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Handbook of Clinical Anesthesia
Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders or Other Directives That Limit Treatment
Table of Contents
Free Topics
About
Absorption
Acute Liver Failure
Anesthetic Actions on Ion Channels
Anesthetic Management of Specific Situations
Anticoagulation and Pharmacologic Therapy
Aortic Reconstruction
Autonomic Nervous System Transmission
Biologic
Calculator - Calculation of the Apgar Score - Calculator
Calculator - Glasgow Coma Scale - Calculator
Cardiopulmonary resuscitation (CPR)
Complications
Components of Resuscitation
Drug Interactions
Early Management of Specific Injuries
Electrolytes
Evolving Practice Arrangements
Figure - Adaptation of the Heart to Obesity and Hypertension
Figure - Adult Tachycardia (with Pulse) Algorithm
Intravenous
Management of High-Risk Parturients
Myasthenia Gravis
Myasthenia Gravis - Anesthesia for Thoracic Surgery
Neuromuscular System and Malignant Hyperthermia
Office Selection and Requirements
Pain Prevention
Pharmacodynamics: Dose Effect on Pain Relief
Physiology and Pharmacology
Physiology of the Infant and the Transition Period
Postanesthesia Care Unit (PACU)
Professionalism and Anesthesia Practice
Special Considerations in the Perioperative Pain Management of Children
Table - American Society of Anesthesiologists' Classification of Surgical Offices According to the Anesthesia and Surgical Procedures Performed
Table - Diagnostic Tools in Abdominal Trauma: Strengths and Weaknesses
The Physiology of Organ Aging
Transfer to the Postanesthesia Care Unit (PACU)
I. Introduction to Anesthesiology
1. The History of Anesthesia
I. Anesthesia Before Ether
II. Anesthesia Principles, Equipment, and Stand ards
III. The History of Anesthetic Agents and Adjuvants
IV. Anesthesia Subspecialties
T - 1-1. Early Analgesics and Soporifics
The History of Anesthesia
V. Professionalism and Anesthesia Practice
2. Scope of Practice
I. Administrative Components of All Anesthesiology Practices
II. Practice Essentials
III. Evolving Practice Arrangements
IV. Health Insurance Portability and Accountability Act
Scope of Practice
T - 2-1. Practice Management Materials Provided by the American Society of Anesthesiologists
T - 2-2. Examples of Anesthesiologists as Participants in Medical Staff Activities
T - 2-3. Materials Provided by the American Society of Anesthesiologists Designed to Establish Practice Stand ards
V. Expansion Into Perioperative Medicine, Hospital Care, and Hyperbaric Medicine
VI. Operating Room Management
3. Occupational Health
I. Physical Hazards
II. Ergonomics and Human Factors
III. Work Hours, Night Call, and Fatigue
IV. Infectious Hazards
Occupational Health
T - 3-1. Sources of Operating Room Contamination
T - 3-2. Types of Reactions to Latex Gloves
V. Emotional Considerations
4. Anesthetic Risk, Quality Improvement, and Liability
Anesthetic Risk, Quality Improvement, and Liability
F - 4-1. Most Common Injuries Leading to Anesthesia Malpractice Claims, 2000 to 2009 (American Society of Anesthesiologists Closed Claims Project)
I. Anesthesia Risk
II. Risk Management
III. Quality Improvement and Patient Safety in Anesthesia
IV. Professional Liability
T - 4-1. Recent Estimates of Anesthesia-Related Death
T - 4-2. Complications Related to Anesthesia
T - 4-3. World Health Organization Surgical Safety Checklist Elements
T - 4-4. The Joint Commission Patient Safety Goals for Accredited Organizations
T - 4-5. Elements Required to Prove Malpractice
T - 4-6. Elements Necessary to Prove Res Ipsa Loquitur
T - 4-7. Steps to Take when Named in a Lawsuit
II. Scientific Foundations of Anesthesia
5. Mechanisms of Anesthesia and Consciousness
F - 5-1. The Meyer-Overton Rule
F - 5-2. Diagram of Subcortical Arousal Circuitry Implicated in Anesthetic-Induced Unconsciousness
F - 5-3. A Multisite Model for Anesthesia
I. What is Anesthesia?
II. How is Anesthesia Measured?
III. What is the Chemical Nature of Anesthetic Target Sites?
IV. How do Anesthetics Interfere with the Electrophysiologic Function of the Nervous System?
Mechanisms of Anesthesia and Consciousness
T - 5-1. Why are Mechanisms of Anesthesia so Difficult to Elucidate?
T - 5-2. Limitations of the Minimum Alveolar Concentration (Mac) Concept
V. Anesthetic Actions on Ion Channels
VI. How are the Molecular Effects of Anesthetics Linked to Anesthesia in the Intact Organism?
VII. Where in the Central Nervous System do Anesthetics Work?
VIII. Conclusions
6. Genomic Basis of Perioperative Medicine
F - 6-1. Categories of Genetic Polymorphisms
F - 6-2. Central Dogma of Molecular Biology
F - 6-3. Pharmacogenomic Determinants of Individual Drug Response Operate by Pharmacokinetic (A) and Pharmacodynamic (B) Mechanisms
Genomic Basis of Perioperative Medicine
I. Scientific Rationale for Perioperative Genomic Medicine
II. Overview of Human Genetic Variation
III. Methodologic Approaches to Studying the Genetic Architecture of Common Complex Diseases
IV. Large-Scale Gene and Protein Expression Profiling: Static Versus Dynamic Genomic Markers of Perioperative Outcomes
IX. Conclusions
T - 6-1. Categories of Perioperative Phenotypes
T - 6-2. Examples of Genetic Polymorphisms Involved in Variable Responses to Drugs Used in the Perioperative Period
V. Genomics and Perioperative Risk Profiling
VI. Pharmacogenomics and Anesthesia
VII. Genomics and Critical Care
VIII. Future Directions
7. Basic Principles of Clinical Pharmacology
Basic Principles of Clinical Pharmacology
F - 7-1. The Plasma Concentration Versus Time Profile Plotted on Both Linear (Red Line, Left Y-Axis) and Logarithmic (Blue Line, Right Y-Axis) Scales for a Hypothetical Drug Exhibiting One-Compartment, First-Order Pharmacokinetics
F - 7-2. The Logarithmic Plasma Concentration Versus Time Profile for a Hypothetical Drug Exhibiting Two-Compartment, First-Order Pharmacokinetics
F - 7-3. Schematic Curve of the Effect of a Drug Plotted Against Dose
F - 7-4. The Changes in Plasma Drug Concentration and Pharmacologic Effect during and after an IV Infusion
I. Pharmacokinetic Principles: Drug Absorption and Routes of Administration
II. Drug Distribution
III. Drug Elimination
IV. Pharmacokinetic Models
IX. Clinical Applications of Pharmacokinetic and Pharmacodynamics to the Administration of IV Anesthetics
T - 7-1. Substrates for CYP Isoenzymes Encountered in Anesthesiology
T - 7-2. Drugs with Significant Renal Excretion Encountered in Anesthesiology
T - 7-3. Classification of Drugs Encountered in Anesthesiology According to Hepatic Extraction Ratios
T - 7-4. Half-lives and Percentage of Drug Removed
T - 7-5. Inducers and Inhibitors of Hepatic Drug Metabolism
V. Compartmental Pharmacokinetic Models
VI. Pharmacodynamic Principles
VII. Drug-Receptor Interactions
VIII. Drug Interactions
8. Electrical and Fire Safety
Electrical and Fire Safety
F - 8-1. When a Faulty Piece of Equipment Without an Equipment Ground Wire is Plugged into an Electrical Outlet Not Containing a Ground Wire, the Instrument Case Becomes Energized (âHotâ)
F - 8-2. When a Faulty Piece of Equipment Containing an Equipment Ground Wire is Properly Connected to an Electrical Outlet with Grounding Protection, the Electrical Current (Dashed Line) Will Preferentially Flow Down the Low-Resistance Ground Wire
F - 8-3. In an Operating Room, the Isolation Transformer Converts the Grounded Power on the Primary Side to an Ungrounded Power System on the Secondary Side of the Transformer
F - 8-4. A Safety Feature of the Isolated Power System is Illustrated
F - 8-5. When a Faulty Piece of Equipment is Plugged into the Isolated Power System, It Decreases the Impedance from Line 1 or Line 2 to the Ground
F - 8-6. A Properly Applied Electrosurgical Unit (ESU) Return Plate
F - 8-7. An Improperly Applied Electrosurgical Unit (ESU) Return Plate
F - 8-8. The Fire Triangle Illustrates the Three Components Necessary for a Fire to Occur
I. Principles of Electricity
II. Electrical Shock Hazards
III. Electrical Power: Grounded
IV. Electrical Power: Ungrounded
IX. Electrosurgery
T - 8-1. Proper Application of the Electrosurgical Unit Dispersive Return Plate
T - 8-2. The Fire Triad: Elements Necessary for a Fire to Start
T - 8-3. Recommendations for the Prevention and Management of Operating Room Fires
V. The Line Isolation Monitor
VI. Ground Fault Circuit Interrupter
VII. Double Isolation
VIII. Microshock
X. Environmental Hazards
XI. Electromagnetic Interference
XII. Construction of New Operating Rooms
XIII. Fire Safety
9. Experimental Design and Statistics
Experimental Design and Statistics
I. Design of Research Studies
II. Data and Descriptive Statistics
III. Hypotheses and Parameters
IV. Statistical Applications
T - 9-1. Data Types
T - 9-2. Descriptive Statistics
T - 9-3. Information Necessary to Accept or Reject the Null Hypothesis
T - 9-4. Strength of Evidence (Increasing Order) Concerning Efficacy
V. Conclusions
III. Anatomy and Physiology
10. Cardiac Anatomy and Physiology
Cardiac Anatomy and Physiology
F - 10-1. An Anterior View of the Heart (Left) Shows Right Coronary and Left Anterior Descending Coronary Arteries
F - 10-2. Schematic Representation of Blood Flow in the Left and Right Coronary Arteries during Phases of the Cardiac Cycle
F - 10-3. Mechanical and Electrical Events of the Cardiac Cycle Showing also the Left Ventricular (LV) Volume Curve and the Heart Sounds
F - 10-4. A Steady-State Left Ventricular (LV) Pressure-Volume Diagram
F - 10-5. The Major Factors That Determine Left Ventricular (LV) Diastolic (Left) and Systolic (Right) Function
I. Gross Anatomy
II. Coronary Physiology
III. Cardiac Myocyte Anatomy and Function
IV. The Cardiac Cycle
T - 10-1. Areas at Risk for Myocardial Ischemia Based on Coronary Artery Distribution
T - 10-2. Determinants of Left Ventricular Diastolic Dysfunction
T - 10-3. Common Causes of Left Ventricular Diastolic Dysfunction
V. The Pressure-Volume Diagram
VI. Factors that Determine Systolic Function
VII. Factors that Determine Diastolic Function
11. Respiratory Function in Anesthesia
F - 11-1. Diagram of Central Nervous System (CNS) Respiratory Centers, Neurofeedback Circuits, Primary Neurohumoral Sensory Inputs, and Mechanical Outputs
F - 11-2. CO(2)-Ventilatory Response Curves
F - 11-3. Distribution of Blood Flow in the Isolated Lung
F - 11-4. Continuum of Ventilation-to-Perfusion Relationships
F - 11-5. The Spirogram Depicts a 4-L Forced Vital Capacity (FVC) on Which the Points Representing 25% and 75% FVC are Marked
F - 11-6. Lung Volumes and Capacities
I. Functional Anatomy of the Lungs
II. Lung Mechanics
III. Control of Ventilation
IV. Oxygen and Carbon Dioxide Transport
IX. Postoperative Pulmonary Function
Respiratory Function in Anesthesia
T - 11-1. Functional Airway Divisions
T - 11-2. Physiologic Changes in Respiratory Function Associated with Aging
T - 11-3. Definitions of Respiratory Terms
T - 11-4. Clinical States Associated with Changes in the Ventilatory Response to Carbon Dioxide
T - 11-5. Pulmonary Function Tests in Restrictive and Obstructive Lung Disease
T - 11-6. Preoperative Pulmonary Assessment
T - 11-7. Respiratory Values for Guiding Weaning from Mechanical Ventilation or Tracheal Extubation
T - 11-8. Effects of Smoking
T - 11-9. Relationship of Operative Site to Postoperative Decreases in Functional Residual Capacity
V. Pulmonary Function Testing
VI. Anesthesia and Obstructive Pulmonary Disease
VII. Anesthesia and Restrictive Pulmonary Disease
VIII. Effects of Cigarette Smoking on Pulmonary Function
12. The Allergic Response
F - 12-1. Type I Immediate Hypersensitivity Reactions (Anaphylaxis) Involve Immunoglobulin E (Ige) Antibodies Binding to Mast Cells or Basophils at the Fc Receptors
F - 12-2. During a Type I Allergic Reaction, Antigen Enters a Patient during Anesthesia Via a Parenteral Route (Intravenous [iv] or Intramuscular [im])
I. Basic Immunologic Principles
II. Hypersensitivity Responses (Allergy)
III. Anaphylactic Reactions
IV. Perioperative Management of the Patient with Allergies
