bluuebunny/crossref_metadata_2025 huggingface dataset:
Spinal Fluid Drainage
Authors: Agarwal Deepak , Arora Lovkesh L.
Published: March 2023

The cerebrospinal fluid (CSF) is contained in the brain ventricles and the cranial and spinal subarachnoid spaces. The mean CSF volume is 150 mL, with 25 mL in the ventricles and 125 mL in subarachnoid spaces. CSF is renewed about four times every 24 hours. The CSF space is a dynamic pressure system. CSF pressure determines intracranial pressure, with physiological values ranging between 3 and 4 mm Hg before the age of 1 year and between 10 and 15 mm Hg in adults. Either alone or in combination with other interventions, CSF drainage remains one of the most frequently used spinal cord protection techniques. Despite no definitive proof of efficacy for reducing spinal cord injury, there are compelling data supporting its use. However, the potential benefit of CSF drainage must be balanced against the risks associated with its use, including nerve injury during insertion, compressive neuraxial hematoma formation, intracranial hemorrhage due to excessive drainage, and infection. The optimal benefit-to-risk ratio can be achieved by understanding the rationale for its use and following practical management guidelines.
Awake Craniotomy
Authors: Shin John S. , Bui Timothy T.
Published: March 2023

Awake craniotomy allows for patient participation in functional testing of eloquent cortical tissue in real-time intraoperatively. This allows for more extensive resections of tumor or ictal foci, providing the potential for better outcomes. The only absolute nonsurgical contraindication to awake craniotomy is patient refusal. Preoperative evaluation must include assessment of the patient’s anxiety, claustrophobia, risk of aspiration, and thorough evaluation of the airway (including risk of obstruction and likelihood of difficult mask ventilation or intubation). The two most common techniques for awake craniotomy are asleep-awake-asleep and monitored anesthesia care. Both approaches allow for sedation and analgesia during the craniotomy, alertness during intraoperative testing, and sedation during closure. Awake craniotomy limits exposure to general anesthesia. This allows for reduced postoperative nausea and vomiting as well as potentially lower costs by reducing hospital length of stay. Overall, awake craniotomy by either approach is well tolerated by the patient and should be considered the standard of care for resection of brain tumors in eloquent areas.
Lung Mechanics
Authors: Davidson Evan , Crimi Ettore
Published: March 2023

Knowledge of respiratory mechanics is fundamental for correct use of mechanical ventilation and full understanding of the impact of lung disease during anesthetic administration. The role of the respiratory system is to deliver oxygen to cells so that respiration can occur. To accomplish this task, the respiratory system during spontaneous breathing generates negative pressure differentials able to overcome airway and tissue resistance, allowing inspiration. In contrast, mechanical ventilation uses positive pressure differentials between the mouth and the alveoli to inflate the lungs and allow for inspiration. The work of breathing, which is responsible for the energy consumption required for respiration, should be kept to a minimum. Increases in work of breathing can lead to fatigue and respiratory failure.
Ventilation-Perfusion
Authors: Bang Jarrod , Sharma Archit
Published: March 2023

Gas exchange occurs in the respiratory zone of the lung, where alveoli are present. For effective gas exchange to occur, alveoli must be ventilated and perfused. Ventilation (V) refers to the flow of air into and out of the alveoli, while perfusion (Q) refers to the flow of blood to alveolar capillaries. A major cause of hypoxemia in anesthesia is ventilation-perfusion (V/Q) mismatch. With more advanced surgery and an aging population, monitoring of V/Q is of increasing importance. This chapter evaluates the different ways that the ventilation and perfusion are altered and how they can cause the patient various effects.
Thoracic and Pulmonary Surgery
Authors: Dabaliz Al-Awwab Mohammad , Stachur Christina
Published: March 2023

Operations involving the trachea, lungs, and chest wall pose unique anesthetic considerations that can provide difficult yet engaging challenges to the anesthesia provider. Special considerations throughout the perioperative period are particularly necessary for pulmonary surgeries. The primary indication for these operations is early stage cancer; other indications include infections, hemorrhage, and air leak. This chapter describes the indications and anesthetics management for patients undergoing thoracic and pulmonary surgery. It outlines what criteria to use for predicting postoperative complications, including the assessment of FEV1, DLCO, and VO2 max. Intraoperative and postoperative management is discussed, as well as techniques for minimizing common complications in these settings.
BiPAP, Airway Pressure Release Ventilation, and Prone Ventilation
Authors: Marrero-Figueroa Neisaliz , Crimi Ettore
Published: March 2023

Biphasic positive airway pressure (BiPAP), airway pressure release ventilation (APRV), and prone ventilation are used as rescue therapies for refractory hypoxemia in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). BiPAP and its variant, APRV, allow the patient to breathe spontaneously at two levels of continuous positive airway pressure (CPAP). BiPAP uses conventional I:E ratios, while APRV is an inverse ratio ventilation. The significant advantages of these two modes of ventilation are the preservation of spontaneous breathing, improved ventilation-perfusion matching, use of lower peak pressure, and better oxygenation. Ventilation in the prone position determines a rapid and sustained improvement in oxygenation in patients with ALI/ARDS. Mechanisms that can explain its beneficial effects include a reduced pleural pressure gradient with more uniform lung inflation and improved lung recruitment, an increase in functional residual capacity, redistribution of regional lung perfusion, variations in diaphragm movement, and better clearance of secretions.
Coronary Artery Bypass Procedures
Authors: Ahmed Andaleeb A.
Published: March 2023

