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Essential clinical anesthesia review keywords, questions and answers for the boards





Essential Clinical Anesthesia
Review: Keywords, Questions
and Answers for the Boards
Edited by

Linda S. Aglio
Harvard Medical School and the Brigham and Women’s Hospital, Boston, MA, USA.

Robert W. Lekowski
The Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA.

Richard D. Urman
The Brigham and Women’s Hospital, Center for Perioperative Management and Medical Informatics, and Harvard Medical School, Boston, MA, USA.

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University Printing House, Cambridge CB2 8BS, United Kingdom
Cambridge University Press is part of the University of Cambridge.
It furthers the University’s mission by disseminating knowledge
in the pursuit of education, learning and research at the highest international levels of excellence.
www.cambridge.org
Information on this title: www.cambridge.org/9781107681309
© Cambridge University Press 2015
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2015
Printed in the United Kingdom by Clays, St Ives plc
A catalogue record for this publication is available from the British Library
Library of Congress Cataloguing in Publication data
Essential clinical anesthesia review : keywords, questions and answers for
the boards / edited by Linda S. Aglio, Robert W. Lekowski, Richard D.
Urman.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-107-68130-9 (Hardback)
I. Aglio, Linda S., editor. II. Lekowski, Robert W., editor.
III. Urman, Richard D., editor.
[DNLM: 1. Anesthesia–Examination Questions. 2. Anesthesia–
Outlines. 3. Anesthetics–administration & dosage–Examination
Questions. 4. Anesthetics–administration & dosage–Outlines.
WO 218.2]
RD82.3
617.90 6076–dc23 2014014929
ISBN 978-1-107-68130-9 Paperback
Cambridge University Press has no responsibility for the persistence or
accuracy of URLs for external or third-party internet websites referred to
in this publication, and does not guarantee that any content on such
websites is, or will remain, accurate or appropriate.
..............................................................................................
Every effort has been made in preparing this book to provide accurate and
up-to-date information which is in accord with accepted standards and
practice at the time of publication. Although case histories are drawn from
actual cases, every effort has been made to disguise the identities of the
individuals involved. Nevertheless, the authors, editors and publishers can


make no warranties that the information contained herein is totally free
from error, not least because clinical standards are constantly changing
through research and regulation. The authors, editors and publishers
therefore disclaim all liability for direct or consequential damages
resulting from the use of material contained in this book. Readers are
strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.


Contents
List of contributors
Preface xvii

xi

History of anesthesia 1
Manisha S. Desai and Sukumar P. Desai

13. Substance abuse and anesthesia 56
Nantthasorn Zinboonyahgoon and Joseph M. Garfield

Section 1 – Preoperative care and
evaluation
1.
2.
3.

Preoperative anesthetic assessment
Emily L. Wang and Jeffrey Lu

Section 2 – Airway management
14. Anatomy of the human airway 61
Richard Hsu and Christopher Chen

3

Obstructive and restrictive lung disease
Emily L. Wang and Jeffrey Lu

15. Airway assessment 64
Richard Hsu and Christopher Chen

8

16. Perioperative airway management 67
Richard Hsu and Maksim Zayaruzny

Anesthetic goals in patients with myocardial
ischemia and heart failure 15
Thomas Hickey and Linda S. Aglio

17. Management of the difficult airway
Richard Hsu and Maksim Zayaruzny

4.

Anesthetic goals in patients with valvular heart
disease 18
Zahra M. Malik and Martin Zammert

5.

Obesity 22
Kelly G. Elterman and Suzanne Klainer

6.

Chronic renal failure 26
Michael Vaninetti and Assia Valovska

7.

Liver disease 30
Julia Serber and Evan Blaney

8.

Principles of diabetes mellitus and perioperative
glucose control 33
Olutoyin Okanlawon and Richard D. Urman

9.

70

Section 3 – Anesthesia equipment
18. Medical gas supply, vacuum, and scavenging
Marc Philip T. Pimentel and James H. Philip

74

19. Anesthesia machine 76
Marc Philip T. Pimentel and James H. Philip
20. Anesthesia ventilators 79
Marc Philip T. Pimentel and James H. Philip

Common blood disorders 37
Rosemary Uzomba, Michael D’Ambra, and Robert
W. Lekowski

10. The elderly patient 43
Allison Clark and Lisa Crossley

21. Anesthesia breathing apparatuses 82
Marc Philip T. Pimentel and James H. Philip
22. Electrical safety 85
Marc Philip T. Pimentel and James H. Philip

Section 4 – Patient monitoring
23. Hemodynamic patient monitoring
Thomas Hickey and Linda S. Aglio

11. Neurologic diseases and anesthesia 45
Nantthasorn Zinboonyahgoon and Joseph
M. Garfield

88

24. The electrocardiogram and approach to diagnosis
of common abnormalities 93
Thomas Hickey and Linda S. Aglio

12. Anesthetic considerations in psychiatric disease 51
Nantthasorn Zinboonyahgoon and Joseph M. Garfield

25. Pulse oximetry and capnography
Hanjo Ko and George P. Topulos

101

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Contents

26. Monitoring of neuromuscular blockade 104
M. Tariq Hanifi, J. Matthew Kynes, and Joseph M. Garfield
27. Thermoregulation and temperature monitoring
Jessica Bauerle and Zhiling Xiong

107

28. Neurophysiologic monitoring 109
Scott W. Vaughan and Linda S. Aglio
29. Intraoperative awareness 113
Nantthasorn Zinboonyahgoon and Joseph M. Garfield

