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Contents

        Associate Editors vii
        Contributors ix

        Preface: Anesthesiology in 2022: Ever in Demand and Ever Evolvingxxiii

        Laurence C. Torsher, Richard P. Dutton, Francis Victor Salinas and Arna Banerjee

        End of Life: What Is the Anesthesiologist’s Role?1

        Stephanie Jones and Teresa A. Mulaikal
        Anesthesiologists receive extensive training in the area of perioperative care and the specialized skills required to maintain life during surgery and complex procedures. Integrated into almost every facet of contemporary medicine, they interact with patients at multiple stages of their health care journeys. While traditionally thought of as the doctors best equipped to save lives, they may also be some of the best doctors to help navigate the chapters at the end of life. Successfully navigating end-of-life care, particularly in the COVID-19 era, is a complicated task. Competing ethical principles of autonomy and nonmaleficence may often be encountered as sophisticated medical technologies offer the promise of extending life longer than ever before seen. From encouraging patients to actively engage in advance care planning, normalizing the conversations around the end of life, employing our skills to relieve pain and suffering associated with dying, and using our empathy and communication skills to also care for the families of dying patients, there are many ways for the anesthesiologist to elevate the care provided at the end of life. The aim of this article is to review the existing literature on the role of the anesthesiologist in end-of-life care, as well as to encourage future development of our specialty in this area.
         Background 1
         Definitions 2
         Settings 3
        Preoperative 3
        Intraoperative 4
        Intensive care unit 5
         Health care disparities 8
         Ethics 8
         Moral resilience and health care provider support 10
         Summary 10
         Clinics care points 11
        Disclosure 12

        Outpatient Robotic surgery: Considerations for the Anesthesiologist15

        Yasmine Tameze and Ying Hui Low
        A shortage of inpatient beds and nurses during the coronavirus disease 2019 pandemic has lent priority to safe same-day discharge after surgery. The minimally invasive nature of robotic surgery has allowed an increasing number of procedures to be done on an outpatient basis. Anesthetic management should be designed to complement the technical advantages of robotic surgery in facilitating early discharge.
         Introduction: nature of the problem 15
         Indications/contraindications of ambulatory robotic surgery 16
        Commonly performed ambulatory robotic surgical procedures 17
        Relative contraindications to robotic surgery 17
        Technique/procedure 18
        Challenges for the anesthesiologist 19
        Management goals 24
         Outcomes 27
         Current controversies/future considerations 27
         Summary 29
         Clinics care points 29
         Disclosure 29

        An Enhanced Ambulatory Surgery Experience for Patients with Cancer Through End-to-End Patient Engagement33

        Todd J. Liu, Hanae K. Tokita, and Brett A. Simon
        Ambulatory surgery centers (ASC) serve an important role for hospital systems of increasing operating capacity and offloading patient volume. When seeking to perform more complex cancer surgeries at an ASC, a systematic approach with care pathways can yield success by facilitating quick recovery for patients and reducing complication rates. End-to-end patient engagement is a key component of patient-centered care at the Josie Robertson Surgery Center and begins the moment the decision to have surgery is made and extends to the postdischarge period to track recovery. Engagement includes comprehensive education, standardization of processes, and setting clear expectations for recovery and discharge.
         Background/Introduction 33
         Case mix and patient population 34
         Layout and facilities 35
         Care pathways 35
        Patient engagement 36
         Summary 43
         Clinics care points 43
        Disclosure 44

