Ebook Basic clinical anesthesia: Part 1

Paul K. Sikka
Shawn T. Beaman
James A. Street
Editors

Basic
Clinical Anesthesia

123


Basic Clinical Anesthesia


wwwwwwwwwww


Paul K. Sikka • Shawn T. Beaman • James A. Street
Editors

Basic Clinical Anesthesia


Editors
Paul K. Sikka, MD, PhD
Department of Anesthesia and Perioperative Medicine
Emerson Hospital, Concord, MA, USA
(former faculty Brigham and Women’s Hospital, Harvard Medical School)
Shawn T. Beaman, MD
Associate Professor
Associate Residency Program Director

Director of Trauma Anesthesiology
Department of Anesthesiology-Presbyterian Hospital
University of Pittsburgh School of Medicine
Pittsburgh, PA, USA
James A. Street, PhD, MD
Chair, Department of Anesthesiology and Perioperative Medicine
Emerson Hospital, Concord, MA, USA
Associate Professor, Northeastern University, Boston, MA, USA
(former faculty Brigham and Women’s Hospital, Harvard Medical School)

ISBN 978-1-4939-1736-5
ISBN 978-1-4939-1737-2 (eBook)
DOI 10.1007/978-1-4939-1737-2
Library of Congress Control Number: 2014956868
Springer New York Heidelberg Dordrecht London
© Springer Science+Business Media New York 2015
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Printed on acid-free paper
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Preface

Basic Clinical Anesthesia is designed as an all-in-one resource for medical students, residents,
and practitioners who seek comprehensive and up-to-date coverage of fundamental information and core clinical topics in anesthesiology. The book comprises 57 chapters organized into
five parts and addresses ambulatory and non-operating room anesthesia, pain management and
regional anesthesia, preoperative evaluation and intraoperative management, specialty anesthesia, and critical care. It encompasses the full range of anesthetic knowledge from clinically
relevant basic science including system physiology and pharmacology to the anesthetic management of very sick patients. Experts have written each chapter to enable new and seasoned
anesthesia practitioners alike to keep abreast of the latest information.
A great effort has been made to present information in a succinct and easy-to-read style, and
numerous tables and color images and illustrations enhance the text. Multiple choice questions
at the end of each chapter allow readers to test themselves and quickly review important facts.
We are pleased to present this brand new textbook and hope that it proves useful to anesthesiology residents, practitioners, and medical students as a core text, a clinical refresher, and/or
an examination preparation tool. The editors gratefully acknowledge the contributions of the
chapter authors and the editorial staff at Springer Science+Business Media. We welcome readers’ constructive suggestions to improve the book in future editions and can be reached at the
email below.
E-mail:
Concord, MA, USA
Pittsburgh, PA, USA
Concord, MA, USA

Paul K. Sikka
Shawn T. Beaman
James A. Street

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Contents

Part I The Basics
1

History of Anesthesia .............................................................................................
Paul K. Sikka

3

2

Preoperative Evaluation ........................................................................................
Ursula A. Galway

7

3

Approach to Anesthesia .........................................................................................
Paul K. Sikka

17

4

Perioperative Airway Management......................................................................
Samuel Irefin and Tatyana Kopyeva

23

5

Anesthesia Machine ...............................................................................................
Preet Mohinder Singh, Dipal Shah, and Ashish Sinha

45

6

Patient Monitoring .................................................................................................
Benjamin Grable and Theresa A. Gelzinis

69

7

Fluid and Electrolyte Balance ...............................................................................
Patrick Hackett and Michael P. Mangione

89

8

Transfusion Medicine ............................................................................................
Matthew A. Joy, Yashar Eshraghi, Maxim Novikov, and Andrew Bauer

101

Part II Anesthetic Pharmacology

9

Mechanisms of Anesthetic Action .........................................................................
Daniela Damian and Andrew Herlich

119

10

Inhalational Anesthetics ........................................................................................
Lee Neubert and Ashish Sinha

123

11

Intravenous Induction Agents...............................................................................
Dustin J. Jackson and Patrick J. Forte

131

12

Opioids and Benzodiazepines................................................................................
James C. Krakowski and Steven L. Orebaugh

139

13

Neuromuscular Blocking and Reversal Agents ...................................................
Emily L. Sturgill and Neal F. Campbell

151

14

Antiemetics .............................................................................................................
Wendy A. Haft and Richard McAffee

159

15

NSAIDs and Alpha-2 Adrenergic Agonists ..........................................................
Stephen M. McHugh and David G. Metro

165

vii


viii

Contents

16

Diuretics ..................................................................................................................
Daniel S. Cormican and Shawn T. Beaman

169

17

Cardiovascular Pharmacology..............................................................................
Ali R. Abdullah and Todd M. Oravitz

175

18

Local Anesthetics....................................................................................................
John E. Tetzlaff

185

19

Allergic Reactions ..................................................................................................
Scott M. Ross and Mario I. Montoya

197

20

Drug Interactions ...................................................................................................
Ana Maria Manrique-Espinel and Erin A. Sullivan

203

Part III

Regional Anesthesia & Pain Management

21

Spinal and Epidural Anesthesia............................................................................
John H. Turnbull and Pedram Aleshi

211

22

Peripheral Nerve Blocks ........................................................................................
Michael Tom and Thomas M. Halaszynski

233

23

Ultrasound-Guided Peripheral Nerve Blocks .....................................................
Thomas M. Halaszynski and Michael Tom

253

24

Pain Management ..................................................................................................
Ramana K. Naidu and Thoha M. Pham

