2018 morgan mikhail’s clinical anesthesiology 6th ed

downloaded from www.medicalbr.com


Get more medical books and resources at

www.medicalbr.com

downloaded from www.medicalbr.com


downloaded from www.medicalbr.com


Copyright©2018byMcGraw-HillEducation.Allrightsreserved.Exceptas
permittedundertheUnitedStatesCopyrightActof1976,nopartofthis
publicationmaybereproducedordistributedinanyformorbyanymeans,or
storedinadatabaseorretrievalsystem,withoutthepriorwrittenpermissionof
thepublisher.
ISBN:978-1-25-983443-1
MHID:1-25-983443-3
ThematerialinthiseBookalsoappearsintheprintversionofthistitle:ISBN:
978-1-25-983442-4,
MHID:1-25-983442-5.
eBookconversionbycodeMantra
Version1.0
Alltrademarksaretrademarksoftheirrespectiveowners.Ratherthanputa
trademarksymbolaftereveryoccurrenceofatrademarkedname,weusenames
inaneditorialfashiononly,andtothebenefitofthetrademarkowner,withno
intentionofinfringementofthetrademark.Wheresuchdesignationsappearin
thisbook,theyhavebeenprintedwithinitialcaps.
McGraw-HillEducationeBooksareavailableatspecialquantitydiscountstouse

aspremiumsandsalespromotionsorforuseincorporatetrainingprograms.To
contactarepresentative,pleasevisittheContactUspageat
www.mhprofessional.com.
Notice
Medicineisanever-changingscience.Asnewresearchandclinicalexperience
broadenourknowledge,changesintreatmentanddrugtherapyarerequired.The
authorsandthepublisherofthisworkhavecheckedwithsourcesbelievedtobe
reliableintheireffortstoprovideinformationthatiscompleteandgenerallyin
accordwiththestandardsacceptedatthetimeofpublication.However,inview
ofthepossibilityofhumanerrororchangesinmedicalsciences,neitherthe
authorsnorthepublishernoranyotherpartywhohasbeeninvolvedinthe
preparationorpublicationofthisworkwarrantsthattheinformationcontained
hereinisineveryrespectaccurateorcomplete,andtheydisclaimall
responsibilityforanyerrorsoromissionsorfortheresultsobtainedfromuseof

downloaded from www.medicalbr.com


theinformationcontainedinthiswork.Readersareencouragedtoconfirmthe
informationcontainedhereinwithothersources.Forexampleandinparticular,
readersareadvisedtochecktheproductinformationsheetincludedinthe
packageofeachdrugtheyplantoadministertobecertainthattheinformation
containedinthisworkisaccurateandthatchangeshavenotbeenmadeinthe
recommendeddoseorinthecontraindicationsforadministration.This
recommendationisofparticularimportanceinconnectionwithnewor
infrequentlyuseddrugs.Inthispublicationweusetheterms“female”and
“male”inaccordancewiththeguidelinesestablishedbytheWorldHealth
Organization.Specifically,referencestofemaleandmalearebasedonthe
anatomyofthereproductivesystems,whichdefinehumansasbiologically
femaleormale.

TERMSOFUSE
ThisisacopyrightedworkandMcGraw-HillEducationanditslicensorsreserve
allrightsinandtothework.Useofthisworkissubjecttotheseterms.Exceptas
permittedundertheCopyrightActof1976andtherighttostoreandretrieveone
copyofthework,youmaynotdecompile,disassemble,reverseengineer,
reproduce,modify,createderivativeworksbasedupon,transmit,distribute,
disseminate,sell,publishorsublicensetheworkoranypartofitwithout
McGraw-HillEducation’spriorconsent.Youmayusetheworkforyourown
noncommercialandpersonaluse;anyotheruseoftheworkisstrictlyprohibited.
Yourrighttousetheworkmaybeterminatedifyoufailtocomplywiththese
terms.
THEWORKISPROVIDED“ASIS.”McGRAW-HILLEDUCATIONAND
ITSLICENSORSMAKENOGUARANTEESORWARRANTIESASTO
THEACCURACY,ADEQUACYORCOMPLETENESSOFORRESULTS
TOBEOBTAINEDFROMUSINGTHEWORK,INCLUDINGANY
INFORMATIONTHATCANBEACCESSEDTHROUGHTHEWORKVIA
HYPERLINKOROTHERWISE,ANDEXPRESSLYDISCLAIMANY
WARRANTY,EXPRESSORIMPLIED,INCLUDINGBUTNOTLIMITED
TOIMPLIEDWARRANTIESOFMERCHANTABILITYORFITNESSFOR
APARTICULARPURPOSE.McGraw-HillEducationanditslicensorsdonot
warrantorguaranteethatthefunctionscontainedintheworkwillmeetyour
requirementsorthatitsoperationwillbeuninterruptedorerrorfree.Neither
McGraw-HillEducationnoritslicensorsshallbeliabletoyouoranyoneelsefor
anyinaccuracy,errororomission,regardlessofcause,intheworkorforany

