Chapter 1 Introduction to Anesthesiology and Perioperative Medicine/ 1 1.1 Introduction/ 1 1.2 Evolution of Anesthesiology/ 1 1.2.1 Ancient History of Anesthesia/ 1 1.2.2 History of Early Modern Anesthesia/ 2 1.3 Improvements in the Safety of Anesthesia/ 3 1.4 Scope of Anesthesia Practice/ 3 1.5 How to Learn Anesthesiology/ 4 1.5.1 Standards and Expectations of Anesthesiologists/ 4 1.5.2 Humanistic Knowledge and Humanistic Feelings/ 5 1.5.3 Fostering Passion or Motivation/ 5 1.6 New Practice and Advancement in Anesthesiology and Perioperative Medicine/ 5 References/ 6 Chapter 2 Preanesthetic Evaluation and Preparation/ 7 2.1 Preoperative Visit and Anesthetic Clinic/ 7 2.1.1 Preoperative Visit/ 8 2.1.2 Anesthesia Clinic/ 9 2.2 Procedures and Methods of Evaluation and Risk Assessment/ 10 2.2.1 Procedures of Evaluation/ 10 2.2.2 Methods of Evaluation/11 2.3 Cardiac Risk Assessment for Patients Undergoing Noncardiac Surgery/ 12 2.4 Pulmonary Risk Assessment for Patients Undergoing Noncardiac Surgery/ 16 2.5 Perioperative Blood Glucose Management/ 18 2.6 Thyroid Function for Patients Undergoing Noncardiac Surgery/ 19 2.7 Kidney Function Assessment for Patients Undergoing Noncardiac Surgery/ 19 2.8 Liver Function Assessment for Patients Undergoing Noncardiac Surgery/ 20 2.9 Coagulation Assessment for Patients Undergoing Noncardiac Surgery/ 21 2.10 Nutrition Status Assessment for Patients Undergoing Cardiac and Noncardiac Surgery/ 22 2.11 Preparation and Medication before Anesthesia/ 23 Case Study/ 25 References/ 26 Chapter 3 General Anesthesia/ 30 3.1 General Anesthetics and Related Drugs/ 30 3.1.1 Inhalation Anesthetics/ 30 3.1.2 Intravenous Anesthetics/ 31 3.1.3 Muscle Relaxants and Antagonists/ 35 3.1.4 Opioids and the Opiate Receptor Antagonists/ 37 3.2 Mechanisms of General Anesthesia/ 39 3.2.1 Theories/ 40 3.2.2 Potential Molecular and Anatomical Targets/ 40 3.2.3 Anatomical Targets and Neural Circuits/ 41 3.3 Administration of General Anesthesia/ 43 6 Contents 3.3.1 Induction of Anesthesia/ 43 3.3.2 Maintenance of Anesthesia/ 44 3.3.3 Judgment of the Depth of General Anesthesia/ 46 3.3.4 Emergence from General Anesthesia/ 47 Case Study/ 47 References/ 48 Chapter 4 Local Anesthesia/ 52 4.1 Local Anesthetics/ 52 4.1.1 Classification and Physical and Chemical Properties/ 52 4.1.2 Mechanisms of Action/ 54 4.1.3 Clinical Pharmacology/ 54 4.1.4 Tissue Toxicity of Local Anesthetics/ 56 4.2 Local Anesthesia/ 57 4.2.1 Topical Anesthesia/ 57 4.2.2 Infiltration Anesthesia/ 57 4.2.3 Systemic Application of Local Anesthetics/ 57 4.2.4 Regional Block/ 58 4.2.5 Neuraxial Block/ 59 4.3 Toxicity of Local Anesthetics and its Management/ 61 4.3.1 Clinical Manifestations/ 61 4.3.2 Toxicity Effects on the Cardiovascular System/ 61 4.3.3 Features of Local Toxicity in the Cardiovascular System/ 62 4.3.4 Management of Local Anesthetic Systemic Toxicity (LAST)/ 62 Case Study/ 62 Bibliography/ 63 Chapter 5 Neuraxial Anesthesia/ 64 5.1 Anatomy/ 64 5.1.1 Skeletal Structure of the Spinal Canal/ 64 5.1.2 Soft Tissues Outside the Spinal Canal/ 64 5.1.3 Spinal Cord and Spinal Nerves/ 65 5.1.4 Entocele and the Interspace of the Spinal Canal/ 66 5.2 Mechanisms and Physiological Effects of Neuraxial Anesthesia/ 66 5.2.1 Mechanisms/ 66 5.2.2 Cardiovascular Effects/ 67 5.2.3 Respiratory Effects/ 67 5.2.4 Gastrointestinal Physiology/ 67 5.2.5 Endocrine Physiology/ 67 5.3 Clinical Applications/ 68 5.3.1 Indications/ 68 5.3.2 