265

25

Orthopedic Anesthesia ...........................................................................................
Tiffany Sun Moon and Pedram Aleshi

297

Part IV Specialty Anesthesia
26

Cardiac Anesthesia.................................................................................................
Mahesh Sardesai

311

27

Vascular Anesthesia ...............................................................................................
Joshua Hensley and Kathirvel Subramaniam

355

28

Thoracic Anesthesia ...............................................................................................
Lundy Campbell and Jeffrey A. Katz

363

29

Neuroanesthesia .....................................................................................................
Brian Gierl and Ferenc Gyulai

397

30

Ambulatory Anesthesia .........................................................................................
Preet Mohinder Singh, Shubhangi Arora, and Ashish Sinha

415

31

Non-operating Room Anesthesia ..........................................................................
Carlee Clark

421

32

Hepatic and Gastrointestinal Diseases .................................................................
Kasia Petelenz Rubin

429

33

Renal and Urinary Tract Diseases ........................................................................
Arielle Butterly and Edward A. Bittner

441

34

Endocrine Diseases.................................................................................................
Paul K. Sikka

459


Contents

ix

35

Neurological and Neuromuscular Diseases..........................................................
Brian Gierl and Ferenc Gyulai

469

36

Ophthalmic Surgery ..............................................................................................
Scott Berry and Kristin Ondecko Ligda

483

37

Ear, Nose, and Throat Surgery .............................................................................
M. Christopher Adams and Edward A. Bittner

489

38

Obstetric Anesthesia ..............................................................................................
Manasi Badve and Manuel C. Vallejo

501

39

Pediatric Anesthesia ...............................................................................................
Terrance Allan Yemen and Christopher Stemland

529

40

Critical Care ...........................................................................................................
Paul K. Sikka

549

41

Postoperative Anesthesia Care..............................................................................
Maged Argalious

575

Part V Special Anesthesia Topics
42

Obesity ..................................................................................................................
Ricky Harika and Cynthia Wells

587

43

The Elderly Patient ................................................................................................
Preet Mohinder Singh and Ashish Sinha

593

44

Pulmonary Aspiration and Postoperative Nausea and Vomiting ......................
Paul C. Anderson and Li Meng

603

45

Acid Base Balance ..................................................................................................
Kristi D. Langston and Jonathan H. Waters

609

46

Trauma ..................................................................................................................
Phillip Adams and James G. Cain

615

47

Spine Surgery .........................................................................................................
Pulsar Li and Laura Ferguson

623

48

Robotic Surgery .....................................................................................................
Kyle Smith and Raymond M. Planinsic

627

49

Patient Positioning and Common Nerve Injuries ...............................................
Jonathan Estes and Ryan C. Romeo

631

50

Substance Abuse .....................................................................................................
Daniel J. Ford and Thomas M. Chalifoux

637

51

Awareness Under Anesthesia ................................................................................
Tiffany Lonchena and Cynthia Wells

643

52

Infectious Diseases .................................................................................................
Seth R. Cohen and Kristin Ondecko Ligda

647

53

Alternative Medicine and Anesthesia ...................................................................
E. Gail Shaffer and Patricia L. Dalby

653

54

Cosmetic Surgery ...................................................................................................
Jessica O’Connor and Patricia L. Dalby

657


x

Contents

55

Hazards of Working in the Operating Room ......................................................
Faith J. Ross and Ibtesam I. Hilmi

661

56

Operating Room Management .............................................................................
Sean M. DeChancie and Mark E. Hudson

667

57

Residency Requirements and Guidelines.............................................................
Joseph P. Resti and Shawn T. Beaman

671

Appendix of Management Algorithms For Certain Clinical Conditions ..................

675

Index .............................................................................................................................

685


Contributors

Ali R. Abdullah, M.B., Ch.B. Department of Critical Care Medicine, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA
M. Christopher Adams, M.D. Department of Anesthesia, Critical Care and Pain Medicine,
Massachusetts General Hospital, Boston, MA, USA
Phillip Adams, D.O. Department of Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Pedram Aleshi, M.D. Department of Anesthesia and Perioperative Care, University of
California, San Francisco, San Francisco, CA, USA
Paul C. Anderson, M.D. Department of Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Maged Argalious, M.D. Department of General Anesthesiology, Celeveland Clinic,
Cleveland, OH, USA
Shubhangi Arora Department of Anesthesia, Brigham and Women’s Hospital, Boston, USA

Manasi Badve, M.D. Department of Anesthesiology and Pain Medicine, P.D. Hindujana
National Hospital and Medical Research Center, Mumbai, Maharashtra, India
Andrew Bauer, M.D. Cleveland Clinic, Cleveland, OH, USA
Shawn T. Beaman, M.D. Department of Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Scott Berry, M.D. Department of Anesthesiology, University of Pittsburgh Medical Center,
Pittsburgh, PA, USA
Edward A. Bittner, M.D., Ph.D., F.C.C.P., F.C.C.M. Department of Anesthesia, Critical
Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
Critical Care Fellowship Director, Massachusetts General Hospital, Boston, MA, USA
Surgical Intensive Care Unit, Massachusetts General Hospital, Boston, MA, USA
Arielle Butterly, M.D. Department of Anesthesia, Critical Care and Pain Medicine,
Massachusetts General Hospital, Boston, MA, USA
Instructor in Anaesthesia, Harvard Medical School, Boston, MA, USA
James G. Cain, M.D., M.B.A., F.A.A.P. Children’s Hospital of Pittsburgh of UPMC,
Pittsburgh, PA, USA
Lundy Campbell, M.D. Department of Anesthesia and Perioperative Care, University of
California, San Francisco, San Francisco, CA, USA

xi


xii

Neal F. Campbell, M.D. Department of Anesthesiology, Children’s Hospital of Pittsburgh,
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Thomas M. Chalifoux, M.D. Department of Anesthesiology, Children’s Hospital of
Pittsburgh of UPMC, Magee-Women’s Hospital of UPMC, University of Pittsburgh School of
Medicine, Pittsburgh, PA, USA
Carlee Clark, M.D. Department of Anesthesiology and Perioperative Medicine, Medical