T - 12-1. Biologic Characteristics of Immunoglobulins
T - 12-10. Tests for Drug Allergy
T - 12-2. Cells that Participate in the Immune Response
T - 12-3. Symptoms Produced by Release of Cytokines
T - 12-4. Classification of Hypersensitivity
T - 12-5. Recognition of Anaphylaxis During Regional and General Anesthesia
T - 12-6. Chemical Mediators of Anaphylaxis
T - 12-7. Drugs Capable of Nonimmunologic Histamine Release
T - 12-8. Management of Anaphylaxis During General Anesthesia
T - 12-9. Drugs Implicated in Allergic Reactions During Anesthesia
The Allergic Response
V. Summary
13. Inflammation, Wound Healing, and Infection
F - 13-1. World Health Organization Schematic of the â5 Momentsâ for Hand Hygiene
I. Infection Control
II. Mechanisms of Wound Repair
III. Wound Perfusion and Oxygenation
Inflammation, Wound Healing, and Infection
IV. Patient Management
T - 13-1. Hand Hygiene Technique
T - 13-2. Recommended Drugs for Common Procedures
T - 13-3. Drugs and Doses Available Routinely for Antibiotic Prophylaxis (Drugs to be given in the Operating Room by an Anethesiologist)
T - 13-4. Factors that may Impair Wound Healing
T - 13-5. Causes of Sympathetically Induced Peripheral Vasoconstriction
T - 13-6. Preoperative Checklist
T - 13-7. Intraoperative Management
T - 13-8. Stand ard Volume Management Guidelines for Surgical Patients
T - 13-9. Postoperative Management
V. Summary
14. Fluids, Electrolytes, and Acid-Base Physiology
F - 14-1. Henderson-Hasselbalch Equation
F - 14-2. Electrocardiographic (ECG) Changes That May Accompany Progressive Increases in Serum Potassium Concentrations
F - 14-3. Treatment of Hyperkalemia
Fluids, Electrolytes, and Acid-Base Physiology
I. Acid-Base Interpretation and Treatment
II. Practical Approach to Acid-Base Interpretation
III. Physiology of Fluid Management
IV. Fluid Replacement Therapy
T - 14-1. Generation of Metabolic Alkalosis
T - 14-10. Physiologic Effects Produced by Respiratory Alkalosis
T - 14-11. Causes of Respiratory Acidosis
T - 14-12. Sequential Approach to Acid-Base Interpretation
T - 14-13. Maintenance Water Requirements
T - 14-14. Possible Advantages and Disadvantages of Colloid Versus Crystalloid Intravenous Fluids
T - 14-15. Conditions Associated with Deficits in Blood Volume and Extracellular Fluid Volume
T - 14-16. Signs and Symptoms of Hypovolemia
T - 14-17. Laboratory Evidence of Hypovolemia
T - 14-18. Clinical Indicators of the Adequacy of Intraoperative Blood Volume Replacement
T - 14-19. Physiologic Role of Electrolytes
T - 14-2. Factors that Maintain Metabolic Alkalosis
T - 14-20. Signs and Symptoms of Hyponatremia
T - 14-21. Precipitating Causes of Inappropriate Antidiuretic Hormone Secretion
T - 14-22. Signs and Symptoms of Hypernatremia
T - 14-23. Treatment of Hypernatremia
T - 14-24. Signs and Symptoms of Hypokalemia
T - 14-25. Treatment of Hypokalemia
T - 14-26. Signs and Symptoms of Hyperkalemia
T - 14-27. Treatment of Severe Hyperkalemia
T - 14-28. Signs and Symptoms of Hypocalcemia
T - 14-29. Treatment of Hypocalcemia
T - 14-3. Physiologic Effects Produced by Metabolic Alkalosis
T - 14-30. Signs and Symptoms of Hypercalcemia
T - 14-31. Signs and Symptoms of Hypomagnesemia
T - 14-32. Treatment of Hypomagnesemia
T - 14-33. Signs and Symptoms of Hypermagnesemia
T - 14-4. Treatment of Metabolic Alkalosis
T - 14-5. Differential Diagnosis of Metabolic Acidosis
T - 14-6. Physiologic Effects Produced by Metabolic Acidosis
T - 14-7. Anesthetic Implications of Metabolic Acidosis
T - 14-8. Calculation of Sodium Bicarbonate Dose
T - 14-9. Causes of Respiratory Alkalosis
V. Colloids, Crystalloid, and Hypertonic Solutions
VI. Fluid Status: Assessment and Monitoring
VII. Electrolytes
15. Autonomic Nervous System: Physiology and Pharmacology
Autonomic Nervous System: Physiology and Pharmacology
F - 15-1. Schematic Distribution of the Craniosacral (Parasympathetic) and Thoracolumbar (Sympathetic) Nervous Systems
F - 15-2. Schematic Diagram of the Efferent Autonomic Nervous System
F - 15-3. Synthesis of Catecholamines
F - 15-4. Blood Pressure and Heart Rate Response to a Valsalva Maneuver (A, Normal; B, Abnormal in a Patient with Cervical Quadriplegia)
I. Functional Anatomy
II. Autonomic Nervous System Transmission
III. Receptors
IV. Autonomic Nervous System Reflexes and Interactions
IX. Angiotensin-Converting Enzyme Inhibitors
T - 15-1. Homeostatic Balance Between Divisions of the Autonomic Nervous System
T - 15-2. Adrenergic Receptors and Order of Potency of Agonists and Antagonists
T - 15-3. Doses and Principal Sites of Action of Adrenergic Agonists
T - 15-4. Hemodynamic Effects of Adrenergic Agonists
T - 15-5. Pharmacokinetics of à Antagonists
T - 15-6. Comparative Effects of Calcium Channel Blockers
T - 15-7. Doses and Sites of Action of Vasodilators
V. Clinical Autonomic Nervous System Pharmacology
VI. Nonadrenergic Sympathomimetic Agents
VII. Sympatholytic Drugs
VIII. Calcium Channel Blockers
X. Vasodilators
16. Hemostasis and Transfusion Medicine
F - 16-1. Overview of Platelet Pathways for Adherence, Activation, Stabilization, and Physiologic Inhibition
F - 16-2. Summary of Secondary Hemostasis and the Intrinsic, Extrinsic, and Common Coagulation Pathways
F - 16-3. Depiction of the Antithrombotic Regulation of Hemostasis
F - 16-4. The Mechanism and Regulation of Fibrinolysis
Hemostasis and Transfusion Medicine
I. Hemostasis and Coagulation
II. Fibrinolysis
III. Laboratory Evaluation of Hemostasis
IV. Laboratory Evaluation of Primary Hemostasis
IX. Blood Products and Transfusion Thresholds
T - 16-1. Medical History as Screening test for Hemostatic Problems
T - 16-10. Residual Risk of Transfusion-Transmitted Infections
T - 16-11. Noninfectious Transfusion Reactions
T - 16-12. Perioperative Blood Conservation Strategies
T - 16-13. Classification of Inherited Von Willebrand Disease
T - 16-14. Scoring Algorithm for the Diagnosis of Disseminated Intravascular Coagulation
T - 16-15. Disorders of Secondary Hemostasis
T - 16-16. Acquired Disorders of Hemostasis
T - 16-17. Oral Anticoagulation Medications
T - 16-2. Acquired Risk Factors for Thrombosis
T - 16-3. Blood Components
T - 16-4. Equations for Tissue Oxygenation
T - 16-5. Clinical Indications of Tissue Hypoxia
T - 16-6. Indications for Platelet Transfusion
T - 16-7. Causes of Acquired Platelet Dysfunction
T - 16-8. Indications for the use of Fresh Frozen Plasma
T - 16-9. Indications for the use of Cryoprecipitate
V. Laboratory Evaluation of Secondary Hemostasis and Coagulation
VI. Diagnosis of Thromboembolic Disorders
VII. Monitoring Anticoagulation Therapeutic Agents
VIII. Blood Component Production
X. Physiologic Compensation for Anemia
XI. Platelets
XII. Fresh Frozen Plasma
XIII. Cryoprecipitate
XIV. The Risks of Blood Product Administration
XIX. Desmopressin
XV. Blood Conservation Strategies
XVI. Disorders of Hemostasis: Diagnosis and Treatment
XVII. Anticoagulation and Pharmacologic Therapy
XVIII. Prothrombin Complex Concentrates
XX. Antifibrinolytic Therapy
IV. Anesthetic Agents, Adjuvants, and Drug Interaction
17. Inhaled Anesthetics
F - 17-1. Chemical Structure of Inhaled Anesthetics
F - 17-10. All Inhaled Anesthetics Produce Similar Dose-Dependent Decreases in the Ventilatory Response to Carbon Dioxide
F - 17-11. Changes in Airway Resistance Before (Baseline) and after Tracheal Intubation Were Significantly Different in the Presence of Sevoflurane Compared with Desflurane
F - 17-12. Shunt Fraction (Top Panel) and Alveolar-Arterial Oxygen Gradient (Bottom Panel) Before, during, and after One-Lung Ventilation (Olv) in Patients Anesthetized with Desflurane or Isoflurane
F - 17-13. Compound a Levels Produced from Three Carbon Dioxide Absorbents during 1 Minimum Alveolar Concentration Sevoflurane Anesthesia Delivered at a Fresh Gas Flow of 1 L/Min (Mean Not Equal to SE)
F - 17-2. The Increase in the Alveolar Anesthetic Concentration (F(A)) Toward the Inspired Anesthetic Concentration (F(I)) is Most Rapid with the Least-Soluble Anesthetics (Nitrous Oxide, Desflurane, and Sevoflurane) and Intermediate with the More Soluble Anesthetics (Isoflurane and Halothane)
F - 17-3. The Concentration Effect is Demonstrated in the Top Half of the Graph in Which 70% Nitrous Oxide (N(2)O) Produces a More Rapid Increase in the Alveolar Anesthetic Concentration (F(A))/Inspired Anesthetic Concentration (F(I)) Ratio of N(2)O Than Does Administration of 10% N(2)O
F - 17-4. Elimination of Anesthetic Gases is Defined As the Ratio of End-Tidal Anesthetic Concentration (F(A)) to the Last F(A) during Administration and Immediately Before Beginning Elimination (F(Ao))
F - 17-5. Cerebral Blood Flow (CBF) Measured in the Presence of Normocapnia and in the Absence of Surgical Stimulation in Volunteers
F - 17-6. Heart Rate and Systemic Blood Pressure Changes (from Awake Baseline) in Volunteers Receiving General Anesthesia with a Volatile Anesthetic
F - 17-7. Cardiac Index (CI), Systemic Vascular Resistance (SVR), and Central Venous Pressure (CVP) Changes from Awake Baseline in Volunteers Receiving General Anesthesia with a Volatile Anesthetic
F - 17-8. Stress Hormone Responses to a Rapid Increase in Anesthetic Concentration from 4% to 12% Inspired
F - 17-9. Comparison of Mean Changes in Resting Paco(2), Tidal Volume, Respiratory Rate, and Minute Ventilation in Patients Receiving an Inhaled Anesthetic
I. Pharmacokinetic Principles
II. Clinical Overview of Current Inhaled Anesthetics
III. Neuropharmacology of Inhaled Anesthetics
Inhaled Anesthetics
IV. The Circulatory System
IX. Anesthetic Degradation by Carbon Dioxide Absorbers
T - 17-1. Physiochemical Properties of Volatile Anesthetics
T - 17-2. Tissue Groups and Pharmacokinetics
T - 17-3. Factors that Increase or Decrease the Rate of Increase of Alveolar Anesthetic Concentration (FA(A))/Inspired Anesthetic Concentration (FI(I))
T - 17-4. Factors that Influence (Increase or Decrease) Minimum Alveolar Concentration
T - 17-5. Drawbacks of Current Volatile Anesthetics
V. The Pulmonary System
VI. Hepatic Effects
VII. Neuromuscular System and Malignant Hyperthermia
VIII. Genetic Effects, Obstetric use, and Effects on Fetal Development
X. Anesthetic Metabolism
XI. Clinical Utility of Volatile Anesthetics
XII. Pharmacoeconomics and Value-Based Decisions
18. Intravenous Anesthetics
F - 18-1. Chemical Structures of Nonopioid Intravenous Anesthetics
F - 18-2. A Model Depicting the Postsynaptic Receptor Sites for the Inhibitory Neurotransmitter Gamma-Aminobutyric Acid (GABA) and the Excitatory Neurotransmitter Glutamate in the Central Nervous System
F - 18-3. Dose-Response Relationships for Sedation with Midazolam and Diazepam
F - 18-4. Simulated Drug Level Curves When a Constant Infusion is Administered after a Full Dose (Curve A), a Smaller Loading Dose (Curve B), and No Loading Dose (Curve C)
F - 18-5. Context-Sensitive Half-Time Values As a Function of Infusion Duration for Intravenous Anesthetics
I. General Pharmacology of Intravenous Anesthetics
II. Comparative Physiochemical and Clinical Pharmacologic Properties
III. Clinical Uses of Intravenous Anesthetics
Intravenous Anesthetics
T - 18-1. Desirable Characteristics of An Intravenous Anesthetic
T - 18-2. Pharmacokinetic Values for Intravenous Anesthetic Drugs
T - 18-3. Factors that Contribute to Interpatient Variability in Pharmacokinetics
T - 18-4. Factors that Contribute to The Hemodynamic Effect of Intravenous Induction
T - 18-5. Induction Characteristics and Dosage Requirements for Intravenous Anesthetic Drugs
T - 18-6. Factors that Influence Intravenous Drug Dose Requirements
19. Opioids
F - 19-1. Chemical Structure of Common Opioids
F - 19-2. Effect of Morphine in Mice Lacking the µ-Opioid Receptor (-/- = Homozygous µ-Opioid Receptor Knockout Mice) and Mice with Intact Receptors (+/+ = Wild-Type Mice) on Analgesic Responses (A, Tail Flick Test in Two Mice) and Respiratory Responses (B, the Hypercapnic Ventilatory Response [HCVR] in Two Mice)
F - 19-3. Schematic Diagram Illustrating the Role of Opioids in Analgesia of Peripheral Inflammation
