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Because of the multiple types and subtypes of von Willebrand disease that have different responses to therapy, it is imperative that hematologic studies be part of the management to help guide the most appropriate therapy. Because alcohol is hypobaric and phenol is hyperbaric, the patient must be positioned accordingly during administration of intrathecal neurolysis. In general, consultation is often requested for assistance with symptoms that are difficult to control, complex decision making, and provider or family support. For the anesthesiologist, recognizing depression and making appropriate referrals is important; depression may affect pain management, quality of life, and treatment decisions. The large body surface area predisposes children to hypothermia with all the associated negative consequences in trauma such as traumatic coagulopathy. The absence of these changes does not rule out the presence of life-threatening injury to the heart or its surrounding structures. Because adrenergic receptors are abundant in prostate tissue, the use of adrenergic agonists would cause vasoconstriction of prostatic blood vessels and a decrease in blood loss. We doubt that the possible occurrence of this phenomenon represents a contraindication to N2O. The proper function of the vent pump should be confirmed at the field before the pump is connected to the patient. If the arms are to be tucked by the side of the patient, then wide, well-padded sleds may be useful. The evaluation and management of coexisting cardiac and pulmonary disease are discussed earlier in this chapter. Bernucci F, Carli F: Functional outcome after major orthopedic surgery: the role of regional anesthesia redefined, Curr Opin Anesthesiol 25:621-628, 2012. The actual choice of anesthetics to be used will depend on circumstances and national availability. However, in clinical practice, remifentanil is mostly given because of hemodynamic variable changes, which is also just an indirect, albeit widely accepted, surrogate for nociception. Resuscitation from hemorrhagic shock refers specifically to restoration of normal circulating blood volume, normal vascular tone, and normal tissue perfusion. Anthrax is a notable exception; its spores have very long persistency, but no infective transmissibility. The anesthesiologist plays a crucial role within the multidisciplinary team to direct the patient toward a multimodal pain treatment plan. Assuming that the heparin-protamine titration curve for an individual patient remains constant throughout the operative period, protamine titration methods may estimate heparin doses required to achieve a desired plasma heparin concentration or the protamine dose needed to reverse a given heparin concentration in blood. The urinary dilution mechanism persists after concentrating defects are present, so a urinary osmolality of 50 to 100 mOsm/kg still may be consistent with advanced renal disease. To avoid the influence of artifacts, the mean of eight block measurements were taken at 2-minute intervals. Early cognitive loss, once thought to be transient, may persist for 5 years after cardiac surgery in as many as 40% of patients. Administration of fluids intravenously (5 mL/kg), careful titration of anesthetics, and immediate treatment of hypotension are especially important. Subsequently, the practice of more generous fluid administration for patients undergoing posterior fossa procedures evolved. When increased mitral insufficiency further exacerbates the hemodynamic changes, repositioning the heart is a simple maneuver that may increase ventricular filling and normalize ventriculoannular geometry. After bimanual massage, oxytocin should be administered as the initial treatment and prophylactic drug for uterine atony. However, fetal clot formation in response to tissue injury is decreased in comparison to that in adults. Hypo-osmolar urine in the face of an elevated and rising serum osmolality strongly supports the diagnosis. Health care staff should remember that a patient may move in response to noxious stimulation and that full curarization is required for surgical procedures involving brain death. Abnormal thyroid function ultimately affects cardiac function in many ways (Table 67-2). Going inside this right upper lobe with the bronchoscope should reveal three orifices (apical, anterior, posterior).