University of South Carolina, Charleston, SC, USA
Seth R. Cohen, D.O. Department of Anesthesiology, University of Pittsburgh Medical Center,
Pittsburgh, PA, USA
Daniel S. Cormican, M.D. Department of Anesthesiology, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA
Patricia L. Dalby, M.D. Department of Anesthesiology, Magee-Women’s Hospital of UPMC,
Pittsburgh, PA, USA
Daniela Damian, M.D. Department of Anesthesiology, Children’s Hospital of Pittsburgh,
Pittsburgh, PA, USA
Sean M. DeChancie, D.O. Department of Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Yashar Eshraghi, M.D. Department of Anesthesiology/Metro Health Medical Center,
Case Western Reserve University School of Medicine, Cleveland, OH, USA
Jonathan Estes, M.D. King’s Daughters Medical Center, Ashland, KY, USA
Laura Ferguson, M.D. Department of Anesthesiology, University of Pittsburgh School
of Medicine, Pittsburgh, PA, USA
Daniel J. Ford, M.D. Department of Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Patrick J. Forte, M.D. Department of Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Ursula A. Galway, M.D. Department of Anesthesiology, Cleveland Clinic Lerner College of
Medicine of Case Western Reserve, Cleveland Clinic, Cleveland, OH, USA
Theresa Gelzinis, M.D. Department of Anesthesiology, University of Pittsburgh, Pittsburgh,
PA, USA
Brian Gierl, M.D. Department of Anesthesiology, University of Pittsburgh, Presbyterian
Hospital, Pittsburgh, PA, USA
Benjamin Grable, M.D. Anesthesia Associates of Medford, Medford, OR, USA
Ferenc Gyulai, M.D. Department of Anesthesiology, University of Pittsburgh, Presbyterian
Hospital, Pittsburgh, PA, USA
Patrick Hackett, M.D. Department of Anesthesiology, University of Pittsburgh Medical

Center, Pittsburgh, PA, USA
Wendy A. Haft, M.D. Department of Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Thomas Halaszynski, D.M.D., M.D., M.B.A. Department of Anesthesiology, Yale University
School of Medicine, New Haven, CT, USA
Ricky Harika, M.D. Department of General Anesthesiology, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA

Contributors


Contributors

xiii

Joshua Hensley Department of Anesthesiology, University of Pittsburgh Medical Center,
Pittsburgh, PA, USA
Andrew Herlich, D.M.D., M.D., F.A.A.P. Department of Anesthesiology, University of
Pittsburgh Medical Center, Pittsburgh, PA, USA
Ibtesam I. Hilmi, M.B.Ch.B., F.R.C.A. Department of Anesthesiology, University of
Pittsburgh School of Medicine, Pittsburgh, PA, USA
Mark E. Hudson, M.D., M.B.A. Department of Anesthesiology, University of Pittsburgh,
Pittsburgh, PA, USA
Samuel Irefin, M.D. Department of General Anesthesiology, Cleveland Clinic,
Cleveland, OH, USA
Dustin J. Jackson, M.D. Department of Anesthesiology, Mount Nittany Medical Center,
PA, USA
Matthew A. Joy, M.D. Department of Anesthesiology, Case Western Reserve University
School of Medicine/Metro Health Medical Center, Cleveland, OH, USA
Jeffrey A. Katz, M.D. Department of Anesthesia and Perioperative Care, University of

California, San Francisco, San Francisco, CA, USA
Tatyana Kopyeva, M.D. Department of General Anesthesiology, Cleveland Clinic,
Cleveland, OH, USA
James C. Krakowski, M.D. Department of Anesthesiology, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA
Kristi D. Langston, D.O. Department of Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Pulsar Li, D.O. Department of Anesthesiology, University of Pittsburgh Medical Center,
Pittsburgh, PA, USA
Kristin Ondecko Ligda, M.D. Department of Anesthesiology, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA
Tiffany Lonchena, M.D. Department of Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Michael P. Mangione, M.D. University of Pittsburgh School of Medicine, Pittsburgh,
PA, USA
Department of Anesthesiology, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
Ana Maria Manrique-Espinel, M.D. Department of Anesthesiology, Children’s Hospital of
Pittsburgh of UPMC, Pittsburgh, PA, USA
Richard McAffee, M.D. Department of Anesthesiology, University of Pittsburgh School of
Medicine, Pittsburgh, PA, USA
Stephen M. McHugh, M.D. Department of Anesthesiology, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA
Li Meng, M.D., M.P.H. Department of Anesthesiology, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA
David G. Metro, M.D. Department of Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Mario I. Montoya, M.D. Department of Anesthesiology, University of Pittsburgh School
of Medicine, Pittsburgh, PA, USA