Coronary artery bypass grafting (CABG) is indicated for chronic stable angina with high-risk coronary disease; unstable angina; post–myocardial infarction angina; and ischemia on noninvasive testing. CABG remains the mainstay for many patients with multivessel disease. The anatomical complexity of CAD, predicted surgical mortality, and anticipated completion of revascularization are some of the crucial factors in deciding revascularization strategy. Standard CABG is performed through a median sternotomy incision and involves the institution of cardiopulmonary bypass (CPB). Vascular conduits like the saphenous vein, internal thoracic artery, and radial artery are grafted between the ascending aorta and coronary artery distal to its obstruction. In addition to on-pump CABG, off-pump CABG (OPCAB), minimally invasive direct CABG (MIDCAB) robotic, and hybrid revascularization strategies are increasingly being used.
Valvular Heart Disease
Authors: Morkos Michael , McConnell Matthew
Published: March 2023

Valvular pathology is a growing concern for the practicing anesthesiologist given the increasing longevity of the patient population. Many patients will present for noncardiac surgery with comorbidities involving stenosis and/or regurgitation in one or more of the four heart valves (aortic, mitral, tricuspid, and pulmonary). These valves are involved throughout the process of blood flow, functioning to preserve pressure gradients and allow for continual forward flow. Awareness of the physiological alterations associated with each valvular pathology and how to optimize the intraoperative hemodynamics is crucial to provide appropriate anesthetic care. Subacute bacterial endocarditis has also been a growing concern impacting which procedures require antibiotic prophylaxis.
Pacemakers and Automated Implantable Cardioverter/Defibrillator (AICD) Implantation
Authors: Guruswamy Jayakar , Parikh Snigdha
Published: March 2023

Cardiovascular diseases are the leading cause of death worldwide, contributing to an estimated 17.9 million deaths annually. Advances in cardiac implantable electrical devices (CIEDs) have resulted in increased life expectancy for these patients, and, as a result, there is a growing proportion of the population who are getting these devices. Approximately 3 million people in the United States have a pacemaker and close to 300,000 people have an implantable cardioverter-defibrillator (ICD), making patients with CIEDs a growing population in the perioperative arena. As these demographics shift, more patients with implanted devices present to the operating room for noncardiac surgeries, and they provide unique challenges. This makes understanding of these devices critical for anesthesiologists.
Perioperative Implications of Pacemakers and AICDs
Authors: Guruswamy Jayakar , Parikh Snigdha
Published: March 2023

The estimated prevalence of cardiac arrhythmias in the United States is approximately 14.4 million, which accounts for approximately 40,000 deaths annually. Advances in cardiac implantable devices combined with an increase in indications for their placement has led to increased implantation of these devices. The presence of these devices poses unique perioperative challenges, especially in the setting of electromagnetic interference, thereby making it important for anesthesia providers to have a complete understanding of these devices. The goal of the perioperative evaluation of a patient with a cardiac implantable electronic device (CIED) consists of determining type of CIED, manufacturer, primary indication for placement, the current setting of the device, if the patient is device dependent, and the possibility of electromagnetic interference.
Ventricular Synchronization
Authors: Guruswamy Jayakar , Parikh Snigdha
Published: March 2023

Approximately 6.5 million adults in the United States have heart failure, which contributed to approximately one in eight deaths in the year 2017 per the Centers for Disease Control and Prevention. Despite advancements in pharmacological therapy available for heart failure and improvements in outcomes, there is still a significant proportion of patients hospitalized with systolic heart failure. Device-based therapies are the latest development in the field of heart failure management. These devices are commonly encountered by anesthesiologists because of the large prevalence of heart failure in the United States. They aim to target patients with systolic dysfunction with dyssynchronous ventricular contraction.
Cardiac Tamponade
Authors: Grandhi Ravi K. , Abd-Elsayed Alaa
Published: March 2023

Cardiac tamponade is a medical emergency that requires close attention. It can be acute, subacute, occult, or regional. Etiologies of pericardial tamponade vary based on whether they are inflammatory or noninflammatory (1). The pericardium is composed of two layers of tissue, the serous visceral and fibrous parietal layers, which have less than 50 mL of serous fluid. Presentation will depend on the amount and rate of accumulation of fluid. Diagnosis can be made by history, physical examination, and imaging studies. Treatment will typically require evacuation of the fluid to reduce the pressure around the heart. Treatment goals include maintaining preload, afterload, and contractility.
Minimally Invasive Direct Coronary Artery Bypass Grafting (MIDCAB)
Authors: Kim John K. , Sofjan Iwan
Published: March 2023

