Intraoperative Awareness

Awareness following general anesthesia is a rare event; however, it may have significant impact on patient satisfaction and long-term morbidity. Detecting intraoperative awareness during a general anesthetic is difficult due to the fact that the signs and symptoms are often absent in documented cases of awareness. Often, intraoperative awareness goes unnoticed until a patient reports the experience. Anesthesiologists should be cognizant of the risk factors associated with an increased risk of intraoperative awareness. Cesarean section performed under general anesthesia, cardiac surgery, and trauma surgery all carry an increased risk. Anesthesiologists should consider patient specific risk factors involving a higher than expected anesthetic requirement in developing their anesthetic plan. In the event of intraoperative awareness, the anesthesiologist’s actions and interactions with the patient are critical in improving the patient’s’ outcome and minimizing long-term psychological stress. Anesthesiologists should acknowledge the event and create a supportive relationship with the patient.

Anesthetic Management of a Patient with Multiple Laryngeal Papillomatosis

Laryngeal papillomatosis is a rare disease, caused by human papilloma virus infection. It can present with various respiratory signs and symptoms, including but not limited to hoarseness, respiratory distress, and stridor. Anesthetic management of this condition is challenging due to multiple factors such as shared airway with the ear, nose, and throat surgeon, potential difficult airway, and associated complications related to jet ventilation and/or laser use in the airway. The chapter discusses the most important and clinically relevant facts related to this condition. Topics covered include difficult airway, airway laser airway fire, jet ventilation, and barotrauma. A case study of a 55-year-old overweight male patient who presents to the operating room for an elective removal of his recurrent laryngeal papillomas is used as an example.

Intraoperative Hyperkalemia

Patients with hypertension, diabetes, and heart disease are at risk for chronic kidney disease and therefore require close monitoring of potassium (K+) levels in order to avoid some of the more concerning consequences of hyperkalemia. Medical therapy in these patients, which often includes angiotensin converting enzyme inhibitors, angiotensin receptor blockers, renin inhibitors, and mineralocorticoid receptor antagonists, while helpful in managing some of the aforementioned comorbidities and ameliorating chronic kidney disease in these patients, places them at increased risk for unwanted K+ elevations. Symptoms of hyperkalemia maybe nonspecific (fatigue, weakness, and gastrointestinal upset), requiring attention therefore to preoperative laboratory analysis to avert the potentially lethal intraoperative consequences of hyperkalemia like asystole and ventricular fibrillation. Emergency surgery in these patients after trauma complicated by crush injury is particularly challenging requiring that the anesthesiologist be well-versed in recognizing the signs of and managing intraoperative hyperkalemia.

Preeclampsia Problem-Based Learning Discussion

This chapter is a problem based learning discussion about the hypertensive diseases in pregnancy and describes incidence, risk factors, etiology, prevention and treatment of the disease. The chapter discusses risk factors for preeclampsia, the etiology and pathogenesis of preeclampsia; prevention of preeclampsia; management of preeclamptic patients; treatment of hypertension in pregnancy; eclampsia prevention and treatment; anesthetic management, including general anesthesia, of the preeclamptic patient; invasive monitoring in the preeclamptic patient; and management of HELLP syndrome. The chapter uses the case study of a 32-year-old woman at 39 weeks gestation who presents to the labor floor with headache, blurry vision, and abdominal pain for 1 day.

Anesthesia in a Pregnant Patient Presenting for Urgent Nonobstetric Surgery

For obstetric patients undergoing nonobstetric surgeries, the anesthesiologist has to take into consideration both maternal and fetal safety during the pre-, intra-, and postoperative periods. The goal of the anesthetic management should be to apply maternal physiologic changes, avoid teratogenic agents, avoid decreased uteroplacental perfusion and/or fetal oxygenation, and prevent preterm labor. Decisions on the timing of the procedure and intraoperative fetal and uterine monitoring must be multidisciplinary. The chapter uses a case study of a 24-year-old woman who is admitted at 33 weeks gestation with nausea, vomiting, and right upper quadrant pain. Topics covered include teratogenicity, uteroplacental perfusion, and reversal agents.

Anaphylaxis in the OR—Causes, Recognition, and Treatment

Anaphylaxis in the operating room is a life-threatening condition that can evolve rapidly. As an anesthesiologist, it is important to understand the pathophysiology, diagnose the condition, recognize the inciting agent/agents, and manage it appropriately. It is equally important to confirm the diagnosis for preventing a catastrophic event from happening in future. This chapter defines anaphylaxis, discusses the clinical manifestations and most common causes, and describes ways it can be diagnosed. It also considers treatment and preventative measures. The chapter uses a case study of a 55-year-old female, weighing 85 kg and a body mass index of 36 with no other known comorbidities, who is scheduled to undergo elective laparoscopic cholecystectomy.

Massive Transfusion

Massive transfusion is defined as transfusion of 3 units of packed red blood cells in less than 1 hour in an adult, replacement of more than 1 blood volume in 24 hours, or replacement of more than 50% of blood volume in 3 hours. Massive transfusion protocols are implemented in cases of life-threatening hemorrhage after trauma, during a surgical procedure, or during childbirth. These protocols are intended to minimize the adverse effects of hypovolemia, dilutional anemia, metabolic complications, and coagulopathy with early empiric replacement of blood products and transfusion of fresh frozen plasma, platelets, and packed red blood cells in a composition that approximates that of whole blood.

Percutaneous Coronary Intervention with Concomitant Atrial Fibrillation

Cardiac comorbidities are oftentimes not limited to a single diagnosis, and multiple cardiac abnormalities may have to be considered when administering an appropriate anesthetic. Atrial fibrillation is an abnormal cardiac rhythm with uncoordinated depolarization of the atria causing an irregularly irregular ventricular response. Optimization requires heart rate control as well as anticoagulation, which must be considered prior to any surgical procedure. Percutaneous coronary intervention or coronary stents are placed in the coronary arteries in the face of coronary artery stenosis. The circumstances of when the stents were placed, as well as the type of stents that were used, will determine how long dual antiplatelet therapy must be undertaken and when elective surgery can take place.

Gastric Ulcer Bleed with a History of Coronary Artery Disease, Hypertension, and Hyperlipidemia

Gastrointestinal (GI) bleed may be encountered fairly commonly by anesthesiologists in routine clinical practice in various settings such as the emergency room, operating rooms, remote nonoperating room locations, and intensive care units. The most common cause of GI bleed is peptic ulcer bleed from the duodenum or stomach. GI bleed can quickly progress to a shock state if not managed promptly and adequately. These patients also suffer from various comorbidities such as coronary artery disease, pulmonary issues, malnutrition, liver disease, hematologic abnormalities, and so on, which calls for comprehensive evaluation and management despite time constraints. Care coordination and communication among various specialists and across multiple settings is essential for optimal outcome in this subset of patients. With advent of advanced endoscopic and interventional radiology techniques, the need for open surgery to control GI bleed is rare in modern-day clinical practice.

Management of the Difficult Airway in the MRI Suite

Management of the difficult airway is common problem anesthesiologists experience every day. From management of the morbidly obese patient, to the patient with severe facial trauma, anesthesiologists are the go to physicians in a hospital when it comes to airway management. With the expansion of nonoperating room anesthesia case volume throughout the world, airway management now brings unique challenges never before experienced by the anesthesiologist. This chapter uses the case study of a 67-year-old morbidly obese male with obstructive sleep apnea, claustrophobia, and known difficult airway who is scheduled to undergo brain magnetic resonance imaging for evaluation of new-onset seizures.