xiv

Tiffany Sun Moon, M.D. Department of Anesthesiology and Pain Management, University
of Texas Southwestern Medical Center, Dallas, TX, USA
Ramana K. Naidu, M.D. Department of Anesthesia and Perioperative Care, UCSF Pain
Management Center, University of California, San Francisco, San Francisco, CA, USA
Lee Neubert, D.O. Department of Anesthesiology, Drexel University College of Medicine,
Philadelphia, PA, USA
Maxim Novikov, M.D. Cleveland Clinic, Cleveland, OH, USA
Jessica O’Connor, D.O. Department of Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Todd M. Oravitz, M.D. Department of Anesthesiology, University of Pittsburgh School of
Medicine, Pittsburgh, PA, USA
VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
Steven L. Orebaugh, M.D. Department of Anesthesiology, University of Pittsburgh
Medical Center, Southside/Mercy Ambulatory Center, Pittsburgh, PA, USA
Thoha M. Pham, M.D. Department of Anesthesia and Perioperative Care, UCSF Pain
Management Clinic, University of California, San Francisco, San Francisco, CA, USA
Raymond M. Planinsic, M.D. Department of Anesthesiology, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA
Joseph P. Resti, M.D. Department of Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of
Philadelphia, Philadelphia, PA, USA
Ryan C. Romeo, M.D. Department of Anesthesiology, Magee-Womens Hospital of UPMC,
Pittsburgh, PA, USA
Faith J. Ross, M.D., M.S. Department of Anesthesiology, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA
Scott M. Ross, D.O. Department of Anesthesiology, University of Pittsburgh Medical Center,
Pittsburgh, PA, USA

Kasia Petelenz Rubin, M.D. Department of Anesthesiology, University Hospitals of
Cleveland/Case Western Reserve University, Cleveland, OH, USA
Mahesh Sardesai, M.D., M.B.A. Department of Anesthesiology, UPMC Shadyside Hospital,
Pittsburgh, PA, USA
E. Gail Shaffer, M.D., M.P.H. Department of Anesthesiology, Children’s Hospital of
Pittsburgh, Pittsburgh, PA, USA
Dipal Shah All India Institute of Medical Sciences, New Delhi, India
Paul K. Sikka, M.D., Ph.D. Department of Anesthesia and Perioperative Medicine, Emerson
Hospital, Concord, MA, USA
Preet Mohinder Singh, M.D. All India Institute of Medical Sciences, New Delhi, India
Ashish Sinha, M.D., Ph.D. Department of Anesthesiology and Perioperative Medicine,
Drexel University College of Medicine, Philadelphia, PA, USA

Contributors


Contributors

xv

Kyle Smith, M.D. Department of Anesthesiology, University of Pittsburgh Medical Center,
Pittsburgh, PA, USA
Christopher Stemland, M.D. Department of Anesthesiology, The University of Virginia
School of Medicine, Charlottesville, VA, USA
James A. Street, PhD, MD Department of Anesthesiology and Perioperative Medicine,
Emerson Hospital, Concord, MA, USA
Emily L. Sturgill, M.D. Department of Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Kathirvel Subramaniam, M.D. Department of Anesthesiology, UPMC Presbyterian
Hospital, Pittsburgh, PA, USA

Erin A. Sullivan, M.D. Division of Cardiothoracic Anesthesiology, Department of
Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
John E. Tetzlaff, M.D. Department of General Anesthesia, Cleveland Clinic’s Anesthesiology
Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University,
Cleveland, OH, USA
Michael Tom, M.D. Department of Anesthesiology, Yale University School of Medicine,
New Haven, CT, USA
John H. Turnbull, M.D. Department of Anesthesia and Perioperative Care, University of
California, San Francisco, San Francisco, CA, USA
Manuel C. Vallejo, M.D., D.M.D. Department of Anesthesiology, West Virginia University
School of Medicine, Morgantown, WV, USA
Jonathan H. Waters, M.D. Department of Anesthesiology, Magee Women’s Hospital of
UPMC, Pittsburgh, PA, USA
Cynthia Wells, M.D. Department of Anesthesiology, University of Pittsburgh School of
Medicine, Pittsburgh, PA, USA
Terrance Allan Yemen, M.D. Department of Anesthesiology and Pediatrics, University of
Virginia Medical Center, Charlottesville, VA, USA


Part I
The Basics


1

History of Anesthesia
Paul K. Sikka
“Gentlemen this is no humbug”

The desire to relieve pain has been a never-ending quest for

humans and is, therefore, responsible for the birth of the specialty “anesthesiology.” From the earliest records when
opium sponges were used to relieve pain until today, the
desire to relieve human pain and suffering has been second
to none.

Inhalational Anesthetic Agents
The road to developing modern inhalational anesthetic
agents started with ether (Table 1.1). The abovementioned
words were used by John Warren, a surgeon, to describe a
successful “public” demonstration of ether anesthesia administered by William Morton (Figs. 1.1 and 1.2) at the
Massachusetts General Hospital on October 16, 1846. The
patient was Edward Gilbert Abbott. Warren performed a
painless surgery on Abbott’s neck tumor, even though Abbott
was aware that the surgery was proceeding. This marked the
inauguration of the specialty “anesthesiology.”
The quest for a pleasant and rapid-acting inhalational
agent leads to the discovery of chloroform which was first
used by J. Y. Simpson for obstetric anesthesia. However, the
administration of chloroform for obstetrics was brought into
fame by John Snow who administered the agent for Queen
Victoria’s deliveries. Ether (unpleasant) and chloroform
(liver and cardiac toxicity) were replaced by ethylene gas
(high concentration requirement and explosive potential),
which was in turn replaced by cyclopropane (more stable).
Finally, came the era of fluorinated inhalational agents
(increased stability, decreased toxicity). Trifluoroethyl vinyl
ether (toxic metabolite) was the first fluorinated anesthetic
agent to be used which was followed by halothane (hepatitis),

P.K. Sikka, M.D., Ph.D. (*)