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Acute myocardial injury can occur in brain-dead donors without a history of coronary artery disease. Thiel T, Heddle N, Greinacher A: Donor exposures in recipients of pooled platelet concentrates, New Engl J Med 368:487-489, 2013. It is dispensed in solutions that can easily become contaminated in the potentially nonsterile conditions that may prevail in disaster management. For example, baroreceptor activation resulting from increased aortic pressure should depress the heart rate, contractility, and vascular tone. The early establishment of intravenous access aids the administration of fluids and drugs. Operative repair of visceral artery stenosis is reserved for symptomatic patients. Therefore, the perfusionist must either decrease the "sweep speed" of the air-oxygen mixture or, less commonly, add carbon dioxide to the oxygenator ventilation system to increase the carbon dioxide content and maintain a PacO2 of 40 mm Hg (and normal pH) as the temperature of the blood decreases. Cardiac complications such as arrhythmia and ischemia occur in 10% to 15% of the thoracic population. Lavoie A, Guay J: Anesthetic dose neuraxial blockade increases the success rate of external fetal version: a meta-analysis, Can J Anaesth 57:408-414, 2010. Closed-loop control was performed during 65% of the time and induction was performed manually, with only propofol controlled remotely and by closed-loop. The tip of the needle is seen to enter the paravertebral space and the pleura is not punctured. Lim W: Antiphospholipid antibody syndrome, Hematology Am Soc Hematol Educ Program 2009:233-239, 2009. An advantage of rigid bronchoscopy over flexible bronchoscopy is that it can bypass the obstruction and provide a ventilation pathway if complete obstruction occurs. They are obviously very simple but can result in astonishing controller performance. The incidence of hypotension (the patient is in a sitting position for treatment) is higher, however. Air entry may also occur via emissary veins, particularly from suboccipital musculature, via the diploic space of the skull (which can be violated by both the craniotomy and pin fixation) and the cervical epidural veins. In addition, clearance of normeperidine is reduced, and patients with severe liver disease may experience neurotoxicity from accumulation of normeperidine. A choice must be made regarding the method of increased opioid delivery, either systemically or through an epidural solution. Induction of anesthesia in patients with a compromised airway requires good communication between the surgical team and the anesthesiologist. The severity of the dysfunction correlates best with the severity of the neurologic injury203 and is sometimes sufficient to require pressor support. No difference was found in the incidence of serious systemic complications between the blocks. Spinal cord angiogram of an extensive degenerative thoracoabdominal aortic aneurysm. Gating produces an inward current of sodium (Na+) and calcium (Ca2+) ions into the peripheral nociceptor terminal. Another technique of mechanical limitation of blood flow to the nonventilated lung is the inflation of a pulmonary artery catheter balloon in the main pulmonary artery of the operative lung. Nakata M, Sumie M, Murata S, et al: Fetoscopic laser photocoagulation of placental communicating vessels for twin-reversed arterial perfusion sequence, J Obstet Gynaecol Res 34:649-652, 2008. Although adjunctive retroperitoneal procedures may allow a larger number of patients to undergo endovascular aortic repair, such procedures are associated with an increased risk for complications, greater blood loss, longer procedure time, and longer hospital length of stay than endovascular repair with standard femoral access. The objectives of this system are to reduce victim mortality and ensure that resources will be allocated only to those who will benefit from them. Thoracic aortic cross-clamping with the use of vasodilator therapy to normalize ventricular loading conditions maintains or increases cardiac output. Procedures related to movement disorders most often target the subthalamic nucleus, the internal segment of the globus pallidus, or the ventral intermediate nucleus of the thalamus. Morgan C, Zappitelli M, Gill P: Statin prophylaxis and inflammatory mediators following cardiopulmonary bypass: a systematic review, Crit Care 13:R165, 2009. Watanabe S, Noguchi E, Yamada S, et al: Sequential changes in arterial oxygen tension in the supine position during one-lung ventilation, Anesth Analg 90:28, 2000.

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The benzodiazepines, especially diazepam,13 have a long half-life and tend to accumulate. Unilateral recurrent laryngeal nerve injury may result in ipsilateral true vocal cord paralysis in the paramedian position. The second phase involves a right-sided thoracotomy in the left lateral position and esophageal reconstruction through the thoracic route. In addition, during awake intubation, airway reflexes are generally maintained sufficiently to guard against pulmonary aspiration, an important point in patients with a high risk of aspiration of gastric contents. Kalisvaart and associates83 attempted to validate the medical risk factor model of delirium in older patients who have had hip surgery. The patient should be placed back on mechanical ventilator support, and medical management should continue until the second neurologic examination and apnea test confirming brain death is completed. The user needs to indicate to the device definite steps of surgery, such as intubation, positioning, disinfection, incision, and 20 minutes to the end, which are also used as variables to modify control of drug dosing. Ropivacaine and levobupivacaine were synthesized to reduce cardiotoxicity that occurs with inadvertent intravascular bolus doses of bupivacaine. Different techniques of exercise such as muscle conditioning and aerobics are efficacious in improving function, pain, disability, and fear avoidance behavior. Commotio cordis describes a scenario during which the chest of a child is struck by an object, such as a baseball or puck, during the critical phase of cardiac repolarization; as a result, ventricular fibrillation is triggered. This wave of casualties may rapidly overwhelm the available hospital resources, and further triage is essential at this stage. A carrier drip flows steadily such Monitoring An arterial line is invariably appropriate. Another group of patients who may benefit from the use of bronchial blockers are cancer patients who have undergone a previous contralateral pulmonary resection. With disease progression, severe disabling intermittent claudication or rest pain-critical limb ischemia-can develop. Despite a tremendous amount of investigative effort, only limited data support the assumption that cerebral monitoring actually improves patient outcome after carotid endarterectomy. Interventional techniques such as intrathecal catheters may be appropriate in some patients151 (also see Chapter 64). Risk indices do not provide specific risk prediction for individuals, but rather place patients in general risk categories, most commonly designated as low (cardiac risk generally < 1%), intermediate (cardiac risk of 1% to 5%), or high (cardiac risk often > 5%). When oral administration is not feasible, parenteral administration of narcotics should be used. Known concerns and risks include catheter migration into the heart across the aortic valve and distal migration with occlusion of the brachiocephalic trunk. The high intrathoracic pressure that can occur with mechanical ventilation, coughing, the Valsalva maneuver, bronchospasm, or positive end-expiratory pressure can actually reverse the direction of a left-to-right shunt or at least make it bidirectional. Streltzer J: Pain management in the opioid-dependent patient, Curr Psychiatry Rep 3:489-496, 2001. Preoperative efforts to minimize pulmonary complications after cardiac surgery include optimizing pulmonary function for patients undergoing elective surgical procedures. The same group followed the simulation study with a trial in 12 patients that had a success rate of 91%; one intubation was not possible because of fogging of the videolaryngoscope and all intubations were performed within 2 to 3 minutes. Intraoperative angiography is an increasingly common component of the management of intracranial aneurysms. Blunt thoracic trauma requiring pneumonectomy is often associated with abdominal and pelvic trauma. Decompression of the gastric pouch in patients undergoing surgery to relieve small bowel obstruction can be achieved with careful introduction of a nasogastric or orogastric tube just before induction of general anesthesia. Most transplant recipients can be managed according to routine anesthetic practice including optimal perioperative respiratory care, antibiotic prophylaxis, and maintenance of immune suppression. Cardiac surgical textbooks suggest that hemodilution is important in minimizing any microcirculatory disturbances that may occur because of increased blood viscosity.