        An Executed Plan to Combat COVID-19 in the United States 45

        William R. Hartman
        Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in late 2019. To date, this coronavirus is responsible for greater than 90 million cases in the United States and more than 1 million confirmed deaths. When this virus came to the United States, testing was unorganized, no effective treatments were known, and no vaccines had been discovered. A plan to correct these deficiencies through cooperative science and efficient clinical trials was implemented to combat this novel virus. This plan developed efficient and inexpensive tests, highly effective medicines to treat and prevent disease progression, and vaccines to immunize the population.
         Viral emergence and effects on society 46
        Emergence 46
         COVID-19 in the community 47
        COVID-19 and pregnancy 48
         Understanding the severe acute respiratory syndrome coronavirus 2 48
        Viral makeup 48
        COVID-19 receptor 49
         Severe acute respiratory syndrome coronavirus 2 pathogenesis 49
        Severe acute respiratory syndrome coronavirus 2 diagnosis 50
         Operation warp speed 52
        Anti-COVID-19 therapeutics 52
         Chloroquine and hydroxychloroquine 52
         Passive immunity and convalescent plasma 53
         Passive immunity and monoclonal antibodies 53
         Dexamethasone 55
        Antivirals 55
         Active immunity and vaccines 56
         Messenger RNA vaccines 56
         Pfizer vaccine 56
         Moderna messenger RNA vaccine 57
         Johnson and Johnson adenoviral vaccine 57
         Summary 58
         Clinics care points 58
        Disclosure 59

        Building Anesthesia Capacity in the Developing World 63

        Kaylyn Sachse
        Over two-thirds of the world’s population do not have access to safe surgical and anesthetic care. Barriers to care include a lack of specialty trained personnel and unavailability of essential operating room resources. Aid efforts with the greatest impact focus on forming partnerships between high- and low-income communities, with the goal of creating self-sustaining programs run by local communities. Together these partnerships can work to build local capacity and expand the trained workforce by educating local providers.
         Background 63
         Short-term medical missions 64
         Education initiatives 64
         Obstetric anesthesia 66
         Regional anesthesia 66
         Summary 67
         Clinics care points 68

        Updates in the Management of Perioperative Vasoplegic Syndrome 71

        Kaitlyn A. Brennan, Monica Bhutiani, Meredith A. Kingeter, and Matthew D. McEvoy
        Vasoplegic syndrome occurs relatively frequently in cardiac surgery, liver transplant, major noncardiac surgery, in post-return of spontaneous circulation situations, and in pateints with sepsis. It is paramount for the anesthesiologist to understand both the pathophysiology of vasoplegia and the different treatment strategies available for rescuing a patient from life-threatening hypotension.
         Background 71
         Causes 72
        Pharmacologic 74
        Ischemia-Reperfusion 75
        Liver Transplant 76
        Return of Spontaneous Circulation After Cardiac Arrest 77
        Immunomodulation 78
        Anaphylaxis 78
        Other 79
         Treatment 79
        Vasopressors 80
         Future research 85
         Summary 85
         Clinics care points 86
        Disclosure 86

        Contemporary Perioperative Management of Direct Oral Anticoagulants 93

        Juan G. Ripoll, Allan M. Klompas, Bradford B. Smith, and Mark M. Smith
        Direct oral anticoagulants (DOACs) have rapidly emerged as popular alternatives to warfarin in the setting of nonvalvular atrial fibrillation, prevention and treatment of venous thromboembolism, and secondary prevention of arterial thrombosis. It is now estimated that more patients in the United States take DOACs than warfarin for approved indications. Studies to date have shown that these drugs are similarly efficacious with perhaps a lower bleeding risk than warfarin. The purpose of this review is to provide insight into the currently available DOACs and discuss the management and reversal strategies for patients in the perioperative period.
         Introduction 93
        Direct oral anticoagulants: factor Xa inhibitors 94
        Direct thrombin inhibitors 102
         Summary 105
         Clinics care points 106
        Disclosure 106

