimulator- and ultrasound-guided approaches are discussed. The use of ultrasound guidance is suggested as it helps in reducing the dose of local anaesthetic required and can ensure circumferential spread of local anaesthetic around peripheral nerves, which hastens the onset of block and improves success rate.
Anaesthesia for thoracic surgery
Authors: Roscoe Andrew , Slinger Peter
Published: April 2017

The conduct of thoracic anaesthesia requires an understanding of respiratory anatomy and physiology in order to optimize patient care whilst facilitating intrathoracic surgery. The preoperative assessment focuses on the underlying diagnosis, with emphasis on the impact of the surgical procedure on the patient’s cardiovascular and respiratory systems. Intraoperative care frequently necessitates lung isolation and proficiency at the variety of techniques available is essential. Additionally, adept management of one-lung ventilation and correction of hypoxaemia is fundamental to providing favourable outcomes. Thoracic surgical procedures may involve the airways, lung parenchyma, mediastinum, oesophagus, major vascular structures, pleura, and chest wall. Each procedure carries its own issues, including the shared airway, hypoxaemia, tracheobronchial compression, cardiac involvement, or major haemorrhage. Specialized procedures, such as lung transplantation, pulmonary endarterectomy, and bronchopulmonary lavage, introduce highly specific challenges. The provision of adequate analgesia can be challenging for the thoracic anaesthetist, and from the options available, it is often tailored to the individual. Awareness of common postoperative complications is necessary, as perioperative interventions aimed at reducing postoperative risk can improve patient outcome.
Anaesthesia for ophthalmic surgery
Authors: Dodds Chris , Kumar Chandra M.
Published: April 2017

Anaesthesia for ophthalmic surgery has always been challenging because the patients range across all ages, but the elderly are especially vulnerable. They have an increased morbidity and are often taking multiple drugs that make even anaesthesia for minor surgery more risky. No wonder there has been a shift in the delivery of anaesthesia towards regional techniques although general anaesthesia remains the technique of choice for many intermediate and most complex ophthalmic operations. Understanding the physiology of the eye, the relevant anatomy, and the ophthalmic drugs patients may receive, all have major influences on the choice of anaesthesia. This varies worldwide but the current preference is firmly in favour of local anaesthesia. A practising ophthalmic anaesthetist should be skilled in a range of different techniques to deal with the needs of different operations, operators, and, most importantly, patients.
Anaesthesia for orthopaedic and trauma surgery
Authors: Sell Alex , Bhalla Paul , Bajaj Sanjay
Published: April 2017

This chapter is divided into three main sections. The first section concerns the patient population that presents for orthopaedic surgery, specifically examining chronic diseases of the musculoskeletal system and the medications commonly used for their management, and the impact this has when these patients present for surgery. Included in this section are the surgical considerations and the anaesthetic implications of orthopaedic surgery, ranging from patient positioning to bone cement implant syndrome. The last part of this first section looks at specific orthopaedic operations, starting with the most commonly performed, hip and knee arthroplasties, and moving onto the specialist areas of spinal deformity, paediatric, and bone tumour surgery that are not usually found outside of specialist centres. The middle section gives a brief overview on analgesia concentrating on pharmacological methods as, although orthopaedic surgery lends itself well to regional anaesthesia, this is covered elsewhere in its own dedicated chapters. No section on analgesia would be complete without mentioning enhanced recovery: the coordinated, multidisciplinary approach that improves the patient experience, increases early mobilization, and reduces length of stay, which should be the standard obtained for every patient. The final section covers the anaesthetic management of in-hospital trauma, giving an overview on initial assessment, timing of surgery, and management of haemorrhage and coagulopathy. This section finishes by covering the orthopaedic-specific topics of compartment syndrome, fat embolism syndrome, and the management of fractured neck of femur and spinal injury.
Anaesthesia for plastic surgery and burns
Authors: Pal Sandip K.
Published: April 2017