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The latter probably accounts for less than 10% of the cerebrovascular sequelae of carotid atherosclerosis. Beermann B, Groschineky-Grind M, Rosen A: Absorption, metabolism and excretion of hydrochlorothiazide, Clin Pharmacol Ther 19:531, 1976. Robinson J, Gott M, Ingleton C: Patient and family experiences of palliative care in hospital: what do we know Lynch T, Connor S, Clark D: Mapping levels of palliative care development: a global update, J Pain Symptom Manage 45:10941106, 2012. However, where circumstances of sterility and storage permit, propofol may be appropriate for rapid procedures such as wound dressing change and burn debridement. Similar to pulse oximetry, cerebral oximetry is based on the different absorption characteristics of the near-infrared spectrum of oxygenated and deoxygenated hemoglobin. This repositions the intraabdominal portion of the esophagus intrathoracic and decreases the competence of the lower esophageal sphincter muscle. Epidural hematoma has been reported in a woman with neurofibromatosis in the setting of a spinal tumor. Other parameters are displayed: last, new infusion rate of remifentanil in g/kg/minute and in mL/hr (pump display). Functional genetic variants in cytokine and leukocyte-endothelial interaction pathways are independently associated with the severity of myonecrosis after cardiac surgery. Chait P, Rico L, Amaral J, et al: Ultrasound-guided core biopsy of mediastinal masses in children, Pediatr Radiol 35:S76, 2005. Schaden E, Kimberger O, Kraincuk P, et al: Perioperative treatment algorithm for bleeding burn patients reduces allogeneic blood product requirements, Br J Anaesth 109:376-381, 2012. Therefore, serum creatinine is a poor predictor of renal function in older individuals. In disaster anesthesia, most ventilation is part of balanced anesthesia to ensure a rapid recovery and throughput of cases. The initial screening of the patient by members of the core team determines what other specialists will be needed for a complete assessment. The da Vinci Robotic Surgical Si System: two surgical consoles, patient-side cart with four mounted surgical arms, and an optical tower. Unnecessary laboratory test screening may reveal abnormally elevated liver enzyme test results in otherwise healthy patients. Chest radiograph of a patient with a hiatal hernia and a dilated intrathoracic stomach, scheduled for hiatal hernia repair via a left thoracotomy. The horizontal portion of the curve indicates that there is initially some latitude for compensation in the face of an expanding intracranial lesion. The diagnostic thick wall of the abscess and the air-fluid level can be appreciated in the right upper thorax. In appreciation of the risks inherent in using a pressurized gas space, most oxygenators are designed with multiple gas outlet ports. Care should also be taken to avoid inadvertent compression or unnecessary manipulation of the umbilical cord, which could lead to vascular reactivity and decreased flow. The procedure is usually performed in the supine position, with the table turned 90 degrees. They include the localized fibrous tumors of pleura (previously referred to as benign mesotheliomas) and malignant pleural mesothelioma. Continuing Education in Anaesthesia, Critical Care & Pain 2012 & the Author [2012]. Once other potential causes have been eliminated, the next step should be a systematic search for an underlying cause or precipitating factor, such as infections. Specific anesthetic drugs have been promoted as brain protectants (see the discussion in Chapter 17). Nekludov M, Antovic J, Bredbacka S, et al: Coagulation abnormalities associated with severe isolated traumatic brain injury: cerebral arterio-venous differences in coagulation and inflammatory markers, J Neurotrauma 24:174-180, 2007. Patients with metabolic syndrome have an increased risk for cardiovascular disease events and are at increased risk for all causes of mortality. Mebazaa A, et al: Practical recommendations for prehospital and early in-hospital management of patients presenting with acute heart failure syndromes, Crit Care Med 36(1 Suppl):S129-S139, 2008. The concept that the injured brain is extremely vulnerable to what would otherwise be a minor insult. With these technologic innovations, new anesthetic implications for patient care are being discovered.