Contraindications/ 68 5.4 Epidural Anesthesia/ 68 5.4.1 Overview/ 68 5.4.2 Puncture Techniques/ 69 5.4.3 Test Dose/ 70 5.4.4 Factors Influencing the Segments of the Block/ 70 5.4.5 Drugs for Epidural Anesthesia/ 71 5.4.6 Administration/ 71 5.4.7 Adjustment of pH for Local Anesthetics/ 71 5.4.8 Additives to Local Anesthetics for Epidural Blocking/ 71 5.5 Spinal Anesthesia (Subarachnoid Anesthesia)/ 71 Contents 7 5.5.1 Puncture Techniques/ 72 5.5.2 Block Segments/ 73 5.5.3 Drug Choice/ 74 5.5.4 Additives/ 74 5.5.5 Differences between Spinal Anesthesia and Epidural Anesthesia/ 75 5.6 Combined Spinal-Epidural Anesthesia/ 75 5.6.1 CSEA for Obstetrical Anesthesia/ 76 5.6.2 CSEA for Geriatric Anesthesia/ 76 5.7 Complications of Neuraxial Anesthesia/ 76 5.7.1 Complications of Spinal Anesthesia/ 76 5.7.2 Complications of Epidural Anesthesia/ 80 5.8 Ultrasound-guided Neuraxial Anesthesia/ 81 5.8.1 Introduction/ 81 5.8.2 Ultrasound-Guided Intradiscal Block/ 82 Case Study/ 84 Bibliography/ 84 Chapter 6 Peripheral Nerve Blocks and Truncal Blocks under Ultrasound Guidance/ 85 6.1 Cervical Plexus Block/ 85 6.1.1 Anatomy/ 85 6.1.2 Superficial Cervical Plexus Block/ 85 6.1.3 Deep Cervical Plexus Block/ 87 6.2 Upper Extremity Blocks/ 87 6.2.1 Anatomy/ 87 6.2.2 Interscalene Brachial Plexus Block/ 87 6.2.3 Supraclavicular Brachial Plexus Block/ 89 6.2.4 Infraclavicular Brachial Plexus Block/ 90 6.2.5 Axillary Brachial Plexus Block/ 93 6.3 Lower Extremity Blocks/ 94 6.3.1 Anatomy/ 94 6.3.2 Lumbar Plexus Block/ 95 6.3.3 Femoral Nerve Block/ 99 6.3.4 Sciatic Nerve Block/ 99 6.4 Truncal Blocks/ 103 6.4.1 Thoracic Paravertebral Block/ 103 6.4.2 Serratus Anterior Plane Block/ 106 6.4.3 Transversus Abdominis Plane Block/ 108 6.4.4 Rectus Sheath Block/ 109 6.4.5 Quadratus Lumborum Block/ 110 6.4.6 Erector Spinae Plane Block/ 113 Case Study/ 115 References/ 116 Chapter 7 Sedation Service and Monitoring Anesthesia Care/ 118 7.1 Definitions/ 118 7.2 Commonly Used Sedatives, Physiological Effects, and Antagonism/ 119 7.3 Indications and Patient Selection/ 121 7.4 Monitoring/ 122 7.5 Common Sedation Techniques, Complications, and Risk Management/ 122 7.6 Monitored Anesthesia Care/ 123 Case Study/ 123 References/ 124 8 Contents Chapter 8 Acupuncture-Medicine Balanced Anesthesia and Perioperative Medicine/ 125 8.1 Acupuncture Technique and Global Perspective/ 125 8.1.1 History of Acupuncture and Acupuncture-Related Techniques/ 125 8.1.2 Global Acceptance of Acupuncture/ 127 8.2 History of Acupuncture Anesthesia in China/ 128 8.3 Research on the Mechanisms of Acupuncture-Medicine Balanced Anesthesia/ 128 8.3.1 Neurophysiological Studies/ 129 8.3.2 CNS Imaging Studies/ 130 8.4 Acupuncture-Medicine Balanced Anesthesia/ 130 8.4.1 Balance between the Pros and Cons of Anesthetics/ 131 8.4.2 Balance of Vital Organs Function/ 133 8.4.3 Enhanced Recovery and Long-term Outcomes/ 134 8.4.4 Optimization of Acupuncture-Anesthetic Balanced Anesthesia/ 135 8.5 Perspectives of Acupuncture-Anesthetic Balanced Anesthesia/ 135 Case Study/ 136 Bibliography/ 137 Chapter 9 Airway Evaluation and Management/ 139 9.1 Airway Evaluation/ 139 9.1.1 Airway Anatomy/ 139 9.1.2 Airway Evaluation/ 141 9.2 Anesthesia for Airway Management/ 143 9.2.1 Preoxygenation for Anesthesia/ 143 9.2.2 Anesthesia Induction with a Neuromuscular Blockade/ 143 9.2.3 Rapid Sequence Induction/ 144 9.2.4 Intravenous Induction without a Neuromuscular Blockade/ 144 9.2.5 Awake Intubation/ 