This chapter describes anaesthesia for plastic surgery including burns. The chapter is divided into some specific areas: reconstructive surgery, burns, and cosmetic surgery. The anaesthetic management is described in detail for some specific procedures including microvascular free flap surgery, cleft repair, hand surgery, burns, and cosmetic surgery. The topic will interest readers planning to specialize in burns and plastic anaesthesia or who simply want to enhance their knowledge and expertise in this field. Specialists in this field require a thorough knowledge of anaesthetic management in adults and extremes of ages, and an understanding of intensive care management and multidisciplinary team work. Since the majority of cosmetic surgery is carried out in the private sector, anaesthetic trainees do not receive any experience in anaesthesia for cosmetic surgery and a section of this chapter gives an account of this surgery. It will also be of interest to anaesthetic trainees who want to complete their plastic surgery and burns module. Currently this module is not a mandatory inclusion in the higher anaesthetic training. The nerve block techniques for hand surgery are described in detail in another chapter in this book.
Anaesthesia for ENT, dental, and maxillofacial surgery
Authors: Irwin Michael G. , Cheung Chi Wai , Wong Gordon Tin Chun
Published: April 2017

The principles of anaesthesia management for otolaryngological and maxillofacial surgery share some similarities and unique challenges. Patients present at all ages and surgery can range from simple, short interventions to major, prolonged, and complicated cases with potential for massive blood loss. Some procedures can be performed under local anaesthesia with sedation whereas, at the other extreme, general anaesthesia with invasive monitoring is required. Microsurgery will necessitate a bloodless field, nerve monitoring is often required, and there is a susceptibility to postoperative nausea and vomiting. Patients with cancer often have poor nutritional status because of catabolism and eating difficulties and, since many head and neck cancers are associated with smoking and excessive alcohol consumption, significant co-morbidity is not unusual. Airway management especially can be challenging because of abnormal anatomy, pathology in this area, and the inherent difficulties of a shared airway. Postoperative management of the airway is particularly challenging as alterations to the anatomy and tissue swelling may have occurred during the course of surgery or thereafter. Last but not least, patients may present acutely with airway complications that require emergent management.
Anatomy, physiology, and pharmacology in paediatric anaesthesia
Authors: Wilton Niall , Anderson Brian J. , Marciniak Bruno
Published: April 2017

Anaesthesia for children is tempered by changes that occur during both growth and development. Drug dose is affected by size and clearance maturation processes as well as the changing body composition that occurs with age. All organ systems undergo these maturation changes and most are complete within the first few years of life. Normal physiological variables in infancy and childhood are quite different from adults. The central nervous, cardiovascular, and respiratory systems are particularly important. Cerebral immaturity and plasticity impacts sensitivity to drugs, pain responses, and behaviour and increases potential harm from apoptosis with anaesthesia. The heart undergoes a transition from fetal to adult circulation during the first few weeks of life. Undiagnosed congenital defects are not uncommon. The neonate is very susceptible to conditions that trigger an increase in pulmonary vascular resistance, with reversion to fetal circulatory patterns. Respiratory anatomy and mechanics affect the propensity to apnoea, airway maintenance, artificial ventilation modalities, uptake of inhalational agents, and tracheal tube sizes. Metabolic rate and oxygen requirements increase with decreasing age. This physiology influences diverse aspects that include the rate of desaturation during apnoea, hypoglycaemia during starvation, cardiac output, drug metabolism, fluid requirements, and heat production or loss.
Neonatal anaesthesia
Authors: Davidson Andrew , Bosenberg Adrian , Stayer Stephen
Published: April 2017