Department of Anesthesia and Perioperative Medicine,
Emerson Hospital, 133 Old Road to Nine Acre Corner,
Concord, MA 01742, USA
e-mail:

methoxyflurane (nephrotoxicity), enflurane (cardiac depression, convulsant properties), and finally isoflurane (synthesized by Ross Terrell in 1965, clinically used in 1971).
John Snow (1813–1858, England) was popularly known
as “the first anesthesiologist” (Fig. 1.3). His research leads to
the development of the concept of minimum alveolar concentration (MAC). He administered ether and chloroform in
various concentrations to anesthetize animals and determined the concentration to prevent movement to a sharp
stimulus. He also described the stages of ether anesthesia
and invented the ether face mask. Joseph Clover (1825–1882,
England) was a leading anesthesiologist in London after
Snow’s death. He favored a nitrous oxide-ether sequence for
anesthesia and introduced pulse monitoring during anesthesia. He designed the Clover-respirator bag (to deliver known
quantities of chloroform), introduced airway management
skills and use of airway cannulas, and designed a portable
anesthesia machine.

The Story of Nitrous Oxide
Joseph Priestly, an Englishman and one of the greatest pioneers of chemistry, first prepared nitrous oxide in 1773.
Horace Wells (Fig. 1.4) of Hartford, CT, was one of the first
to recognize the anesthetic potential of nitrous oxide. On
December 10, 1844, while attending an exhibition where
nitrous oxide was made available to the audience for inhalation, he noticed that Samuel Cooley, one of the guests, was
unaware that his leg was injured while dancing. The next day
Horace Wells allowed Gardner Colton, a dentist, to extract
his tooth under nitrous oxide inhalation. Horace Wells
described his procedure as a success. A few weeks later
Wells tried to simulate the same procedure for dental extraction in a medical student in Boston. The medical student

screamed and Wells was labeled as a failure. He finally committed suicide in 1848. After his death, Colton led the revival
of nitrous oxide, one of the oldest anesthetic agents, which is
still being used.

P.K. Sikka et al. (eds.), Basic Clinical Anesthesia,
DOI 10.1007/978-1-4939-1737-2_1, © Springer Science+Business Media New York 2015

3


4

P.K. Sikka

Table 1.1 Ether milestones
William E. Clarke

January 1842,
Rochester, NY

Crawford W. Long

March 1842,
Jefferson, Georgia

James Y. Simpson

November 1847,
Edinburgh,
Scotland

Teeth extraction of Ms.
Hobbie by dentist
E. Pope
Neck tumor excision of
Mr. Venable. Fee
charged $2.00
Among the first to use
ether and then
chloroform for labor
pain relief

Fig. 1.3 John Snow 1813–1858, the first anesthesiologist (courtesy of
the Wood Library-Museum of Anesthesiology, Park Ridge, Illinois)

Fig. 1.1 William T. G. Morton 1819–1868 (courtesy of the Wood
Library-Museum of Anesthesiology, Park Ridge, Illinois)

Fig. 1.4 Horace Wells 1815–1848 (courtesy of the Wood LibraryMuseum of Anesthesiology, Park Ridge, Illinois)

Intravenous Anesthetics

Fig. 1.2 A replica of William Morton’s ether inhaler as used at the first
public demonstration of ether anesthesia on October 16, 1846 (courtesy
of the Wood Library-Museum of Anesthesiology, Park Ridge, Illinois)

Phenobarbital, a barbiturate, was the first intravenous induction agent developed. It was synthesized by Emil Fischer and
Joseph von Mering in 1903. Phenobarbital caused prolonged
periods of unconsciousness and was associated with slow

1

5

History of Anesthesia

emergence. Hexobarbital, a short-acting barbiturate, was
clinically introduced in 1932. This was replaced by a more
potent and rapidly acting barbiturate, thiopental, which was
first clinically used in 1934.
Curare was the first muscle relaxant to be used by Harold
Griffith in 1942 for an appendectomy. Succinylcholine was
synthesized by Daniel Bovet in 1949 and till today is one of
the most widely used muscle relaxants. In 1960s muscle
relaxants with steroidal nucleus, pancuronium and
vecuronium, were synthesized. The opioid “fentanyl” (chemical R4263) was synthesized in 1960 by Paul Janssen and
remains one of the most popular pain-relieving agents used
today. In 1977, propofol was synthesized by Imperial
Chemical industries and is widely in use at present for sedation or induction and maintenance of anesthesia.

Table 1.2 Airway milestones
William Macewan, 1878

Alfred Kirstein, 1895
N. Korotkoff, 1905
M. Neu, 1910
Sir Ivan Magill, 1920

Arthur Guedel, 1926

Phillip Ayre, 1937
Lucien Morris
British engineers

Airway and the Anesthesia Machine
Jay Heidbrink, Samuel White, and Charles Teter (American
dentists) were the first to develop instruments in order to use
compressed cylinders of nitrous oxide and oxygen. Then
came the Boyle machines (Henry Boyle, England) and the
Draeger machines (Heinrich Draeger, Germany). The first
use of carbon dioxide absorbers occurred in 1906 (Franz
Kuhn, Germany), which were made simpler and less bulky
by Ralph Waters. In 1930, Brian Sword created an anesthesia
machine with a circle system and an in-circuit carbon dioxide absorber. Airway milestones are listed in Table 1.2.