downloaded from www.medicalbr.com


damagesresultingtherefrom.McGraw-HillEducationhasnoresponsibilityfor
thecontentofanyinformationaccessedthroughthework.Underno

circumstancesshallMcGraw-HillEducationand/oritslicensorsbeliableforany
indirect,incidental,special,punitive,consequentialorsimilardamagesthat
resultfromtheuseoforinabilitytousethework,evenifanyofthemhasbeen
advisedofthepossibilityofsuchdamages.Thislimitationofliabilityshallapply
toanyclaimorcausewhatsoeverwhethersuchclaimorcausearisesincontract,
tortorotherwise.

downloaded from www.medicalbr.com


Contents
ChapterAuthors
Contributors
ResearchandReview
Foreword
Preface

1ThePracticeofAnesthesiology
SECTION

I

AnestheticEquipment&Monitors

2TheOperatingRoomEnvironment
CharlesE.Cowles,Jr.,MD,MBA,FASA

3BreathingSystems
4TheAnesthesiaWorkstation
5CardiovascularMonitoring

6NoncardiovascularMonitoring
SECTION

downloaded from www.medicalbr.com


II

ClinicalPharmacology

7PharmacologicalPrinciples
8InhalationAnesthetics
9IntravenousAnesthetics
10AnalgesicAgents
11NeuromuscularBlockingAgents
12CholinesteraseInhibitors&OtherPharmacologicalAntagonists
toNeuromuscularBlockingAgents

13AnticholinergicDrugs
14AdrenergicAgonists&Antagonists
15HypotensiveAgents
16LocalAnesthetics
17AdjunctstoAnesthesia
SECTION

III

AnestheticManagement

downloaded from www.medicalbr.com

18PreoperativeAssessment,Premedication,&Perioperative
Documentation

19AirwayManagement
20CardiovascularPhysiology&Anesthesia
21AnesthesiaforPatientswithCardiovascularDisease
22AnesthesiaforCardiovascularSurgery
23RespiratoryPhysiology&Anesthesia
24AnesthesiaforPatientswithRespiratoryDisease
25AnesthesiaforThoracicSurgery
26Neurophysiology&Anesthesia
27AnesthesiaforNeurosurgery
28AnesthesiaforPatientswithNeurological&PsychiatricDiseases
29AnesthesiaforPatientswithNeuromuscularDisease
30KidneyPhysiology&Anesthesia
31AnesthesiaforPatientswithKidneyDisease
32AnesthesiaforGenitourinarySurgery
downloaded from www.medicalbr.com


33HepaticPhysiology&Anesthesia
MichaelRamsay,MD,FRCA

34AnesthesiaforPatientswithLiverDisease
MichaelRamsay,MD,FRCA

35AnesthesiaforPatientswithEndocrineDisease
36AnesthesiaforOphthalmicSurgery

37AnesthesiaforOtolaryngology–Head&NeckSurgery
38AnesthesiaforOrthopedicSurgery
EdwardR.Mariano,MD,MAS

39AnesthesiaforTrauma&EmergencySurgery
BrianP.McGlinch,MD

40Maternal&FetalPhysiology&Anesthesia
MichaelA.Frölich,MD,MS

41ObstetricAnesthesia
MichaelA.Frölich,MD,MS

42PediatricAnesthesia
43GeriatricAnesthesia
44Ambulatory&Non–OperatingRoomAnesthesia
SECTION

RegionalAnesthesia&Pain
downloaded from www.medicalbr.com


IV

Management

45Spinal,Epidural,&CaudalBlocks
46PeripheralNerveBlocks
SarahJ.Madison,MDandBrianM.Ilfeld,MD,MS(Clinical
Investigation)