Neonatal anaesthesia requires an understanding of how neonates differ from adults and older children in anatomy, physiology, and pharmacology. There are also pathological and surgical conditions in neonates that are associated with unique anaesthesia challenges. Organ systems are generally immature, reducing the clearance of many drugs, while different water and fat content results in altered volumes of distribution. Pharmacological management is further complicated by a lack of basic pharmacokinetic data for the use of most anaesthetic drugs in neonates. At birth, there is a transition from a fetal circulation. Some aspects of fetal physiology can persist and have an impact on anaesthesia care, for example, exaggerated hypoxic pulmonary vasoconstriction. Small size, organ immaturity, and reduced physiological reserve can also result in rapid changes to cardiovascular or respiratory status during surgery. Neonates are also very vulnerable to injury, particularly pulmonary or neurological damage. Even brief episodes of over-inflation or hyperoxia may have long-lasting effects on the lung. Safe neonatal anaesthesia thus requires appropriate equipment and ventilators, careful monitoring, and the rapid management of changes in circulatory or respiratory status. Neonates that need surgery often have other significant co-morbidities; for example, prematurity, sepsis, congenital cardiac disease, or a wide variety of syndromes. Safe anaesthesia requires a careful preoperative assessment looking for such co-morbidities and a good understanding of how these may have an impact on anaesthesia.
Anaesthesia for medical imaging and bronchoscopic procedures
Authors: Brandt Sebastian , Gehring Hartmut
Published: April 2017

Anaesthesia in ‘remote areas’ is required for medical imaging (CT, MRI, PET-CT), angiography, endoscopy, and interventions (stenting, thrombectomy, coiling, laser therapy, biopsies, radiotherapy) in a number of medical disciplines (paediatrics, radiology, cardiology, pulmonology, gastroenterology, surgery, cardiac surgery, emergency medicine). The spectrum of anaesthetic techniques is broad. It reaches from standby (monitored anaesthesia care), through analgesia and sedation (with spontaneous breathing), to general anaesthesia and mechanical ventilation. Regional anaesthesia techniques are also required under certain circumstances. In the last few years there has been a move away from open procedures to interventional techniques. The complexity of these interventions has increased (i.e. interventional cardiac valve replacements) and the patients tend to be older and suffer from a multitude of co-morbidities. Many of these interventions are performed in the ‘hostile environment’ of the intervention suite. Intervention suites are typically not designed to offer anaesthetists an ideal working area. The space may be limited and medical equipment impedes access to the patient. The infrastructure may be suboptimal (e.g. no central medical gases supply). Protection for staff and equipment against radiation and high magnetic fields must be considered. Loud noise from machinery and shielded walls, doors, and windows may hinder communication and hearing acoustic alarms. The distance to the operating theatre may be considerable and thus support from senior anaesthetists and supply of additional equipment may take some time to arrive. Anaesthesia outside the operating theatre is sometimes underestimated as trivial. Performing a ‘quick’ interventional case can evolve within seconds into a challenge even for the experienced anaesthesiologist if a surgical or anaesthesiological complication occurs. Non-operating-theatre anaesthesia has a higher severity of injuries and more substandard care than operating theatre anaesthesia. This is not acceptable and anaesthetists must ensure the same high standard of anaesthesia care and patient safety both inside and outside the operating theatre.
Pulmonary disease and anaesthesia
Authors: Mills Gary H.
Published: April 2017

Respiratory adverse events are the commonest complications after anaesthesia and have profound implications for the recovery of the patient and their subsequent health. Outcome prediction related to respiratory disease and complications is vital when determining the risk:benefit balance of surgery and providing informed consent. Surgery produces an inflammatory response and pain, which affects the respiratory system. Anaesthesia produces atelectasis, decreases the drive to breathe, and causes muscle weakness. As the respiratory system ages, closing capacity increases and airway closure becomes an increasing issue, resulting in atelectasis. Increasing comorbidity and polypharmacy reduces the patient’s ability to eliminate drugs. The proportion of major operations on older frailer patients is rising and postoperative recovery becomes more complicated and the demand for critical care rises. At the same time, the population is becoming more obese, producing rapid decreases in end-expiratory lung volume on induction, together with a high incidence of sleep-disordered breathing. Despite this, many high-risk patients are not accurately identified preoperatively, and of those that are admitted to critical care, some are discharged and then readmitted to the intensive care unit with complications. Respiratory diseases may lead to increases in pulmonary vascular resistance and increased load on the right heart. Some lung diseases are primarily fibrotic or obstructive. Some are inflammatory, autoimmune, or vasculitic. Other diseases relate to the drive to breathe, the nerve supply to, or the respiratory muscles themselves. The range of types of respiratory disease is wide and the physiological consequences of respiratory support are complex. Research continues into the best modes of respiratory support in theatre and in the postoperative period and how best to protect the normal lung. It is therefore essential to understand the effects of surgery and anaesthesia and how this impacts existing respiratory disease, and the way this affects the balance between load on the respiratory system and its capacity to cope.
Heart disease and anaesthesia
Authors: Hert Stefan De , Wouters Patrick
Published: April 2017