F - 19-4. Context-Sensitive Half-Times for Remifentanil, Fentanyl, and Morphine
F - 19-5. The Variability Observed in Morphine Analgesic Effect
F - 19-6. Effect of a Short Remifentanil Infusion on Breathing
F - 19-7. Breathing Pattern in Sleep Apnea
I. Short History
II. The Endogenous Opioid System
III. Opioid Receptor Knockout Mice
IV. Classification of Exogneous Opioids
IX. PKPD Models for Opioid Effect: Which end Point Serves the Clinician Best?
Opioids
T - 19-1. Classification of Exogenous Opioids
T - 19-2. Examples of Pharmacogenetic Variations that Influence Opioid Analgesia
T - 19-3. Patients at Higher Risk for Opioid-Related Respiratory Depression
T - 19-4. Other Opioid-Related Side Effects in Addition to Respiratory Depression
V. Opioids Acting at Opioid and Nonopioid Receptors
VI. Opioid Mechanisms
VII. Routes of Administration
VIII. Pharmcokinetics (PK) and Pharmacodynamics (PD)
X. Pharmacodynamics: Dose Effect on Pain Relief
XI. Pharmacogenetics
XII. Opioid-Induced Respiratory Depression
XIII. Other Opioid-Related Side Effects
XIV. Remifentanil for Obstetric Labor Pain
XV. Gender Differences
20. Neuromuscular Blocking Agents
F - 20-1. Schematic Representation of the Neuromuscular Junction
F - 20-2. Example of a Dose-Response Relationship
F - 20-3. Duration of Action of Neuromuscular Blockade with 1 mg/Kg of Succinylcholine (Sux) and 1.2 mg/Kg of Rocuronium Followed 3 Minutes Later by 16 mg/Kg of Sugammadex (Roc-Sug)
F - 20-4. Electrode Placement to Obtain Contraction of the Adductor Pollicis Muscle
F - 20-5. Median Time to Recovery to a Train-of-Four Ratio of 0.9 with Neostigmine and Sugammadex
F - 20-6. Median Time to Recovery of a Train-of-Four (Tof) Ratio Greater Than 0.9 in Adult Patients When Sugammadex 2 mg/Kg Was Given at Recovery of the Second Twitch in the Tof
I. Physiology and Pharmacology
II. Neuromuscular Blocking Agents
III. Depolarizing Blocking Drugs: Succinylcholine
IV. Nondepolarizing Drugs
Neuromuscular Blocking Agents
T - 20-1. Definition of Neuromuscular Blocking Drugs According to The Onset and Duration of Block At The Adductor Pollicis
T - 20-10. Altered Responses to Neuromuscular Blocking Agents
T - 20-11. Monitoring Nondepolarizing Neuromuscular Blockade
T - 20-12. Pharmacokinetics of Anticholinesterase Drugs
T - 20-13. Factors Affecting Neostigmine Reversal
T - 20-14. Recommended Doses of Anticholinesterase Drugs and Anticholinergic Drugs Based On Train-Of-Four Stimulation
T - 20-15. Sugammadex and Clinical Use
T - 20-2. Characteristics of Phase I Depolarizing Blockade
T - 20-3. Characteristics of The Nondepolarizing Neuromuscular Blockade
T - 20-4. Side Effects of Succinylcholine
T - 20-5. Typical Pharmacokinetic Data for Nondepolarizing Muscle Relaxants
T - 20-6. Comparative Pharmacology of Nondepolarizing Muscle Relaxants
T - 20-7. Autonomic and Histamine-Releasing Effects of Muscle Relaxants
T - 20-8. Mechanisms for Clearance of Nondepolarizing Muscle Relaxants
T - 20-9. Drug Interactions Involving Muscle Relaxants
V. Drug Interactions
VI. Altered Responses to Neuromuscular Blocking Agents
VII. Monitoring Neuromuscular Blockade
VIII. Reversal of Neuromuscular Blockade
21. Local Anesthetics
F - 21-1. Addition of Dexamethasone to Either Ropivacaine or Bupivacaine Increases the Duration of Analgesia after Interscalene Brachial Plexus Block
I. Mechanism of Action of Local Anesthetics
II. Pharmacology and Pharmacodynamics
III. Pharmacokinetics of Local Anesthetics
IV. Clinical Use of Local Anesthetics
Local Anesthetics
T - 21-1. Classification of Nerve Fibers
T - 21-10. Dose-Dependent Systemic Effects of Lidocaine
T - 21-11. Treatment of Systemic Toxicity From Local Anesthetics
T - 21-12. Recommended Lipid Emulsion Dosing for Treatment of Local Anesthetic Cardiovascular Toxicity
T - 21-13. Incidence of Transient Neurologic Symptoms After Spinal Anesthesia
T - 21-14. Possible Causes of Transient Neurologic Symptoms
T - 21-2. Physiochemical Properties of Clinically used Local Anesthetics
T - 21-3. Effects of The Addition of Epinephrine to Local Anesthetics
T - 21-4. Typical Peak Plasma Concentrations (C(max)) After Regional Anesthetics
T - 21-5. Pharmacokinetic Parameters of Clinically used Local Anesthetics
T - 21-6. Determinants of The Rate and Extent of Systemic Absorption of Local Anesthetics
T - 21-7. Clinical use of Local Anesthetics
T - 21-8. Clinical Profile of Local Anesthetics
T - 21-9. Central Nervous System and Cardiovascular System Toxicity
V. Toxicity of Local Anesthetics
V. Preanesthetic Evaluation and Preparation
22. Preoperative Patient Assessment and Management
I. Introduction
II. Changing Concepts in Preoperative Evaluation
III. Approach to the Healthy Patient
IV. Evaluation of the Patient with Known Systemic Disease
IX. Perioperative Laboratory Testing
Preoperative Patient Assessment and Management
T - 22-1. Components of the Airway Physical Examination
T - 22-10. Management Decisions in Coordination with the Surgeon for Patients with Obstructive Sleep Apnea
T - 22-11. Recommendations for Perioperative Glucose Management in Patients with Diabetes
T - 22-12. Recommended Laboratory Testing
T - 22-13. Questions to Address in Preoperative Evaluation
T - 22-14. Top 10 Factors Predisposing to Aspiration
T - 22-15. Summary of Fasting Recommendations to Reduce the Risk of Pulmonary Aspiration
T - 22-16. Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration
T - 22-17. Goals for Preoperative Medication
T - 22-18. Drugs Used for Pharmacologic Premedication
T - 22-19. Comparison of Pharmacologic Variables of Benzodiazepines
T - 22-2. Airway Classification System
T - 22-20. Comparative Effects of Anticholinergics
T - 22-21. Side Effects of Anticholinergic Drugs
T - 22-22. Preoperative Surgical Antibiotic Prophylaxis
T - 22-3. Screening Evaluation for the Pulmonary System
T - 22-4. Screening Evaluation for the Cardiovascular System
T - 22-5. American Society of Anesthesiologists Physical Status Classification
T - 22-6. Clinical Predictors of Increased Perioperative Cardiovascular Risk (Myocardial Infarction, Congestive Heart Failure)
T - 22-7. Cardiac Risk Stratification for Noncardiac Surgical Procedures
T - 22-8. Factors Commonly Associated with an Increased Risk of Obstructive Sleep Apnea
T - 22-9. Questions to Ask During the Preoperative Evaluation Regarding the Presence of Symptoms and Signs of Obstructive Sleep Apnea
V. Indications for Further Cardiac Testing
VI. Pulmonary Disease
VII. Endocrine Disease
VIII. Other Organ Systems
X. Summary of Preoperative Evaluation
XI. Preparation for Anesthesia
XII. Preoperative Medication
XIII. Psychological and Pharmacologic Preparation for the Pediatric Patient
XIV. Antibiotic Prophylaxis
23. Rare Coexisting Diseases
I. Musculoskeletal Diseases
II. The Myotonias
III. Familial Periodic Paralysis
IV. Myasthenia Gravis
IX. Collagen Vascular Diseases
Rare Coexisting Diseases
T - 23-1. Coexisting Diseases that Influence Anesthesia Management
T - 23-10. Criteria Used in the Malignant Hyperthermia
T - 23-11. Safe Versus Unsafe Drugs in Malignant Hyperthermia
T - 23-12. Drugs Known to Precipitate Porphyria
T - 23-13. Types of Anemia
T - 23-14. Drugs that Produce Hemolysis in Patients with Glucose-6-Phosphate Dehydrogenase Deficiency
T - 23-15. Clinical Manifestations of Sickle Cell Disease
T - 23-16. Types of Collagen Vascular Diseases
T - 23-17. Extra-Articular Manifestations of Rheumatoid Arthritis
T - 23-2. Clinical Features of Familial Periodic Paralysis
T - 23-3. Summary of the Different Presentations of Myasthenia Gravis
T - 23-4. Osserman Staging System for Myasthenia Gravis
T - 23-5. Comparison of Myasthenia Gravis and Myasthenic Syndrome
T - 23-6. The Most Frequently Encountered Types of Seizures
T - 23-7. Anticonvulsant Drugs
T - 23-8. Clinical Features of Parkinson Disease
T - 23-9. Treatment of an Acute Episode of Malignant Hyperthermia
V. Guillain-Barré Syndrome (Polyaradiculoneuritis)
VI. Central Nervous System Diseases
VII. Inherited Disorders
VIII. Anemias
X. Skin Disorders
24. The Anesthesia Workstation and Delivery Systems for Inhaled Anesthetics
F - 24-1. Draeger Medical Fabius Gs Anesthesia Workstation (A) and Ge Healthcare Aisys Anesthesia Workstation (B)
F - 24-2. The Virtual Anesthesia Machine Simulator, an Interactive Model of an Anesthesia Machine (A) and Ge Healthcare Aisys Anesthesia Carestation (B)
F - 24-3. Schematic Diagram of the Mapleson Systems
F - 24-4. The Bain Circuit (Coaxial Version of Mapleson D)
F - 24-5. Inspiratory (A) and Expiratory (B) Phases of Gas Flow in a Traditional Circle System with an Ascending Bellows Ventilator
I. Anesthesia Workstation Stand ards and Pre-Use Procedures
II. Stand ards for Anesthesia Machines and Workstations
III. Failure of Anesthesia Equipment
IV. Safety Features of Newer Anesthesia Workstations
IX. Anesthesia Breathing Circuits
T - 24-1. American Society for Testing and Materials Stand ards for Manufactured Workstations
T - 24-10. Clinical Signs that the Carbon Dioxide Absorbent is Exhausted
T - 24-11. Interactions of Inhaled Anesthetics with Carbon Dioxide Absorbents
T - 24-12. Recommendations when Absorbents that Dedrage Volatile Anesthetics are Used
T - 24-13. Hazards Associated with Ventilators
T - 24-14. Niosh Recommendations for Maximum Levels for Exposure of Personnel to Trace Anesthetic Gases and Vapors
T - 24-15. Hazards Introduced by Scavenging Systems
T - 24-2. Comparison of Anesthesia Workstation Functions
T - 24-3. Preoperative Anesthesia Workstation Checklist
T - 24-4. Vaporizer Models and Characteristics
T - 24-5. Safety Features of Variable-Bypass Vaporizers
T - 24-6. Hazards Associated with Variable-Bypass Vaporizers
T - 24-7. Variables that Determine The Amount of Carbon Dioxide Rebreathing Associated with Mapleson Systems
T - 24-8. Characteristics of a Circle System
T - 24-9. Chemical Reactions of Carbon Dioxide with Soda Lime
The Anesthesia Workstation and Delivery Systems for Inhaled Anesthetics
V. Checkout of the Anesthesia Workstation
VI. Anesthesia Workstation Pneumatics
VII. Web-Based Anesthesia Software Simulation: The Virtual Anesthesia Machine
VIII. Vaporizers
X. CO(2) Absorbents
XI. Anesthesia Ventilators
XII. Anesthesia Workstation Variations
XIII. Waste Gas Scavenging Systems
VI. Anesthetic Management
25. Commonly Used Monitoring Techniques
Commonly Used Monitoring Techniques
F - 25-1. The Oxyhemoglobin Dissociation Curve
F - 25-2. The Normal Capnogram
F - 25-3. The Progression of Intracardiac Pressures from Central Venous Pressure (CVP) to End-Diastolic Left Ventricular Pressure