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The typical pathophysiologic changes associated with brain death are further described in Table 75-1. Electronic advances then led to major miniaturization using integrated circuits as opposed to discrete components. In the United Kingdom, where brainstem death criteria are adopted, the brain death criteria for children are as follows: after 2 months of age, criteria should be the same as in adults; between 37 weeks of gestation and 2 months of age, it is rarely possible to diagnose brain death confidently; and before 37 weeks of gestation, the criteria for brain death cannot be applied. Treatment goals include relaxation of the uterus to aid replacement, maternal fluid resuscitation, and increased uterine tone after replacement to reduce postpartum hemorrhage. Laviolle B, Basquin C, Aguillon D, et al: Effect of an anesthesia with propofol compared with desflurane on free radical production and liver function after partial hepatectomy, Fundam Clin Pharmacol 26:735-742, 2012. Immediate postoperative improvements in symptoms and pulmonary function are common, and many patients are able to discontinue or reduce home oxygen therapy. When ventricular dyssynchrony is reduced, the heart is able to contract more efficiently and increase left ventricular ejection fraction and cardiac output, while working less and consuming less oxygen. Confirmation of the diagnosis comes from the causative organism in blood, lymph nodes, or sputum cultures. Yet fibrinolytic therapy has several contraindications (Box 82-6) and also has the risk of intracranial hemorrhage resulting in major disability or death in 1% to 2% of the patients. As with implantable pacemakers, defibrillating devices need to be small and reliable and have adequate longevity. Burger-Klepp U, Karatosic R, Thum M, et al: Transesophageal echocardiography during orthotopic liver transplantation in patients with esophagogastric varices, Transplantation 94(2): 192-196, 2012. Rubber and synthetic materials, such as polyethylene and butyl rubber, are more resistant. Although cultural and religious diversity may lead to great differences in attitudes toward brain death and no global consensus exists on diagnostic criteria, the concept of brain death as defining the death of the individual is widely accepted1,2 and many countries have published recommendations or legal requirements for the diagnosis of brain death as a necessary prerequisite for organ donation. Subsequent abdominal surgeries will be needed in hemodynamically stable patients and should not present unusual anesthetic challenges. In the presence of a shunt, the potential enlargement of receiving chambers and high downstream pressure are important. Phrenic nerve infiltration and interscalene brachial plexus block289 have had some success but carry a risk of causing diaphragm dysfunction. Greater hemodynamic stability and decreased pharmacologic intervention during emergence have been reported in patients undergoing carotid endarterectomy Chapter 69: Anesthesia for Vascular Surgery 2151 with propofol versus isoflurane. Pao2 (mm Hg) or Pao2/Fio2 ratio Final Pao2 >100 Arterial blood gas: pH Glucose (mg/dL) Urine output (mL/kg/h) in 4 hours before procurement Ejection fraction of left ventricle Hemoglobin (mg/dL) 7. This may cause transient hypotension and will also cause a transient further fall in the PaO2 as the blood flow is temporarily redistributed to the nonventilated lung. Endovascular treatment of patients with acute ischemic stroke is undergoing intense investigation. A comprehensive laboratory panel that includes electrolytes, complete blood count, and platelet count is appropriate before surgery. All the brainstem reflexes (except those of the respiratory Chapter 76: Brain Death 2317 centers) need not be present for the organism to be said to be alive, but they are tested to confirm preservation of brainstem functions. Vasodilators, if used, should be gradually reduced and discontinued before unclamping. As described at the end of this section, this vasoconstriction may prove to be their ultimate downfall. Blood flow through tissues and organs below the level of aortic occlusion is dependent on perfusion pressure and is independent of cardiac output. Anesthesia can be induced through a standard intravenous line, followed by large-bore intravenous and arterial lines placed after induction. The kidney also plays a role in the conjugation of morphine, accounting for nearly 40% of its metabolism. It is estimated that more than 225,000 bariatric surgical procedures are performed annually in the United States. Such patients may become preoccupied with pain and somatic processes, which may disrupt sleep, cause irritability, and social withdrawal. The high-frequency setting should not be set below 30 Hz, and the low-frequency setting should not be above 1 Hz. Retrospective data from the University of Pittsburgh Medical Center suggest that primary acute renal failure after weight loss surgery occurs in approximately 2% of patients. In addition, point-of-care testing typically relies on whole blood samples for testing as opposed to laboratory-based testing using plasma or processed platelets.