30. Inhalation anesthetics 115
Carly C. Guthrie and Jeffrey Lu
118

32. Pharmacodynamics of inhalation agents
Carly C. Guthrie and Jeffrey Lu

47. Administration of general anesthesia
Carly C. Guthrie and Jeffrey Lu

121

161

49. Monitored anesthesia care 169
Lisa M. Hammond and James Hardy
50. Patient positioning and common nerve injuries
J. Matthew Kynes and Joseph M. Garfield

33. Intravenous induction agents 124
Lisa M. Hammond and James Hardy

172

Section 9 – Managing the transition
from anesthesia

34. Mechanisms of anesthetic actions 127
Lisa M. Hammond and James Hardy
35. Pharmacokinetics of intravenous agents
Alissa Sodickson and Richard D. Urman

164

48. Total intravenous anesthesia 166
Alissa Sodickson and Richard D. Urman

Section 6 – Intravenous anesthetics
and adjunct drugs

130

51. Emergence from anesthesia 174
Pete Pelletier and Galina Davidyuk

36. Opioids 133
Alissa Sodickson and Richard D. Urman

52. Postoperative complications in the post-anesthesia
care unit 177
Pete Pelletier and Galina Davidyuk

37. Muscle relaxants 137
M. Tariq Hanifi and Michael Nguyen

53. Management of postoperative nausea and
vomiting 179
M. Tariq Hanifi and Michael Nguyen

140

39. Perioperative pulmonary aspiration prophylaxis
Emily L. Wang and Jeffrey Lu

143

147

41. COX inhibitors and alpha2-adrenergic agonists
Iuliu Fat and Devon Flaherty

vi

45. Pharmacology of local anesthetics: mechanism of
action and pharmacokinetics 159
Jessica Bauerle and Zhiling Xiong

Section 8 – Anesthetic techniques

31. Pharmacokinetics of inhalation agents
Carly C. Guthrie and Jeffrey Lu

40. Perioperative antiemetic therapies
Iuliu Fat and Devon Flaherty

Section 7 – Pharmacology of local
anesthetics

46. Clinical applications of local anesthetics
Julia Serber and Evan Blaney

Section 5 – Inhalation anesthetics

38. Reversal of neuromuscular blockade
M. Tariq Hanifi and Michael Nguyen

44. Allergic reactions 156
Iuliu Fat and Devon Flaherty

54. Cognitive changes after surgery and anesthesia
Allison Clark and Lisa Crossley

181

Section 10 – Regional anesthesia
149

55. Anatomy of the vertebral column and spinal cord
Jennifer Oliver and Jose Luis Zeballos

42. Diuretics 151
Iuliu Fat and Devon Flaherty

56. Spinal anesthesia 187
Jennifer Oliver and Jose Luis Zeballos

43. Drug interactions 153
Iuliu Fat and Devon Flaherty

57. Epidural anesthesia 190
Jennifer Oliver and Jose Luis Zeballos

183


Contents

58. Principles of ultrasound-guided nerve blocks
Rejean Gareau and Kamen Vlassakov

192

59. Upper extremity nerve blocks 194
Rejean Gareau and Kamen Vlassakov

75. Pacemakers and automated implantable
cardioverter-defibrillators 249
Jessica Patterson and John A. Fox
76. Ventricular assist devices 252
Jessica Patterson and John A. Fox

60. Lower extremity nerve blocks 197
Rejean Gareau and Kamen Vlassakov

Section 11 – Fluid and electrolyte balance
61. Fluid replacement 202
Pingping Song and Gyorgy Frendl
62. Acid–base balance in anesthesia and intensive
care medicine 205
Pingping Song and Gyorgy Frendl
63. Ion balance 209
Pingping Song and Gyorgy Frendl

77. Anesthetic considerations for surgical repair
of the thoracic aorta 254
Jessica Patterson and John A. Fox
78. Cardiac transplantation in the adult
Jessica Patterson and John A. Fox

257

79. Persistent postoperative bleeding in cardiac
surgical patients 259
Rosemary Uzomba, Michael D’Ambra, and Robert
W. Lekowski

Section 14 – Vascular anesthesia

64. Total parenteral nutrition 214
Pingping Song and Gyorgy Frendl

80. Carotid endarterectomy 265
Agnieszka Trzcinka and Shaheen Shaikh
81. Abdominal aortic aneurysm 267
Mohab Ibrahim and Linda S. Aglio

Section 12 – Transfusion medicine
65. Blood products 217
Hanjo Ko and Robert W. Lekowski

82. Endovascular abdominal aortic aneurysm repair
Andrea Girnius and Annette Mizuguchi

66. Blood transfusion 219
Hanjo Ko and Robert W. Lekowski

270

83. Peripheral vascular disease 272
Andrea Girnius and Annette Mizuguchi

67. Massive transfusion 222
Hanjo Ko and Robert W. Lekowski
68. Normovolemic hemodilution, perioperative blood
salvage, and autologous blood donation 224
Hanjo Ko and Robert W. Lekowski

Section 15 – Thoracic anesthesia
84. Respiratory physiology 274
Hanjo Ko and George P. Topulos
85. Oxygen and carbon dioxide transport
Hanjo Ko and George P. Topulos

Section 13 – Cardiac anesthesia

277

86. Lung isolation techniques 279
Yuka Kiyota, Philip M. Hartigan, and
George P. Topulos

69. Cardiac physiology 225
Erich N. Marks and Lauren J. Cornella
70. Cardiovascular pharmacology 230
Erich N. Marks and Lauren J. Cornella