        What Is the Role of Dexmedetomidine in Modern Anesthesia and Critical Care? 111

        Adaora M. Chima, Mohamed A. Mahmoud, and Suryakumar Narayanasamy
        Dexmedetomidine’s unique sedative properties have led to its widespread use. Dexmedetomidine has a beneficial pharmacologic profile including analgesic sparing effects, anxiolysis, sympatholysis, organ-protective effects against ischemic and hypoxic injury, and sedation which parallels natural sleep. An understanding of predictable side effects, effects of age-related physiologic changes, and pharmacokinetic and pharmacodynamic effects of dexmedetomidine is crucial to maximize its safe administration in adults and children. This review focuses on the growing body of literature examining advances in applications of dexmedetomidine in children and adults.
         Introduction 111
         Perioperative applications of dexmedetomidine 112
         Preoperative applications 112
         Intraoperative applications 114
        Procedural sedation 114
        Airway procedures 116
        Neurosurgery 116
        Cardiothoracic surgery 117
        Abdominal surgery 117
        Fetal surgery 119
        Ambulatory procedures 119
        Obesity and bariatric surgery 119
        Dental procedures 119
        Regional anesthesia adjunct 120
        Vascular surgery 120
         Post-procedural applications 120
        Emergence agitation 120
        Postoperative shivering 121
        Post-anesthesia care unit recovery profile 121
         Critical care applications 121
        Sedation 121
        Sepsis and septic shock 122
        Delirium 122
         Palliative care applications 123
        Cautions/contraindications 123
         Summary 123
         Clinics care points 124
        Acknowledgments 124
        Disclosure 124

        Anesthetic Management and Considerations for Electrophysiology Procedures 131

        Yang Gu, Heather L. Lander, Ravie Abozaid, Francis M. Chang, Hugo S. Clifford, Mehmet K. Aktas, Brandon F. Lebow, Kunal Panda, and Julie A. Wyrobek
        The number of electrophysiology (EP) procedures being performed has dramatically increased in recent years. This escalation necessitates a full understanding by the general anesthesiologist as to the risks, specific considerations, and comorbidities that accompany these now common procedures. Procedures reviewed in this article include atrial fibrillation and flutter ablation, supraventricular tachycardia ablation, ventricular tachycardia ablation, electrical cardioversion, pacemaker insertion, implantable cardioverter-defibrillator (ICD) insertion, and ICD lead extraction. General anesthetic considerations as well as procedure-specific concerns are discussed. Knowledge of these procedures will add to the anesthesiologist’s armamentarium in safely caring for patients in the EP laboratory.
         Introduction 131
         General anesthetic considerations in electrophysiology 132
        Staffing and location 132
        Environment 132
        Anesthesiology equipment and monitoring 132
        Patient comorbidities 133
        Medications 134
         Cardiac ablation procedures 135
        Atrial fibrillation and flutter ablation 136
        Supraventricular tachycardia ablation 137
        Ventricular tachycardia ablation 137
         Electrical cardioversion 139
        Pacemaker and implantable cardioverter-defibrillator insertion 139
         Lead extraction 141
         Summary 143
         Clinics care points 143
         Disclosure 143

        Opioid-Free Anesthesia: The Pros and Cons 149

        Valeria Carcamo-Cavazos and Maxime Cannesson
        Appropriate perioperative pain control is essential to aid in patients’ recovery after surgery; however, acute postsurgical pain remains poorly treated and there continues to be an overreliance on opiates. Perioperative pain control starts in the operating room, and opiate-free anesthesia (OFA), where no opiates are used intraoperatively, has been proposed as a feasible strategy to further minimize opiates in the perioperative period. In this article, we address the potential benefits and shortcomings of OFA, while exploring tools available to accomplish multimodal anesthesia and ideally OFA, and the evidence behind the techniques proposed.
        Introduction 150
         Is opioid-free anesthesia feasible? 152
        The pro argument 152
        The con argument 152
         What are the pharmacologic tools for conducting opioid-free anesthesia? 153
        The pro argument 153
        The con argument 158
         What are the techniques that facilitate opioid-free anesthesia? 158
        The pro argument 158
        The con argument 160
         Should opioid-free anesthesia be part of every enhance recovery after surgery pathway? 161
        The pro argument 161
        The con argument 161
         Summary/discussion 161
         Clinics care points 162
        Conflicts of interest 163