F - 25-4. A Normal Central Venous Pressure (CVP) Trace
F - 25-5. Pressure Tracing Observed during the Flotation of a Pulmonary Artery Catheter
I. Monitoring Inspired Oxygen Concentration
II. Monitoring of Arterial Oxygenation by Pulse Oximetry
III. Monitoring of Expired Gases
IV. Invasive Monitoring of Systemic Blood Pressure
IX. Monitoring of Body Temperature
T - 25-1. Detection of Critical Events by Implementing gas Analysis
T - 25-2. Arterial Cannulation and Direct Blood Pressure Monitoring
T - 25-3. Indications for Placement of An Intra-Arterial Catheter
T - 25-4. Adverse Effects Associated with Pulmonary Artery Monitoring
V. Intermittent Noninvasive Monitoring of Systemic Blood Pressure
VI. Monitoring of Central Venous and Right-Heart Pressures
VII. Monitoring of Cardiac Output by Pulmonary Artery Catheter
VIII. Monitoring of Cardiac Output by Arterial Waveform Analysis
X. Monitoring of Processed EEG Electroencephalographic Signals
XI. Future Trends in Monitoring
26. Echocardiography
Echocardiography
F - 26-1. Orientation of the Examiner'S Hand for an Imaging Plane of 0 Degrees
F - 26-2. Color-Flow Doppler of the Aortic Valve (AV) in the Midesophageal Long-Axis (ME AV LAX) View
F - 26-3. Two-Dimensional Evaluation of Left Ventricular (LV) Global and Regional Function
F - 26-4. Quantitation of Left Ventricular (LV) Systolic Function
F - 26-5. Echocardiographic Findings in Pericardial Effusion
I. Principles and Technology of Echocardiography
II. Two-Dimensional and Three-Dimensional Transesophageal Echocardiography
III. Doppler Echocardiography and Hemodynamics
IV. Echocardiographic Evaluation of Systolic Function
IX. Congenital Heart Disease (Chd)
T - 26-1. Application of Intraoperative Echocardiography
T - 26-2. Contraindications to Transesophageal Echocardiography Probe Placement
T - 26-3. Main Uses of Various Transesophageal Echocardiography Views
V. Evaluation of Left Ventricular Diastolic Function
VI. Evaluation of Valvular Heart Disease
VII. Diseases of the Aorta
VIII. Cardiac Masses
X. Echocardiography-Assisted Procedures
XI. Echocardiography Outside the Operating Room
27. Airway Management
Airway Management
F - 27-1. Alignment of Oral and Pharyngeal Axes
F - 27-2. Use of the Direct Laryngoscope Blade
F - 27-3. Mallampati or Samsoon-Young Classification of the Oropharyngeal View
F - 27-4. The Cormack-Lehane Laryngeal View Scoring System: Grade 1 (A), Grade 2 (B), Grade 3 (C), and Grade 4 (D)
F - 27-5. The American Society of Anesthesiologists Difficult Airway Algorithm
F - 27-6. The Airway Approach Algorithm: a Decision Tree Approach to Entry into the American Society of Anesthesiologists Difficult Airway Algorithm
I. Review of Airway Anatomy
II. Clinical Management of the Airway
III. The Difficult Airway Algorithm
IV. Awake Airway Management
T - 27-1. Steps to Favorably Affect Outcome As Related to Airway Management
T - 27-10. Features of The Laryngeal Mask Airway Proseal
T - 27-11. Pulmonary Aspiration
T - 27-12. Tracheal Extubation
T - 27-13. Factors to Consider in Proceeding with Regional Anesthesia (Ra) After The Patient has Been Judged to have a Difficult Airway
T - 27-2. Anatomic Differences Between Pediatric and Adult Airways
T - 27-3. Signs, Symptoms and Disorders with Airway Management Implications
T - 27-4. Summary of Pooled Sensitivity and Specificity of Commonly Used Methods of Airway Evaluation
T - 27-5. Techniques of Common Airway Indexes Measurement
T - 27-6. Presence of Risk Factors and Incidence of Difficult Intubation
T - 27-7. Advantages of the Laryngeal Mask Airway in Supraglottic Surgery
T - 27-8. Contraindications to Use of a Supraglottic Airway
T - 27-9. Complications with Use of a Supraglottic Airway
28. Patient Positioning and Potential Injuries
I. General Principles
II. Supine Positions
III. Brachial Plexus and Upper Extremity Injuries
IV. Ulnar Neuropathy
IX. Head-Down Positions
Patient Positioning and Potential Injuries
T - 28-1. Variations in Supine Positions
T - 28-2. Brachial Plexus and Upper Extremity Injuries
T - 28-3. Other Supine Position Problems
T - 28-4. Variations of Lateral Positions
T - 28-5. Complications of Lateral Positions
T - 28-6. Variations of Prone Positions
T - 28-7. Complications of Prone Positions
T - 28-8. Complications of Head-Elevated Positions
V. Other Supine Position Problems
VI. Lateral Position
VII. Prone Positions
VIII. Head-Elevated Positions
29. Monitored Anesthesia Care
F - 29-1. Schematic Depiction of the Changes in Drug Concentration during Continuous Infusion of a Drug (Green Line Indicates Maintenance of a Therapeutic Concentration) or Intermittent Bolus Injection of a Drug (Orange Line Indicates That the Drug Concentration is Often above or below the Desired Therapeutic Concentration)
F - 29-2. The Time to Awakening is Determined by the Duration of Infusion (Context-Sensitive Half-Time), the Difference in the Plasma Concentration at the End of the Procedure, and the Plasma Concentration below Which Awakening Will Occur
F - 29-3. The Plasma Concentration of Midazolam at Which 50% of Subjects Will Fail to Respond to Verbal Command (Cp50) is a Function of Age
I. Terminology
II. Preoperative Assessment
III. Techniques of Monitored Anesthesia Care
IV. Pharmacologic Basis of Monitored Anesthesia Care Techniques: Optimizing Drug Administration
IX. Respiratory Function and Sedative-Hypnotics
Monitored Anesthesia Care
T - 29-1. Causes of Patient Agitation During Monitored Anesthesia Care
T - 29-2. Dose Ranges for Drugs Used to Produce Sedation/Analgesia
T - 29-3. Comparison of the Important Properties of Midazolam and Diazepam
T - 29-4. Recommended Regimen for Use of Flumazenil
T - 29-5. Indications for Administration of an Opioid During Monitored Anesthesia Care
T - 29-6. Comparative Properties of Propofol and Dexmedetomidine
T - 29-7. Monitoring Techniques and Devices Used During Monitored Anesthesia Care
T - 29-8. Continuum of Depth of Sedation
V. Distribution, Elimination, Accumulation, and Duration of Action
VI. Drug Interactions in Monitored Anesthesia Care
VII. Specific Drugs Used During Monitored Anesthesia Care
VIII. Patient-Controlled Sedation and Analgesia
X. Supplemental Oxygen Administration
XI. Monitoring During Monitored Anesthesia Care
XII. Sedation and Analgesia by Nonanesthesiologists
30. Ambulatory Anesthesia
Ambulatory Anesthesia
F - 30-1. Guide to Determine the Length of Monitoring for Former Preterm Infants with a Postconceptual Age of <60 Weeks
F - 30-2. Operating Room Delays are the Major Reasons Orthopedic Surgeons Do Not Favor Regional Anesthesia
F - 30-3. Recovery Was Faster When an Infraclavicular Brachial Plexus Block with a Short-Acting Local Anesthetic Was Used Compared with General Anesthesia and Wound Infiltration for Outpatients Undergoing Hand and Wrist Surgery
I. Place, Procedures, and Patient Selection
II. Preoperative Evaluation and Reduction of Patient Anxiety
III. Managing the Anesthetic: Premedication
IV. Intraoperative Management: Choice of Anesthetic Method
T - 30-1. Independent Risk Factors for Adverse Respiratory Events in Children with Upper Respiratory Tract Infections
T - 30-2. Suggested Guidelines to Reduce the Risk of Pulmonary Aspiration
T - 30-3. Patients at Greatest Risk for Postoperative Nausea and Vomiting
T - 30-4. Approaches for Reducing the Incidence of Postoperative Nausea and Vomiting
T - 30-5. Advantages of Laryngeal Mask Airways
V. Management of Postanesthesia Care
31. Office-Based Anesthesia
I. Brief Historical Perspective of Office-Based Anesthesia
II. Advantages and Disadvantages
III. Office Safety
IV. Patient Selection
IX. Postanesthesia Care Unit (PACU)
Office-Based Anesthesia
T - 31-1. Advantages and Disadvantages of Office-Based Anesthesia
T - 31-10. Definitions of Levels of Sedation/Analgesia by the American Society of Anesthesiologists
T - 31-2. Causes of Injury in the Office
T - 31-3. Characteristics of Patients Who May not be Good Cand idates for Office-Based Procedures
T - 31-4. Sentinel Events that Should Trigger a Chart Review and be Presented at a Performance Improvement Quality Assurance Meeting
T - 31-5. Equipment Needed for Safe Delivery of Office-Based Anesthesia
T - 31-6. Emergencies that may Occur within an Office that Require Contingency Plans
T - 31-7. American Society of Anesthesiologists' Classification of Surgical Offices According to the Anesthesia and Surgical Procedures Performed
T - 31-8. Factors Considered by Accrediting Agencies
T - 31-9. Guidelines for the Pediatric Perioperative Anesthesia Environment
V. Surgeon Selection
VI. Office Selection and Requirements
VII. Procedure Selection
VIII. Anesthetic Techniques
X. Regulations
XI. Business and Legal Aspects
XII. Conclusions
32. Nonoperating Room Anesthesia (NORA)
F - 32-1. A Three-Step Paradigm for NORA
I. The Three-Step Approach to Nora
II. Patient Safety in Nora
III. Sedation and Anesthesia
IV. Environmental Considerations for Nora
IX. Specific Procedures: Electroconvulsive Therapy (ECT)
Nonoperating Room Anesthesia (NORA)
T - 32-1. Patient Factors Requiring Sedation or Anesthesia for Nonoperating Room Procedures
T - 32-2. Common Nonoperating Room Anesthesia Procedures
T - 32-3. ASA Stand ards for Nonoperating Room Anesthetizing Locations
T - 32-4. Definition of General Anesthesia and Levels of Sedation/Analgesia
T - 32-5. Common Terms Used in Radiation
T - 32-6. Clinical Manifestations of Immediate and Nonimmediate Hypersensitivity Reactions to Radiocontrast Agents
T - 32-7. Considerations in Patients Presenting for the Transjugular Intrahepatic Portosystemic Shunt Procedure
T - 32-8. Common Radiosensitive Tumors in Children
V. Intravenous Contrast Agents
VI. Specific Procedures: Diagnostic and Interventional Radiology
VII. Specific Procedures: Interventional Cardiology
VIII. Specific Procedures: Gastroenterology
X. Specific Procedures: Dental Surgery
33. Anesthesia for the Older Patient
Anesthesia for the Older Patient
I. Demographics and Economics of Aging
II. The Process of Aging
III. The Physiology of Organ Aging
IV. Drug Pharmacology and Aging
IX. Perioperative Complications
T - 33-1. Effect of Age on Drug Dosing
T - 33-2. The Effects of Aging on the Cardiovascular System
T - 33-3. Adverse Outcomes Associated with Inadequate Postoperative Pain Relief in Elderly Patients
T - 33-4. Effect of Age on Selected Perioperative Complications and Associated Mortality
T - 33-5. Risk Factors for Delirium in Elderly Patients
V. Cardiovascular Aging
VI. Pulmonary Aging
VII. Thermoregulation and Aging
VIII. Conduct of Anesthesia
X. The Future
34. Epidural and Spinal Anesthesia