Minimally invasive direct coronary artery bypass (MIDCAB) is an approach to surgical coronary revascularization that offers an alternative strategy to traditional techniques involving sternotomy and cardiopulmonary bypass for patients who are suitable candidates. During MIDCAB procedures, a smaller incision is made in the intercostal spaces lateral to the sternum, and the graft vessel is carefully harvested and anastomosed onto a beating heart. Although further studies are required to confirm any long-term advantages, MIDCAB may offer several benefits compared to traditional surgical techniques, such as decreased duration of mechanical ventilation, intensive care unit stay, and hospitalization, as well as the need for fewer blood transfusions. However, MIDCAB also presents unique challenges to both the surgical and anesthesiology teams. This chapter discusses the procedural aspects of MIDCAB as well as considerations for anesthetic management.
Carotid Endarterectomy
Authors: Grandhi Ravi K. , Joseph Claire
Published: March 2023

Carotid endarterectomy is an important procedure to remove plaques in the carotid artery to assist with revascularization after an ischemic stroke. Plaque is most commonly removed from the location of maximum turbulence where the common carotid artery divides into the internal and external carotid artery. Many patients requiring carotid endarterectomy have other comorbidities, including coronary artery disease, that require preoperative assessment and optimization. Intraoperatively, patients require invasive blood pressure monitoring and either general or regional anesthesia. If general anesthesia is used, then neurophysiological monitoring is required. Further, some of these patients may require a carotid shunt to transiently provide perfusion to the brain. Postoperatively, these patients require close monitoring of their vitals and neuromuscular status.
Anesthesia for Upper and Lower GI Endoscopy
Authors: Leer Ethan H.
Published: March 2023

With advancement of minimally invasive techniques, an increasing number of gastrointestinal (GI) endoscopic procedures are performed in the United States. These procedures are typically performed under minimal or moderate sedation. However, individual responses to sedatives can be different, and the depth of sedation might need to be changed throughout a single procedure. The intended level of sedation has to be determined based on patient medical comorbidities, procedure, and duration. It is then critical that anesthesia personnel are trained and proficient in providing all levels of sedation and managing the airway in emergent situations to ensure patient safety while providing optimal procedural conditions.
Management in Renal Failure and Arteriovenous (AV) Shunts
Authors: Haugen Lacey , Jani Jai
Published: March 2023

Anesthetic management of patients with end-stage renal disease (ESRD) and arteriovenous (AV) shunts is complicated due to the physiologic changes of ESRD and the kidneys’ role in metabolism and excretion of medications. This chapter discusses renal physiology and the pathophysiology of ESRD, including renal blood flow (RBF) and glomerular filtration rate (GFR), intravascular volume, hypertension, cardiac disease, electrolyte and acid base anomalies, as well as platelet dysfunction, bleeding, diathesis, and anemia. The focus is on the effects ESRD has on pharmacokinetics, and commonly used anesthetic drugs are discussed, including intravenous and volatile anesthetics, neuromuscular blockers (NMBs), opioids, benzodiazepines, and vasoactive medications. Anesthetic techniques, including regional anesthesia (RA), general anesthesia (GA), and local anesthesia (LA) infiltration, used for AV shunt insertion are covered. Last, preoperative, intraoperative, and postoperative considerations are reviewed.
Anesthesia for Extracorporeal Shock Wave Lithotripsy
Authors: Harb Alain , Geara Elie
Published: March 2023

Urolithiasis is a common condition in the United States. It is more common in men than women and most often presents in the third to fourth decade. Most urinary stones can pass spontaneously; however, 20% require urologic intervention. Extracorporeal shock wave lithotripsy (ESWL) has gradually replaced open and percutaneous surgical techniques as the treatment of choice for most urinary stones in the kidney or upper ureter. Pain experienced during ESWL has several origins: cutaneous, somatic, and visceral. It is proportional to the energy density of the shock wave at the skin entry site and the size of the focal zone. Modern lithotripters generally deliver shock waves of lower energy, resulting in less patient discomfort. A wide variety of anesthetic techniques have been employed alone and in combination for ESWL, including general, epidural, and spinal anesthesia; flank infiltration; nerve blocks; and topical application of EMLA (eutectic mixture of local anesthetic) cream. First-generation lithotripters generally required general or neuraxial anesthesia, whereas procedures using modern lithotripters may be completed with conscious sedation or monitored anesthesia care. When neuraxial blockade is utilized, a sensory level of T6 is necessary. Shock waves can cause arrhythmias and injury to the lungs. Pregnancy and untreated bleeding disorders are contraindications to ESWL.
Pharmacologic Prevention and Treatment of Renal Failure
Authors: Walia Anureet , Sharma Archit
Published: March 2023

Acute kidney injury (AKI) in the intensive care unit is associated with significant mortality and morbidity. AKI affects up to 50% of critically ill patients. The cause of AKI is often multifactorial, with preexisting comorbidities further increasing the risk. The most common and generalized forms of acute renal failure are prerenal conditions and intrarenal acute tubular necrosis (ATN). There are various fluid resuscitation strategies that are employed in treatment of AKI, including colloids, crystalloids, and bicarbonate, and this chapter evaluate the evidence in that regard. The chapter also discusses the current evidence related to the role of volume expansion, nephrotoxic medications, and use of N-acetylcysteine in AKI.
Fluid Therapy and Homeostasis
Authors: Rovira Miguel , Giordano Christopher
Published: March 2023