87. Anesthetic management for pulmonary
resection 282
Yuka Kiyota, George P. Topulos, and
Philip M. Hartigan

71. Adjunct cardiovascular drugs 238
Erich N. Marks and Lauren J. Cornella
72. Coronary artery bypass grafting utilizing
cardiopulmonary bypass 241
Erich N. Marks and Lauren J. Cornella

88. Lung transplantation for end-stage lung disease
Stephanie Yacoubian and Ju-Mei Ng

73. Off-pump coronary artery bypass 244
Zahra M. Malik and Martin Zammert

89. Bronchoscopy and mediastinoscopy: anesthetic
implications 291
Stephanie Yacoubian and Ju-Mei Ng

74. Transesophageal echocardiography
Zahra M. Malik and Martin Zammert

90. Management of mediastinal mass 295
Stephanie Yacoubian and Ju-Mei Ng

246

286

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Contents

Section 16 – Neuroanesthesia

105. Parathyroid disorders 339
Hyung Sun Choi and Vesela Kovacheva

91. Principles of neurophysiology 300
Whitney de Luna and Linda S. Aglio

106. Pheochromocytoma and carcinoid tumors
Hyung Sun Choi and Vesela Kovacheva

92. Cerebral protection 303
Whitney de Luna and Linda S. Aglio
93. Craniotomy 305
Whitney de Luna and Linda S. Aglio

107. Syndrome of inappropriate antidiuretic hormone,
diabetes insipidus, and transsphenoidal pituitary
surgery 345
Syed Irfan Qasim Ali and Vesela Kovacheva

94. Cerebrovascular diseases 308
Agnieszka Trzcinka and Shaheen Shaikh

108. Disorders of the adrenal cortex 348
Syed Irfan Qasim Ali and Vesela Kovacheva

95. Anesthesia for electroconvulsive therapy
Agnieszka Trzcinka and Shaheen Shaikh

311

Section 17 – Anesthesia for renal and
urinary tract diseases
96. Renal physiology 314
Michael Vaninetti and Assia Valovska

98. Kidney and pancreas transplantation
Michael Vaninetti and Assia Valovska

357

319

99. Anesthesia for intra-abdominal surgery
Kelly G. Elterman and Suzanne Klainer

322

100. Principles of laparoscopic surgery 325
Olutoyin Okanlawon and Richard D. Urman
101. Principles of anesthesia for esophageal and gastric
surgery 328
Olutoyin Okanlawon and Richard D. Urman
102. Principles of anesthesia for breast and gynecologic
surgery 331
Olutoyin Okanlawon and Richard D. Urman
334

Section 19 – Anesthesia for endocrine
diseases
104. Thyroid disorders 336
Hyung Sun Choi and Vesela Kovacheva

109. Malignant hyperthermia 351
Zinaida Chepurny and Alvaro A. Macias

111. Muscular dystrophy and myotonic dystrophy
Zinaida Chepurny and Alvaro A. Macias

Section 18 – Anesthesia for general surgical
procedures

103. Anesthesia for liver transplantation
Julia Serber and Evan Blaney

Section 20 – Anesthesia for neuromuscular
and collagen disease
110. Myasthenia gravis 354
Zinaida Chepurny and Alvaro A. Macias

97. Urology 316
Michael Vaninetti and Assia Valovska

viii

342

Section 21 – Anesthesia for ocular, ear,
and throat diseases
112. Ophthalmic procedures 360
Caryn Barnet and Dongdong Yao
113. Common otolaryngology procedures
Caryn Barnet and Dongdong Yao

362

114. Lasers, airway surgery, and operating
room fires 364
Caryn Barnet and Dongdong Yao

Section 22 – Anesthesia for orthopedic
and trauma surgery
115. Anesthesia for common orthopedic procedures
Christopher Voscopoulos and David Janfaza
116. Rheumatoid arthritis and scoliosis 372
Christopher Voscopoulos and David Janfaza
117. Anesthetic management in spine surgery 375
Christopher Voscopoulos and David Janfaza
118. Anesthesia for trauma 378
Christopher Voscopoulos and David Janfaza

367


Contents

Section 23 – Obstetric anesthesia
119. Physiologic changes during pregnancy
Brendan McGinn and Jie Zhou

135. Office-based anesthesia 427
Jonathan R. Meserve and Richard D. Urman

382

Section 26 – Management aspects of
anesthesia practice

120. Analgesia for labor 385
Brendan McGinn and Jie Zhou
121. Anesthesia for cesarean delivery
Brendan McGinn and Jie Zhou

388

136. Patient safety, quality assurance, and risk
management 429
Jaida Fitzgerald and Robert W. Lekowski

122. Obstetric hemorrhage 390
Benjamin Kloesel and Michaela K. Farber

137. Operating room management: core principles
Jaida Fitzgerald and Robert W. Lekowski

123. Preeclampsia 393
Benjamin Kloesel and Michaela K. Farber
124. Pregnant patients with comorbid diseases
Benjamin Kloesel and Michaela K. Farber

431

138. Practice management 433
Jaida Fitzgerald and Robert W. Lekowski

396

139. Principles of medical ethics 435
Christian Peccora and Richard D. Urman

125. Anesthesia for fetal intervention 399
Benjamin Kloesel and Michaela K. Farber

140. Risks in the operating room 438
Jaida Fitzgerald and Robert W. Lekowski

Section 24 – Pediatric anesthesia
126. Basic considerations for pediatric anesthesia
Laura Westfall and Susan L. Sager