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Schematic representation of various herniation pathways: (1) sub-falcine, (2) uncal (transtentorial), (3) cerebellar, and (4) transcalvarial. Guillozet N: the risks of paracervical anesthesia: intoxication and neurological injury of the newborn, Pediatrics 55:533-536, 1975. Matjasko J, Petrozza P, Cohen M, et al: Anesthesia and surgery in the seated position: analysis of 554 cases, Neurosurgery 17: 695-702, 1985. Volatile inhaled anesthetics are titrated to the level of surgical stimulation, which varies during the phases of the procedure. Two living donor deaths were reported in 2010, further illustrating the risk to living donors. Kudoh A, Katagai H, Takazawa T: Antidepressant treatment for chronic depressed patients should not be discontinued prior to anesthesia, Can J Anaesth 49:132-136, 2002. Small doses of midazolam will reduce the incidence of patient awareness but also can contribute to hypotension. In this case, nitrous oxide should be avoided for at least 1 month, or until the bubble is resorbed. In 1992, a marked increase in the number of carotid endarterectomies occurred after the results of two largescale, prospective randomized trials were published. Even though these supplements cannot legally claim to treat a disease, they can claim to reduce the risk of a disease. The largest increase in cardiac output occurs immediately after delivery, when cardiac output can increase by 80% to 100% more than prelabor values. Some cases may require early intubation and ventilation, and more will require O2 and supported ventilation in the early stages. Even relatively mild outside temperatures can result in hypothermia with long exposure times53 (also see Chapter 54). The goal is to decrease the arterial blood pressure by 20% to 25% within 30 to 60 minutes. Pancreas transplant centers pursue a comprehensive, multidisciplinary evaluation and selection process before listing candidates. In others, unfavorable anatomy with an increased likelihood of a difficult cannulation and hematoma formation may also encourage the use of alternate access sites. An even slower heart rate control (<70 beats/minute) may reduce myocardial ischemia after vascular surgery41; some added risk exists with this approach. The advantages of monitoring carotid stump pressure are that it is inexpensive, relatively easy to obtain, and continuously available during carotid clamping (dynamic stump pressure). Robots in anesthesia can be divided into pharmacologic robots, which deliver drugs to establish or maintain components of anesthesia, and manual robots, which are able to assist or replace human gestures in anesthesia. A prospective analysis from 1987 to 1990 resulted in seven cases of sepsis in patients receiving platelets for thrombocytopenia secondary to bone marrow failure. Some research groups have used these control mechanisms for closed-loop administration of anesthetics. The clinical usefulness of any monitoring technique ultimately depends on patient selection, accurate interpretation of data, and appropriate therapeutic intervention. The hip is dislocated and the femoral vein is probably obstructed during reaming and insertion of the femoral prosthesis, resulting in blood stasis and blood clot formation. Occasionally, during the perioperative period, the cardiac anesthesiologist or surgeon must replace a distal peripheral arterial catheter. Neohepatic Stage Reperfusion of the graft through the portal vein begins the neohepatic stage. Given the frequent incidence of cardiac morbidity and mortality in patients undergoing aortic reconstruction, factors that influence ventricular work and myocardial perfusion are of prime importance. Because of the large volume of local anesthetics frequently used for peripheral nerve blocks, the issue of systemic toxicity must be considered. Excision of craniopharyngiomas and pituitary tumors with suprasellar extension may entail dissection in and around the hypothalamus. This survey indicates that American neurologists have neither a consistent rationale for accepting brain death as death nor diagnostic tests for brain death. In addition, the abnormal motion of these bicuspid leaflets causes some turbulent flow into the aorta, which eventually can lead to dilatation and subsequent rupture or dissection. Aggressive management of blood pressure in the preoperative period is necessary to minimize the risk of rupture.