47ChronicPainManagement
BruceM.Vrooman,MD,MS,FIPPandRichardW.Rosenquist,MD

48EnhancedRecoveryProtocols&OptimizationofPerioperative
Outcomes
GabrieleBaldini,MD,MScandTimothyMiller,MBChBFRCA

SECTION

V

Perioperative&CriticalCare
Medicine

49ManagementofPatientswithFluid&ElectrolyteDisturbances
50Acid–BaseManagement
51FluidManagement&BloodComponentTherapy
52Thermoregulation,Hypothermia,&MalignantHyperthermia
downloaded from www.medicalbr.com


53NutritioninPerioperative&CriticalCare
54AnestheticComplications
55CardiopulmonaryResuscitation
N.MartinGiesecke,MDandGeorgeW.Williams,MD,FASA,FCCP

56PostanesthesiaCare
57CommonClinicalConcernsinCriticalCareMedicine
58InhalationTherapy&MechanicalVentilationinthePACU&

ICU

59Safety,Quality,&PerformanceImprovement
Index

downloaded from www.medicalbr.com


ChapterAuthors
GabrieleBaldini,MD,MSc
AssociateProfessor
MedicalDirector,MontrealGeneralHospitalPreoperativeCentre
DepartmentofAnesthesia
McGillUniversityHealthCentre
MontrealGeneralHospital
Montreal,Quebec,Canada

JohnF.ButterworthIV,MD
ProfessorandChairman
DepartmentofAnesthesiology
VirginiaCommonwealthUniversitySchoolofMedicine
VCUHealthSystem
Richmond,Virginia

CharlesE.Cowles,Jr.,MD,MBA,FASA
AssociateProfessor/AssistantClinicalDirector
DepartmentofAnesthesiologyandPerioperativeMedicine
UniversityofTexasMDAndersonCancerCenter
Houston,Texas

MichaelA.Frölich,MD,MS
ProfessorandAssociateViceChairforResearch
DepartmentofAnesthesiologyandPerioperativeMedicine
UniversityofAlabamaatBirmingham
Birmingham,Alabama

N.MartinGiesecke,M.D.
downloaded from www.medicalbr.com


ProfessorandViceChairmanforAdministrativeAffairs
DepartmentofAnesthesiology
McGovernMedicalSchool
UniversityofTexasHealthScienceCenteratHouston
Houston,Texas

BrianM.Ilfeld,MD,MS(ClinicalInvestigation)
ProfessorofAnesthesiology,InResidence
DivisionofRegionalAnesthesiaandPainMedicine
DepartmentofAnesthesiology
UniversityofCaliforniaatSanDiego
SanDiego,California

DavidC.Mackey,MD
Professor
DepartmentofAnesthesiologyandPerioperativeMedicine
UniversityofTexasMDAndersonCancerCenter
Houston,Texas

SarahMadison,MD

AssistantProfessor
DepartmentofAnesthesiology,Perioperative&PainMedicine
StanfordUniversity
Stanford,California

EdwardR.Mariano,MD,MAS
Professor
DepartmentofAnesthesiology,Perioperative&PainMedicine
StanfordUniversitySchoolofMedicine
Chief,Anesthesiology&PerioperativeCareService
AssociateChiefofStaff,InpatientSurgicalServices
VeteransAffairsPaloAltoHealthCareSystem
PaloAlto,California

BrianP.McGlinch,M.D.

downloaded from www.medicalbr.com


AssistantProfessor
DepartmentofAnesthesiology
UniversityofMinnesota
Minneapolis,Minnesota
Colonel,MedicalCorps,UnitedStatesArmyReserve
CommandSurgeon
84thTrainingCommand
FortKnox,Kentucky

TimothyMiller,MBChBFRCA
AssociateProfessor

Chief,DivisionofGeneral,VascularandTransplantAnesthesia
DepartmentofAnesthesiology
DukeUniversitySchoolofMedicine
Durham,NorthCarolina

MichaelRamsay,MD,FRCA
Chairman,DepartmentofAnesthesiology
BaylorUniversityMedicalCenter
BaylorScottandWhiteHealthCareSystem
Professor
TexasA&MUniversityHealthCareFaculty
Dallas,Texas

RichardW.Rosenquist,MD
Chairman,DepartmentofPainManagement
ClevelandClinic
Cleveland,Ohio