401

141. Statistics for anesthesiologists and researchers
Jaida Fitzgerald and Robert W. Lekowski

Section 27 – Pain management

127. Preoperative evaluation of the pediatric patient
and coexisting diseases 405
Laura Westfall and Susan L. Sager

142. Neurophysiology of pain 444
Christian Peccora and Jie Zhou

128. Anesthetic considerations for common
procedures in children 408
Laura Westfall and Susan L. Sager

143. Postoperative acute pain management
Christian Peccora and Jie Zhou

129. Neonatal surgical emergencies 411
Jonathan R. Meserve and Susan L. Sager

144. Multidisciplinary approach to chronic pain
management 453
Cyrus Ahmadi Yazdi and Srdjan S. Nedeljkovic

130. Congenital heart disease 414
Jonathan R. Meserve and Susan L. Sager
131. Management of postoperative pain in children
Jonathan R. Meserve and Susan L. Sager
132. Neonatal resuscitation: clinical and practical
considerations 420
Jonathan R. Meserve and Susan L. Sager

Section 25 – Ambulatory and remote
location anesthesia

441

417

448

145. Psychological evaluation and management of
patients with chronic pain 455
Cyrus Ahmadi Yazdi and Srdjan S. Nedeljkovic
146. Interventional pain management I:
Epidural, sympathetic, and neural blockade
procedures 457
Cyrus Ahmadi Yazdi and Srdjan S. Nedeljkovic
147. Interventional pain management II: Implantable
and other invasive therapies 460
Cyrus Ahmadi Yazdi and Srdjan S. Nedeljkovic

133. Introduction to ambulatory anesthesia 423
Jonathan R. Meserve and Richard D. Urman

148. Complications associated with interventions
in pain medicine 462
J. Tasker Gundy and Elizabeth M. Rickerson

134. Anesthesia outside the operating room 425
Jonathan R. Meserve and Richard D. Urman

149. Back pain 464
J. Tasker Gundy and Jie Zhou

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Contents

Section 29 – Special topics

150. Complex regional pain syndrome 467
J. Tasker Gundy and Elizabeth M. Rickerson

167. Bronchopleural fistula 518
Yuka Kiyota, George P. Topulos, and Philip M. Hartigan

151. Cancer pain 469
J. Tasker Gundy and Elizabeth M. Rickerson

168. Inhaled nitric oxide 520
Yuka Kiyota and Stanton Shernan

Section 28 – Intensive care unit

169. Skin and collagen disorders 521
Richard Hsu and Christopher Chen

152. Cardiopulmonary resuscitation 472
Christopher Voscopoulos and Joshua Vacanti

170. Anesthesia for aesthetic surgery 523
Richard Hsu and Maksim Zayaruzny

153. Multiorgan failure and its prevention 477
Timothy D. Quinn and Sujatha Pentakota

171. Intra-abdominal hypertension and abdominal
compartment syndrome 525
Kelly G. Elterman and Suzanne Klainer

154. Supraventricular arrhythmias 480
Timothy D. Quinn and Sujatha Pentakota
155. Cardiac failure in the intensive care unit
Krishna Parekh and David Silver

483

156. Sedation in the surgical intensive care unit
Krishna Parekh and David Silver

485

157. Weaning from mechanical ventilation 487
Marc Philip T. Pimentel and James H. Philip
158. Acute lung injury and acute respiratory distress
syndrome 490
Beverly Chang and Gyorgy Frendl
159. Nosocomial infections 494
Beverly Chang and Gyorgy Frendl
160. Septic shock and sepsis syndromes
Beverly Chang and Gyorgy Frendl

499

161. Anesthetic management of the brain-dead organ
donor 504
Allison Clark and Lisa Crossley
162. Principles of trauma management
Hanjo Ko and Robert W. Lekowski

506

163. Venous thromboembolic disease in the critically
ill patient 508
Andrea Girnius and Annette Mizuguchi

172. Carbon monoxide and cyanide poisoning
Iuliu Fat and Devon Flaherty
173. Chemical and biologic warfare agents: an
introduction for anesthesiologists 531
Joyce Lo and Laverne D. Gugino

174. Anesthesia for robotic surgery 534
Michael Vaninetti, Joyce Lo, and Assia Valovska
175. Human immunodeficiency virus, methicillin-resistant
Staphylococcus aureus, and vancomycin-resistant
Enterococcus 537
Benjamin Kloesel and Michaela K. Farber
176. Alternative medicines and anesthesia 539
Syed Irfan Qasim Ali and Richard D. Urman
177. Anesthesia in high altitudes 542
Stephanie Yacoubian, Syed Irfan Qasim Ali, Felicity
Billings, and Richard D. Urman
178. Medical informatics and information management
systems in anesthesia 545
Syed Irfan Qasim Ali and Richard D. Urman
179. Hypertrophic cardiomyopathy and prolonged
QT interval 547
Thomas Hickey and Linda S. Aglio

164. Traumatic brain injury 510
Whitney de Luna and Linda S. Aglio
165. Burn management 513
Christopher Voscopoulos and Joshua Vacanti
166. Common ethical issues in the intensive care
unit 516
Christopher Voscopoulos and Joshua Vacanti

x

528

Index

549



List of contributors

and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

Galina Davidyuk, MD PhD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

Gyorgy Frendl, MD PhD
Associate Professor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