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Hemorrhage control is probably the most critical aspect of prehospital trauma care, particularly in combat casualty care. Maternal anesthesia is maintained with epidural anesthesia, supplemented by administration of intravenous opioid, inhaled N2O, and/or intravenous propofol; this allows adequate time for elimination of the volatile agents during surgical closure of the abdominal incision. The preferred type of fluid for intravascular volume expansion during donor nephrectomy is not known. A semilogarithmic plot of plasma concentration versus time shows that the vecuronium concentration remained at a much higher level during the elimination phase in patients with cirrhosis (open circles) than in normal control patients (black circles). Niemi G, Breivik H: Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline, Acta Anaesthesiol Scand 42:897-909, 1998. Ko S, Nakajima Y, Kanehiro H, et al: Significant influence of accompanying chronic hepatitis status on recurrence of hepatocellular carcinoma after hepatectomy: result of multivariate analysis, Ann Surg 224:591-595, 1996. Construction of the newly created pouch allows it to drain through only a narrow opening. Nagpal K, Arora S, Abboudi M, et al: Postoperative handover: problems, pitfalls, and prevention of error, Ann Surg 252:171-176, 2010. Capella J, Capella R: Is routine invasive monitoring indicated in surgery for the morbidly obese Singh S, Nautiyal A: Neurologic complications of bariatric surgery, Mayo Clin Proc 80:136-137, 2005. Kidney transplants have steadily increased over the past 40 years worldwide, with the growth of kidney transplant programs throughout Europe, North America, and Asia, as well as in many developing countries. Protamine, a strongly basic polycationic protein, directly inhibits heparin in a stoichiometric manner. Donations may be scheduled more than once a week, but the last donation should occur no less than 72 hours before surgery, to allow time for restoration of intravascular volume and for transport and testing of the donated blood. In approximately 20% to 40% of patients with chronic aortic dissection, significant aneurysmal dilatation of the descending thoracic or thoracoabdominal aorta will develop. The unpredictable timing of this event adds to the concerns regarding these patients. Von Willebrand disease not infrequently manifests as menorrhagia, and postpartum hemorrhage commonly occurs in women with underlying disorders of hemostasis. This is especially valuable in obese patients undergoing laparotomy, as described earlier in this chapter. As the ventricular pressures exceed the atrial pressures, flow abruptly stops, and pressures are elevated and equalized in all four chambers. The duration of monitoring is based on gestational age, fetal condition, and plan for fetal distress. Ko R, Kruger M, McRae K, et al: the use of air in the inspired gas mixture during two-lung ventilation delays lung collapse during one-lung ventilation, Anesth Analg 108:1092, 2009. An increased incidence of residual neuromuscular block and pulmonary complications occur in patients receiving pancuronium in contrast to atracurium or vecuronium198 (see also Chapters 34 and 35). During the 1990s, intrathecal lidocaine and 2-chloroprocaine were associated with multiple case reports of transient neurologic symptoms and longer lasting cauda equine syndrome. Multicenter Study of Perioperative Ischemia Research Group, N Engl J Med 335(23):1713-1720, 1996. Algorithms are designed to minimize unnecessary and indiscriminate blood product transfusion. Some recommend leaving the back half of the cervical collar in place during laryngoscopy. Although an effective intravascular expander, it has not gained widespread popularity, probably because of its effects on coagulation, particularly with regard to increased bleeding and platelet function. However, even these patients will then have to be repositioned and the diseased lung turned to the nondependent side. Cardiovascular Complications Hyperdynamic circulation-characterized by a high cardiac output, low arterial blood pressure, and low systemic vascular resistance-is the hallmark of end-stage liver disease. Atrial fibrillation is the most common dysrhythmia after cardiac surgery, although it usually develops 2 to 5 days postoperatively. Suppress renovascular constriction-by ensuring adequate volume preload and use of infusions of mannitol, calcium entry blockers, and angiotensin-converting enzyme inhibitors. Before 32 weeks gestation, an acceleration has a peak of 10 or more bpm above baseline, with a duration of 10 seconds or more but less than 2 minutes from onset to return. The abnormality in platelet factor 3 correlates can be corrected with dialysis, although prolongation of the bleeding time can be observed in well-dialyzed patients.

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Table 72-10 contains data indicating that the pharmacokinetics of all the cholinesterase inhibitors is similar in healthy patients and in patients with well-functioning newly transplanted kidneys. Endovascular procedures on the thoracoabdominal aorta and aortic arch often require these novel stent-grafts. Garb J, Welch G, Zagarins S, et al: Bariatric surgery for the treatment of morbid obesity: a meta-analysis of weight loss outcomes for laparoscopic adjustable gastric banding and laparoscopic gastric bypass, Obes Surg 19:1447-1455, 2009. These solutions are prepared commercially from albumin fractions from large pools of plasma reconstituted in isotonic electrolyte solutions. It is essential that correction of preoperative fluid deficits, maintenance of intraoperative fluid requirements, and replacement of blood loss be accomplished before unclamping. In patients with aneurysmal disease of the entire aortic arch, the traditional "elephant trunk" procedure has been combined with a second-stage stentgraft procedure of the descending thoracic aorta. Reduction typically requires a very deep level of sedation, which may be facilitated by nondepolarizing neuromuscular blockade (see also Chapters 34 and 35). They used their closed-loop propofol system mostly for small-scale studies in which they focused on the theoretical development of their models. These advantages include the absence of skeletal and cardiac