Local and Regional Anesthesia
Carl Koller was one of the pioneers in discovering the local
anesthetic properties of cocaine (an extract of the coca leaf). He
used it extensively in his practice to anesthetize the eyes for
ophthalmic surgery. William Halsted and Richard Hall used
cocaine to perform blocks of the sensory nerves of the face and
arms. Both ended up becoming addicted to cocaine (a phenomenon which was not understood until later). Leonard Corning
coined the term spinal anesthesia in 1885 (administered cocaine
to produce blockade of the lower extremity). August Bier
(credited for spinal anesthesia) and Theodore Tuffier were the
first to describe spinal anesthesia with the mention of escape of
cerebrospinal fluid. August Bier was also the first to report the
technique of intravenous regional anesthesia with procaine, a
procedure later modified by Mackinnon Holmes. Regional
anesthesia milestones are listed in Table 1.3.

Finally, it is worth mentioning that Ralph Waters was the
first president of the American Society of Anesthesiologists
(ASA) in 1945. He is credited to raise the academic standards in anesthesia and launched extensive anesthesia residency training programs.

Robert Miller, 1941
Sir Robert Macintosh, 1941
Glen Millikan, 1945
F. Robertshaw, 1953
Bain-Spoerel apparatus, 1972
A. Brain, 1981

First orotracheal intubation with
flexible metal tubes, technique
advanced by Franz Kuhn, 1900,
Germany
First direct vision laryngoscope
Blood pressure measurement
First to apply rotameters in
anesthesia
Technique for blind nasal
intubations, Magill’s airway tubes,
and angulated forceps
Cuffed airway tubes
Ayre’s T-piece (reduce work of
breathing)
Copper Kettle, first temperaturecompensated vaporizer
Tecota (temperature-compensated
trichloroethylene air vaporizer),
Fluotec, the first series of agentspecific vaporizers
Miller straight blade

Macintosh curved blade
Developed the first pulse oximeter
Double lumen tubes
Light weight breathing apparatus
Laryngeal mask airways (LMA)

Table 1.3 Regional anesthesia milestones
Heinrich Quincke, 1899
Dudley Tail and Guidlo
Caglieri, 1899
Heinrich Braun, 1900

Arthur Barker, 1907
Achille Dogliotti, 1931
William Lemmon, 1940
Lofgren and Lundquist, 1943
Edward Tuohy, 1944
Labat and Wertheim
Rovenstein
John Bonica

Described the technique of lumbar
puncture
Advocated use of small needles to
prevent CSF escape
Used epinephrine to prolong the
effect of local anesthetics, first to
use procaine, “father of conduction
anesthesia”
Concept of hyperbaric solutions

Loss of resistance technique
Concept of continuous spinal
anesthesia
Synthesis of lidocaine
The famous “Tuohy” needle
First American Society for regional
anesthesia
First American chronic pain clinic
Multidisciplinary pain clinic

Further Reading
1. Frolich MA, Caton D. Pioneers in epidural needle design. Anesth
Analg. 2001;93:215–20.
2. Greene NM. Anesthesia and the development of surgery (18461896). Anesth Analg. 1979;58:5–12.


6
3. Griffith HR, Johnson GE. The use of curare in general anesthesia.
Anesthesiology. 1942;3:418–20.
4. Knapp H. Cocaine and its use in ophthalmic and general surgery.
Arch Ophthalmol 1884;13:402.
5. Lyons AS, Petrucelli RJ. Medicine: an illustrated history. New York:
Abradale Press; 1978. p. 530.

P.K. Sikka
6. McIntyre AR. Historical background, early use and development of
muscle relaxants. Anesthesiology. 1959;20:409–15.
7. Waters RM. Pioneering in anesthesiology. Postgrad Med.
1948;4:265–70.

2

Preoperative Evaluation
Ursula A. Galway

Preoperative evaluation of patients undergoing anesthesia is
a mandatory requirement as per the American Society of
Anesthesiologists (ASA) and the Joint Commission for the
Accreditation of Healthcare Organizations (JCAHO). Goals
of preoperative evaluation are summarized in Fig. 2.1.
Preoperative evaluation should include a detailed patient’s
history, medications and allergies, previous surgeries including anesthetic problems, physical and airway examination,
NPO status, and formulation of an anesthetic plan. A basic
anesthetic pre-evaluation is summarized in Table 2.1.

Preoperative System Review
Cardiovascular
In general, history should include questions about hypertension (diastolic BP < 110 mmHg), angina, myocardial infarction, congestive cardiac failure, arrhythmias (atrial fibrillation
on warfarin), valvular disease, lipids status, and the presence
of a pacemaker/AICD. Specific guidelines for preoperative
cardiac evaluation for noncardiac surgery were initially
developed in 1980 by the American Heart Association and
American College of Cardiology. This included an algorithm
to assist in clinical decision making for cardiac evaluation.
The most recent revision of this was in October 2007. The
algorithm (Table 2.2) is now based on several factors:
• Need for surgery
• Presence of active cardiac conditions
• Surgical risk

• Functional capacity
• Clinical indicators/risk factors

U.A. Galway, M.D. (*)
Department of Anesthesiology, Cleveland Clinic Lerner College of
Medicine of Case Western Reserve, Cleveland Clinic,
9500 Euclid Avenue, Cleveland, OH 44195, USA
e-mail:

Need for Surgery

During emergency surgeries, cardiac complications are
significantly increased, up to 2–5 times more frequent when
compared to similar elective procedures. Due to the nature of
emergency surgery, it is not possible to optimize the patient
with significant cardiac comorbidities that are currently not
under control. In addition, the nature of the surgery and the
insult to the system that has already occurred may make perioperative precautions (i.e., maintenance of blood pressure,
avoidance of anemia, use of invasive monitors, etc.) all that
one can do to decrease perioperative morbidity and mortality.
If the surgery is emergent, then surgery needs to happen
regardless of the patient’s comorbidities. The physician
should determine cardiac status and tailor anesthetic management based on that. However, if the surgery is not an
emergency, the physician needs to determine the surgical
risk, whether or not the patient has active cardiac conditions,
clinical risk factors, and what the patient’s functional capacity is, and tailor preoperative workup based on this.
Active Cardiac Conditions

If a patient has any active cardiac conditions, this mandates
further evaluation and intensive management, which may

result in surgical delay. Active cardiac conditions are listed
in Table 2.3. If a patient has active cardiac conditions involving the coronary arteries, then one must take into consideration how long the surgery can wait. This timing is related to
the period that the patient needs to be on antiplatelet medication after revascularization:
• Balloon angioplasty—delay surgery 2–4 weeks
• Bare metal stent—delay surgery 4–6 weeks to allow
endothelialization of stent. Administer aspirin and Plavix
for 4 weeks.
• Drug-eluting stent—need to complete 12 months of dual
antiplatelet therapy
Surgical Risk

Surgical risk is divided into three categories—high (vascular), intermediate, and low (Table 2.4). The evaluating

P.K. Sikka et al. (eds.), Basic Clinical Anesthesia,
DOI 10.1007/978-1-4939-1737-2_2, © Springer Science+Business Media New York 2015

7


U.A. Galway

8

clinician must also take into account the type of surgery
the patient is scheduled to undergo. Factors related to the
type of surgery are a function of the degree of invasiveness. Therefore, the amount of expected blood loss, duration of the procedure, potential patient-related stress, and
fluid shifts associated with the procedure all need to be
taken into account. Once all of these factors are evaluated,
a final decision can be made as to the patient’s potential for
experiencing a perioperative cardiac complication. Patients

undergoing low-risk surgery do not need any additional
cardiac testing, unless of course active cardiac conditions
are present.
Functional Capacity

Functional capacity involves assessing metabolic equivalent
of task (MET) (Table 2.5). If the patient is unable to obtain
an exercise level of 4 MET or MET cannot be obtained, further testing may be warranted depending on the patient’s
clinical risk factors and the invasiveness of surgery. Patients
who can achieve more than 4 MET rarely need any additional cardiac testing.

Fig. 2.1 Goals of preoperative evaluation

Table 2.1 Basic preoperative evaluation
Patient particulars
Allergies
Medications
Previous surgeries
Anesthesia problems
System review
Airway examination
Physical examination
Laboratory values
NPO status
Anesthetic plan
Regional anesthesia
Invasive monitoring
ASA classification

Age

Sex
Drug and type of allergy: rash/anaphylaxis
List of medications and those taken in AM
List of surgeries
PONV
MH
See below
Class 1–4
Neck movements
Cardiac
Pulmonary
CBC
Chemistry
Full stomach precautions?
General
Regional
Spinal
Epidural
Arterial line
Central venous catheter
1–6 (E)

Height

Weight

Other
Dentition (dentures/caps/crown)
Neurological
Vitals/others

Coagulation
ECG/chest X-ray/others
TIVA
MAC
Nerve block: single shot/continuous
Pulmonary artery catheter

Table 2.2 Cardiac evaluation algorithm
Active cardiac conditions
Yes
No

Surgical risk

Functional capacity

Clinical risk factors

Surgical class

Low
Intermediate or
high

>4 MET
<4 MET

3 or more

Vascular

Intermediate
Vascular
Intermediate
Vascular
Intermediate

1–2
None
MET metabolic equivalent of task

Plan
Testing and treatment
Surgery
Surgery
Testing/surgery
Surgery/beta-blockers or testing
Surgery/beta-blockers or testing
Surgery/beta-blockers or testing
Surgery
Surgery


2 Preoperative Evaluation

9

Table 2.3 Active cardiac conditions

Clinical Risk Factors

Unstable coronary
syndromes

Unstable angina
Acute myocardial infarction within 30 days
Congestive heart failure Decompensated
Arrhythmias
Heart block
Atrial fibrillation
Ventricular tachycardia
Symptomatic bradycardia
Severe valvular disease Severe aortic stenosis (mean pressure
gradient greater than 40 mmHg, valve area
less than 1 cm2, presence of symptoms)
Symptomatic mitral stenosis

Table 2.4 Surgical risk
High—vascular (cardiac
risk >5 %)
Aortic
Major vascular
Peripheral vascular

Intermediate (cardiac risk
1–5 %)
Orthopedic
Head and neck
Prostate
Intraperitoneal or
intrathoracic

Carotid endarterectomy

Low (cardiac
risk <1 %)
Endoscopy
Breast
Eye

Table 2.5 Assessing metabolic equivalent of task (MET)
MET
1–3 MET

4–9 MET

10 MET or greater

Activity
Taking care of yourself
(eating, desk work),
walking 1–2 blocks
Climb stairs, walk briskly,
running short distance,
moderate sports
Active sports (swimming,
ski, jogging)

Perioperative
cardiac risk
High

Intermediate to low

Low

Table 2.6 Clinical risk factors
Heart disease

Congestive heart failure
(CHF)

Cerebrovascular disease
Diabetes mellitus
Renal insufficiency

Myocardial infarction >1 month
Positive stress test
Nitroglycerin use
Angina
Q waves on EKG
History of CHF
Positive chest X-ray (pulmonary
vascular redistribution)
Peripheral edema, presence of third
heart sound (S3) and rales on chest
auscultation, dyspnea
History of stroke or transient ischemic
attack (TIA)
Insulin therapy
Serum creatinine > 2