Whitney de Luna, MD
Clinical Fellow of Anaesthesia, Johns Hopkins University
School of Medicine
Resident, The Johns Hopkins Hospital, Baltimore, MD, USA

Rejean Gareau, MD FRCP(C)
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

Manisha S. Desai, MD
Clinical Associate Professor of Anesthesiology
University of Massachusetts School of Medicine
Worcester, MA, USA
Sukumar P. Desai, MD
Assistant Professor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Kelly G. Elterman, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Michaela K. Farber, MD MS
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Iuliu Fat, MD PhD FRCP
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Jaida Fitzgerald, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Devon Flaherty, MD MPH
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
John A. Fox, MD
Assistant Professor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative

xii

Joseph M. Garfield, MD
Associate Professor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Andrea Girnius, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Laverne D. Gugino, MD PhD
Associate Professor of Anaesthesia, Harvard Medical School
Director of Intraoperative Neurophysiological Monitoring
Department of Anesthesiology, Perioperative and Pain
Medicine
Brigham and Women’s Hospital, Boston, MA, USA
J. Tasker Gundy, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Carly C. Guthrie, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Lisa M. Hammond, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
M. Tariq Hanifi, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA


List of contributors

James Hardy, MB BS
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Philip M. Hartigan, MD
Assistant Professor of Anaesthesia, Harvard Medical School
Director of Thoracic Anesthesia
Department of Anesthesiology, Perioperative and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Thomas Hickey, MD MS
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Richard Hsu, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Mohab Ibrahim, MD PhD
Assistant Professor of Anesthesiology and Pharmacology,
University of Arizona Medical School
Director of the Pain Clinic, University of Arizona Medical
Center, Tucson, AZ, USA
David Janfaza, MD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Yuka Kiyota, MD MPH
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Suzanne Klainer, MD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Benjamin Kloesel, MD MSBS
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Hanjo Ko, MD MSc
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and

Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Bhavani Kodali, MD
Associate Professor of Anaesthesia, Harvard Medical School
Vice Chair of Clinical Affairs
Department of Anesthesiology, Perioperative and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Vesela Kovacheva, MD PhD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology,
Perioperative and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
J. Matthew Kynes, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Robert W. Lekowski, MD
Residency Program Director at the Department of
Anesthesiology, Perioperative and Pain Medicine, Brigham
and Women’s Hospital and Assistant Professor of Anesthesia,
Harvard Medical School, Boston, MA, USA
Joyce Lo, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Jeffrey Lu, MD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Alvaro A. Macias, MD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Zahra M. Malik, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Erich N. Marks, MD
Assistant Professor at the Department of Anesthesiology,
University of Wisconsin, Madison, WI, USA
Brendan McGinn, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and

xiii

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List of contributors

Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Jonathan R. Meserve, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Annette Mizuguchi, MD
Assistant Professor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Srdjan S. Nedeljkovic, MD
Assistant Professor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Fellowship Director, Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Ju-Mei Ng
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Michael Nguyen, MD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Olutoyin Okanlawon, MD MPH
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

xiv

Christian Peccora, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Pete Pelletier, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Sujatha Pentakota, MD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
James H. Philip, ME(E) MD
Professor of Anaesthesia, Harvard Medical School
Anesthesiologist and Director of Clinical Bioengineering
Department of Anesthesiology, Perioperative and Pain
Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Marc Philip T. Pimentel, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Timothy D. Quinn, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

Jennifer Oliver, DO MPH
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

Elizabeth M. Rickerson, MD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Palliative Care Physician, Department of Psychosocial
Oncology and Palliative Care
Dana Farber Cancer Institute, Boston, MA, USA

Krishna Parekh, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

Susan L. Sager, MD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Boston Children’s Hospital, Boston, MA, USA

Jessica Patterson, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

Julia Serber, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine, Brigham and Women’s Hospital, Boston,
MA, USA


List of contributors

Shaheen Shaikh, MD
Assistant Professor of Anaesthesia
University of Massachusetts Medical School
Director of Neuroanesthesia
University of Massachusetts Medical Center, Worcester, MA, USA
Stanton Shernan, MD
Professor of Anaesthesia, Harvard Medical School
Director of Cardiac Anesthesia, Department of Anesthesiology,
Perioperative and Pain Medicine Brigham and Women’s
Hospital, Boston, MA, USA
David Silver, MD
Associate Professor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Alissa Sodickson, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Pingping Song, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
George P. Topulos, MD
Associate Professor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Agnieszka Trzcinka, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Richard D. Urman, MD MBA CPE
Medical Director of Procedural Sedation at the Brigham and
Women’s Hospital, Co-Director of the Center for
Perioperative Management and Medical Informatics, and
Assistant Professor of Anesthesia at Harvard Medical School,
Boston, MA, USA
Rosemary Uzomba, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Joshua Vacanti, MD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative

and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Assia Valovska, MD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Michael Vaninetti, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Scott W. Vaughan, DO
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Kamen Vlassakov, DO
Assistant Professor of Anaesthesia, Harvard Medical School
Director of Orthopedic Anesthesia
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Christopher Voscopoulos, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Emily L. Wang, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Laura Westfall, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA
Zhiling Xiong, MD PhD
Assistant Professor of Anaesthesia, Harvard Medical School
Director of General Surgery Anesthesia, Department of
Anesthesiology, Perioperative and Pain Medicine, Brigham
and Women’s Hospital, Boston, MA, USA
Stephanie Yacoubian, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