145 9.2.6 Endotracheal Tube Changes/ 146 9.3 Methods to Maintain a Patent Airway/ 146 9.3.1 The Head-tilt Chin-lift Maneuver and the Oral Airway/ 146 9.3.2 Pharyngeal Airway/ 147 9.3.3 Endotracheal Intubation/ 147 9.3.4 Laryngeal Mask Airway/ 150 9.3.5 Esophageal-Tracheal Airway/ 152 9.3.6 Videolaryngoscopes/ 152 9.3.7 Tracheostomy/ 152 9.4 Difficult Airway and Emergency Airway Techniques/ 152 9.4.1 Definition and Evaluation of Difficult Airway/ 152 9.4.2 Management of the Difficult Airway and Emergency Airway/ 153 9.4.3 Emergency Airway Techniques/ 155 9.5 Management of Tracheal Extubation/ 156 9.5.1 Extubation Plan/ 156 9.5.2 Extubation Preparation/ 157 9.5.3 Extubation Procedure/ 157 9.5.4 Post-extubation Management/ 158 Case Study/ 158 Bibliography/ 159 Chapter 10 Monitoring during Anesthesia/ 160 10.1 Introduction/ 160 10.2 Standard Monitoring Modalities/ 160 Contents 9 10.2.1 Qualified Anesthesia Provider/ 160 10.2.2 Basic Monitoring during Anesthesia/ 161 10.2.3 Additional Monitoring during Anesthesia/ 162 10.3 Hemodynamic Monitoring/ 162 10.3.1 Blood Pressure/ 163 10.3.2 Central Venous Pressure/ 166 10.3.3 Cardiac Output/ 168 10.3.4 Pulmonary Artery Pressure and Pulmonary Artery Occlusion Pressure/ 170 10.3.5 Echocardiography/ 171 10.3.6 Electrocardiography/ 172 10.4 Respiratory Function Monitoring/ 173 10.4.1 Mandatory Respiratory Monitors/ 173 10.4.2 Oxygenation/ 173 10.4.3 Capnography and Spirometry/ 174 10.4.4 Respiratory Mechanics/ 175 10.5 Analysis of Arterial Blood Gas/ 175 10.5.1 Sample Source and Collection/ 175 10.5.2 Temperature Correction/ 175 10.6 Neuromuscular Blockade Monitoring/ 176 10.6.1 Indications/ 176 10.6.2 Contraindications and Complications/ 176 10.6.3 Principles of Measurement and Devices/ 176 10.6.4 Clinical Considerations/ 177 10.7 Depth of Anesthesia/ 177 10.7.1 Clinical Observation/ 177 10.7.2 Electroencephalogram (EEG) and EEG-Based Indices/ 179 10.7.3 Evoked Potentials/ 179 10.8 Monitoring of Cerebral Perfusion/ 181 10.8.1 Indications and Contradictions/ 181 10.8.2 Principles of Measurement and Devices/ 181 10.8.3 Clinical Considerations/ 183 10.9 Thrombelastogram/ 183 10.9.1 Indications/ 183 10.9.2 Principles of Measurement and Devices/ 183 10.9.3 Clinical Considerations/ 183 Case Study/ 183 References/ 185 Chapter 11 Postanesthesia Care Unit Management and Anesthesia Intensive Care Unit/ 187 11.1 Introduction/ 187 11.2 Admission to the PACU/ 187 11.3 The PACU Workflow and PACU Discharge Criteria/ 187 11.3.1 The Workflow of PACU/ 187 11.3.2 Discharge Criteria/ 188 11.4 Common Side Effects and Complications/ 189 11.4.1 Respiratory System/ 189 11.4.2 Cardiovascular System/ 190 11.4.3 Postoperative Nausea and Vomiting/ 193 11.4.4 Delayed Awakening/ 193 11.4.5 Emergence Delirium/ 194 10 Contents 11.4.6 Shivering/ 195 11.4.7 Hypothermia/ 195 11.4.8 Postoperative Surgical Hemorrhage/ 196 11.5 Postoperative Pain Management in the PACU/ 197 11.5.1 Pharmacological Management/ 197 11.5.2 Regional Anesthesia Techniques/ 197 11.5.3 Patient-Controlled Analgesia/ 197 11.6 Anesthesia ICU Recovery/ 197 11.6.1 Cardiothoracic Intensive Care Unit Admission Criteria/ 198 11.6.2 The ICU Workflow and ICU Discharge Criteria/ 198 11.7 Anesthesia Intensive Care Unit/ 199 11.7.1 Principles and Facilities in AICU/ 199 11.7.2 Staffing Requirements for AICU/ 200 11.7.3 Medical Quality Control in AICU/ 201 11.7.4 The Main Types of Patients Admitted to AICU/ 201 11.7.5 Management of