Cardiovascular disease is a leading cause of mortality. Hypertension is one of the major risk factors for cardiovascular disease. Classically, hypertension is subdivided according to the aetiology into primary and secondary hypertension. Ischaemic heart disease constitutes a major concern for perioperative morbidity and mortality. Therefore important efforts are directed towards the identification of the patient at risk for perioperative cardiac complications and towards optimization of the cardiac status before intervention. Cardiac rhythm disturbances fall into two general classes: bradyarrhythmias and tachyarrhythmias. While single isolated extra or skipped heart beats are usually harmless, serious heart rhythm disturbances are caused by an underlying heart disease. Valvular heart disease refers to any disease process involving any valve of the heart. Valvular heart disease may be as a result of a stenosis or an insufficiency of the valve, or both. It is characterized by pressure or volume overload to the atria and the ventricles (or both). It is this overload that will be responsible for the symptomatology of the disease. As a result of significant advances in prenatal diagnosis, cardiac surgery, interventional cardiology, and perioperative medicine, about 90% of infants with congenital heart disease are currently expected to reach adulthood. Management of these patients requires insight into (1) the primary cardiac lesion, (2) the type of cardiac surgical or interventional procedure(s) performed, (3) the presence of residual defects or sequelae, (4) the current physical status (i.e. balanced vs unbalanced), (5) the effects of surgery or pregnancy on their pathophysiological condition, and (6) the presence of comorbidity.
Hepatic and renal disease and anaesthesia
Authors: Ray Komal , Bellamy Mark
Published: April 2017

Anaesthesia for the patient with liver or renal disease may seem daunting, not least because of the multisystem nature of these seemingly single-system conditions. Both kidney and liver disease are associated with systemic manifestations, and often with multiple co-morbidities. There are inherent complexities in patient assessment and risk stratification. The process of preoperative optimization is a complex one, and has to be tailored to the individual, based on a detailed understanding both of the pathophysiology of the organ dysfunction, and its clinical implications. The practical conduct of anaesthesia is further complicated by unexpected or atypical reactions to therapeutic agents (pharmacodynamic effects) as well as unexpected durations of action and drug interactions (altered pharmacokinetics). This chapter is not an exhaustive treatise on the topic, nor can it be; it does, however, attempt to point towards important issues to be considered.
Anaesthesia in the elderly
Authors: Veering Bernadette , Dodds Chris
Published: April 2017

The elderly population continues to grow. As surgical intervention in disease processes becomes more aggressive, the anaesthetist is faced with an increasing number of elderly patients. Elderly patients should be approached with a clear understanding of ageing, how it occurs, how it affects specific organ systems, and how it may influence clinical care, when a patient is subjected to an operation. The ageing process is a multifactorial process, resulting in a decreased capacity for adaptation and producing a gradual decrease in functional reserve of many organ systems. This has significant effects on the physiological responses to surgical and pharmacological trespass faced during anaesthesia. Increasing age is associated with changes in the response to a wide variety of drugs. Changes in dose–response relationships may be as a result of changes in pharmacokinetics, pharmacodynamics, or a combination of both. One should realize that increasing age is associated with a large inter-individual variability in dose requirements. As such, it is important to carefully titrate the dose against the desired clinical effect in an older patient. Preoperative physical and mental state are the most important determinants of per- and postoperative morbidity and mortality. The number of co-morbidities increases with advanced age and as such, optimization of the medical condition is essential to reduce the morbidity and mortality.
Anaesthesia for the obese patient
Authors: Servin Frédérique S. , Billard Valérie
Published: April 2017