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List of contributors

xvi

Dongdong Yao, MD PhD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

Jose Luis Zeballos, MD
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

Martin Zammert, MD
Instructor of Anaesthesia, Harvard Medical School
Director of Vascular Anesthesia, Department of
Anesthesiology, Perioperative and Pain Medicine, Brigham
and Women’s Hospital, Boston, MA, USA

Natthasorn Zinboonyahgoon, MD
Clinical Fellow of Anaesthesia, Harvard Medical School
Resident, Department of Anesthesiology, Perioperative and
Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA

Maksim Zayaruzny, MD
Assistant Professor of Anaesthesia, University of
Massachusetts Medical School
Anesthesiologist, University of Massachusetts Medical Center,
Worcester, MA, USA

Jie Zhou, MD MS MBA
Instructor of Anaesthesia, Harvard Medical School
Anesthesiologist, Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital, Boston, MA, USA


Preface

Significant advances in basic science and the clinical practice of
anesthesiology over the past decade have contributed exponentially to our specialty and necessitated the writing of this book.
Our aim has been to provide a comprehensive and readily
available reference and training source, prepared by a team
of experts in their field, to clarify the basics of anesthetic
management, including all new guidelines and recently
developed standards of care.
Essential Clinical Anesthesia Review: Keywords, Questions
and Answers for the Boards is the first review book of its kind
published to serve as a companion for the written and recertification board examinations, based on Essential Clinical
Anesthesia and other authoritative sources.
In addition, it presents a group of important clinical entities
covering critical anesthetic scenarios. It is an invaluable resource
to any practicing anesthesia provider looking for an up-to-date
review of problem-oriented patient management issues.
The material in this book will serve a wide range of learners
and practitioners: medical students during their anesthesia
rotation; residents and fellows studying for ABA (American

Board of Anesthesiology) boards; student nurse anesthetists
and certified registered nurse anesthetists (CRNAs); and practicing physicians. It will also serve as a source of review for the
continuing education and ABA re-certification for the practicing anesthesiologist.
This book is organized into 29 sections and reflects the
content of Essential Clinical Anesthesia and other Cambridge
University Press resources. Each section has several chapters
organized according to the ABA keyword list for a particular
problem or clinical case scenario. The keyword list is
followed by a concise discussion that includes preoperative
assessment, intraoperative management, and postoperative
pain management.
The book is designed to emphasize the fundamental
concepts or keywords that are required to pass an exam and
gives the reader the opportunity to see the application of these
concepts in everyday practice. The text reflects the opinions
and the clinical experiences of anesthesia experts at Harvard
Medical School as well as individually known national experts
in the field of anesthesiology.

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History of anesthesia
Manisha S. Desai and Sukumar P. Desai

Keywords
Morton
Wells
Long
Jackson
Although anesthetic properties of nitrous oxide and ether were
discovered in the 1800s, surgical operations were likely carried
out under varied degrees of analgesia from times immemorial.
Opiates, alcohol, cannabinoids, belladona derivatives, soporific
sponges, and mesmerism were used to offer relief during
surgery and are a testament to man’s ingenuity.
Joseph Priestley (1733–1804, UK) discovered oxygen in
1771, and nitrous oxide in 1772. Humphry Davy (1778–1829,
UK) discovered the analgesic properties of nitrous oxide in
1800 and termed it “laughing gas”; however, he did not use it
in any clinical setting. In the United States, recreational use
of ether and nitrous oxide was common in the 1840s
(ether frolics and laughing gas parties). William E. Clarke
(1819–1898, USA), while a medical student, was the first to
administer ether for dental extraction in January 1842. On
March 30, 1842, Crawford W. Long (1815–1878, USA) administered ether to James Venable during removal of a tumor
from his back. Long continued using ether during surgery,
but did not publish his findings until 1849. During an evening
of public entertainment in 1844, Gardner Quincy Colton
(1814–1898, USA) administered nitrous oxide to Samuel
A. Cooley. Cooley injured himself as he was returning to his
seat but did not feel any pain for a few minutes. Horace Wells
(1815–1848, USA) attended the same demonstration and
believed this was due to the analgesic effects of nitrous oxide.
The next morning, fellow dentist John M. Riggs (1811–1885,
USA) removed one of Wells’ teeth painlessly while Colton
administered nitrous oxide. Wells used nitrous oxide for pain
relief in his own dental practice, but when he attempted to
demonstrate this effect at Massachusetts General Hospital in
1845, the subject cried out in pain during the procedure,
although later admitting that he did not remember any pain.