Critically Ill Patients in AICU/ 202 11.7.6 Vital Organ Support/ 204 11.7.7 Specialized Treatment in Several Fields/ 205 11.7.8 Diagnosis and Treatment Techniques Used in AICU/ 206 Case Study/ 209 References/ 210 Chapter 12 Perioperative Management of Temperature/ 212 12.1 Physiological Regulation of Body Temperature/ 212 12.1.1 Afferent Sensory Fibers/ 212 12.1.2 Central Regulation/ 212 12.1.3 Efferent Pathways/ 213 12.2 Physiological Response to Cold/ 213 12.3 Physiological Responses to Heat/ 214 12.4 Factors Affecting Body Temperature During Surgery/ 215 12.4.1 Patient Factors/ 215 12.4.2 Anesthetic Factors/ 217 12.4.3 Surgery Factors/ 217 12.5 Detrimental Effects of Abnormal Temperature/ 217 12.5.1 Detrimental Effects of Unintentional Hypothermia/ 217 12.5.2 Detrimental Effects of Hyperthermia/ 219 12.6 Perioperative Body Temperature Management/ 219 12.6.1 Preoperative Evaluation and Preheating/ 220 12.6.2 Intraoperative Heating/ 220 12.7 Hypothermic Anesthesia/ 221 12.7.1 Definition/ 221 12.7.2 Clinical Applications/ 221 12.7.3 Cerebral Protection/ 221 12.7.4 Cardiovascular Effects/ 222 12.7.5 Applied Surgeries/ 222 12.7.6 Techniques Used for Induced Hypothermia/ 222 12.7.7 Supportive Therapy/ 222 12.7.8 Controlled Rewarming/ 222 12.7.9 Adverse Effects and Controversial Areas/ 223 Case Study/ 223 References/ 223 Chapter 13 Perioperative Hemodynamic Management/ 227 13.1 Cardiovascular Physiology and Pathology/ 227 13.1.1 Cardiac Anatomy/ 227 13.1.2 Cardiac Conduction System/ 228 13.1.3 Myocardial Cells Function/ 228 13.1.4 Coronary Artery Perfusion/ 229 13.1.5 Preload, Afterload, and Myocardial Contractility/ 229 13.1.6 Peripheral Vasculature Regulation/ 230 13.1.7 Stenosis and Insufficient Valvular Disease/ 230 13.2 Cardiovascular Medications/ 230 13.2.1 Classification of Vasoactive Medications/ 230 13.2.2 Common Medications Used to Manage Perioperative Hypertension/ 231 13.2.3 Common Medications Used to Manage Perioperative Hypotension/ 231 13.2.4 Common Medications Used to Treat Heart Failure/ 231 13.2.5 Selection of Appropriate Vasoactive Medications and Optimization of Hemodynamics/ 232 13.2.6 Common Medications Used to Treat Arrhythmia/ 232 13.3 Techniques or Devices for Assisting Circulation/ 233 13.3.1 Intra-aortic Balloon Pump/ 233 13.3.2 Pacemaker/ 234 13.3.3 Implantable Cardioverter Defibrillators/ 235 13.4 Induced Hypotension Technique/ 236 13.4.1 Indications/ 236 13.4.2 Methods/ 236 13.4.3 Monitors/ 237 13.4.4 Potential Risks and Complications/ 237 Case Study/ 237 References/ 238 Chapter 14 Perioperative Respiratory Support/ 239 14.1 Respiratory Physiology/ 239 14.1.1 Pulmonary Ventilation/ 239 14.1.2 Lung Volumes and Capacities/ 241 14.1.3 Gas Exchange/ 242 14.1.4 Control of Breathing/ 243 14.2 Perioperative Respiratory Failure/ 244 14.2.1 Pathophysiology of Acute Respiratory Failure/ 244 14.2.2 Acute Lung Injury and Acute Respiratory Distress Syndrome/ 245 14.2.3 Acute Cardiogenic Pulmonary Edema/ 245 14.3 Treatment of Respiratory Failure/ 245 14.3.1 Oxygen Therapy/ 245 14.3.2 Secretion Clearance/ 247 14.3.3 Pharmacologic Therapies/ 247 14.3.4 Mechanical Ventilation/ 247 14.3.5 Protective Lung Ventilation and Extracorporeal Respiratory Support/ 252 Case Study/ 254 Bibliography/ 257 Chapter 15 Fluid and Electrolyte Therapy/ 258 15.1 Fluid Physiology/ 258 15.1.1 General/ 258 12 Contents 15.1.2 Redistribution Mechanisms of Body Fluid Balance/ 258 15.2 Fluid Pharmacology/ 259 