This chapter covers the basics of fluid homeostasis and fluids that are employed to maintain homeostasis in the perioperative setting. It begins with a basic review of human physiology in relation to fluids, age, and gender. Historical background is also provided on the 4–2–1 rule, the method of choice for determining fluid rate administration that has been passed on from generation to generation of physicians. Then it transitions into how the homeostasis is maintained in the perioperative setting. Particular emphasis is given to the most commonly administered fluids, such as PlasmaLyte, lactated Ringer’s, normal saline (crystalloids), and albumin (colloids). The reader will learn what these fluids are made of, what makes them different, as well as how and why certain fluids should be given and when they could be potentially dangerous.
Disseminated Intravascular Coagulation
Authors: Lemmink Gretchen A. , Conhaim Jay
Published: March 2023

Disseminated intravascular coagulation (DIC) is a life-threatening complication that arises due to the progression of an underlying systemic disorder. Trauma, sepsis, malignancy, and obstetrical emergencies are only some of the myriad conditions that can precipitate DIC. With the onset of DIC, the normal hemostatic response to procoagulants, such as tissue factor, becomes pathologic. Inappropriate activation of the extrinsic clotting cascade ensues, resulting in systemic microvascular thrombosis, a consumptive coagulopathy, hemorrhage, end-organ ischemia, and even death. Prompt diagnosis of DIC relies on both clinical suspicion and laboratory evaluation of coagulopathy using prothrombin time (PT), activated partial thromboplastin time (aPTT), serum fibrinogen, platelet count, and serum fibrin degradation markers. Scoring systems exist to aid in the diagnosis. A patient presenting to the operating room with DIC will require serial evaluation of coagulopathy and ongoing blood component therapy as well as prompt treatment of the inciting underlying disorder.
Use of Uncrossmatched Products
Authors: Stachur Christina
Published: March 2023

Certain clinical situations, such as massive hemorrhage, necessitate transfusion of blood products before crossmatched blood is available. This chapter describes why uncrossmatched blood products are used and what type of uncrossmatched products are commonly used. Uncrossmatched products are used in situations where a patient’s ABO blood group is unknown, and the patient requires a life-saving transfusion that cannot wait for crossmatched blood to be prepared. The risks and benefits of using uncrossmatched packed red blood cells (pRCBs), plasma, and whole blood are covered, as well as how Rhesus status affects selection and transfusion of products. Finally, it describes the clinical markers anesthesia providers should be wary of in cases of transfusion reaction.
Anatomy of the Endocrine System
Authors: Nalbandyan Ruzanna , Ragheb-Mueller Nawal E.
Published: March 2023

The endocrine system consists of a collection of glands that secrete a variety of hormones. These hormones travel to specific target organs via the bloodstream and regulate many vital functions of the body, including metabolism, reproduction, growth and development, response to injury, stress, and mood. The integral parts of the endocrine system are the hypothalamus, pituitary gland, thyroid gland, parathyroids, pineal gland, endocrine pancreas (islets of Langerhans), adrenal glands, and gonads (ovaries and testes). Hormonal regulation of the glands is via neural regulation or by feedback mechanisms from the endocrine glands and other circulating factors. This chapter discusses these integral parts and their functions.
Diabetes Mellitus
Authors: Mori Benjamin B. G. , Al-Jindi Piotr
Published: March 2023

Diabetes mellitus (DM) is a common chronic disorder associated with cardiovascular disease and microvascular complications, often necessitating surgical intervention. These patients are at an increased risk of perioperative infection and postoperative morbidity and mortality. The complex interplay of stress from surgery, anesthesia, and fasting, along with additional postoperative factors such as infection, altered nutritional intake, hyperalimentation, and emesis, can lead to labile blood glucose levels. There is a clear association between perioperative hyperglycemia and adverse clinical outcomes, although the exact mechanism(s) underlying this remains unclear. Perioperative DM management focuses on glycemic control. Substantial evidence indicates that the correction of hyperglycemia with insulin administration reduces complication rates and decreases mortality in cardiac and general surgery patients.
Painful Disease States
Authors: Rushmer Timothy , Abd-Elsayed Alaa
Published: March 2023

This chapter serves as an outline of the different types of pain and pain syndromes, while subsequent chapters go into greater detail on each of these pain states. Pain sensation serves as a physiologic protective system to warn and prevent contact with noxious or damaging stimuli. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” With such an open definition, it is best to further classify different types of pain and pain states. Frequently, this is done pathophysiologically, etiologically, anatomically, and in terms of duration.
Peripheral Neuropathies
Authors: Mauer Kim , Abd-Elsayed Alaa
Published: March 2023

The peripheral neuropathy chapter has a great deal of focus on the anatomy of nerves as well as the pathophysiology of nerves when conduction or the myelin sheath is altered. The chapter focuses on the general anatomy of the nerve structure.
Premedications
Authors: Barnett Natalie R. , Fromer Ilana R.
Published: March 2023