However, Wells’ reputation never recovered from this apparent fiasco, and his life ended tragically in 1848. William
Thomas Green Morton (1819–1868, USA), an associate of
Wells, was present during the failed demonstration. He
consulted with Harvard professor Charles T. Jackson
(1805–1880, USA) and conducted experiments with ether.
On October 16, 1846 Morton performed the first successful
public demonstration of ether anesthesia while surgeon John
Collins Warren (1778–1856, USA) removed a vascular tumor
from the neck of Edward Gilbert Abbott. October 16 has
thereafter been celebrated as Ether Day, and the amphitheater
in which the procedure took place, Ether Dome, has been
preserved as a museum at Massachusetts General Hospital,
Boston.
News about the anesthetic properties of ether and nitrous
oxide spread rapidly, and other agents were investigated for
such properties. Obstetrician James Y. Simpson (1811–1870,
UK) introduced chloroform for relief of labor pain in Edinburgh in 1847. John Snow (1813–1858, UK) is recognized as
the first physician to work full time as an anesthetist. Relief of
labor pain remained controversial until Snow administered
chloroform to Queen Victoria (1819–1901) during the birth
of Prince Leopold in 1853, and Princess Beatrice in 1857.
Equipment to administer anesthetics developed over the next
several decades, and the risk of anesthesia became evident as
reports of anesthesia-related deaths appeared in newspapers
and medical journals.
Karl Koller (1857–1944, Austria) discovered the local anesthetic properties of cocaine, when applied to the conjunctiva,
in 1884. William S. Halsted (1852–1922, USA) used it for a
nerve block later that year, and August Bier (1861–1949,
Germany) performed the first clinical spinal anesthetic in
1898, and introduced intravenous regional anesthesia in
1908. Harvey W. Cushing (1869–1939, USA) and Ernest
A. Codman (1869–1940, USA), while medical students, introduced anesthetic records in 1894. Caudal epidural anesthesia
was introduced independently by Jean A. Sicard (1872–1929,
France) and Fernand Cathelin (1873–1945, France) in 1901.
Henry Edmund Gaskin Boyle (1875–1941, UK) introduced a

Essential Clinical Anesthesia Review: Keywords, Questions and Answers for the Boards, ed. Linda S. Aglio, Robert W. Lekowski, and Richard
D. Urman. Published by Cambridge University Press. © Cambridge University Press 2015.

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History of anesthesia

portable apparatus to administer nitrous oxide and oxygen
in 1917. Lumbar epidural anesthesia was introduced by Fidel
Pagés (1886–1923, Spain) in 1921. Torsten Gordh (1907–2010,
Sweden) introduced lidocaine into clinical use in 1944. The
routine use of intravenous barbiturate anesthesia (with agent
pernoston) was introduced by Rudolph Bumm (1899–1942,
Germany) in 1927. Harold R. Griffith (1894–1985, Canada)
and Enid Johnson (1909–2001, Canada) introduced curare in
1942. The use of neuromuscular blockers greatly facilitated
surgery in major body cavities, and mechanical ventilation.
Laryngoscopy and tracheal intubation became routine procedures, and new drugs (local anesthetics, intravenous agents, and
inhalation anesthetics) were introduced in subsequent decades.
Comprehensive anesthesia machines and routine monitoring
equipment were introduced in the 1960s and 1970s. Automatic
blood pressure measuring devices, capnography, and pulse
oximetry were introduced in the 1980s. Standards for intraoperative monitoring were developed at Harvard Medical
School, and adopted by the American Society of Anesthesiologists in 1986. Technological changes have introduced ultrasound and echocardiography to our specialty, and
anesthesiologists have expanded their scope of practice to
include perioperative care, critical care, and the treatment of
chronic pain. Ambulatory surgery and delivery of anesthesia
care outside the operating rooms are recent developments.
Credit for the discovery of general anesthesia ought to be
divided as follows – Clarke for the first use of ether for dental
extraction, Long for introducing ether for general surgery,
Wells for the introduction of nitrous oxide, Morton for
the first successful public demonstration of ether, and

2

Jackson for the instruction he provided to Morton. Anesthesia
is truly one of the most important discoveries in medicine, and
it is unique in that the discovery occurred over a very brief
period in the 1840s and events related to its discovery took
place in America.

Question

Which one of the following statements is TRUE about
individuals deserving credit for the discovery of anesthesia?
a. William Thomas Green Morton was the first to use nitrous
oxide successfully during a surgical operation.
b. Horace Wells successfully demonstrated the use of ether
for dental extraction.
c. Charles T. Jackson was the first to discover the anesthetic
properties of nitrous oxide.
d. Crawford W. Long was the first to use ether successfully
during a surgical operation.

Answer

d. Crawford W. Long was the first to use ether during a surgical
operation in 1842. William E. Clarke used ether during a tooth
extraction a few months earlier. Horace Wells’ administration
of nitrous oxide anesthesia during dental surgery was only
partially successful since the patient cried out during the
procedure. Charles T. Jackson advised Morton about the use of
ether, and did not play a role in the discovery of the anesthetic
properties of nitrous oxide. Morton was the first to publicly
demonstrate the efficacy of ether as an anesthetic, four years
after Long.


Section 1
Chapter

1

Preoperative care and evaluation

Preoperative anesthetic assessment
Emily L. Wang and Jeffrey Lu

Keywords
Preoperative assessment
Cardiovascular system evaluation
Functional capacity
ACC/AHA Guidelines on Perioperative
Cardiovascular Evaluation and Care for Noncardiac
Surgery
Active cardiac conditions
Clinical risk factors
Classification of cardiac risk for noncardiac surgery
Perioperative β-blockade
Percutaneous coronary intervention
Hypertension: perioperative management
Pulmonary system evaluation
Airway and anesthetic history
Gastrointestinal reflux
Neurologic conditions
Diabetes mellitus
Renal conditions
Hepatic conditions
Pregnancy
Allergies
Social history
Family history evaluation
Medications
Physical exam
Preoperative laboratory testing
ASA Physical Status Classification System
ASA NPO Guidelines for Fasting
Preoperative assessment: provides an evaluation of the patient’s
anesthetic risk for the proposed procedure, and allows recommendations to be made that help maximize patient safety. The
anesthetic risk evaluation is based on the knowledge of the
patient and the surgery. The goals of a preoperative assessment
include a history and physical examination (including airway
evaluation, medication usage, and past anesthetic and surgical
experiences), control of comorbidities and perioperative