15.2.1 Crystalloid Solution/ 259 15.2.2 Colloid Solution/ 259 15.3 Pathophysiology of Perioperative Fluid Shift/ 260 15.4 Assessment and Treatment of Perioperative Fluid and Electrolyte Disorders/ 261 15.4.1 Assessment of Fluid and Electrolyte Disorders/ 261 15.4.2 Perioperative Fluid and Electrolyte Therapy/ 263 15.4.3 Characteristics of Fluid Therapy in Different Pathological Situations/ 265 15.5 Goal-Directed Fluid Therapy/ 266 15.5.1 Definition of GDFT/ 266 15.5.2 Indicators Used in GDFT/ 267 15.5.3 Monitoring Methods of GDFT/ 267 Case Study/ 268 Bibliography/ 270 Chapter 16 Blood Transfusion/ 271 16.1 Introduction/ 271 16.1.1 Transfusion History/ 271 16.1.2 Patient Blood Management/ 271 16.2 Blood Component Transfusion/ 272 16.2.1 Preparation of Blood Components/ 272 16.2.2 Storage of Blood Products/ 273 16.2.3 Compatibility Tests/ 274 16.3 Transfusion Therapy and Massive Transfusion/ 276 16.3.1 Indications for Transfusion/ 276 16.3.2 Massive Transfusion/ 278 16.4 Adverse Transfusion Reactions/ 279 16.4.1 Hemolytic Transfusion Reaction/ 279 16.4.2 Delayed Hemolytic Transfusion Reaction/ 280 16.4.3 Nonhemolytic Transfusion Reactions/ 280 16.4.4 Infectivity of Blood/ 281 16.4.5 Transfusion-Associated Graft-versus-Host Disease/ 281 16.4.6 Transfusion-Related Acute Lung Injury/ 281 16.4.7 Transfusion-Related Immunomodulation/ 282 16.5 Autologous Transfusion/ 282 16.5.1 Preoperative Autologous Donation/ 282 16.5.2 Acute Normovolemic Hemodilution/ 282 16.5.3 Cell Salvage/ 282 16.6 Patient Blood Management in Obstetrics/ 283 16.6.1 Postpartum Hemorrhage/ 283 16.6.2 Cell Salvage in Obstetrics/ 284 16.6.3 Tranexamic Acid/ 284 16.6.4 Miscellaneous Consideration/ 285 16.7 PBM for Patients with Cancer/ 285 16.7.1 Anemia & Transfusion for Patients with Cancer/ 285 16.7.2 Intraoperative Cell Salvage for Patients with Cancer/ 286 16.8 Management of Perioperative Coagulation/ 286 16.8.1 Normal Hemostasis/ 286 16.8.2 Intrinsic Anticoagulant Mechanisms/ 287 16.8.3 Disorders of Hemostasis/ 288 16.8.4 Monitoring Coagulation/ 291 Case Study/ 292 References/ 293 Chapter 17 Perioperative Adverse Events/ 294 17.1 Adverse Events of Cardiovascular System/ 294 17.1.1 Severe Hypotension/ 294 17.1.2 Severe Hypertension/ 295 17.1.3 Significant Dysrhythmias/ 296 17.1.4 Myocardial Infarction/ 297 17.1.5 Cardiac Tamponade/ 298 17.1.6 Acute Heart Failure/ 299 17.2 Adverse Events of Respiratory System/ 300 17.2.1 Severe Hypoxemia/ 300 17.2.2 Severe Hypercapnia/ 301 17.2.3 Laryngospasm/ 302 17.2.4 Bronchospasm/ 303 17.2.5 Aspiration/ 304 17.2.6 Pneumothorax/ 305 17.2.7 Pulmonary Embolism/ 305 17.2.8 Lung Infection/ 306 17.3 Other Perioperative Adverse Events or Side-Effects/ 307 17.3.1 Oliguria, Anuria, and Polyuria/ 307 17.3.2 Hypothermia/ 308 17.3.3 Hyperthermia/ 309 17.3.4 Malignant Hyperthermia/ 309 17.3.5 Anaphylactic and Anaphylactoid Reactions/ 310 17.3.6 Hypoglycemia/ 311 17.3.7 Blindness and Eye Injury/ 312 17.3.8 Position-Related Nerve Injury/ 313 17.3.9 Skin Injury/ 314 Case Study/ 315 References/ 317 Chapter 18 Anesthesia for Ambulatory Surgery/ 319 18.1 Definitions of Ambulatory Surgery/ 319 18.2 Patients' Selection Criteria/ 320 18.2.1 Procedures that Can be Performed on an Ambulatory Basis/ 320 18.2.2 Suitability of a Patient for Ambulatory Surgery/ 320 18.3 Pre-anesthetic Visit and Evaluation/ 323 18.3.1 Ways of Pre-anesthetic Visit and Evaluation/ 323 18.3.2 Contents of Pre-anesthetic Visit and Evaluation/ 