Epidural and Spinal Anesthesia
F - 34-1. Anatomy of the Vertebral Column
F - 34-2. Human Sensory Dermatomes
F - 34-3. Examples of Commercially Available Spinal and Epidural Needles
F - 34-4. Midline Approach to the Subarachnoid Space
F - 34-5. Proper Hand Position When Using the Loss of Resistance Technique to Locate the Epidural Space
F - 34-6. In the Supine Position, Hyperbaric Local Anesthetic Solutions Injected at the Height of the Lumbar Lordosis (Circle) Flow Down the Lumbar Lordosis to Pool in the Sacrum and in the Thoracic Kyphosis
F - 34-7. The Cardiovascular Effects of Spinal and Epidural Anesthesia in Volunteers with T5 Sensory Blocks
I. Anatomy
II. Technique
III. Spinal Anesthesia
IV. Continuous Spinal Anesthesia
IX. Pharmacology
T - 34-1. Land marks for Vertebral Interspaces
T - 34-10. Treating Hemodynamic Changes Secondary to Spinal and Epidural Anesthesia
T - 34-11. Transient Neurologic Symptoms
T - 34-12. Conditions that May Increase the Risk of Spinal or Epidural Anesthesia
T - 34-13. Choice of Spinal or Epidural Anesthesia
T - 34-2. Patient Position for Performance of Spinal Anesthesia
T - 34-3. Representative Surgical Procedures Appropriate for Spinal Anesthesia
T - 34-4. Factors that May Influence the Spread of Local Anesthetic Solutions in the Subarachnoid Space
T - 34-5. Dose and Duration of Local Anesthetics Used for Spinal Anesthesia
T - 34-6. Factors that May Influence the Duration of Sensory Blockade Produced by Spinal Anesthesia
T - 34-7. Local Anesthetics Used for Surgical Epidural Anesthesia
T - 34-8. Factors that May Influence the Spread of Local Anesthetic Solutions in the Epidural Space
T - 34-9. Factors that Influence the Duration of Sensory Blockade Produced by Epidural Anesthesia
V. Epidural Anesthesia
VI. Continuous Epidural Anesthesia
VII. Epidural Test Dose
VIII. Combined Spinal-Epidural Anesthesia
X. Physiology
XI. Complications
XII. Contraindications
XIII. Choice of Spinal or Epidural Anesthesia
VII. Anesthesia for Surgical Subspecialties
35. Peripheral Nerve Blockade
F - 35-1. Schematic of the Cervical Plexus, Which Arises from the Anterior Primary Rami of C2-C4
F - 35-10. Cutaneous Innervation from the Terminal Nerves of the Lower Extremity
F - 35-11. Ultrasound-Guided Femoral Nerve Block
F - 35-12. Land marks for the Sciatic Nerve Block Using a Posterior Gluteal Approach When a Nerve Stimulation Procedure is Used
F - 35-2. Needle Insertion Points and Angles for the Deep Cervical Plexus Blockade
F - 35-3. The Cervical, Thoracic, Lumbar, and Sacral Dermatomes of the Body
F - 35-4. Greater and Lesser Occipital Nerve Distribution, Supply, and Block Needle Insertion Sites
F - 35-5. Schematic of the Brachial Plexus
F - 35-6. Courses of the Terminal Nerves of the Upper Extremity
F - 35-7. Cutaneous Innervation of the Upper Extremity Nerves
F - 35-8. Probe Placement (A) and Ultrasound Image (B) during Paravertebral Block in the Thoracic Spine
F - 35-9. The Lumbar (A; L1-L4) and Sacral (B; L4-S4) Plexuses
I. General Principles and Equipment
II. Specific Techniques: Head and Neck, Upper Extremities, Chest, and Abdomen
III. Specific Techniques: Lower Extremity
Peripheral Nerve Blockade
T - 35-1. Setup and Monitoring for Regional Blocks
T - 35-2. Useful Anatomical Land marks for Localizing Nerves During Common Ultrasound-Guided Peripheral Nerve Blocks
T - 35-3. Techniques for Brachial Plexus Blockade
T - 35-4. Intravenous Regional Anesthesia
T - 35-5. Terminal Nerves of the Lumbar Plexus
T - 35-6. Nerves at the Ankle
36. Anesthesia for Neurosurgery
Anesthesia for Neurosurgery
F - 36-1. The Circle of Willis, Which Supplies Blood Flow to the Brain
F - 36-2. Intracranial Compliance (Elastance) Curve
F - 36-3. Cerebrovascular Response to a Change in Arterial Carbon Dioxide Partial Pressure (Paco(2)) from 25 to 65 Mm Hg
F - 36-4. Cerebrovascular Response to a Change in Arterial Oxygen Partial Pressure (Pao(2))
F - 36-5. Cerebral Autoregulation Maintains Cerebral Blood Flow Constant Between 60 to 160 Mm Hg
F - 36-6. Transcranial Doppler Tracing with Release of the Cross-Clamp during Carotid Endarterectomy
F - 36-7. Particulate Emboli Seen on Transcranial Doppler in a Patient with Symptoms of Transient Ischemic Attacks Consistent with Right Carotid Artery Territory Embolization
I. Neuroanatomy
II. Neurophysiology
III. Pathophysiology
IV. Monitoring
IX. Anesthesia and Traumatic Brain Injury
T - 36-1. Events that May Interrupt Homeostatic Mechanisms for Brain Protection
T - 36-2. Monitoring Central Nervous System Function
T - 36-3. Electroencephalogram Frequencies
T - 36-4. Indications for Electroencephalographic Monitoring
T - 36-5. Influence of Anesthetic Technique On Central Nervous System Monitoring
T - 36-6. Interventions to Lower Intracranial Pressure
T - 36-7. Interventions for Management of Inadequate Cerebral Perfusion Pressure
T - 36-8. Monitors of Cerebral Oxygenation and Metabolism
T - 36-9. Glasgow Coma Scale
V. Cerebral Perfusion
VI. Cerebral Protection
VII. Anesthetic Management
VIII. Common Surgical Procedures
X. Anesthesia for Spine Trauma and Complex Spine Surgery
37. Anesthesia for Thoracic Surgery
Anesthesia for Thoracic Surgery
F - 37-1. The Order of Tests to Determine the Cardiopulmonary Status of the Patient and the Extent of Lung Resection That Would Be Tolerated
F - 37-2. Flow-Volume Loops Relative to Lung Volumes in a Normal Subject in a Patient with Chronic Obstructive Pulmonary Disease (COPD), a Patient with Fixed Obstruction (Tracheal Stenosis), and a Patient with Pulmonary Fibrosis (Restrictive Defect)
F - 37-3. Left Main Stem Endobronchial Intubation Using a Carlens Tube
F - 37-4. Fiberoptic Bronchoscopic View of the Main Carina (A), âLeft Bronchial Carinaâ (B), and Right Bronchus (C)
F - 37-5. Malposition of the Left Bronchial Limb of the Double-Lumen Tube (DLT)
I. Preoperative Evaluation
II. Preoperative Preparation
III. Intraoperative Monitoring
IV. One-Lung Ventilation
IX. Anesthesia for Diagnostic Procedures
T - 37-1. Patient Medical History that Should be Obtained Before Thoracic Surgery
T - 37-10. Anesthetic Considerations in Management of a Patient with Bronchopleural Fistula
T - 37-11. Anesthetic Considerations for Tracheal Resection
T - 37-12. Anesthetic Considerations in Management of Thymectomy for Treatment of Myasthenia Gravis
T - 37-13. Postoperative Considerations Following Thoracic Surgery
T - 37-2. Physical Examination that Should be Performed Before Thoracic Surgery
T - 37-3. Conditions that Correlate with Postoperative Complicatoins
T - 37-4. Invasive Monitoring for Thoracic Surgery
T - 37-5. Indications for One-Lung Ventilation
T - 37-6. Steps to Verify The Position of a Double-Lumen Tube
T - 37-7. Use of a Fiberoptic Bronchoscope to Verify Proper Placement of a Double-Lumen Tube
T - 37-8. Clinical Approach to One-Lung Ventilation Management
T - 37-9. Anesthetic Considerations During Mediastinoscopy
V. Management of One-Lung Ventilation
VI. Clinical Approach to Management of One-Lung Ventilation
VII. Choice of Anesthesia for Thoracic Surgery
VIII. Hypoxic Pulmonary Vasoconstriction
X. Anesthesia for Special Situations
XI. Myasthenia Gravis
XII. Postoperative Management and Complications
38. Anesthesia for Cardiac Surgery
Anesthesia for Cardiac Surgery
F - 38-1. The Pathophysiology of Aortic Stenosis
F - 38-2. The Pathophysiology of Aortic Insufficiency
F - 38-3. The Pathophysiology of Mitral Stenosis
F - 38-4. The Pathophysiology of Mitral Regurgitation La = Left Atrium; LV = Left Ventricle
F - 38-5. Diagram of a Cardiopulmonary Bypass Circuit
I. Coronary Artery Disease (CAD)
II. Valvular Heart Disease
III. Aortic Diseases
IV. Cardiopulmonary Bypass
T - 38-1. Determinants of Coronary Blood Flow
T - 38-10. Diagnosis and Therapy of Cardiovascular Dysfunction After Cardiopulmonary Bypass
T - 38-11. Indications and Contraindications for Intra-Aortic Balloon Pumps
T - 38-12. Side Effects of Protamine
T - 38-13. Reasons for Postoperative Re-Exploration
T - 38-14. Manifestations of Cardiac Tamponade
T - 38-15. Classification of Congenital Heart Defects
T - 38-16. Preoperative Evaluation of Children with Congenital Heart Disease
T - 38-17. Classification of Cardiac Murmurs
T - 38-18. Choice of Drugs During Maintenance of Anesthesia for Correction of Congenital Cardiac Defects
T - 38-19. Medications Administered by Continuous Intravenous Infusion
T - 38-2. Monitoring for Myocardial Ischemia
T - 38-20. Criteria for Tracheal Extubation After Complex Procedures
T - 38-3. Treatment of Intraoperative Myocardial Ischemia
T - 38-4. Guidelines for Coronary Artery Bypass Graft Surgery
T - 38-5. Components of Cardiopulmonary Bypass
T - 38-6. Data From Preoperative Evaluation
T - 38-7. Monitors for Cardiac Surgery Requiring Cardiopulmonary Bypass
T - 38-8. Checklist for Management of Patients Undergoing Cardiopulmonary Bypass
T - 38-9. Causes of Right or Left Ventricular Dysfunction After Cardiopulmonary Bypass
V. Preoperative and Intraoperative Management
VI. Minimally Invasive Cardiac Surgery
VII. Postoperative Considerations
VIII. Anesthesia for Children with Congenital Heart Disease
39. Anesthesia for Vascular Surgery
Anesthesia for Vascular Surgery
F - 39-1. Approximate Range of Odds Ratios for Risk Factors for Symptomatic Peripheral Arterial Disease
F - 39-2. Typical Overlap in Vascular Disease Affecting Different Organ Systems
F - 39-3. Systemic Hemodynamic Response to Aortic Unclamping
I. Vascular Disease: Epidemiologic Medical and Surgical Aspects
II. Chronic Medical Problems and Management in Vascular Surgery Patients
III. Other Medical Problems in Vascular Surgery
IV. Organ Protection in Vascular Surgery Patients
T - 39-1. Clinical Predictors of Increased Periopeartive Risk for Myocardial Infarction, Congestive Heart Failure, and Death
T - 39-2. Pharmacologic Prophyaxis Agains Acute Vascular Events in Patients Undergoing Vascular Surgery
T - 39-3. Other Medical Problems in Vascular Surgery Patients
T - 39-4. Prevention of Perioperative Myocardial Infarction in Vascular Surgery Pateints
T - 39-5. Protection of The Central Nervous System and Spinal Cord
T - 39-6. Prevention of Perioperative Myocardial Infarction in Vascular Surgery Pateints
T - 39-7. Postoperative Management Following Carotid Endarterectomy
T - 39-8. Complications of Endovascular Abdominal Aneurysm Repair
V. Carotid Endarterectomy
VI. Aortic Reconstruction
VII. Lower Extremity Revascularization
40. Obstetrical Anesthesia
F - 40-1. Management of a difficult Airway in Pregnancy
F - 40-2. Classification and Mechanism of Fetal Heart Rate Patterns