        Anesthesia Machine and New Modes of Ventilation 167

        Aditi Balakrishna, Lucille Brunker, and Christopher G. Hughes
        Mechanical ventilation is ubiquitous in the operating room. This article explores the anesthesia machine as a ventilator, examining its unique features and differences from ventilators designed for long-term use. It will describe standard and nonstandard modes of ventilation. The reader will develop a more nuanced understanding of how to tailor ventilation and oxygenation strategies based on patient and anesthetic scenarios as well as with the assistance of new technologies.
         Introduction 167
        Anesthesia machine overview 167
        Principles of lung-protective ventilation in the operating room 169
        Standard modes of ventilation 170
        Patient conditions and impact on ventilation 173
        Ventilation strategies for different anesthetic/surgical conditions 176
        Jet ventilation 177
        Choosing fraction of inspired oxygen 178
        Advanced monitoring tools 179
         Summary discussion 180
         Clinics care points 180
        Acknowledgments 181
        Conflicts of interest 181

        Anesthesia and Analgesia for the Obese Parturient 185

        Mary Yurashevich, Cameron R. Taylor, Jennifer E. Dominguez, and Ashraf S. Habib
        Obesity is a worldwide epidemic and is associated with an increased risk of hypertension, diabetes, and obstructive sleep apnea. Pregnant patients with obesity experience a higher risk of maternal and fetal complications. Anesthesia also poses higher risks for obese parturients and may be more technically challenging due to body habitus. Safe anesthesia practice for these patients must take into consideration the unique challenges associated with the combination of pregnancy and obesity.
         Predelivery planning 187
         Labor analgesia 187
         Anesthesia for cesarean delivery 189
        Spinal Anesthesia 189
        Combined Spinal Epidural Anesthesia 190
        Continuous Spinal Anesthesia 190
        Double Catheter Technique 190
         General anesthesia for cesarean delivery 190
         Special considerations 192
        Patient Positioning 192
        Blood Pressure Monitoring 192
        Vascular Access 193
        Neuraxial Needle Placement 193
        Local Anesthetic Dosing 194
        Thromboprophylaxis 195
         Summary 195
         Clinics care points 195
        Disclosure 196

        Contemporary Anesthetic Evaluation and Management for Electroconvulsive Therapy 201

        Francis V. Salinas
        Electroconvulsive therapy (ECT) is a medical treatment most often used in patients with severe major depression that has not responded to other treatments. ECT is also indicated for patients with other severe psychiatric conditions, including bipolar disorder, schizophrenia, schizoaffective disorders, catatonia, and neuroleptic malignant syndrome. Contemporary “modified ECT” involves inducing general anesthesia with neuromuscular blockade before inducing the therapeutic seizure. The goal of this review is to combine an evidence-based update with the experience of the author’s institution to provide a practical approach to anesthetic care for the patient undergoing ECT.
         Introduction 201
         Technical and procedural aspects of electroconvulsive therapy 202
        Procedural location and monitoring 202
        Stimulating electrode placement 203
        Electrical stimulus 203
        Seizure quality and duration 204
         Physiological changes during electroconvulsive therapy 204
         Preanesthetic assessment and management 205
        Coexisting cardiac disease 205
        Coexisting neurologic disease 206
        Electroconvulsive therapy in pregnancy 207
        Management of anticoagulation during electroconvulsive therapy 208
        Management of chronically administered psychotropic medications 209
         Anesthetic management for the electroconvulsive therapy procedure 210
        Preanesthetic medications 211
        Choice of induction anesthetic agent 213
        Depth of anesthesia 214
        Neuromuscular blocking agents 215
        Management of hemodynamic response during electroconvulsive therapy 216
        Management of postictal agitation 216
         Summary 216
         Clinics care points 217
         Disclosure 217

        Advocacy for Anesthesiologists 223

        Richard P. Dutton, Sherif Zaafran, and Moeed Azam
        Advocating for anesthesiology is a professional responsibility. We need to make the public aware of the role we play in assuring their safety and comfort; and we must also ensure that payment models are fair and commensurate with the quality of our work.
         Introduction 223
         Why get involved? 224
         Getting involved 225
        Personal participation 225
        Society membership 226
        Political action 228
        What to get involved in the hot issues of 2022 229
        Workforce 229
        Opioid prescribing 230
        Payment for anesthesia services 231
        Surprise medical billing 233
        Scope of practice 236
         Summary 237
         Clinics care points 237
        Disclosure 237