Obesity is becoming an epidemic health problem, and the number of surgical patients with a body mass index of more than 50 kg m−2 requiring anaesthesia is increasing. Obesity is associated with physiopathological changes such as metabolic syndrome, cardiovascular disorders, or sleep apnoea syndrome, most of which improve with weight loss. Regarding pharmacokinetics, volumes of distribution are increased for both lipophilic and hydrophilic drugs. Consequently, doses should be adjusted to total body weight (propofol for maintenance, succinylcholine, vancomycin), or lean body mass (remifentanil, non-depolarizing neuromuscular blocking agent). For all drugs, titration based on monitoring of effects is recommended. To minimize recovery delays, drugs with a rapid offset of action such as remifentanil and desflurane are preferable. Poor tolerance to apnoea with early hypoxaemia and atelectasis warrant rapid sequence induction and protective ventilation. Careful positioning will prevent pressure injuries and minimize rhabdomyolysis which are frequent. Because of an increased risk of pulmonary embolism, multimodal prevention is mandatory. Regional anaesthesia, albeit technically difficult, is beneficial in obese patients to treat postoperative pain and improve rehabilitation. Maximizing the safety of anaesthesia for morbidly obese patients requires a good knowledge of the physiopathology of obesity and great attention to detail in planning and executing anaesthetic management. Even in elective surgery, many cases can be technical challenges and only a step-by-step approach to the avoidance of potential adverse events will result in the optimal outcome.
Acute illness in the postoperative period
Authors: Marx Gernot , Fries Michael
Published: April 2017

As more complex and risky surgical procedures are carried out in industrialized countries, anaesthetists are confronted with higher incidences of acute life-threatening conditions during the perioperative period. This is especially true for older patients with concomitant morbidities. Sepsis, cardiovascular complications including myocardial infarction, pulmonary embolism, and stroke, as well as massive bleeding are among the most severe complications that may arise during any time in the postoperative period starting as early as in the post-anaesthesia care unit. Early identification along with rapid stabilization of vital signs are key to improving outcomes in these patients.
Transport of the critically ill patient
Authors: Flutter Laura , Melzer-Gartzke Christoph , Spies Claudia , Bion Julian
Published: April 2017

The safe transport of critically ill patients is recognized internationally as a key competency for clinicians working in anaesthesia, critical care, and emergency medicine. This includes inter- and intra-hospital, land, and air transport. The centralization of specialist services and growing demand for critical care beds have increased pressure on hospitals to provide transfer support for critically ill patients. A variety of systems have emerged to facilitate the increasing need for both inter- and intra-hospital transfer of patients, ranging from a national coordinated retrieval service to the ad hoc utilization of on-call teams. The potential for complications during all types of transfer has been well documented. In order to improve safety, a number of national guidelines and courses have been developed to provide a standardized approach to transfer medicine. This chapter reviews the current literature on the subject and provides a summary of best practice for the transfer of the critically ill patient.
The angular power spectrum measurement of the Galactic synchrotron emission in two fields of the TGSS survey
Authors: Choudhuri Samir , Bharadwaj Somnath , Ali Sk. Saiyad , Roy Nirupam , Intema Huib. T. , Ghosh Abhik
Published: April 2017