diseases, laboratory and cardiac testing as indicated, anesthetic
risk assessment, anesthetic plan formulation, and patient
education and informed consent. Significant abnormalities
detected by the patient’s history, physical exam, and associate
risk factors may necessitate further testing and evaluation if it
will affect the patient’s treatment, management, or outcomes.
Cardiovascular system evaluation: cardiovascular status should
be evaluated for all routine preoperative evaluations. Cardiovascular disease has a high prevalence in most patient populations, and
cardiovascular complications may result in significant morbidity
and mortality. It is important to assess functional capacity, symptoms that may indicate significant cardiac disease, and obtain
information regarding prior cardiac events and test results.
Functional capacity: a patient’s functional capacity is based
on history, and is expressed in the form “metabolic equivalent
of task” (MET). MET is defined as the ratio of metabolic rate
during a specific physical activity to a reference metabolic rate
at rest, set by convention to 3.5ml O2/kg/min or equivalently,
1 kcal/kg/h. There is an increased perioperative cardiac risk
for patients unable to achieve a 4 MET functional capacity,
which is roughly equivalent to climbing two flights of stairs or
walking two city blocks.
American College of Cardiology (ACC) and American Heart
Association (AHA) Guidelines on Perioperative Cardiovascular
Evaluation and Care for Noncardiac Surgery: offers a step-wise
approach in the following algorithm: “Cardiac evaluation and
care algorithm for noncardiac surgery based on active clinical
conditions, known cardiovascular disease, or cardiac risk
factors for patients 50 years of age or greater.”
“Active cardiac conditions” definition:
1. Unstable coronary syndromes: unstable or severe angina,
may include stable angina in unusually sedentary patients,
recent MI (within 30 days).
2. Decompensated heart failure, or worsening or new-onset
heart failure.
3. Significant arrhythmias: Mobitz II or third-degree AV
block, symptomatic ventricular arrhythmias,
supraventricular arrhythmias with uncontrolled ventricular
rate, symptomatic bradycardia.

Essential Clinical Anesthesia Review: Keywords, Questions and Answers for the Boards, ed. Linda S. Aglio, Robert W. Lekowski, and Richard
D. Urman. Published by Cambridge University Press. © Cambridge University Press 2015.

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Section 1: Preoperative care and evaluation

Need for emergency
noncardiac surgery?

Step 1

Yes
(Class I, LOE C)

Operating room

Perioperative surveillance
and postoperative risk
stratification and risk factor
management

No

Active cardiac
conditions*

Step 2

Yes
(Class I, LOE B)

Evaluate and treat per
ACC/AHA guidelines

Consider
operating room

No

Step 3

Low risk surgery

Yes
(Class I, LOE B)

Proceed with
planned surgery†

No

Step 4

Functional capacity
greater than or equal to 4 METs without
symptoms‡

Step 5

Yes
(Class IIa, LOE B)

No or unknown

1 or 2 clinical
risk factors||

3 or more clinical
risk factors||
Vascular surgery

Intermediate
risk surgery
Vascular surgery

Class IIa,
LOE B
Consider testing if it will
change management

Proceed with
planned surgery§

No clinical
risk factors||
Intermediate risk
surgery

Proceed with planned surgery with HR control (Class IIa, LOE B)
or consider noninvasive testing (Class IIb, LOE B) if it will change management

Class I,
LOE B

Proceed with
planned surgery

Figure 1.1 Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for
patients 50 years of age. *See Table 23 for active clinical conditions. †See class III recommendations in Table 2.6, Noninvasive Stress Testing. ‡See Table 2.1 for
estimated MET level equivalent. §Noninvasive testing may be considered before surgery in specific patients with risk factors if it will change management.
||Clinical risk factors include ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease. Consider
perioperative β-blockade for populations in which this has been shown to reduce cardiac morbidity/mortality. HR, heart rate; LOE, level of evidence. (Modified
from Fleisher, L. A., Beckman, J. A., Brown, K. A. et al. 2007. ACC/AHA 2007. Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery:
Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 116: 1971–1996.)

4. Severe valvular disease: severe aortic stenosis (valve area
<1cm2, pressure gradient >40 mm Hg, or symptomatic),
symptomatic mitral stenosis.
“Clinical risk factors” definition:
1. diabetes mellitus
2. renal insufficiency
3. history of cerebrovascular disease
4. history of ischemic heart disease
5. history of compensated or prior heart failure
Classification of cardiac risk for noncardiac surgery:
1. High risk (>5%): emergent (especially in the elderly),
aortic and other major vascular, peripheral vascular,
and prolonged procedures with major blood loss or
fluid shifts.

4

2. Intermediate risk (<5%): carotid endarterectomy, head and
neck, intraperitoneal and intrathoracic, orthopedic, and
prostate procedures.
3. Low risk (<1%): endoscopic, superficial, cataract, and
breast procedures.
Based on ACC/AHA guidelines, further testing is directed by
clinical assessment findings in relation to the complexity and
invasiveness of the proposed procedure. However, emergency
surgical procedures preclude preoperative evaluation, and risk
factor management may require intensive care or postoperative invasive cardiac interventions.
Perioperative β-blockade: two groups mandated for
β-blockade according to AHA/ACC guidelines are patients
already taking β-blockers, and vascular patients with
recent positive provocative cardiac testing. It is also likely



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