324 18.4 Anesthetic Management of Ambulatory Surgery/ 324 18.4.1 Anesthetic Staff and Anesthetic Equipment/ 324 18.4.2 Choice of Anesthetic Methods/ 325 18.4.3 Selection of Anesthetics/ 327 18.5 Treatments during the Recovery Period and Follow-up Visits/ 329 18.5.1 Recovery from Ambulatory Anesthesia/ 329 18.5.2 Postoperative Analgesia/ 331 18.5.3 Postoperative Nausea and Vomiting/ 334 18.5.4 Follow-up Visit/ 335 Case Study/ 335 References/ 336 Chapter 19 Perioperative Administration of Endoscopic and Minimally Invasive Procedures/ 344 19.1 Perioperative Administration of Laparoscopic Surgery/ 344 19.1.1 Pathophysiology of Laparoscopic Surgery/ 344 19.1.2 Anesthetic Management of Laparoscopic Surgery/ 345 19.1.3 Prevention and Treatment of Complications Associated with Pneumoperitoneum/ 347 19.1.4 Postanesthetic Management of Laparoscopic Surgery/ 347 19.2 Perioperative Administration of Thoracoscopic Surgery/ 348 19.2.1 Characteristics and Indications for Thoracoscopic Surgery/ 348 19.2.2 Lung Isolation Techniques/ 349 19.2.3 Respiratory Management of OLV/ 352 19.2.4 Fluid Management/ 353 19.2.5 Postoperative Analgesia/ 354 19.3 Anesthesia for Endoscopic Gastrointestinal Procedures/ 354 19.4 Anesthesia for Bronchoscopy Procedures/ 356 19.5 Anesthesia for Interventional Cardiology Procedures/ 357 19.5.1 Electrophysiology Studies and Catheter Ablation/ 357 19.5.2 Percutaneous Transcatheter Cardiac Valve Intervention/ 357 19.6 Anesthesia for Image-Guided Neuroradiology Procedures/ 359 Case Study/ 360 References/ 361 Chapter 20 Shock/ 365 20.1 Introduction/ 365 20.1.1 Definition/ 365 20.1.2 Classification/ 365 20.1.3 Pathophysiology/ 367 20.1.4 Signs and Symptoms of Shock/ 369 20.1.5 Clinical Presentations/ 369 20.2 Monitors, Biomarkers and Imaging Studies/ 370 20.2.1 Clinical Parameters/ 370 20.2.2 Laboratory Parameters/ 370 20.2.3 Biomarkers/ 371 20.2.4 Imaging Studies/ 371 20.3 Prevention, Treatment and Outcomes of Shock/ 371 20.3.1 Prevention of Shock/ 371 20.3.2 Management of Shock/ 372 20.3.3 Predicted Outcomes of Shock/ 372 20.4 Commonly Observed Shocks in the Line of Work/ 373 20.4.1 Cardiogenic Shock/ 373 20.4.2 Hypovolemic Shock/ 374 20.4.3 Septic Shock/ 376 20.4.4 Anaphylactic Shock/ 378 Case Study/ 379 References/ 382 Chapter 21 Multiple Organ Dysfunction Syndrome/ 384 21.1 Etiologies of Multi-organ Dysfunction Syndrome/ 384 21.2 Mechanisms of MODS/ 385 21.2.1 Ischemia-Reperfusion Injury and MODS/ 385 21.2.2 Systemic Inflammatory Response Syndrome and MODS/ 387 21.2.3 Intestinal Motility Theory/ 389 21.3 Clinical Diagnosis, Evaluation, and Monitoring/ 390 21.3.1 Clinical Diagnosis and Stages/ 390 21.3.2 Clinical Evaluation/ 392 21.4 Prevention and Treatment/ 393 Case Study/ 394 References/ 395 Chapter 22 Cardiopulmonary-Cerebral Resuscitation/ 397 22.1 Etiologies and Pathophysiology of Cardiac Arrest/ 397 22.2 Cardiopulmonary Resuscitation/ 398 22.2.1 Physiology of Circulation during Closed-Chest Compression/ 398 22.2.2 Basic Life Support/ 399 22.2.3 Advanced Cardiac Life Support/ 404 22.3 Post-resuscitation Care/ 409 22.3.1 Hemodynamic Monitoring and Maintenance/ 409 22.3.2 Respiratory Function Monitoring and Maintenance/ 411 22.3.3 Renal Function Monitoring and Support/ 411 22.3.4 Maintenance of Fluid, Electrolyte, and Acid-Base Balance/ 411 22.3.5 Cares for other Systems/ 411 22.4 Cerebral Resuscitation/ 412 22.4.1 Pathophysiology of the Brain/ 412 22.4.2 General Management of Cerebral