Recent Advances in Anesthesiology

Otolaryngology procedures involve the airway either directly or take place in close proximity to the airway which necessitate the sharing of the airway by the surgical and anesthesia teams. Close co-operation, open communication, clear delineation of the plan as well as backup contingencies for intubation and airway care between the surgical and anesthesia teams are required for successful patient care. Care should be taken in paralyzing a patient with a potentially difficult airway until the ability to mask the patient has been confirmed. Laryngeal disorders can be infectious, benign or malignant growths. Head and neck surgery is complex and muscle relaxation is often contraindicated by the need to monitor nerve function. Pediatrics, epiglottitis, and the aspiration of foreign bodies emphasize this need for close cooperation and communication between all involved in the patient care – surgical staff, anesthesia staff, and nursing staff, for the best results and in order to ensure patient safety.

Given a higher prevalence of smoking, pulmonary and cardiovascular disease, and in many cases carcinoma, thoracic surgical patients experience a higher risk for perioperative morbidity and mortality than that of broader surgical populations. Careful preoperative assessment of functional status and a focus on optimizing preexisting conditions prove critical to successful surgical outcomes. As open thoracotomies decline in number, minimally invasive surgeries – including video assisted thoracoscopy (VAT) and robotic surgical approaches pose new challenges for intraoperative anesthetic management. Although double lumen endotracheal tubes remain the most common approach to lung isolation, an array of newer endobronchial blockers provide opportunities to facilitate surgery in patients with difficult airways as well as those requiring lobar isolation to tolerate surgical resection. Surgery of the esophagus and trachea continue to pose enormous challenges to both our intraoperative management and postoperative care. In thoracic surgery, perhaps more so than any other field, there is no doubt that anesthetic interventions in the preoperative, intraoperative, and postoperative settings directly impact patient survival and recovery. Evolving surgical techniques – particularly the move toward less invasive surgery – will challenge our current dogma pertaining to anesthetic management of the thoracic surgical patient – necessitating outcomes based research to further reduce adverse perioperative outcomes and enhance surgical recovery.

Cardiac anesthesia encompasses the care of patients with cardiac disease; it is not limited to the care of patients undergoing cardiac surgery. In order to provide a successful cardiac anesthetic, it is imperative to understand fundamental aspects of cardiovascular physiology. These concepts include preload, afterload, and contractility; and how they relate to pressure-work versus volume-work for the heart. These concepts guide the management of specific disease conditions such as aortic stenosis, aortic insufficiency, mitral stenosis, mitral insufficiency, hypertrophic cardiomyopathy, as well as systolic heart failure and diastolic heart failure. A brief introduction to ventricular assist devices is included as well.

Neuro-anesthesia involves the anesthetic management of neurosurgical patients based on pathophysiology of the central nervous system and the effects of anesthetic agents on the CNS. The anesthetic goal is to avoid secondary injury to the brain and limit the possibility of neurologic deficits in the postoperative period. It is also to provide a rapid wakeup (where appropriate), at the end of the case in order to test for any deficits. Awake craniotomy is used to increase lesion removal from the brain and also minimizing the damage caused to the eloquent cortex. A working scalp block is mandatory for the success of an awake craniotomy.

In this chapter, we review c-ommon critical care medicine illnesses and syndromes, including epidemiology, diagnosis and treatment. Prominent topics discussed include: sepsis, ARDS, shock, GI bleeding, hypertensive emergency, acute kidney injury, toxidromes and exposures, and delirium.

Since the field of critical care is constantly changing, it is important for anesthesiologists to stay knowledgeable of these changes in order to provide optimal care to critically ill patients in the perioperative period. The purpose of this chapter is to provide an update for clinicians on ICU issues relevant to clinical practice. Topics which will be discussed include: modes of mechanical ventilation, renal replacement therapy, antibiotic prophylaxis, nutritional support, sedation management, transport of patients, and transfer of care.

The difficult airway is a reality that every practitioner of anesthesia will encounter. The most difficult airway is the unanticipated difficult airway. Due to the enormous efforts and work of professional societies awareness has been raised, training has improved, and skills are kept current. New devices such as the Laryngeal Mask Airway (LMA) and video laryngoscopy have made securing the difficult airway an easier task. Increased awareness of obstructive sleep apnea has helped improve patient safety. This article attempts to discuss the key components of the difficult airway algorithms of the ASA, DAS, CAFG; with a focus on the airway exam, oxygenating the patient, developing a plan and backup plans, and finally the options when doing.

Medicine is above all a moral endeavor. Anesthesiologists are tasked with evaluating the overall medical condition of the patient not just performing a scheduled procedure – they are the primary care physicians in the perioperative period. This is becoming even more so since physicians are most often employees of large healthcare delivery systems. These systems view patients as objects that must be put through the system quickly to optimize profits. Currently, proceduralists and/or surgeons are only responsible for the technical aspects of their procedure; the care of the patient is the anesthesiologist’s problem. Anesthesiologists have an ethical duty to put the patient’s interests foremost. Often this places them in conflict with surgeons and the healthcare system who perceive anesthesiologists as hindering through-put and interfering with profit. Anesthesiologists are given a perfunctory period in which they have to establish a relationship with the patient, determine the patients’ wishes, and obtain informed consent. The basis for understanding the ethical foundations of the processes involved is discussed in this chapter.

The following section presents several clinical scenarios of cases which were notable for the impression left on the practitioner. Interesting diagnostic points are discussed. The hope is that these cases will help cement points that are addressed elsewhere in the book. Discussions are meant to be thought-provoking rather than definitive. Hopefully it will be enjoyable and beneficial.