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
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