Resuscitation/ 412 22.4.3 Specific Measures of Cerebral Resuscitation/ 413 22.4.4 Prognostication Following Cardiopulmonary Resuscitation/ 413 22.5 Pediatric CPR/ 413 22.5.1 Characteristics of Pediatric CPR/ 413 22.5.2 CPR in Infants and Children/ 414 22.6 Neonatal CPR/ 415 22.6.1 Basic procedures of neonatal CPR/ 415 22.6.2 Post-resuscitation Care/ 417 Case Study/ 418 References/ 419 Chapter 23 Perioperative Use of Ultrasound/ 420 23.1 Introduction/ 420 23.2 Physics of Ultrasound Imaging/ 421 23.2.1 Properties of Ultrasound Waves/ 421 23.2.2 Ultrasound Transducer/ 421 23.2.3 Ultrasound Imaging/ 422 23.3 Perioperative Echocardiography/ 23.3.1 Indications, Risks, and Safety of TEE/ 424 23.3.2 Probe Insertion and Manipulation/ 424 23.3.3 Basic TEE Views/ 426 23.3.4 Common Indications and Diagnosis/ 427 23.4 Point of Care Ultrasound in Critical Care Medicine/ 430 23.4.1 Ultrasound of the Heart/ 430 23.4.2 Ultrasound to Evaluate Volume Status/ 434 23.4.3 Ultrasound of the Lung/ 436 23.4.4 Ultrasound of the Abdomen/ 439 23.4.5 Ultrasound of the Lower Extremity Vascular System/ 441 23.4.6 Airway/ 443 16 Contents 23.4.7 Gastric Ultrasound and Aspiration Risk Assessment/ 444 23.4.8 Shock Exam/ 446 Case Study/ 447 References/ 449 Chapter 24 Nutritional Support for Patients with Critical Illness/ 451 24.1 Nutrition Assessment/ 451 24.2 Nutrition Balance/ 451 24.2.1 Assessment Technique/ 452 24.2.2 Nitrogen Requirement/ 452 24.3 Enteral Feeding/ 454 24.3.1 Indications and Specifications/ 454 24.3.2 Selection of the Enteral Formula/ 455 24.3.3 Delivery and Administration of Enteral Nutrition/ 456 24.4 Parenteral Nutrition/ 456 24.4.1 Indications and Specifications/ 456 24.4.2 Vitamins and Trace Elements/ 456 24.4.3 Effects on Fluid and Acid-Base Balance and Glucose Homeostasis/ 457 24.4.4 Central Venous Access/ 457 24.4.5 Impaired ��Disposal Systems��/ 457 24.5 Measuring the Nutritional Goal Achievement/ 457 24.5.1 Serial Markers to Measure/ 457 24.5.2 Reasons for the Underachievement of Goals/ 458 24.5.3 Clinical Pearls and Pitfalls/ 458 24.5.4 ��Designer�� Enteral Feedings: Facts and Myths/ 458 24.5.5 Hepatic Formula/ 458 24.5.6 Renal Formula/ 458 24.5.7 Pulmonary Formula/ 459 24.5.8 Metabolic Stress (critical care) Formula/ 459 24.5.9 Glycemic Control Formula/ 459 24.6 Special Topic: Nutrition for Immunomodulation Formula/ 459 24.6.1 Glutamine/ 460 24.6.2 Arginine/ 460 24.6.3 Nucleotides/ 460 24.6.4 Structured Lipids/ 460 24.6.5 Antioxidant Therapy/ 460 24.7 SARS-CoV-2 Infection, Covid-19, and Immune Response/ 461 24.7.1 There are Many Challenges in Providing Adequate Nutrition for Patients with COVID-19 and Critically Ill/ 461 24.7.2 Nutrition Plays Multiple Roles in Supporting the Immune System/ 461 24.7.3 Poor Nutrition May Not Provide Enough of the Nutrients Needed by the Immune System/ 462 Case Study/ 462 Bibliography/ 464 Chapter 25 Pain/ 467 25.1 Pathophysiology of Pain/ 467 25.1.1 Neural Pathways Involved in Pain Signal Processing/ 467 25.1.2 Acute Pain/ 468 25.1.3 Chronic Pain/ 468 25.2 Evaluation of Pain/ 469 25.2.1 Pain Measurement/ 469 Contents 17 25.2.2 Psychological Evaluation/ 470 25.2.3 Electromyography and Nerve Conduction Studies/ 471 25.3 Commonly Used Analgesics/ 471 25.3.1 Nonsteroidal Anti-inflammatory Drugs/ 471 25.3.2 Opioids/ 472 25.3.3 Calcium Channel Blockers/ 473 25.3.4 Sodium Channel Blockers/ 473 25.3.5 Antiepileptics/ 473 25.3.6 Antidepressants/ 474 25.4 Acute Pain Care/ 