muscle stimulation, minimal discomfort during delivery of energy, the possibility of performing the procedure in conscious patients, and the discrete nature of resulting lesions. Other possible options for awake intubation include, but are not limited to , direct laryngoscopy with Macintosh and Miller laryngoscopes, blind nasal intubation, use of a GlideScope or other video laryngoscope, use of a lighted stylet, and so on. The R value may be prolonged by a deficiency of one or more plasma coagulation factors or inhibitors such as heparin. Based on a 2007 systematic review of the literature, no single invasive option is significantly better than another, and all have success rates of approximately 85% to 90%. Achievement of intraoperative brain relaxation to facilitate surgical access to the aneurysm. When there is any uncertainty regarding the airway or the cervical spine, direct laryngoscopy (with vigorous atlanto-occipital extension) should probably be avoided when the exigencies of the situation do not require an immediate rapid-sequence induction. In the most recent conflict, the time from injury in the Middle East until return to the United States is frequently less than 81 hours for even the most seriously injured patients. Some procedures can be performed with the aid of monitored anesthesia care or regional blocks, provided a certain patient comfort level can be achieved. Diabetes insipidus is the most likely, although the cerebral salt-wasting syndrome can potentially occur. Intraoperative life-threatening airway compression usually has responded to one of two therapies: either repositioning of the patient (it must be determined before induction if there is a position that causes less compression and fewer symptoms) or rigid bronchoscopy and ventilation distal to the obstruction (this means that an experienced bronchoscopist and equipment must always be immediately available in the operating room for these cases). Employing a sample of whole blood, the Hemostasis Analysis System (Hemodyne, Bethesda, Md. Goudreau and associates72 reported that during the apnea test complications such as a marked blood pressure decrease or the development of ventricular arrhythmia developed in 27 (39%) of 70 patients with pretest unfavorable factors but developed in only 11 (15%) of 74 patients without them. Generally, wide exposure of the surgical field is established via a midline laparotomy extended by sternotomy. Patients with poor vision in the nonoperative eye face much greater potential functional loss. Robots can consist of the following elements: "effectors," which can be the equivalent of human arms or legs; "sensors," acting as infusion pumps, which perceive the environment and transfer it into information that can be fed to computers; a central processing unit, which works as the brain; and several other electronic, electric, or mechanical pieces of equipment, such as a screen with an interface, that mimic fundamental human functions. Traditionally, the use of ketamine in the patient with a traumatic brain injury has been controversial but, in fact, may be a good choice as an induction of anesthesia in patients with head injuries. Healthy endothelial cells possess antiplatelet, anticoagulant, and profibrinolytic effects to inhibit clot formation. In one study of fetoscopic surgery, maternal administration of a remifentanil infusion (0. Monitoring resuscitation with invasive monitors is gradually changing to noninvasive approaches that assess the return of adequate metabolism, respiration, and O2 transport in peripheral tissue beds. Outcomes with Hospice Care Hospice care decreases patient symptom burden44 and increases caregiver satisfaction, with 98% of family members recommending hospice care to others. Worldwide, meperidine is the most commonly used long-acting opioid in obstetric practice82 but, unfortunately, the most likely to result in side effects. In utero treatment raises complex and difficult ethical, social, and legal issues that go far beyond that of most adult or pediatric surgical interventions and include questions regarding maternal rights, access to care, and the option for pregnancy termination.

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The patient scheduled to undergo a pneumonectomy is considered at high risk for perioperative morbidity and mortality. Wappler R, Rossaint R, Baumert J, et al: Multicenter randomized comparison of xenon and isoflurane on left ventricular function in patients undergoing elective surgery, Anesthesiology 106:463471, 2007. Care should be taken, however, to prevent circulatory collapse by the concomitant administration of intravenous colloid solutions because intravascular volume reequilibration occurs 6 to 8 hours after the removal of a larger volume of ascitic fluid. When endothelial cells are activated, they express tissue factor, which converts prothrombin to thrombin. Prolonged exposure of the abdominal viscera results in significant third-space losses; adequate volume expansion with crystalloid or colloids is often required. Some clinicians may decide that it is the "path of least resistance" to simply avoid it and to avoid having to worry about the considerations it creates. Making the correct diagnosis is important because interventions commonly employed in systolic failure-such as diuretics and inotropes-may exacerbate diastolic dysfunction. The specialty of anesthesiology was also instrumental in the creation of modern prehospital emergency medicine. Febrile seizures are the most common seizure disorder in childhood, occurring in 2% to 5% of children, typically between the ages of 6 months and 5 years. Contraindications Pregnancy and untreated bleeding disorders are the only contraindications to lithotripsy. However, after infusion of more than 20 mL/kg in 24 hours, dextran 70 may interfere with normal blood clotting, causing a deficiency with crossmatching procedures and possibly a bleeding diathesis. Badjatia N, et al: Guidelines for Prehospital Management of Traumatic Brain Injury, ed 2, Prehosp Emerg Care 12(1 Supp 1): 1-52, 2008. Beyond the standard history, physical, and electrocardiogram, routine screening testing for cardiac disease does not appear to be cost-effective for all prethoracotomy patients. Some centers have set up specialized vascular step-down units in