F - 40-3. Algorithm for Neonatal Resuscitation
F - 40-4. Recommendations for Management of Parturients and Surgical Procedures
I. Physiologic Changes of Pregnancy
II. Placental Transfer and Fetal Exposure to Anesthetic Drugs
III. Anesthesia for Labor and Vaginal Delivery
IV. Anesthesia for Cesarean Delivery
IX. Substance Abuse
Obstetrical Anesthesia
T - 40-1. Physiologic Changes of Pregnancy
T - 40-10. Congenital Heart Disease and the Parturient
T - 40-11. Hemodynamic Goals with Valvular Lesions
T - 40-12. Problems Associated with Prematurity
T - 40-13. Side Effects of Ã(2-)Agonists Administered to Stop Premature Labor
T - 40-14. Substance Abuse Among Women of Childbearing Age
T - 40-15. Anesthetic Considerations Associated with Cocaine or Amphetamine Abuse
T - 40-16. Assessment of Fetal Well-Being
T - 40-17. Three-Tiered System for the Evaluation of Fetal Heart Rate Tracings
T - 40-18. Events Associated with Neonatal Depression at Birth
T - 40-19. Resuscitation Equipment in the Delivery Room
T - 40-2. Determinants of Drug Passage Across the Placenta
T - 40-20. Steps in Newborn Resuscitation
T - 40-21. Calculation of the Apgar Score
T - 40-22. Considerations in the Management of Anesthesia for Nonobstetric Surgery in Pregnant Women
T - 40-3. Characteristics of Fetal Circulation that Delay Drug Equilibration
T - 40-4. Tests to Rule out Intrathecal or Intravascular Placement of a Lumbar Epidural Catheter
T - 40-5. Epidural Anesthesia for Cesarean Section
T - 40-6. General Anesthesia for Cesarean Section
T - 40-7. Anesthetic Complications in Obstetric Patients
T - 40-8. Symptoms of Severe Preeclampsia
T - 40-9. Considerations in the Management of Parturients with Preeclampsia or Eclampsia
V. Anesthetic Complications
VI. Management of High-Risk Parturients
VII. Preterm Delivery
VIII. Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome
X. Fetal Monitoring
XI. Newborn Resuscitation in the Delivery Room
XII. Anesthesia for Nonobstetric Surgery in Pregnant Women
41. Neonatal Anesthesia
F - 41-1. Schematic Representation of Fetal and Neonatal Circulation
F - 41-2. Schematic of Reduced Cardiac Reserve in Fetal and Newborn Animal Hearts Compared with Adult Hearts
F - 41-3. Static Lung Volumes of Infants and Adults
F - 41-4. Correlation of Mean Pulmonary Arterial Pressure with Age in 85 Normal-Term Infants Studied during the First 3 Days of Life
F - 41-5. Complicating Anatomic Factors in Infants
I. Physiology of the Infant and the Transition Period
II. Anatomy of the Neonatal Airway
III. Anesthetic Drugs in Neonates
IV. Anesthetic Management of the Neonate
Neonatal Anesthesia
T - 41-1. Normal Blood Gas Values in Neonates
T - 41-2. Comparison of Normal Respiratory Values in Infants and Adults
T - 41-3. Anesthetic Drugs for use in Neonates
T - 41-4. Abnormalities Associated with the Preterm Infant: Common Anesthetic Concerns
T - 41-5. Major Factors to Consider in Planning the Anesthesia for Neonate
T - 41-6. Regional Anesthesia Techniques that are Useful in Neonates
T - 41-7. Postoperative Pain Management for Neonates and Infants
T - 41-8. Surgical Procedures Performed in the First Week of Life
T - 41-9. Surgical Procedures Performed in the First Month of Life
V. Special Considerations
VI. Surgical Procedures in Neonates
42. Pediatric Anesthesia
F - 42-1. Developmental Changes in Common Cytochromes of Interest in Pediatric Anesthesia
F - 42-2. Age and the Minimum Alveolar Concentration (MAC) of Isoflurane from Premature Infants to Adults
F - 42-3. Algorithm to Diagnose and Manage Laryngospasm in Children
F - 42-4. Position of the Child after Tracheal Extubation in Preparation for Transfer to the Postanesthesia Care Unit and the Pediatric Intensive Care Unit
I. Anatomy and Physiology
II. Pharmacology
III. Respiration
IV. Cardiovascular
IX. Intravenous
Pediatric Anesthesia
T - 42-1. Anatomic Features of the Upper Airway in Infants Compared with Adults
T - 42-10. Factors Associated with Laryngospasm
T - 42-11. Causes of Bradycardia in Infants and Children
T - 42-12. Risk Factors for Postoperative Nausea and Vomiting in Children
T - 42-13. Causes of Delayed Emergence from Anesthesia in Children
T - 42-2. Airway Anomalies that may Present Problems During Anesthesia
T - 42-3. Normal Range of Resting Heart Rates and Blood Pressure in Children
T - 42-4. Factors Increasing The Washin of Inhalatonal Anesthetics in Children Compared with Adults
T - 42-5. Fasting Guidelines for Children Requiring Elective Anesthesia
T - 42-6. Medical Conditions to Consider in the Pediatric Patient
T - 42-7. Criteria to Cancel Anesthesia with an Upper Respiratory Tract Infection
T - 42-8. Sbe Prophylaxis Recommendations by The American Heart Associatoin
T - 42-9. Full Stomach and Rapid Sequence Induction
V. Central Nervous System
VI. Renal
VII. Hepatic
VIII. In Vivo Metabolism
X. Sedatives
XI. Preoperative Assessment
XII. Induction of Anesthesia
XIII. Preoperative Preparation
XIV. Induction Techniques
XV. Maintenance of Anesthesia
XVI. Emergency and Recovery from Anesthesia
XVII. Transfer to the Postanesthesia Care Unit (PACU)
43. Anesthesia for Laparoscopic and Robotic Surgeries
Anesthesia for Laparoscopic and Robotic Surgeries
I. Surgical Techniques
II. Physiologic Effects
III. Anesthetic Management
IV. Pain Prevention
T - 43-1. Advantages of Minimally Invasive Surgery
T - 43-10. Prevention of Cardiopulmonary Changes in Patients with Significant Cardiopulmonary Disease
T - 43-11. Causes of Capnothorax
T - 43-12. Diagnosis of Capnothorax
T - 43-13. Management of Capnothorax During Laparoscopic Procedure
T - 43-2. Potential Complications During Laparoscopy
T - 43-3. Hemodynamic Effects of Minimally Invasive Surgery
T - 43-4. Regional Circulatory Changes During Laparoscopy
T - 43-5. Renal Function During Laparoscopy
T - 43-6. Pulmonary Changes During Laparoscopy
T - 43-7. Differential Diagnosis of Cardiovascular Collapse During Laparoscopy
T - 43-8. Causes of Hypoxemia During Laparoscopy
T - 43-9. Differential Diagnosis of Hypercarbia During Laparoscopy
V. Intraoperative Complications
VI. Postoperative Considerations
VII. Ambulatory Laparoscopic Procedures
VIII. Summary
44. Anesthesia and Obesity
Anesthesia and Obesity
F - 44-1. Effects of Obesity, Positioning, and Anesthesia on Lung Volumes
F - 44-2. Interrelationship of Cardiovascular and Pulmonary Sequelae of Obesity
F - 44-3. Adaptation of the Heart to Obesity and Hypertension
F - 44-4. Body Composition in Extremely Obese and Weight-Reduced States Compared with Reference Values for Women
F - 44-5. Ramped Position with âStackingâ of Towels and Blankets
F - 44-6. Illustration of the Walter Henderson Maneuver
I. Definition and Epidemiology
II. Management of Obesity
III. Pathophysiology
IV. Pharmacology
IX. Postoperative Considerations
T - 44-1. Classification of Obesity and Systemic Disease Risk According to Waist Circumference
T - 44-2. Anesthetic Implications of Obesity
T - 44-3. Summary of Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea: a Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea
T - 44-4. Conditions that Characterize the Metabolic Syndrome
T - 44-5. Intravenous Drug Dosing in Obesity
T - 44-6. Preopeartive Evaluation of Obese Patients
T - 44-7. Advantages of Neuraxial Anesthetic Techniques in Obese Patients
T - 44-8. Postoperative Considerations in Obese Patients
T - 44-9. Critical Care and Resuscitation
V. Preoperative Evaluation
VI. Intraoperative Considerations
VII. Monitored Anesthesia Care and Sedation
VIII. Regional Anesthesia
X. Critical Care and Resuscitation
XI. Morbidity and Mortality
45. The Liver: Surgery and Anesthesia
F - 45-1. Basic Structure of a Liver Lobule Showing the Cellular Plates, the Blood Vessels, the Bile-Collecting System and the Lymph Flow System Composed of the Spaces of Disse, and the Interlobular Lymphatics
F - 45-2. The Pathogenetic Mechanism of the Hepatorenal Syndrome
F - 45-3. Transjugular Intrahepatic Portal Systemic Shunt (Tips) Procedure
I. Assessment of Hepatic Function
II. Hepatobiliary Imaging
III. Liver Biopsy
IV. Hepatic and Hepatobiliary Diseases
IX. Pregnancy-Related Liver Diseases
T - 45-1. Hepatic Function in Health
T - 45-2. Blood Tests and the Differential Diagnosis of Hepatic Dysfunction
T - 45-3. Hepatobiliary Imaging
T - 45-4. General Measures to Reduce Cerebral Edema
T - 45-5. Distinguishing Features of Intrahepatic Cholestasis of Pregancy (ICP), Hellp Syndrome, and Acute Fatty Liver of Pregnancy (AFLP)
T - 45-6. Preoperative Evaluation of Hepatic Function
T - 45-7. Risk of Surgery in Patients with Cirrhosis (Modified Child-Pugh Score)
T - 45-8. Pharmacokinetics and Pharmacodynamic Alterations in Patients with Liver Disease
T - 45-9. Causes of Potoperative Liver Dysfunction
The Liver: Surgery and Anesthesia
V. Acute Liver Failure
VI. Acute Hepatitis
VII. Alcoholic Hepatitis
VIII. Drug-Induced Liver Injury
X. Cirrhosis and Portal Hypertension
XI. Hemostasis
XII. Cardiac Manifestations
XIII. Renal Dysfunction
XIV. Pulmonary Complications
XIX. Chronic Hepatocellular Disease
XV. Hepatic Encephalopathy (HE)
XVI. Ascites
XVII. Varices
XVIII. Chronic Cholestatic Disease
XX. Hepatocellular Carcinoma (HCC)
XXI. Nonalcoholic Fatty Liver Disease
XXII. Preoperative Management
XXIII. Intraoperative Management
XXIV. Transjugular Intrahepatic Portosystemic Shunt Procedure
XXV. Hepatic Resection
XXVI. Postoperative Liver Dysfunction
46. Endocrine Function
Endocrine Function
F - 46-1. Schematic Depiction of the Four Stages of Synthesis and Release of Thyroid Hormone
F - 46-2. The Relationship Among Perioperative Injury, Hyperglycemia, and Outcomes
F - 46-3. Modulators of Perioperative Hyperglycemia
I. Thyroid Gland
II. Parathyroid Gland s
III. Adrenal Cortex
IV. Adrenal Medulla
T - 46-1. Effects of Triiodothyronine On Receptor Concentrations
T - 46-10. Manifestations of Glucocorticoid Excess
T - 46-11. Management of Patients Undergoing Adrenalectomy
T - 46-12. Supplemental Steroid Coverage Regimens
T - 46-13. Manifestations of Pheochromocytoma
T - 46-14. Anesthetic Management of Patients with Pheochromocytoma
T - 46-15. Classification of Diabetes Mellitus
T - 46-16. Criteria for The Diagnosis of Diabetes
T - 46-17. Properties of Selected Glucose-Lowering Drugs
T - 46-18. Preoperative Evaluation of Patients with Diabetes Mellitus
T - 46-19. Current Recommendations for Glycemic Control
T - 46-2. Tests of Thyroid Function
T - 46-20. Factors that Influence the Selection of Diabetic Management Regimen
T - 46-21. Intraoperative Management Regimens for Patients with Diabetes Mellitus
T - 46-22. Manifestations of Hyperosmolar Nonketotic Coma