475 25.4.1 Postoperative Pain Management/ 475 25.4.2 Labor Analgesia/ 476 25.5 Chronic Pain Management/ 479 25.5.1 Introduction/ 479 25.5.2 Common Chronic Pain Syndromes/ 479 25.5.3 Drugs Used in Pain Management/ 481 25.5.4 Interventional Pain Therapies/ 482 25.6 Cancer Pain Care/ 483 25.6.1 Introduction/ 483 25.6.2 Pharmacological Cancer Pain Treatments/ 484 Topic Discussion/ 487 References/ 489 Chapter 26 Enhanced Recovery after Surgery/ 490 26.1 Introduction/ 490 26.2 Components of ERAS Pathways/ 490 26.2.1 Preoperative Considerations/ 490 26.2.2 Intraoperative Interventions/ 493 26.2.3 Perioperative Fluid Therapy/ 496 26.2.4 Postoperative Interventions/ 497 26.3 Challenges to the Implementation of ERAS Pathways/ 500 Case Study/ 501 References/ 502 Chapter 27 Anesthesia and Perioperative Mortality or Organ Injury/ 506 27.1 Surgical Stress Response/ 506 27.1.1 Immunologic Response/ 506 27.1.2 Metabolic and Neuroendocrine Response/ 507 27.1.3 Effects on the Brain/ 507 27.1.4 Regional Anesthesia Effects on Stress Response/ 507 27.2 Anesthesia and Perioperative Mortality/ 508 27.2.1 Perioperative Mortality/ 508 27.2.2 Risk Factors Associated with Perioperative Mortality/ 508 27.3 Association between Anesthesia and Organ Injury/ 508 27.3.1 Cardiac Injury/ 509 27.3.2 Renal Injury/ 512 27.3.3 Brain Injury/ 513 27.3.4 Lung Injury/ 516 27.3.5 Hepatic Injury/ 518 Case Study/ 520 References/ 522 18 Contents Chapter 28 Preventive Measures of Perioperative Infection for COVID-19 and Beyond/ 527 28.1 Introduction/ 527 28.2 COVID-19/ 527 28.2.1 Etiology/ 527 28.2.2 Epidemiology/ 528 28.2.3 Clinical Manifestations/ 528 28.2.4 Precautions for SARS-CoV-2 Infection/ 528 28.2.5 Precautions in Perioperative Settings when Caring for Patients with Suspected or Confirmed COVID-19/ 528 28.2.6 Workflow for Perioperative Management during the COVID-19 Pandemic/ 529 28.3 Anesthesia Management in the Dedicated Operating Room/ 529 28.3.1 Preoperative Preparation/ 529 28.3.2 Anesthesia Management/ 530 28.4 Postanesthesia Equipment Care and Medical Waste Disposal/ 531 28.4.1 Anesthesia Equipment Care and Operating Room Disinfection/ 531 28.4.2 Disposal of Medical Waste/ 532 28.5 Perioperative Protection of Respiratory Infectious Diseases in Children/ 532 28.5.1 Preoperative Preparation/ 532 28.5.2 Process of Anesthesia/ 533 28.5.3 Postoperative Registration and Follow-up/ 534 28.5.4 Suggestions for the Preparation and Performance of First-aid and Tracheal Intubation Outside the Operating Room/ 534 28.6 Other Issues Related to COVID/ 535 28.6.1 Suggestions for Central Vein Catheterization/ 535 28.6.2 Suggestions for Sedation under an Anesthetic Monitor Outside the Operating Room/ 535 28.6.3 Prevention, Surveillance of COVID-19 Infection among Anesthesia Providers/ 535 28.7 Anesthesiologists amid COVID-19 and Beyond: A Perspective of the Present and Future Challenges/ 536 References/ 538 Chapter 29 New Frontiers in Anesthesiology/ 539 29.1 General Anesthesia and Brain Health/ 539 29.1.1 General Anesthesia and Developing Brain/ 539 29.1.2 General Anesthesia and Aged Brain/ 542 29.2 Artificial Intelligence in Anesthesiology/ 544 29.2.1 Monitoring Depth of General Anesthesia/ 545 29.2.2 Target-controlled Infusion of Anesthetics/ 545 29.2.3 Prediction of Major Adverse Events/ 546 29.2.4 Ultrasonic Visualization Technology/ 546 29.2.5 Pain Management/ 547 29.2.6 Management of Medical Recourses/ 547 Summary/ 547 References/ 548