Characterizing the diffuse Galactic synchrotron emission at arcminute angular scales is needed to reliably remove foregrounds in cosmological 21-cm measurements. The study of this emission is also interesting in its own right. Here, we quantify the fluctuations of the diffuse Galactic synchrotron emission using visibility data for two of the fields observed by the TIFR GMRT Sky Survey. We have used the 2D Tapered Gridded Estimator to estimate the angular power spectrum (Cℓ) from the visibilities. We find that the sky signal, after subtracting the point sources, is likely dominated by the diffuse Galactic synchrotron radiation across the angular multipole range 240 ≤ ℓ ≲ 500. We present a power-law fit, $C_{\ell }=A\times \big (\frac{1000}{l}\big )^{\beta }$, to the measured Cℓ over this ℓ range. We find that (A, β) have values (356 ± 109 mK2, 2.8 ± 0.3) and (54 ± 26 mK2, 2.2 ± 0.4) in the two fields. For the second field, however, there is indication of a significant residual point source contribution and for this field we interpret the measured Cℓ as an upper limit for the diffuse Galactic synchrotron emission. While in both fields the slopes are consistent with earlier measurements, the second field appears to have an amplitude that is considerably smaller compared to similar measurements in other parts of the sky.
ALMA polarization observations of the particle accelerators in the hotspot of the radio galaxy 3C 445
Authors: Orienti M. , Brunetti G. , Nagai H. , Paladino R. , Mack K.-H. , Prieto M. A.
Published: April 2017

We present Atacama Large Millimeter Array polarization observations at 97.5 GHz of the southern hotspot of the radio galaxy 3C 445. The hotspot structure is dominated by two bright components enshrouded by diffuse emission. Both components show fractional polarization between 30 and 40 per cent, suggesting the presence of shocks. The polarized emission of the western component has a displacement of about 0.5 kpc outward with respect to the total intensity emission and may trace the surface of a front shock. Strong polarization is observed in a thin strip marking the ridge of the hotspot structure visible from radio to optical. No significant polarization is detected in the diffuse emission between the main components, suggesting a highly disordered magnetic field likely produced by turbulence and instabilities in the downstream region that may be at the origin of the extended optical emission observed in this hotspot. The polarization properties support a scenario in which a combination of both multiple and intermittent shock fronts due to jet dithering and spatially distributed stochastic second-order Fermi acceleration processes are present in the hotspot complex.
Enhanced Overwintering Survival of Stevia by QoI Fungicides Used for Management of Sclerotium rolfsii
Authors: Koehler A. M. , Shew H. D.
Published: April 2017

Stevia (Stevia rebaudiana) is a herbaceous perennial under evaluation as a new crop in the southeastern United States. Stem rot caused by Sclerotium rolfsii is common in stevia plantings in North Carolina, with symptoms including wilting, root and stem necrosis, and plant death. Fungicide efficacy trials for management of S. rolfsii were conducted over 2 years. Fungicides evaluated included azoxystrobin, flutolanil, and tebuconazole applied at three timings. Azoxystrobin applied to transplants 1 week prior to planting had the lowest area under the disease progress curve values across all trials. Fungicide plots were also used to evaluate overwintering of stevia. End-of-season stand counts were compared with spring emergence counts to quantify overwintering survival. In spring 2015, plots treated with azoxystrobin in 2014 had greater overwintering survival (78%) than other fungicide treatments (38%) and the control (38%). Similar results were obtained at two locations in spring 2016 in plots treated with azoxystrobin or pyraclostrobin in 2015. Successful overwintering of stevia directly impacts the profitability of second- and third-year harvests and enhances the likelihood of long-term establishment of stevia as a viable crop. Future studies will be directed at elucidating the mechanism of the enhanced overwintering survival of plants treated with quinone outside inhibitor fungicides.
Multiple-level Replantation in Elderly Patients: Risk Versus Benefit
Authors: Jakubietz Rafael G. , Jakubietz Michael G. , Meffert Rainer H. , Schmidt Karsten
Published: April 2017

Multiple-level amputations of the upper extremity represent a surgical challenge generally only attempted in young patients. This case demonstrates a successful replantation in an elderly woman. The postoperative course was complicated by disseminated intravascular coagulopathy most likely due to inadequate resuscitation. Hand trauma is often underestimated in its general severity. Upper extremity amputations need to be handled similar to polytraumatized patients.
The Anatomy of the Medial Patellofemoral Complex
Authors: Tanaka Miho J.
Published: April 2017