T - 46-23. Manifestations of Diabetic Ketoacidosis
T - 46-24. Management of Diabetic Ketoacidosis
T - 46-25. Anesthetic Problems Associated with Acromegaly
T - 46-3. Preparation of Hyperthyroid Patients
T - 46-4. Possible Complications of Thyroid Surgery
T - 46-5. Management of Thyroid Storm
T - 46-6. Manifestations of Hypothyroidism
T - 46-7. Management of Myxedema Coma
T - 46-8. Manifestations of Hypocalcemia
T - 46-9. Comparative Pharmacology of Corticosteroids
V. Diabetes Mellitus
VI. Pituitary Gland
VII. Endocrine Responses to Surgical Stress
47. Anesthesia for Otolaryngologic Surgery
Anesthesia for Otolaryngologic Surgery
I. Anesthesia for Pediatric Ear, Nose, and Throat Surgery
II. Ear Surgery
III. Airway Surgery
IV. Pediatric Airway Emergencies
T - 47-1. Stop Questionnaire to Screen Adult Patients for Obstructive Sleep Apnea
T - 47-2. Goals of Anesthesia for Tonsillectomy and Adenoidectomy
T - 47-3. Postoperative Complications of Tonsillectomy
T - 47-4. Anesthetic Considerations for Tympanoplasty and Mastoidectomy
T - 47-5. Causes of Stridor
T - 47-6. Signs and Symptoms Specifically Examined in Patients with Stridor
T - 47-7. Establishment of An Artificial Airway in The Presence of Epiglottitis
T - 47-8. Anesthesia for Laser Surgery
V. Anesthesia for Pediatric and Adult Surgery
VI. Upper Airway Infections
48. Anesthesia for Ophthalmologic Surgery
Anesthesia for Ophthalmologic Surgery
F - 48-1. Diagram of Ocular Anatomy
F - 48-2. Path That Local Anesthetic Might Follow if Accidently Injected into the Subarachnoid Space during Performance of a Retrobulbar or Peribulbar Block
I. Ocular Anatomy
II. Ocular Physiology
III. Effects of Anesthesia and Adjuvant Drugs on Intraocular Pressure
IV. Oculocardiac Reflex
IX. Principles of Laser Therapy
T - 48-1. Requirements for Ophthalmic Surgery
T - 48-2. Events that Alter Intraocular Pressure
T - 48-3. Factors that Influence Choice of Anesthesia
T - 48-4. Complications of Needle-Based Ophthalmic Anesthesia
T - 48-5. General Principles of Monitored Anesthesia Care
T - 48-6. Considerations for Strabismus Surgery
T - 48-7. Considerations for Intraocular Surgery
T - 48-8. Postoperative Ocular Complications
T - 48-9. Etiology of Ischemic Optic Neuropathy Following Spine Surgery
V. Anesthetic Ramifications of Ophthalmic Drugs
VI. Preoperative Evaluation
VII. Anesthesia Techniques
VIII. Anesthetic Management of Specific Situations
X. Postoperative Ocular Complications
49. The Renal System and Anesthesia for Urologic Surgery
F - 49-1. The Gross Anatomy (A) and Internal Structure of the Genitourinary System and Kidney
F - 49-2. Renal Blood Flow (RBF) Autoregulation
F - 49-3. Site of Action of Commonly Available Diuretics
I. Renal Anatomy and Physiology
II. Clinical Assessment of the Kidney
III. Perioperative Nephrology
IV. Diuretic Drugs: Effects and Mechanisms
IX. Specific Procedural Considerations
T - 49-1. Clinical Assessment of the Kidney
T - 49-10. Properties of Commonly Used Irrigating Solutions for Transuretheral Resection Procedures
T - 49-11. Signs and Symptoms of Acute Hyponatremia
T - 49-12. Treatment of Transurethral Resection Syndrome
T - 49-13. Spectrum of Kidney Stones Types: Compositon, Frequency and Causes
T - 49-14. Contraindications to Shock Wave Lithotripsy
T - 49-2. Electrolyte Disorders
T - 49-3. Acid-Base Disorders
T - 49-4. Nephrotoxins Commonly Found in the Hospital Setting
T - 49-5. Factors Contributing to Hyperkalemia in Chronic Renal Failure
T - 49-6. The Uremic Syndrome
T - 49-7. Nondepolarizing Muscle Relaxants in Renal Failure
T - 49-8. Physiology of Carbon Dioxide Peritoneum in the Trendelenburg Position
T - 49-9. Risk of Complications Associated with Steep Trendelenburg Position
The Renal System and Anesthesia for Urologic Surgery
V. High-Risk Surgical Procedures
VI. Common Urologic Surgical Procedures
VII. Cystectomy and Other Major Bladder Surgeries
VIII. Prostatectomy
X. Therapies for Urolithiasis
XI. Urogynecology- and Pregnancy-Related Urologic Procedures
XII. Impotence Surgery and Medication
XIII. Pediatric Surgical Urologic Disorders
XIV. Urologic Surgical Emergencies
50. Anesthesia for Orthopedic Surgery
Anesthesia for Orthopedic Surgery
F - 50-1. Prone Position with the Patient'S Head Turned and the Dependent Ear and Eye Protected from Pressure
I. Preoperative Assessment
II. Selection of Anesthetic Technique
III. Surgery to the Spine
IV. Surgery to the Upper Extremities
T - 50-1. Preoperative Assessment of Orthopedic Surgical Patients
T - 50-10. Criteria for Diagnosis of Fat Embolism Syndrome
T - 50-11. Antithrombotic Regimens to Prevent Thromboembolism in Orthopedic Surgical Patients
T - 50-12. Pharmacologic Activities of Anticoagulants, Antiplatelet Agents, and Thrombolytics
T - 50-13. Recommendations for Management of Patients Receiving Neuraxial Blockade and Anticoagulant Drugs
T - 50-2. Advantages of Regional Versus General Anesthesia for Orthopedic Surgical Procedures
T - 50-3. Characteristics of Autonomic Hyperreflexia
T - 50-4. Anesthetic Considerations for Surgical Correction of Scoliosis
T - 50-5. Monitoring for Patients Undergoing Scoliosis Surgery
T - 50-6. Changes After Major Spine Surgery that may Influence the Ability to Perform Epidural or Spinal Anesthesia
T - 50-7. Regional Anesthetic Techniques for Upper Extremity Surgery
T - 50-8. Lumbosacral Techniques for Major Lower Extremity Surgery
T - 50-9. Anesthetic Considerations for Microvascular Surgery for Limb Replantation
V. Surgery to the Lower Extremities
VI. Microvascular Surgery
VII. Pediatric Orthopedic Surgery
VIII. Other Considerations
51. Transplant Anesthesia
I. Anesthetic Management of Organ Donors
II. Living Kidney Donors
III. Living Liver Donors
IV. Immunosuppressive Agents
IX. Small Bowel and Multivisceral Transplantation
T - 51-1. Characteristics of the Ideal Deceased Lung Donor
T - 51-10. Significant Differences Among Ventricular Assist Devices
T - 51-11. Anesthetic Management for Heart Transplantation
T - 51-12. Drugs that may Cause Renal Dysfunction when Coadministred with Calcineurin Ihnibitors
T - 51-13. Effect of Denervation on Cardiac Pharmacology
T - 51-2. Immunosuppressive Drugs
T - 51-3. Complications of Chronic Immune Suppression
T - 51-4. Diagnoses of Patients on Adult Renal Trnsplant Waiting List
T - 51-5. Diagnoses Leading Toliver Transplantation in Adults
T - 51-6. Multisystem Complications of End-Stage Liver Disease
T - 51-7. Lung Recipient Selection Guidelines
T - 51-8. Living Lung Donor Criteria
T - 51-9. Stages in the Development of Heart Failure: Recommended Therapy by Stage
Transplant Anesthesia
V. Corneal Transplantation
VI. Renal Transplantation
VII. Liver Transplantation
VIII. Pancreas and Islet Transplantation
X. Lung Transplantation
XI. Heart Transplantation
XII. Composite Tissue Transplantation
XIII. Managment of Transplant Patients for Nontransplant Surgery
52. Trauma and Burns
F - 52-1. Clinical Sequence for Initial Management of a Patient with Major Trauma
F - 52-2. Canadian Cervical Spine (C-Spine) Rule Designed to Diagnose C-Spine Injury and Identify Patients Who Require Further Radiographic (Computed Tomography) Evaluation
F - 52-3. Schematic Representation of the âBloody Vicious Cycleâ or âLethal Triad.â
F - 52-4. Thromboelastogram
F - 52-5. The Rate of Rise in Core Temperature with Circulating Water and Forced-Air Devices Used in Healthy Anesthetized Volunteers
F - 52-6. Physiologic Effects of Abdominal Compartment Syndrome
I. Initial Evaluation and Resuscitation
II. Cervical Spine Injury
III. Direct Airway Injuries
IV. Management of Breathing Abnormalities
IX. Management of Intraoperative Complications
T - 52-1. Guidelines for Management of Traumatic Shock
T - 52-10. Clinical Features Associated with Intraoperative Mortality
T - 52-2. Advanced Trauma Life Support Classification of Hemorrhagic Shock
T - 52-3. Response to Initial Fluid Administration
T - 52-4. Two-Level Initial Evaluation of Consciousness
T - 52-5. Common Clinical, Radiographic, and Ultrasound Features of Thoracic Aortic Injuries
T - 52-6. Diagnostic Tools in Abdominal Trauma: Strengths and Weaknesses
T - 52-7. New Proposed Rule to Estimate Body Surface Areas of Normal and Obese Patients
T - 52-8. Symptoms of Carbon Monoxide Toxicity as a Function of the Blood Carboxyhemoglobin Level
T - 52-9. Guidelines for Initial Fluid Resuscitation after Thermal Injury
Trauma and Burns
V. Management of Shock
VI. Early Management of Specific Injuries
VII. Burns
VIII. Operative Management
X. Electrolyte and Acid-Base Disturbances
XI. Early Postoperative Considerations
53. Emergency Preparedness for and Disaster Management of Casualties from Natural Disasters and Chemical, Biologic, Radiologic, Nuclear, and High-Yield Explosive (Cbrne) Events
Emergency Preparedness for and Disaster Management of Casualties from Natural Disasters and Chemical, Biologic, Radiologic, Nuclear, and High-Yield Explosive (Cbrne) Events
F - 53-1. The Multiple Issues for Which the Federal Emergency Management Agency Must Prepare and with Which Agencies It Must Coordinateâthe Us Departments of Justice, Health and Human Services, Agriculture, Commerce, and Defense
I. Preparation: Personal Preparedness
II. Role of Anesthesiologist in Management of Mass Casualties
III. Chemical
IV. Biologic
T - 53-1. Examples of Chemical, Biologic, Radiologic, Nuclear, and High-Yield Explosive Events
T - 53-2. Evaluation of Patients Who Do Not Require Immediate Treatment But May Require Delayed Care
T - 53-3. Diagnosis of Nerve Agent Toxicity
T - 53-4. Biologic Agents Used for Warfare
V. Nuclear Radiation
VIII. Perioperative and Consultative Services
54. Postanesthesia Recovery
I. Value and Economics of the Postanesthesia Care Unit
II. Levels of Postoperative/Postanesthesia Care
III. Postanesthetic Triage
IV. Safety in the Postanesthesia Care Unit
IX. Cardiovascular Complications
Postanesthesia Recovery
T - 54-1. Components of a Postanesthesia Care Unit Admission Report
T - 54-2. The two Most Commonly Used Postanesthesia Care Unit Discharge Criteria Systems
T - 54-3. Elements of the Postanesthesia Evaluation
T - 54-4. Manifestations of Obstructive Sleep Apnea
T - 54-5. Causes of Acidemia
T - 54-6. Miscellaneous Complications in the Postanesthesia Care Unit
V. Admission to the Postanesthesia Care Unit
VI. Postoperative Pain Management
VII. Discharge Criteria
VIII. Postoperative Evaluation
X. Postoperative Pulmonary Dysfunction
XI. Postoperative Renal Complications
XII. Metabolic Complications
XIII. Glucose Disorders and Control
XIV. Electrolyte Disorders
XV. Miscellaneous Complications