If the patient is undergoing intermediate-risk surgery and has
an activity level of less than 4 MET, one must establish how
many clinical risk factors the patient has (Table 2.6). If there
are no clinical risk factors then one may proceed with surgery. If one or more risk factors are present, then additional
cardiac testing may be considered if it will change management. If no cardiac testing is decided, then one may proceed
with surgery with heart rate control.
If the patient is undergoing high-risk surgery and has an
activity level of less than 4 MET, one must establish how
many clinical risk factors the patient has. If there are no clinical risk factors, then it may be fine to proceed with surgery.
If there are 1–2 clinical risk factors, then consider additional
cardiac testing if it will change management, or proceed to
the operating room with heart rate control. If there are three
or more clinical risk factors, then proceed with additional
cardiac testing.

Pulmonary
Asthma and COPD

Both asthma and COPD increase the risk of postoperative
respiratory failure. The history should include questions
about the type of therapy including steroid use, severity (ER
visits, intubation), and any aggravating factors, such as aspirin use or exercise. The patient should be instructed to continue their inhalers as usual and to bring them with them on
the day of surgery. If the patient has worsening symptoms or
poorly controlled COPD/asthma, a pulmonary consult may
be warranted.
Sleep Apnea

The evaluating physician should inquire about snoring (confirmed by a partner), hypertension, chronic fatigue, and obesity. Patients that wear continuous positive airway pressure
(CPAP) masks should be instructed to bring their machines
on the day of surgery.

Smoking

Patients should be instructed to stop smoking before surgery.
Smoking increases airway reactiveness, inhibits ciliary motility to remove secretions, causes poor wound healing, and
increases the rate of complications after surgery. The maximal
beneficial effects occur if smoking is stopped for at least 8
weeks prior to surgery. However, carboxyhemoglobin (carbon
monoxide—CO) levels decrease in the first 12–24 h after stopping smoking (improves oxygenation). Both nicotine and CO
have negative effects on the heart (increase oxygen demand,
decrease contractility). It should be noted that in some patients,
airway reactiveness and secretions might increase paradoxically for about a week after smoking cessation.


10

Neurological
In general, one should inquire about diseases such as multiple sclerosis, myasthenia gravis and muscular disorders, and
spinal cord injury (level of lesion—risk of hypertensive crisis in lesions above T6). The evaluating physician should
inquire about the type of seizure type, frequency, and medications. Antiseizure medications should be continued
throughout the perioperative period. If the patient cannot
take oral medications postoperatively, then intravenous formulations should be substituted. Any baseline functional and
neurological impairments (any residuals) should be documented. If the patient has advanced dementia, the evaluating
physician may need to take history or to get informed consent from a family member or health care proxy.

U.A. Galway

have to be used instead of a laryngeal mask airway). Patients
may be given aspiration prophylaxis preoperatively. Obesity
increases anesthesia risks. Documentation of body mass
index (BMI) (weight in kg/height in m2), airway difficulties,

and presence of comorbid conditions such as hypertension,
diabetes, and sleep apnea is important. These patients may
require special equipment in the operating room, such as a
large blood pressure cuff, adequate padding, wide stretchers,
and larger operating room beds.

Pregnancy
Childbearing age women should be asked if there is any
chance of pregnancy. A pregnancy test should be performed
on all women of childbearing age. Usually, the test is valid
for 2 weeks.

Renal
Chronic kidney disease is a complex systemic disease that
results commonly from conditions, such as diabetes mellitus,
hypertension, and glomerulonephritis. For patients on hemodialysis, the frequency and route of administration of dialysis
should be documented, including a plan for timing of dialysis
perioperatively. A potassium level should be obtained preoperatively. Volume control is a critical issue in dialysis patients,
and these patients may be prone to hypotension.

Family History
One should evaluate for a history of malignant hyperthermia
(presence or family history), pseudocholinesterase deficiency (history of unexplained prolonged weakness or postoperative intubation in otherwise healthy patients), and other
neuromuscular disorders.

Prior Anesthetic History
Hepatic
Etiologies of liver disease include alcoholic, infectious, autoimmune, or neoplastic processes. End-stage liver disease
may manifest with ascites, coagulopathies, and encephalopathy with alterations in drug distribution and metabolism.
Platelet count and coagulation profile should be evaluated

preoperatively in these patients.

Patients should be questioned on their prior surgeries—
type and approximate dates. They should also be questioned on whether they had any history of difficult
intubation, postoperative nausea or vomiting, poor venous
access, mask “phobia” or claustrophobia, and any other
problems perioperatively.

Allergies and Social Habits
Endocrine
For patients with diabetes mellitus (DM), history should
include the type of DM (I/II), insulin or oral medications,
and presence of associated diseases, such as hypertension,
coronary, vascular, cerebrovascular, or renal disease. A history of hemoglobin A1-C results can be used to establish the
degree of blood glucose control. Patients with a history of
thyroid disease should be euthyroid before surgery.

Gastrointestinal
A positive history of gastroesophageal reflux may result in a
change in the anesthetic plan (endotracheal intubation may

A history of alcohol intake, smoking, and illegal drug use
should be obtained. These patients may experience an
increased tolerance to anesthetic agents and the potential for
unexpected withdrawal following the surgery.

Medications
All medications and their dosages, including medications
taken in AM of surgery, should be documented. The following instructions should be given to patients preoperatively:
• Medications to be taken on the day of surgery include betablockers, asthma medications, antihypertensives (except

ACE inhibitors and diuretics), antiseizure medications,