BruceM.Vrooman,MD,MS,FIPP
Chief,SectionofPainMedicine
Dartmouth-HitchcockMedicalCenter
AssociateProfessorofAnesthesiology
GeiselSchoolofMedicineatDartmouth
Lebanon,NewHampshire

downloaded from www.medicalbr.com


JohnD.Wasnick,MD,MPH
StevenL.BerkEndowedChairforExcellenceinMedicine

ProfessorandChair
DepartmentofAnesthesia
TexasTechUniversityHealthSciencesCenter
SchoolofMedicine
Lubbock,Texas

GeorgeW.Williams,MD,FASA,FCCP
ViceChairforCriticalCareMedicine
AssociateProfessorofAnesthesiologyandNeurosurgery
ProgramDirector,CriticalCareMedicineFellowship
UniversityofTexasHealthScienceCenteratHouston–McGovernMedical
School
Houston,Texas

downloaded from www.medicalbr.com


Contributors
KallolChaudhuri,MD,PhD
Professor
DepartmentofAnesthesia
WestVirginiaUniversitySchoolofMedicine
Morgantown,WestVirginia

SwapnaChaudhuri,MD,PhD
Professor
DepartmentofAnesthesia
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

LydiaConlay,MD
Professor
DepartmentofAnesthesia
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

JohannesDeRiese,MD
AssistantProfessor
DepartmentofAnesthesiology
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

SuzanneN.Northcutt,MD
AssociateProfessor
DepartmentofAnesthesia

downloaded from www.medicalbr.com


TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

AschrafN.Farag,MD
AssistantProfessor
DepartmentofAnesthesia
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

PranavShah,MD
AssistantProfessor

DepartmentofAnesthesiology
VCUSchoolofMedicine
Richmond,Virginia

RobertJohnston,MD
AssociateProfessor
DepartmentofAnesthesia
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

SabryKhalil,MD
AssistantProfessor
DepartmentofAnesthesiology
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

SanfordLittwin,MD
AssistantProfessor
DepartmentofAnesthesiology
St.Luke’sRooseveltHospitalCenterandColumbiaUniversityCollegeof
PhysiciansandSurgeons
NewYork,NewYork

AlinaNicoara,MD

downloaded from www.medicalbr.com


AssociateProfessor
DepartmentofAnesthesiology

DukeUniversityMedicalCenter
Durham,NorthCarolina

NitinParikh,MD
AssociateProfessor
DepartmentofAnesthesia
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

CooperW.Phillips,MD
AssistantProfessor
DepartmentofAnesthesiology
UTSouthwesternMedicalCenter
Dallas,Texas

ElizabethR.Rivas,MD
AssistantProfessor
DepartmentofAnesthesiology
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

BettinaSchmitz,MD,PhD
AssociateProfessor
DepartmentofAnesthesia
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

ChristianeVogt-Harenkamp,MD,PhD
AssistantProfessor
DepartmentofAnesthesia

TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

downloaded from www.medicalbr.com


DeniseJ.Wedel,MD
ProfessorofAnesthesiology
MayoClinic
Rochester,Minnesota

downloaded from www.medicalbr.com


ResearchandReview
ChaseClanton,MD
FormerlyResident,DepartmentofAnesthesiology
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

AaronDarais,MD
FormerlyResident,DepartmentofAnesthesiology
TexasTechUniversityMedicalCenter
Lubbock,Texas

JacquelineE.Geier,MD
FormerlyResident,DepartmentofAnesthesiology
St.Luke’sRooseveltHospitalCenter
NewYork,NewYork

BrianHirsch,MD
FormerlyResident,DepartmentofAnesthesiology
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

ShaneHuffman,MD
FormerlyResident,DepartmentofAnesthesiology
TexasTechUniversityMedicalCenter
Lubbock,Texas

RahulK.Mishra,MD
FormerlyResident,DepartmentofAnesthesiology

downloaded from www.medicalbr.com


TexasTechUniversityMedicalCenter
Lubbock,Texas

CeciliaN.Pena,MD
FormerlyResident,DepartmentofAnesthesiology
TexasTechUniversityMedicalCenterHospital
Lubbock,Texas

SpencerThomas,MD
FormerlyResident,DepartmentofAnesthesiology
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

TrevorWalker,MD

FormerlyResident,DepartmentofAnesthesiology
TexasTechUniversityMedicalCenter
Lubbock,Texas

CharlotteM.Walter,MD
FormerlyResident,DepartmentofAnesthesiology
TexasTechUniversityMedicalCenter
Lubbock,Texas

KarvierYates,MD
FormerlyResident,DepartmentofAnesthesiology
TexasTechUniversityMedicalCenter
Lubbock,Texas