The term “medial patellofemoral complex” (MPFC) was proposed to describe the static medial stabilizer of the patella, typically referred to as the medial patellofemoral ligament. In light of our increasing understanding of the attachment of its fibers to the quadriceps tendon in addition to the patella, the term MPFC is used in this article. The purpose of this article is to describe and discuss the anatomy of the MPFC.
Complications of Tibial Tuberosity Osteotomy
Authors: Johnson Alex A. , Cosgarea Andrew J.
Published: April 2017

It is important to understand potential complications of tibial tuberosity osteotomies (TTOs) and how to avoid them. TTO is associated with a 1% to 3% rate of tibial fracture and 1% rate of nonunion. Early weight-bearing and complete detachment of the distal tuberosity may increase these risks. Painful screws requiring removal occur in 3% to 77% of cases. Use of small (3.5- mm diameter), countersunk screws reduces this risk. Recurrent instability occurs in ∼5% of cases at 5 years. The risk of deep-vein thrombosis (4%) after TTO is higher than that associated with other sports surgeries (1% to 2%). The risk of wound complications is ∼1% and can be reduced with meticulous handling of soft tissues and avoidance of large medial incisions. The risk of deep infection is <1%. Severe complications such as compartment syndrome and pulmonary embolism are rare.
Biomechanical Analysis of Tibial Tuberosity Medialization and Medial Patellofemoral Ligament Reconstruction
Authors: Elias John J. , Smith Bradley W. , Daney Blake T.
Published: April 2017

Biomechanical studies are commonly performed to evaluate the influence of medial patellofemoral ligament (MPFL) reconstruction and tibial tuberosity medialization on patellar tracking and patellofemoral contact pressures. The most common method is in vitro simulation of knee function, but computational simulation of knee function and computational reconstruction of in vivo motion can also be utilized. The current review of the biomechanical literature indicates that MPFL reconstruction and tibial tuberosity medialization reduce lateral patellar tracking. Decreased lateral patellofemoral contact pressures have also been noted. For MPFL reconstruction, the most commonly noted biomechanical concerns are graft overtensioning and nonanatomic attachment on the femur leading to overconstraint of the patella and elevated medial contact pressures. For tuberosity medialization, the influence of altered tibiofemoral kinematics on postoperative function is unknown. Future biomechanical studies should emphasize inclusion of anatomic features and tracking patterns related to patellar instability, with comparison between the surgical approaches for continued development of treatment guidelines.
Increased Level of Serum Hepcidin in Female Adolescent Athletes
Authors: Sandström Göran , Rödjer Stig , Jacobsson Stefan , Nelson Dick , Börjesson Mats
Published: April 2017

Objective:

To determine the serum hepcidin concentration and standard hematological parameters in a group of female adolescent athletes, compared with a group of nonathlete females.

Design:

A case–control study.

Setting:

A senior high school for athletes in Gothenburg, Sweden.

Participants:

All female athletes (70), at the school were offered to take part. Fifty-six athletes accepted. From a random sample of age-matched nonathletes, 71 students were recruited to the control group.

Main Outcome Measures:

Iron deficiency (ID) was determined by levels of serum iron, total iron-binding capacity, transferrin saturation (TS), and ferritin. Serum hepcidin was determined by a mass spectrometry method. All samples were taken at least 12 hours after training.

Results:

The main result was the finding of a significantly elevated serum hepcidin level in the athlete group, 4.7 nmol/L compared with 3.3 nmol/L (P < 0.001) in the nonathlete group. In the athlete group, the serum iron concentration was significantly lower, 14.0 μmol/L compared with 17.6 μmol/L (P = 0.003) in the nonathlete group. No difference was found regarding TS, total iron binding capacity, and ferritin. There was no difference in the occurrence of ID or iron deficiency anaemia (IDA).

Conclusions:

These findings show an increase in serum hepcidin in a large group of female athletes. The elevated hepcidin levels may affect the iron balance of the athletes, adding to the traditional explanation of dietary intake/iron loss balance.