Perioperative stress and anxiety related to surgery and anesthesia in the pediatric population can have long-term sequelae with negative effects on both patients and caregivers. Reducing perioperative anxiety is an essential element of pediatric anesthetic care that must be clearly understood by those involved in the perioperative care of children. There are various methods involved in minimizing perioperative anxiety; these range from utilizing different forms of topical anesthetics in an effort to eliminate or minimize pain associated with peripheral intravenous placement to pharmacological premedications, most often including midazolam, ketamine, and dexmedetomidine; caregiver and child preparation; as well as distraction techniques. These different tools can be used in conjunction with one another for the ultimate goal of safe and effective care of the pediatric patient while generating the least amount of psychological trauma possible.
Opioid Dosing and Sensitivity—Pediatrics
Authors: Hanna Rewais B. , Abd-Elsayed Alaa
Published: March 2023

Perioperative pediatric pain management is an exceedingly difficult proposition due to the unique challenges children provide in regard to pain assessment. The incidence of pain in hospitalized children is estimated to be between 33% and 82%, yet clinicians will attest to the fact pediatric pain is often more difficult to treat than that of adults. Moreover, dosing opioids for children is another distinct challenge due to immature metabolism and clearance pathways. With the advent of a multitude of pain management modalities in children, including nonopioid analgesics, oral opioids, patient-controlled anesthesia (PCA), and nerve blocks, it is imperative clinicians understand opioid dosing and sensitivity in this vulnerable population.
NPO Guidelines for Pediatric Patients
Authors: Klein Jonathan W.
Published: March 2023

A patient’s fasting status is a vital aspect of the preoperative evaluation. The American Society of Anesthesiologists has well-established fasting guidelines to ensure a patient’s safety when undergoing elective procedures. These practice guidelines are evidence based and are considered to be best practice. These standards protect the patient from potential aspiration during the anesthetic, which could lead to severe morbidity and mortality. This information is imparted to the patient prior to their elective procedure requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia and should be adhered to; if not this will result in case delay or cancellation as long as the case remains elective.
Acyanotic Defects
Authors: Sinton Jamie W.
Published: March 2023

Acyanotic cardiac defects include largely septal defects such as atrial septal defects (ASDs), ventricular septal defects, and complete atrioventricular canal defects (including atrioventricular valvular [AVV] disease associated with complete atrioventricular septal defects), obstructive lesions, and cardiomyopathy. Acyanotic cardiac defects also involve left-to-right shunting lesions, and obstructive lesions. Obstructive lesions discussed in this review are William syndrome and Shone complex. As dilated cardiomyopathy is the most common type in pediatrics, it is the focus of the cardiomyopathy section. Patent ductus arteriosus (PDA) is discussed elsewhere, and valvular heart disease such as the Ebstein anomaly are rare enough to preclude mention here.
Cardiac Surgery
Authors: Sinton Jamie W.
Published: March 2023

Just as there are major physiologic differences between children and adults, so too are there differences in cardiac surgery and cardiopulmonary bypass (CPB). Monitoring of children undergoing cardiac surgery requires knowledge of anatomy and communication with the surgeon in deciding location of placement of invasive lines. Children undergo significant physiologic trespass during CPB, such as colder temperatures, greater hemodilution, and greater blood product exposure. Enhanced cardiopulmonary interdependence and shunt physiology make this heterogenous group of surgeries noteworthy. Pediatric cardiac surgery has evolved to include transparent reporting of outcomes, and survival has become commonplace. For that reason, neurodevelopmental outcomes, early extubation, and hospital length of stay have become targets for improvement.
Meconium Aspiration Syndrome
Authors: Nathani Harsh , Gwam Chike
Published: March 2023

Meconium aspiration syndrome (MAS) is respiratory distress in a newborn caused by the presence of meconium in the tracheobronchial airway. The syndrome can vary from mild respiratory distress to life-threatening respiratory failure. The development of MAS is related to the aspiration of MSAF during the antepartum or intrapartum periods and is related to fetal hypoxia and postmature delivery. The pathophysiology of MAS is secondary to airway obstruction, impaired gas exchange, chemical pneumonitis, and surfactant dysfunction and can be exacerbated by the development of persistent pulmonary hypertension. The management of MAS is primarily supportive, and there remains controversy regarding the use of suctioning, corticosteroids, and amnioinfusion.
General and Urologic Surgery
Authors: Valliani Arif , Patel Nimesh
Published: March 2023

In pediatric surgeries, general abdominal and urologic procedures are frequent interventions. Most of the underlying principles are similar to those of the adult population. Enhanced perioperative care depends on thorough patient history and physical examination supported by laboratory investigation. Many surgeries are currently performed with minimally invasive techniques. Commonly, laparoscopic-assisted procedures require general anesthesia with a secure airway device to avoid the risk of aspiration and laryngospasm. Children coming with bowel obstruction or trauma for abdominal exploration are considered to have a full stomach, and rapid sequence induction is recommended. With some exceptions, like acute urinary obstruction or testicular torsion, many pediatric urologic procedures are elective, and most of them are done in an ambulatory setting. Preoperative anxiolysis is important to consider in the wide pediatric age group population. A regional anesthesia technique can be used as an adjuvant or as a sole anesthetic technique and has been shown to enhance the recovery in children undergoing both minor and major surgeries.
Regional Techniques
Authors: Lazar Alina
Published: March 2023

