By Richard D. Urman MD, Jesse M. Ehrenfeld MD
- Provides speedy entry to the main appropriate, evidence-based info in each quarter of anesthesiology, together with medications, intraoperative difficulties, differential analysis, universal illness states, sufferer overview, and anesthetic concerns for every subspecialty.
- Features new chapters on better restoration After surgical procedure and Anesthesia for Bariatric Surgery.
- Includes more desirable content material on restoration after surgical procedure, ultrasonography, echocardiography, local anesthesia, and protracted pain.
- Uses a reader-friendly, bulleted define layout with quite a few tables, diagrams, and therapy algorithms throughout.
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Romanelli AMBULATORY ANESTHESIA Ursula A. Galway ANESTHESIA FOR AESTHETIC SURGERY & SURGERY OUTSIDE OF THE OPERATING ROOM Ruchir Gupta and Padma Surampudi CHRONIC PAIN MANAGEMENT Tanja S. Frey ORGAN TRANSPLANTATION Amanda J. Rhee and Mark Abel ANESTHESIA FOR THE ELDERLY Raymond C. Roy ECG INTERPRETATION Amanda J. Rhee and Linda Shore-Lesserson ETHICAL ISSUES & EVENT DISCLOSURE Jesse M. Ehrenfeld and Richard D. Urman EMERGENCY ALGORITHMS Tracy Palumbo Dovich COMMON MEDICAL PHRASES IN SPANISH Salomon M.
INHALED ANESTHETIC UPTAKE • Agent levels in the brain depend on agent levels (partial pressure) in the alveolus • Goal is to achieve rise in Fa (alveolar anesthetic concentration)/Fi (inspired anesthetic concentration) • ↑ Fa/Fi →↑ speed of induction (see Fig. Induction kinetics of commonly inhaled anesthetics. , halothane) • Tissue: Blood partition coefficient = time for equilibrium of tissue with arterial blood Cardiac Output • Increased cardiac output results in faster uptake but ↓ alveolar concentration (Fa) and therefore slower induction (more blood passing through lungs = anesthetic is carried away faster).
25) may cause transient but significant sympathetic stimulation Sevoflurane • Key features: Least pungent (best choice for inhalational induction); fast onset/offset of action; causes ↓ tachycardia than desflurane or isoflurane; does not sensitize myocardium to catecholamines • Disadvantages: Controversial potential for nephrotoxicity due to metabolic production of fluoride ion and degradation to Compound A (nephrotoxic in animals). , MH susceptibility, severe PONV) • Low-dose infusions/small incremental boluses used for procedural sedation, regional anesthesia adjunct • Most IV anesthetics are capable of causing transient apnea with induction doses; respiratory depressant effects ↑ by co-administration of narcotics • Direct myocardial depressant properties “unmasked” by hypovolemia, critical illness, or catecholamine depletion; use caution and adjust dosing accordingly • Agents with varying extent and route of metabolism show similar duration of action after bolus (induction) dosing because termination of effect is due to redistribution to skeletal muscle or fat • Drugs bound to plasma proteins are unavailable for uptake by target organs; dosing for highly protein-bound drugs may need adjustment in disease states with ↓ protein production (CHF, malignancy, renal or hepatic failure) PROPOFOL (DIPRIVAN) • Widely used for anesthetic induction, though associated with CV depression • Reduce/titrate dose for elderly, critically ill, hypovolemic (↓ central distribution volume, ↓ clearance → ↑ myocardial depression) • Infusion common for MAC and TIVA; rapid clearance makes context-sensitive half-life <40 min for infusions up to 8 hrs • Hepatic and extra-hepatic clearance to inactive metabolites; minimal kinetic changes in renal/liver disease • Insoluble alkylphenol formulated in lipid emulsion containing egg yolk lecithin (most egg allergies are to egg white antigens, though avoidance prudent with clear hx of egg anaphylaxis) • Lipid emulsion supports bacterial growth linked to sepsis; observe aseptic technique and use within 12 hrs of opening • Prolonged infusion linked to rare but lethal syndrome of arrhythmias, lipemia, metabolic acidosis, rhabdomyolysis FOSPROPOFOL (LUSEDRA) • Water-soluble propofol prodrug, indicated for adult procedural sedation via IV bolus • Give bolus doses >4 min apart to prevent dose stacking while prodrug is transformed • Key features: ↓ pain on injection, slower onset, ↑ duration of action compared to propofol ETOMIDATE (AMIDATE) • Favored for induction in hemodynamically unstable patients due to minimal direct myocardial depression, though may still cause hypotension in hypovolemic patients • Adrenal suppression (blocks hydroxylases in cortisol pathway) limits use as infusion; importance of transient effect after single dose is highly controversial, may affect outcome in sepsis (Intensive Care Med.