ShirazYazdani,MD
AssistantProfessor
DepartmentofAnesthesiology
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas

downloaded from www.medicalbr.com


Foreword
WhenanewresidencytrainingprograminanesthesiawasbeginninginRwanda
in2006,wewerelookingforasuitabletextbooktorecommendtothetrainees.
WechoseClinicalAnesthesiologybyMorganandMikhail.Iamhappytostate
thattoday,12yearslater,theresidentsarestillmakingthesamechoice.Over
onethirdofallcopiesofthelasteditionweresoldoutsideofNorthAmericathus
underliningthepopularityofthistextbookaroundtheworld.

Amajorchangeineditorsandauthorsoccurredwiththe5theditionanditis
clearthattheystayedtruetotheidealsoftheoriginaleditors.Nowin2018,the
6theditionispresentedtous.Thetextcontinuestobesimple,concise,and
easilyreadable.TheuseofKeyConceptsatthebeginningofeachchapteris
veryusefulandfocusesthereader’sattentionontheimportantpoints.The
authorshaveworkedhardnottoincreasethesizeofthebookbuttoupdatethe
material.Expandedchaptersoncriticalcare,onenhancedrecoveryafter
anesthesia,andontheuseofultrasoundwillbeveryusefultoreaders.This
textbookcontinuestoprovideacomprehensiveintroductiontotheartand
scienceofanesthesia.
Congratulationstotheauthorsandeditorsontheirfinework.
AngelaEnrightMB,FRCPC
PastPresident,WorldFederationofSocietiesofAnaesthesiologists(WFSA)

downloaded from www.medicalbr.com


Preface
My,howtimeflies!Canhalfadecadealreadyhavepassedsincewelastedited
thistextbook?Yet,thetimehaspassedandourfieldhasundergonemany
changes.Wearegratefultothereadersofthefiftheditionofourtextbook.The
widespreaduseofthisworkhaveensuredthatthetimeandeffortrequiredto
produceasixtheditionarejustified.
Aswastrueforthefifthedition,thesixtheditionrepresentsasignificant
revision.Afewexamplesareworthnoting:
•Thosefamiliarwiththesequenceandgroupingofcontentinthefifthedition
willnoticethatchaptershavebeenreorderedandcontentbrokenoutor
consolidatedtoimprovetheflowofinformationandeliminateredundancy.
•Thealertreaderwillnotethatthesectiononcriticalcaremedicinehasbeen
expanded,reflectingtheincreasingnumberofverysickpatientsforwhom

wecare.
•Enhancedrecoveryaftersurgeryhasprogressedfromanimportantconceptto
acommonlyusedacronym(ERAS),aspecialtysociety,and(soon)standard
ofcare.
•Ultrasoundhasneverbeenmoreimportantinanesthesiapractice,anditsuse
invariousproceduresisemphasizedthroughoutthetextbook.
Somethingsremainunchanged:
•Wehavenotburdenedourreaderswithlargenumbersofunnecessary
references.Wehopethatlonglistsofreferencesattheendoftextbook
chapterswillsoongothewayofthelibrarycardcatalogandlong-distance
telephonecharges.Weassumethatourreadersareasfondof(andlikelyas
facilewith)GoogleScholarandPubMedasarewe,andcangeneratetheir
ownlistsofreferenceswhenevertheylike.WecontinuetoprovideURLsfor
societies,guidelines,andpracticeadvisories.
•WecontinuetoemphasizeKeyConceptsatthebeginningofeachchapter
thatlinktothechapterdiscussion,andcasediscussionsattheend.

downloaded from www.medicalbr.com


•Wehavetriedtoprovideillustrationsandimageswhenevertheyimprove
theflowandunderstandingofthetext.
Onceagain,thegoalexpressedinthefirsteditionremainsunchanged:“to
provideaconcise,consistentpresentationofthebasicprinciplesessentialtothe
modernpracticeofanesthesia.”And,onceagain,despiteourbestintentions,we
fearthaterrorswillbefoundinourtext.Wearegratefultothemanyreaders
whohelpedimprovethelastedition.Pleaseemailusat
whenyoufinderrors.Thisenablesustomakecorrectionsinreprintsandfuture
editions.
JohnF.Butterworth,IV,MD

DavidC.Mackey,MD
JohnD.Wasnick,MD,MPH

downloaded from www.medicalbr.com