which lower risk patients can be evaluated frequently by specialized nursing staff. Muscle relaxants are usually given early in the sequence of anesthetic induction, particularly if relatively large doses of opioids are administered, to minimize chest wall rigidity (see also Chapter 34). Inadequate postoperative pain control can increase plasma oxytocin levels and increase the risk for preterm labor. Gentileschi P, Kini S, Catarci M, Gagner M: Evidence-based medicine: open and laparoscopic bariatric surgery, Surg Endosc 16:736-744, 2002. As the patient population presenting for noncardiac thoracic surgery has evolved, so have the anesthetic techniques to manage these patients. In a study of 755 donors who received an epidural catheter for postoperative pain management, no complications associated with the epidural catheter were reported. In this small study, 14 patients received manual sedation (manual analogue-sedation because both propofol and remifentanil were used) and 15 patients received automated analogue-sedation using the dual-loop control system for 8 to 24 hours. It is usually performed because endotracheal intubation during general anesthesia is judged to be too risky. Intraoperative monitoring should include an arterial catheter and central venous access. These abnormalities can range from mild changes in memory or attention to signs and symptoms of neuromuscular irritability. Although the 100% sensitivity will indeed prevent unrecognized intravascular catheter placement, a 21% falsepositive rate is problematic because these catheters would be inappropriately removed. Use of only volatile anesthetics at higher concentrations is associated with increased blood loss secondary to uterine atony because all volatile anesthetics are uterine muscle relaxants. A thoracic epidural catheter is usually placed to provide postoperative analgesia. The pathophysiologic mechanisms of brain death have profound effects at the molecular, cellular, and tissue levels. In both these cases, however, hypoxia and hypercapnia may be as damaging as the transient increase in pressure caused by the drug. Some infants and children with chronic respiratory disease or insufficiency may be responsive only to supranormal Paco2 levels. As discussed previously, routine preoperative coagulation testing lacks either predictive value or cost efficacy.

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Long-term administration of antiplatelet medications to ensure conduit patency should be noted. We recommend against the routine use of monitoring of the antiXa level (grade 1A). The appropriate regional anesthetic would include the arthritic shoulder; an appropriate anesthetic might be an interscalene block. During an ex utero intrapartum therapy procedure, the head and upper torso of a fetus with a neck mass are delivered and the airway secured using direct laryngoscopy. For these procedures, evaluation is focused on patients with major clinical predictors of risk. The organs are removed with their vascular structures after isolation in an order according to their susceptibility to ischemia, with the heart first and the kidney last. The brachial plexus is fixed at two points: proximally by the transverse process of the cervical vertebrae and distally by the axillary fascia. If hypotension occurs after adequate fluid replacement, then dopamine and ephedrine are preferable to direct-acting vasopressors to minimize vasoconstriction in the graft. Ripoll C, Groszmann R, Garcia-Tsao G, et al: Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis, Gastroenterology 133(2):481-488, 2007. Those most severely injured who reached medical aid were unconscious, unresponsive, and often in respiratory arrest. Thus, if a parturient chooses neuraxial analgesia despite the increased risk for a prolonged second stage and maternal fever, no evidence indicates that any point in the first stage of labor is "too early" to initiate analgesia. Absence of movement of bulbar musculature, including facial and oropharyngeal muscles. Defining and implementing optimal perioperative care for older adults is of increasing importance to all stakeholders in health care, including consumers, insurers, and government agencies. This results in microvascular coagulation and fibrinolysis and has deleterious effects on platelet function. Because of its low potential to spread outside of the lungs, multifocal bronchioloalveolar carcinoma can be treated by lung transplantation. The most important principle in health care decision making for older patients is autonomy. This question has been the basis for a decades-old debate: alpha-stat versus pH-stat blood gas management (Table 67-8). They may decrease pharyngeal musculature tone, which is essential in maintaining airway patency. Orgel E, McCarter R, Jacobs S: A failing medical educational model: a self-assessment by physicians at all levels of training of ability and comfort to deliver bad news, J Palliat Med 13:677-683, 2010. However, "the whole brain" does not require the irreversible cessation of functioning of every brain neuron. The informed consent includes full disclosure of possible complications and is facilitated by a patient advocate in many institutions with no relationship to the recipient. In Slinger P, editor: Principles and practice of anesthesia for thoracic surgery, New York, 2011, Springer, p 497. In the multitask environment of an intensive care unit, closed-loop control of propofol sedation might be very helpful (see also Chapter 101). If the initial uterine intervention and replacement is not successful with nitroglycerine because of lack of relaxation, maternal pain, hemodynamic instability, or other logistics, transfer to the operating room should occur. However, in the cohort of children 2 to 5 years old, girls have exhibited a doubling in prevalence of obesity since the 1990s, whereas boys have undergone an increase of only 25%. Blunt trauma most commonly results in an injury to the tracheobronchial tree within 2. Three fatalities from air embolus were reported over a 5-year interval to the New York State Department of Public Health, for an overall fatality risk of 1 in 30,000. Without the coadministration of opioids, use of 50% N2O in O2 is safe and does not result in hypoxia, unconsciousness, or loss of protective airway reflexes.