Regional anesthesia is increasingly being used in the perioperative management of children as a result of advancements in technology, such as better ultrasound and appropriate size equipment, and in an attempt to provide excellent analgesia while minimizing opioid-induced side effects. The most common techniques used are caudal and epidural anesthesia. Trunk blocks such as paravertebral, transversus abdominis plane, rectus sheath, and ilioinguinal/iliohypogastric are becoming a popular means of providing analgesia for thoracic and abdominal procedures. Recently described quadratus lumborum and erector spinae plane blocks are also being incorporated in pediatric practice and provide good alternatives to neuraxial blocks. Peripheral nerve blocks of the lower and upper extremity are used particularly in older children, both as single shot and increasingly as continuous infusion techniques. Regional anesthesia has a long record of safety and is usually performed under general anesthesia or heavy sedation.
Placenta
Authors: McLendon Roneisha
Published: March 2023

The placenta is a very important organ integral to fetal development and primarily responsible for providing oxygen and nutrition. The placenta allows for transfer of deoxygenated blood and fetal waste elimination through the maternal circulation. Deficiencies in placental development and alterations to uteroplacental blood flow can have acute implications impacting fetal viability. Placental development creates a low-resistance uterine blood flow system to increase blood flow to the placenta. In relation to neuraxial analgesia, in the absence of hypotension, epidural analgesia either increases or does not change uteroplacental blood flow. The effect of general anesthesia on uteroplacental drug flow is highly drug dependent and requires consideration of other contributing factors.
Drugs and Adjuvants
Authors: Anthony Cometa M. , Thompson Jordan
Published: March 2023

Physiologic changes in pregnancy alter the maternal volume of distribution, plasma protein concentrations, and the elimination half-life of intravenous medications. Providing the parturient with analgesia and anesthesia during labor and delivery requires the anesthesiology provider to have a thorough understanding of the drugs and adjuvants available to ensure the comfort and safety of the mother, fetus, and neonate. These medications can be provided to the parturient systemically via intravenous or inhalational routes; however, the more common and superior analgesic delivery method occurs by neuraxial administration. General anesthesia may also be used for cesarean delivery, but it is typically avoided due to the increased aspiration risk and potentially difficult airway management in the parturient.
Tocolytic Drugs
Authors: Al-Jindi Piotr , Potere Bethany
Published: March 2023

Tocolytic agents are agents that inhibit uterine contraction and allow enough time for corticosteroids to help with lung maturation. They are administered in cases of premature labor between the 22nd and 34th weeks of gestational age. They are divided into betamimetics, calcium channel blockers, cyclooxygenase inhibitors, and magnesium sulfate. Betamimetics can be used for a short period of time; their prolonged use is not recommended due to extensive side effects, including maternal death. They are associated with pulmonary edema, tachycardia, arrhythmias, hyperglycemia, and hypokalemia. Calcium channel blockers are more beneficial than β-adrenergic agents for prolongation of pregnancy, neonatal morbidity, and maternal side effects. Magnesium sulfate is not effective in delaying labor, and it does not have an advantage over other tocolytic agents when it comes to neonatal and maternal outcomes, as it shown in a Cochrane review. However, evidence suggests that magnesium sulfate reduces the severity of cerebral palsy in surviving infants if administered when the birth is anticipated before 32 weeks of gestation. It does prolong the action of depolarizing and nondepolarizing muscle relaxant and can have serious side effects if overdosed.
Drug Effects on the Newborn
Authors: Aquino Ben
Published: March 2023

Important factors in maternal-fetal drug transmission are the mode of transmission, fetal physiology affecting drug effects, and salient points of a few commonly used peripartum maternal drugs. Drug Effects on the Newborn looks specifically at peripartum maternal administration of drugs and their subsequent effect of those drugs on the fetus and neonate. Maternally self-ingested drugs are among that list, but the focus here is on medications administered by obstetricians and, most importantly, the anesthesia provider. This chapter looks briefly at mechanisms of maternal-fetal drug transmission, factors affecting this transmission, fetal physiology affecting drug actions, and effects of a few specific, noteworthy, and commonly used drugs in obstetric anesthesia.
Preeclampsia and Eclampsia
Authors: Genis Alina
Published: March 2023

Pre-eclampsia is a multisystem disorder of pregnancy occurring after 20 weeks of gestation that continues to contribute significantly to maternal and fetal morbidity and mortality. Mortality occurs most frequently secondary to hemorrhagic stroke and the complications of seizures. Diagnosis involves criteria that include hypertension along with other signs of end-organ impairment, such as renal insufficiency, thrombocytopenia, impaired hepatic function, pulmonary edema, or new-onset neurological symptoms. Management of preeclampsia includes aggressive blood pressure control, seizure prophylaxis, and optimizing the timing of delivery. The only curative treatment is delivery of the fetus and placenta, often leading to preterm delivery. Anesthetic goals include early neuraxial analgesia, avoidance of general anesthesia if possible, management of drastic hemodynamic changes, and fluid optimization.
Supine Hypotensive Syndrome
Authors: Ahmed Muhammad Fayyaz , Kamel Ihab
Published: March 2023