55. Critical Care Medicine
Critical Care Medicine
I. Anesthesiology and Critical Care Medicine: The Future
II. Critical Care Medicine: A Systems and Evidence-Based Approach
III. Neurologic and Neurosurgical Critical Care
IV. Cardiovascular and Hemodynamic Aspects of Critical Care
IX. Nutrition in Critically Ill Patients
T - 55-1. Leapfrog ICU Physician Staffing (IPS) Stand ard
T - 55-2. Predictors of Poor Outcome After Traumatic Brain Injury
T - 55-3. ICU Management of Patients with Severe Traumatic Brain Injury (Assuming Initial Surgical Management)
T - 55-4. Definitions of Sepsis and Organ Failure
T - 55-5. Management of Severe Sepsis and Septic Shock
T - 55-6. Rifle Classification of Acute Kidney Injury
T - 55-7. Risk Factors for Venous Thromboembolism
V. Acute Respiratory Failure
VI. Acute Renal Failure
VII. Endocrine Aspects of Critical Care Medicine
VIII. Anemia and Transfusion Therapy in Critical Illness
X. Sedation of Critically Ill Patients
XI. Complications in the Intensive Care Unit: Detection, Prevention, and Therapy
56. Acute Pain Management
Acute Pain Management
F - 56-1. Afferent Pathways Involved in Nociceptive Regulation
F - 56-2. Efferent Pathways Involved in Nociceptive Regulation
F - 56-3. Pain Sensitization
F - 56-4. The Four Elements of Pain Processing are Transduction, Transmission, Modulation and Perception
F - 56-5. Schematic of the Neurochemistry of Somatosensory Processing at Peripheral Sensory Nervy Endings
F - 56-6. Schematic Representation of Peripheral and Spinal Mechanism Involved in Neuroplasticity
F - 56-7. Primary Nociceptive Transmission in the Spinal Cord
F - 56-8. Linear Visual Analogue Scale and Faces Pain Assessment Tool
I. Acute Pain Defined
II. Anatomy of Acute Pain
III. Pain Processing
IV. Chemical Mediators of Transduction and Transmission
IX. Opioid Analgesics
T - 56-1. Primary Afferent Nerves
T - 56-10. Intrathecal Analgesia
T - 56-11. Intrathecal Analgesic Additives
T - 56-12. Recommended Dosing Regimen of Local Anesthetics for Continuous Peripheral Nerve Blockade
T - 56-13. Risk Factors for Nerve Injury During the Performance of Regional Anesthesia
T - 56-14. Advantages of Ultrasound-Guided Regional Anesthesia
T - 56-15. Surgical Guidelines for Perioperative Pain Management of Opioid-Tolerant Patients
T - 56-16. Challenges for Acute Pain Management in Children
T - 56-2. Algogenic Substances
T - 56-3. Consequences of Poorly Managed Acute Pain
T - 56-4. Features of Pain Commonly Addressed During Assessment
T - 56-5. Opioid Equianalgesic Dosing
T - 56-6. Adult Dosing Guidelines for Nonopioid Analgesics
T - 56-7. Usual Intravenous Opioid Patient-Controlled Analgesia Regimens for Opioid-Nachr(239)ve Adult Patient
T - 56-8. Relative Risk Factors Associated with Patient-Controlled Analgesia
T - 56-9. Guidelines for Adult Epidural Catheter Dosing Regimen
V. The Surgical Stress Response
VI. Preemptive Analgesia
VII. Strategies for Acute Pain Management
VIII. Assessment of Acute Pain
X. Nonopioid Analgesic Adjuncts
XI. Methods of Analgesia
XII. Continuous Peripheral Nerve Blockade Caveats
XIII. Complications from Regional Anesthesia
XIV. Perioperative Pain Management of Opioid-Dependent Patients
XV. Organization of Perioperative Pain Management Services
XVI. Special Considerations in the Perioperative Pain Management of Children
57. Chronic Pain Management
Chronic Pain Management
F - 57-1. Anatomy and Physiology of Somatosensory and Pain Processing
I. Anatomy, Physiology, and Neurochemistry of Somatosensory Pain Processing
II. Management of Common Pain Syndromes
III. Neuropathic Pain Syndromes
IV. Cancer Pain
T - 57-1. Primary Afferent Nerves
T - 57-10. Recommended Drugs for Chronic Pain Syndromes
T - 57-11. Commonly Used Antidepressants
T - 57-12. Commonly used Anticonvulsants
T - 57-13. Contraindications to Percutaneous Decompression
T - 57-14. Indications for Spinal Cord Stimulator Implantation
T - 57-15. Questions to Consider Before Intrathecal Pump Placement
T - 57-16. Complications of Intrathecal Drug Delivery Systems
T - 57-2. Common Causes of Low Back Pain
T - 57-3. Complications of Epidural Steroid Injections
T - 57-4. Criteria for the Diagnosis of Myofascial Pain Syndrome and Fibromyalgia
T - 57-5. Symptoms of Sensorimotor Distal Polyneuropathy
T - 57-6. Signs and Symptoms of Chronic Regional Pain Syndrome
T - 57-7. Etiology and Characteristics of Cancer Pain
T - 57-8. Neurolytic Blocks for Visceral Pain from Cancer
T - 57-9. Recommended Drugs for Chronic Pain Syndromes
V. Pharmacologic Management of Pain
VI. Interventional Procedures
58. Cardiopulmonary Resuscitation
Cardiopulmonary Resuscitation
F - 58-1. Simplified Adult Basic Life Support (BLS) Algorithm
F - 58-2. Advanced Cardiac Life Support (ALCS) Circular Algorithm
F - 58-3. Adult Bradycardia (with Pulse) Algorithm
F - 58-4. Adult Tachycardia (with Pulse) Algorithm
F - 58-5. Pediatric Health Care Provider Basic Life Support (BLS) Algorithm
F - 58-6. Pediatric Advanced Life Support Pulseless Arrest Algorithm
I. History
II. Scope of the Problem
III. Ethical Issues: Do not Resuscitate Orders in the Operating Room
IV. Components of Resuscitation
IX. Postresuscitation Care
T - 58-1. History of Cardiopulmonary Resuscitation
T - 58-2. Techniques Used for Airway Maintenance During Cardiopulmonary Resuscitation
T - 58-3. Techniques of Rescue Breathing
T - 58-4. Techniques of Closed Chest Compression
T - 58-5. Critical Variables Associated with Successful Resuscitation
T - 58-6. Adult Advanced Cardiac Life Support Drugs and Doses
T - 58-7. Determinants of Transthoracic Impedance
V. Pharmacologic Therapy
VI. Electrical Therapy
VII. Putting it all Together
VIII. Pediatric Cardiopulmonary Resuscitation
Appendices
A. Formulas
B. Atlas of Electrocardiography
Acknowledgments
Atrial Fibrillation
Atrial Flutter
Atrial Pacing
Atrioventricular Block (First-degree)
Atrioventricular Block (Second-degree), Mobitz Type I/Wenckebach Block
Atrioventricular Block (Second-degree), Mobitz Type II
Atrioventricular Block (Third-degree), Complete Heart Block
Bundle Branch BlockâRight (RBBB)
Bundle-Branch Blockâ Left (Lbbb)
Calcium
Coronary Artery Disease
DDD Pacing
Digitalis Effect
Lead Placement
Multifocal Atrial Tachycardia
Myocardial Ischemia
Paroxysmal Atrial Tachycardia (PAT)
Pericardial Tamponade
Pericarditis
Pneumothorax
Premature Atrial Contraction (PAC)
Premature Ventricular Contraction (PVC)
Pulmonary Embolus
Sinus Arrest
Sinus Arrhythmia
Sinus Bradycardia
Sinus Tachycardia
Subarachnoid Hemorrhage
Subendocardial Myocardial Infarction (SEMI)
The Normal ElectrocardiogramâCardiac Cycle
Torsades De Pointes
Ventricular Fibrillation
Ventricular Pacing
Ventricular Tachycardia
Wolff-Parkinson-White Syndrome (WPW)
C. Pacemaker and Implantable Cardiac Defibrillator Protocols
Cardiac Implantable Electronic Devices (CIED)âPacemakers
Cardiac Implantable Electronic Devices (CIEDs)âImplantable Cardiac Defibrillators (ICDs)
F - 1. Example of an Algorithm for Perioperative Management of Patients with CIED
General Principles of Perioperative Management of Patients with CIED
Optimization of Pacing after Cardiopulmonary Bypass (CPB)
Pacemaker and Implantable Cardiac Defibrillator Protocols
Potential Intraoperative Problems with Cardiac Electronic Implantable Devices
Recommendations for Postoperative Follow-up of the Patient with CIED (see Tables 7 and 8)
Risk Mitigation Strategies
T - 1. Abbreviation Table
T - 2. Generic Pacemaker Code: NASPE/BPEG Revised (2002)
T - 3. Generic Defibrillator Code (NBG): NASPE/BPEG
T - 4. Essential Elements of The Information Given to The CIED Physician
T - 5. Essential Elements of The Preoperative CIED Evaluation to Be Provided to The Operative Team
T - 6. Example of a Stepwise Approach to the Perioperative Management of the Patient with a Cardiac Implantable Electronic Device
T - 7. Specific Procedures and Writing Committee Recommendations on Postoperative CIED Evaluation
T - 8. Indications for the Interrogation of Cieds Prior to Patient Discharge or Transfer From a Cardiac Telemetry Environment
T - 9. Treatment of Pacemaker Failure
D. American Heart Association (AHA) Resuscitation Protocols
Adult Advanced Cardiac Life Support Pulseless Arrest Algorithm
Adult Basic Life Support (BLS) Healthcare Provider Algorithm
Algorithm for Resuscitation of the Newly Born Infant
American Heart Association (AHA) Resuscitation Protocols
Bradycardia Algorithm
Cardiocerebral Resuscitation Algorithm
Pals (Pediatric Advanced Life Support) Bradycardia Algorithm
Pals Pulseless Arrest Algorithm
Pals Tachycardia Algorithm for Infants and Children with Rapid Rhythm and Evidence of Poor Perfusion
Pediatric Advanced Life Support Medication for Cardiac Arrest and Symptomatic Arrhythmias
Pediatric Health Care Provider Basic Life Support Algorithm
The Tachycardia Overview Algorithm
E. American Society of Anesthesiologists Stand ards, Guidelines, and Statements
American Society of Anesthesiologists Stand ards, Guidelines, and Statements
Basic Stand ards for Preanesthesia Care
Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia
Distinguishing Monitored Anesthesia Care (âMACâ) From Moderate Sedation/Analgesia (Conscious Sedation)
Ethical Guidelines for the Anesthesia Care of Patients with Do-not-Resuscitate Orders or Other Directives that Limit Treatment
Fire Safety Algorithm
Position on Monitored Anesthesia Care
Practice Advisory for the Prevention and Management of Operating Room Fires
Stand ards for Basic Anesthetic Monitoring
Stand ards for Postanesthesia Care
F. The Airway Approach Algorithm and Difficult Airway Algorithm
F - 1. Airway Approach Algorithm
F - 2. Difficult Airway Algorithm
G. Malignant Hyperthermia Protocol
H. Herbal Medications
A
Alfalfa - A
Angelica Root - A
Anise - A
Arnica Flower - A
Asafoetida - A
B
B - Bilberry
B - Bogbean
B - Bromelain
C
Cayenne - C
Celery - C
Chamomile - C
Clove - C
D
Dand elion - D
Danshen - D
Devil'S Claw - D
Dong Quai - D
E
Echinacea - E
Ephedra - E
F
F - Fenugreek
F - Feverfew
F - Fish Oil
F - Flaxseed Oil
G
Garlic (Pertains to Supplement Product) - G
Ginger (Pertains to Supplement Product) - G
Ginkgo - G
Ginseng - G
Goldenseal - G
Grape Seed - G
Green Tea - G
H
Herbal Medications
Horse Chestnut - H
K
Kava-Kava - K
L
Licorice - L
Lovage Root - L
M
Meadowsweet - M
O
Onions - O
P
Papain - P
Parsley - P
Passion Flower - P
Q
Quassia - Q
R
Red Clover - R
S
Saw Palmetto - S
St. John'S Wort - S
Sweet Clover - S
T
T - Tumeric
V
Valerian - V
Vitamin E - V
W
Willow Bark - W
Front Matter
Contributing Authors
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