The supine hypotension syndrome (SHS) is a reduction in maternal systolic blood pressure of 15 and 30 mm Hg or an increase in heart rate of 20 beats/min, with or without symptoms, when the patient is in the supine position. SHS is caused by aortocaval compression and can lead to decreased uteroplacental perfusion and nonreassuring fetal heart rate patterns. It begins around 18–20 weeks and typically manifests as pallor, hypotension, dizziness, nausea, tachycardia and sweating during the third trimester. Vasodilation imposed by systemic anesthetics and neuraxial blockade may amplify the reduction in maternal blood pressure caused by SHS. Proper left uterine displacement is a pivotal preventive and therapeutic intervention in managing parturients beyond 20 weeks gestation.
Postpartum Hemorrhage
Authors: Im Mary J. , Kamel Ihab
Published: March 2023

Postpartum hemorrhage (PPH) is a significant and life-threatening obstetric complication. It is defined as blood loss greater than or equal to 1000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours of birth. The increase in uterine blood flow and the role of placental implantation, separation, and uterine contractility renders the management of PPH critical and multifaceted. Common causes of PPH include uterine atony, genital trauma, retained placenta, uterine inversion, and placenta accreta. Measures to minimize PPH should be implemented when appropriate. Proper assessment and prompt management of obstetric hemorrhage is critical for maternal well-being and survival.
Apgar Scoring
Authors: Ahmed Muhammad Fayyaz , Kamel Ihab
Published: March 2023

The Apgar scoring system was developed in 1953 by Virginia Apgar to differentiate between infants who require resuscitation efforts and those for whom routine care is sufficient. Apgar scoring is performed while care is being delivered. The Apgar system has since become a standard neonatal assessment tool, comprising 1- and 5-minute assessments of appearance, pulse, grimace, activity, and respiration. A score of 8 to 10 is normal, while a score of 0 to 3 is a sign of fetal distress requiring immediate resuscitation. The low score is considered a nonspecific sign of illness, which may be one of the first indications of encephalopathy. The score is used in conjunction with routine neonatal assessment.
Anesthetic Considerations in Breastfeeding
Authors: Levin Lora B. , Cannon Jeffrey W.
Published: March 2023

Breastfeeding provides several health benefits to both infant and mother, and there should be little to no disruption in breastfeeding after the administration of anesthesia to a breastfeeding mother. All anesthetic drugs transfer to breast milk in small but relatively safe amounts. The amount of drug that transfers is called the relative infant dose (RID). Some mothers will be under the impression that they should “pump and dump” after undergoing anesthesia while breastfeeding. However, the current American Society of Anesthesiologists guidelines state that breastfeeding is safe to resume after anesthesia as soon as the mother is awake, alert, and stable. A reasonable anesthetic plan for a breastfeeding mother will consider using short-acting agents; minimizing the use of benzodiazepines and narcotics by employing multimodal analgesia, peripheral nerve blocks, and considering neuraxial anesthesia; and avoiding agents with higher RID, such as morphine and agents with active metabolites such as codeine and tramadol. A useful resource to consult for updated information on drugs and breastfeeding is the Drugs and Lactation Database (LactMed) from the National Library of Medicine.
Management of Traumatic Brain Injury
Authors: Vasudevan Bharathram , Nasr Ned F.
Published: March 2023

Traumatic brain injury (TBI) is a major cause of mortality and morbidity worldwide. Primary brain injury occurs at the time of trauma due to external mechanical forces, while secondary brain injury occurs for hours to days after the trauma. The cornerstone of perioperative management lies in prevention of secondary brain injury by preventing elevated intracranial pressure (ICP), hypotension, hypoxia, hypo- or hypercarbia, hypo- or hyperglycemia, hyperthermia, seizures, and coagulopathy. The clinical severity of TBI is assessed by calculating the Glasgow Coma Scale score. Airway management can be challenging, and rapid sequence intubation is performed with manual inline stabilization. Cerebral autoregulation is disrupted, and anesthetic management should ensure adequate cerebral perfusion pressures of 60–70 mm Hg. ICP monitoring is frequently performed, and elevated ICP above 22 mm Hg is treated with head elevation, adequate analgesia and sedation, decreasing intrathoracic pressure, temporary hyperventilation, cerebrospinal fluid drainage, and osmotherapy. Postoperative mechanical ventilation and neuro–intensive care management are often required.
Geriatrics
Authors: Mechlin Maggie W. , Jones Courtney R.
Published: March 2023

Elderly (generally defined as > 65 years old) and medically complex patients represent an increasing proportion of people requiring anesthetic care both inside and outside of the operating room. As patients live longer, they are requiring and qualifying for more invasive procedures and operations than ever before. These difficulties can range from the need to plan a safe, balanced anesthetic and minimize the risk of complications to the need to prepare for the expected risk of morbidity and mortality. The physiologic changes that occur with aging and the issues with multiple comorbidities and polypharmacy complicate both anesthetic planning and execution. In addition, as patients progressively deteriorate, it may be necessary to explore their end-of-life wishes to ensure that care is consistent with the patient’s personal values.
Prescription Medication Overdose
Authors: Huynh Peter , Abd-Elsayed Alaa
Published: March 2023

Data collected by the National Center for Health Statistics and Centers for Disease Control and Prevention have illustrated the ongoing trend of prescription medication overdose. It is very common to encounter patients in the perioperative period who use prescription medications to manage their comorbidities. Despite the best efforts at prescribing drugs, physicians often encounter patients who do not understand the frequency, dose, or name of their medications. Therefore, it is important for anesthesiologists to understand the signs, symptoms, and treatment options for prescription medication overdose. This chapter discusses some common classes involved in medication overdose: opioids, benzodiazepines, and cardiac medications, such as β-blockers.
Needle-Stick Injury
Authors: Saad Ramsey , Hanna Joseph Salama
Published: March 2023

Needle-stick injury is an unfortunate but not uncommon occupational risk. Risk factors for unintentional needle-stick injuries include long work hours, fatigue, and the emergent nature of interventions. Both attending and resident physicians are at risk, although the risk may be slightly higher among trainees. Given the risk to healthcare providers in general and anesthesiologists in particular, anesthesiologists should be familiar with the protocols of prevention and early intervention in the event of this occurrence. Using universal precautions for prevention of blood-borne infections is of paramount importance. This chapter outlines the various methods of prevention and early intervention in the event of exposure.
Intravascular Catheter and Urinary Catheter Infections
Authors: Ma Zhe , Chung Kevin W.
Published: March 2023

Catheter-related bloodstream infections (CRBSIs) are a common cause of morbidity and mortality in critically ill patients. All types of intravascular catheters are associated with some risk; however, nontunneled central venous catheters (CVCs) and pulmonary artery catheters (PACs) carry the highest risk. Recent guidelines favor subclavian and internal jugular over femoral catheterization; meta-analyses have shown no difference in CRBSI across the three sites, particularly including considerations for operator skill, risk of mechanical complications, and specific patient factors. Prolonged catheterization increases the risk of CRBSI, but routine replacement of catheters is not recommended unless a catheter complication is noted on inspection or its clinical need has been met. CRBSI is often diagnosed by exclusion as alternative bacterial sources should be investigated given the presentation of nonspecific symptoms. Treatment of CRBSI should allow for empiric therapy to cover common drug-resistant organisms, ultimately tailored to specific patient culture data. Decision for catheter removal should include considerations for clinical indication and risks involved with replacement. Bacteriuria in patients with indwelling bladder catheters is another common occurrence. Risks factors for the development of urinary tract infection (UTI) include duration of catheterization, female sex, older age, and diabetes mellitus. UTIs can occur as a result of extra- or intraluminal infections. Diagnosis typically requires the presence of bacteriuria with 105 CFU/mL or more in a clean-catch specimen or collection from catheter port proximal to the collection bag along with UTI symptoms. Antibiotic therapy should be tailored to culture data and whether the infection has extended beyond the bladder.
Antimicrobials
Authors: Shirur Mo , Chung Kevin W.
Published: March 2023

Antibiotics play a ubiquitous role in the daily life of an anesthesiologist, in both the perioperative setting and the intensive care unit (ICU). Generally classified based on their mechanisms of action, antibiotics were traditionally broadly separated into two main categories: bactericidal antibiotics, which show in vitro activity in killing bacteria, and bacteriostatic antibiotics, which show the ability to diminish bacterial growth. This chapter discusses the major antibiotics used in the clinical setting today. A simpler classification based on activity against gram-positive and gram-negative bacteria is used. Additionally, the most common antifungal agents and followed by anesthetic considerations in this regard are discussed.
Mechanical Ventilation
Authors: Abdelmalak Mena , Chung Kevin W.
Published: March 2023

Mechanical ventilation is one of the most critical tasks performed by anesthesiologists. It is imperative for the anesthesiologist to understand the different modes of mechanical ventilation, their advantages and roles, and possible complications. Volume control ventilation (VCV) ensures a set minute ventilation is delivered, while pressure control ventilation (PCV) regulates the airway pressures delivered. Synchronized intermittent-mandatory ventilation (SIMV) shares many similarities to VCV but with the added benefit of supporting patient-generated respiratory efforts. SIMV is often used when transitioning from mandatory ventilation to pressure support ventilation (PSV), which consists entirely of patient-generated respiratory efforts given mechanical support. Weaning a patient from mechanical ventilation consists of progressively diminishing ventilatory assistance, and there are many factors that may result in difficulty in weaning. Barotrauma and volutrauma are two notable complications related to mechanical ventilation.
Introduction
Authors: Berman Carol W.
Published: March 2023

Why theater is important for our brains and lives may not be immediately clear to people. I have found it essential in my life. First I studied medicine and became a psychiatrist. Then I had the opportunity to learn playwriting, which I did at the Neighborhood Playhouse. Many of my plays have been produced here in New York City. New neural networks are developed in the brain when we watch plays. It is not a dying media as some critics claim. It is alive and well. Shakespeare is understandable, especially when his plays are seen live on the stage. Transference occurs when people project their early emotions on to people in their present lives. Meisner technique stresses that actors must focus on each other and interact with them, whereas Stanislavski requires the actor to focus on inner feelings.